Anesthesia Key

B. Briefly describe 5 recommended standards of care for a high-risk patient from the third National Emergency Laparotomy Audit (NELA) report (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

C. List 4 commonly quoted risk calculators used for general surgery patients undergoing emergency laparotomy (4 marks)

D. On further assessment, the patient has a prominent history of side effects due to high dose systemic opioids

What measures, additional to simple analgesics, can be considered to facilitate an opioid sparing anaesthetic technique in this patient? (4 marks)

E. What intraoperative targets are recommended during management of an emergency laparotomy patient with signs of septic shock? (5 marks)

System	Goals
Cardiovascular (2 marks)	1.——————— 2.———————
Respiratory (3 marks)	1.——————— 2.——————— 3.———————

System

Goals

A. List the absolute (3 marks) and relative (2 marks) indications for placement of a double lumen tube in anaesthesia and critical care.

Total 20 marks

Question 3

A 79-year-old life-long smoker attends for preoperative assessment, prior to right pneumonectomy.

Absolute

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Relative

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B. List methods of preoperative respiratory assessment you may use in an adult to assess their suitability for pneumonectomy. Give threshold values where required (5 marks)

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C. How would you manage hypoxaemia during one-lung anaesthesia? (8 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

7.———————

8.———————

D. What is ventilation-perfusion coupling? What does it achieve? (2 marks)

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Total marks 20

Question 4

A. List 4 risk factors for pre-eclampsia (4 marks)

B. List criteria used in the diagnosis of mild pre-eclampsia (3 marks)

C. List 3 drugs and their doses you would use to treat hypertension, and in the order you would use them (3 marks)

Antihypertensive choice	Drug	Initial dose and route	Maintenance
1st (1 mark)
2nd (1 mark)
3rd (1 mark)

D. Give 2 further signs or symptoms that define pre-eclampsia as being severe (2 marks)

E. Give details of the magnesium administration regimen used in severe pre-eclampsia (2 marks)

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F. List 3 signs or symptoms of magnesium toxicity (3 marks)

G. How should magnesium toxicity be managed? (3 marks)

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Total 20 marks

Question 5

A 39-year-old man is scheduled for the excision of a medulloblastoma from his posterior cranial fossa.

He is to be in the sitting position for his surgery.

A. List 3 contraindications to the sitting position (3 marks)

B. What are the complications associated with surgery in the sitting position? (3 marks)

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C. List 2 ways in which the risk of venous air embolism can be minimized (2 marks)

D. Complete this table with the clinical features of venous air embolism (8 marks)

Cardiovascular (4 marks)
Respiratory (3 marks)
CNS (1 mark)

E. List 4 specific monitors that can be used to detect venous air embolism during anaesthesia (4 marks)

A. Give 2 clinical features which are specific to Graves’ disease (2 marks)

Total 20 marks

Question 6

A 49-year-old woman requires elective total thyroidectomy. She has a history of hyperthyroidism and Graves’ disease. Her drug history includes carbimazole and propranolol.

B. List 4 preoperative signs specific to goitre which may indicate potential airway difficulty during induction of anaesthesia (4 marks)

C. What clinical signs of hyperthyroidism can be detected at the bedside? (4 marks)

System	Signs
CNS (1 marks)	1.
CVS (2 marks)	1.——————— 2.———————
General (1 mark)	1.

D. What are the biochemical indicators of hyperthyroid disease? (1 mark)

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E. During surgery the patient becomes acutely unwell. You suspect thyroid storm. List 4 of the classical presenting features of thyroid storm (4 marks)

F. Explain the importance of checking serum calcium postoperatively following total thyroid surgery (1 mark)

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G. Name the clinical signs which may be elicited on examination in this situation and describe their associated examination findings (4 marks)

Clinical sign (2 marks)	Examination findings (2 marks)
————————	————————
————————	————————

Total 20 marks

Question 7

A 6-year-old child presents with a dental abscess requiring surgery. She suffers from Down’s syndrome. She has mild developmental delay and cannot cooperate with preoperative assessment.

A. Define Down’s syndrome (2 marks)

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B. List the airway issues relevant to the anaesthetic management of this particular child (6 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

C. Give 2 options for induction of anaesthesia (1 mark)

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D. Complete the table evaluating the risks and benefits of each method (8 marks)

Technique

Pros (4 marks)

Cons (4 marks)

IV induction/

RSI

Gas induction

E. Give 3 postoperative considerations (3 marks)

A. What are the effects of malnutrition in the critical care patient? (3 marks)

Total 20 marks

Question 8

A 29-year-old woman is ventilated in intensive care unit (ICU). She was admitted 48 hours ago with community acquired pneumonia. She has a history of anorexia nervosa and depression. She weighs 46kg.

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B. You commence enteral feeding via the nasogastric route. What are the risk factors for developing refeeding syndrome in critical care patients? (4 marks)

C. Describe the metabolic changes that occur in refeeding syndrome? (3 marks)

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D. List 6 clinical features of refeeding syndrome? (6 marks)

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E. What are the National Institute for Health and Care (NICE) recommendations for nutrition in patients at high risk of developing refeeding syndrome? (4 marks)

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Total 20 marks

Question 9

A 61-year-old unknown male is admitted to the intensive care unit with deteriorating conscious level. He is intubated and ventilated. The neurology team have recommended further investigation with an MRI scan of the head.

