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Short Answer Questions in Anaesthesia


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© 1997
Greenwich Medical Media
219 The Linen Hall
162-168 Regent Street
London
W1R 5TB

ISBN 1 900151 235

First Published 1997

Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the UK Copyright
Designs and Patents Act, 1988, this publication may not be reproduced, stored, or transmitted, in any form or by any means, without
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licences issued by the Copyright Licensing Agency in the UK, or in accordance with the terms of the licences issued by the
appropriate Reproduction Rights Organization outside the UK. Enquiries concerning reproduction outside the terms stated here
should be sent to the publishers at the London address printed above.

The right of Geoffrey B Rushman to be identified as author of this work has been asserted by him in accordance with the Copyright,
Designs and Patents Act 1988.

The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and
cannot accept any legal responsibility or liability for any errors or omissions that may be made.

A catalogue record for this book is available from the British Library

Distributed worldwide by
Oxford University Press

Production and Design by


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Printed in Great Britain by


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Page iii

Short Answer Questions in Anaesthesia


How to Manage the Answers

Geoffrey Rushman
Page vii

Contents

Preface v

1. Advice on answering short answer questions 2

What the words in examination questions mean

2. General anaesthesia

What factors show that intubation of the larynx will be difficult enough to indicate 6
fibroptic intubation?

How do you manage the physiological consequences of surgical manoeuvres during 7


abdominal laparoscopy?

What are the factors that prolong the action of nondepolarising relaxants? 7

What are the "anaesthetic" problems caused by morbid obesity? 8

How would you prevent unplanned awareness during general anaesthesia? 8

How do you detect unplanned awareness during general anaesthesia? 9

What are the advantages and limitations of the laryngeal mask airway? 9

How do you manage total intravenous anaesthesia? 10

Write short notes on ondansetron 10

How do you manage sedoanalgesia? 11

Under what circumstances should general anaesthesia for elective cases be postponed 11
and why?

How would you determine the causes of arterial hypotension (80/60 mmHg.) during a 12
prostatectomy, and how would you manage it?
Page viii

What are the causes and management of hypoventilation immediately following 12


anaesthesia?

What causes bradycardia during general anaesthesia and what is the management of 13
this condition?

List the causes and briefly note the management of tachycardia (>100 bpm) during 14
general anaesthesia in an adult

Why do some patients suffer circulatory collapse at the induction of general 15


anaesthesia and how would you manage it?

What signs would lead you to suspect that a patient under general anaesthesia was 16
developing malignant hyperpyrexia? Describe your immediate management

What is the pathophysiology of malignant hyperpyrexia? How would you investigate 17


it?

You are asked to construct a question sheet for day-case patients to answer on 18
admission to hospital. What questions would you ask?

What protocol would you construct to guide surgeons on selecting adult patients for 19
day-case anaesthesia?

Describe the anaesthetic arrangements involved in a gynaecological day-case list of 15 20


patients for dilatation and curettage of the uterus

Write short notes on rocuronium 21

Give an account of the pharmacology of propofol 22

Compare and contrast halothane and desflurane 22

What are the pharmacological problems presented by a patient taking monoamine- 23


oxidase inhibitors (MAOI) who requires emergency anaesthesia for a bleeding
duodenal ulcer? Discuss the pharmacological problems presented

List the causes of "suxamethonium apnoea". How would you diagnose and manage it 23
once it had occurred?

Describe the Bain system and its functions 23

What are the safety devices involved in delivery of oxygen from a cylinder on an 24
anaesthetic machine to an anaesthetised patient through a Bain system?

Compare two types of anaesthetic breathing system used for a healthy spontaneously 24
breathing child weighing 20kg

Write short notes on desflurane 25

Describe the circle system for anaesthesia. What are its advantages and limitations? 26

What are the features of an anaesthetic machine which are designed to minimise the 27
risk of delivering hypoxic gas mixtures?

Write short notes on dantrolene 27


Write short notes on ketamine 28

List the physical properties of desflurane, and describe the characteristics of a suitable 29
vaporiser

How do you estimate bloodloss during various types of surgery? 29

Write short notes on minimum alveolar concentration 30

Write short notes on propofol 30

Write short notes on mivacurium 31


Page ix

Write short notes on hyoscine 31

Write short notes on glycopyrronium (glycopyrollate) 32

3. Paediatric anaesthesia

How does the physiology of children aged 1 year differ from that of adults? 34

Write short notes on EMLA cream 34

What psychological factors influence your anaesthesia for children aged 2-3 years? 35

What facilities are required for transfer of a 2-month old baby to a paediatric unit? 35

A 6-week old child has projectile vomiting and is presented for laparotomy. Describe 36
the general anaesthetic problems of this case

Describe the management of acute epiglottitis in a child of three years 36

Describe the management of acute laryngotracheitis in a child of three years of age, 37


presenting with cyanosis

What are the aims of premedication in children? Describe the pharmacology