A. What logistical challenges are faced by the anaesthetist taking an intensive care patient for MRI scan? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

B. What magnetic field strengths are typically used in an MRI scanner? (1 mark)

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C. What is the fringe field (1 mark) and its significance? (2 marks)

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D. The patient has now been transferred to the anaesthetic room outside the MRI scanner.

Briefly describe 5 of the steps which should be performed to ensure the patient remains safe before entering the magnetic field (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

E. Outline the potential MRI-specific hazards to this patient inside the scanning room (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

F. Describe the problem encountered following spontaneous or emergency shutdown of the magnetic field (1 mark)

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Total 20 marks

Question 10

A 9-year-old child requires anaesthesia for appendicectomy. He has been vomiting and you plan a rapid sequence induction.

A. What is the physiological basis for preoxygenation prior to anaesthesia? (2 marks)

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B. What are the advantages and disadvantages of preoxygenating a child in this scenario? (4 marks)

Advantages (2 marks)	Disadvantages (2 marks)

C. How you would assess the efficacy of preoxygenation? (3 marks)

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D. Label the 4 cartilaginous structures within the larynx indicated on the diagram (4 marks)

Reproduced from Training in Anaesthesia, Catherine Spoors and Kevin Kiff, Figure 6.10. Copyright Oxford University Press, 2011. Reproduced with permission of the Licensor through PLSclear.

E. Name the remaining 2 unpaired cartilages of the larynx (2 marks)

F. At the end of the operation you extubate the child. The abdomen is moving but no airflow is detected at the mouth. You diagnose laryngospasm.

Outline the pathophysiology of laryngospasm (5 marks)

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Total 20 marks

Question 11

You are asked to urgently assess a 2-year-old boy in the emergency department who has stridor of acute onset over 2–3 hours. He is sitting upright with suprasternal and subcostal recession. He has no medical history.

A. What is the definition of stridor? (2 marks)

————————

B. Why are paediatric airways more prone to stridor than adults? (2 marks)

C. List discriminating features of the differential diagnoses provided (13 marks)

Croup (3 marks)	1.——————— 2.——————— 3.———————
Epiglottitis (3 marks)	1.——————— 2.——————— 3.———————
Anaphylaxis (2 marks)	1.——————— 2.———————
Inhaled foreign body (2 marks)	1.——————— 2.———————
Bacterial tracheitis (3 marks)	1.——————— 2.——————— 3.———————

D. Briefly describe 3 main principles in the management of croup (3 marks)

A. Describe the process of cell salvage from surgical site to reinfusion of red cells to the patient (5 marks)

Total 20 marks

Question 12

A 76-year-old lady presents with an infected hip replacement. She is scheduled for a revision hip replacement. You intend to use cell salvage as part of your perioperative management.

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B. What specific considerations are there for cell salvage in this particular patient? (3 marks)

————————

C. You also intend to use thromboelastography (TEG) as part of your management.

What is TEG? (2 marks)

D. What are the limitations of TEG? (4 marks)

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E. Identify and describe the clinical significance of the following parameters obtained from a TEG in the following table (6 marks)

————————

Reproduced from SAQs for the Final FRCA, Shorthouse J et al., Figure 3. Copyright Oxford University Press, 2011. Reproduced with permission of the Licensor through PLSclear.

	Name	Description
R (2 marks)
α angle (2 marks)
MA (2 marks)

Total 20 marks

Exam 5 Answers

Many of the following questions contain more answers than there are marks allocated. This redundancy is intentional and is to ensure that a spread of possible answers by the candidate are recognized. 1 mark is awarded per correct point up to the maximum specified in each subsection.

Question 1

A 69-year-old man presents following an episode of amaurosis fugax. His investigations have identified an 80% stenosis of his left carotid artery. You see him in the preoperative period.

A. What is the optimal medical management of this clinical picture? (4 marks)

1. Antiplatelet therapy

2. Treatment of hypertension

3. Statin and diet control to lower cholesterol

4. Smoking cessation advice

5. Reduction in alcohol consumption

(4)

B. Following a multidisciplinary team discussion, he is to have a left carotid endarterectomy.

List the advantages and disadvantages of regional anaesthesia for this operation (6 marks)

Advantages (3 marks)

Disadvantages (3 marks)

1. Allows real time neurological monitoring

2. Avoids risks of airway intervention

3. Decreased shunt rate

4. Allows arterial closure at ‘normal’ BP with potential reduction in the risk of post-op haematoma

(3)

1. Risks from performing block

2. Requires still, co-operative patient.

3. Restricted access to airway

4. Risks of conversion to general anaesthetic (GA) if complications arise

5. Patient stress or pain may increase the risk of myocardial ischaemia

(3)

(6)

C. You are going to perform deep and superficial cervical plexus blocks as part of your anaesthetic management.

Outline the relevant anatomy and relations of the cervical plexus for the blocks (2 marks)

1. The plexus sits on the anterior surface of the 4 upper cervical vertebrae

2. It is inferior to the sternocleidomastoid muscle

3. The cervical plexus is formed from the anterior divisions of the 4 upper cervical nerves C1–C4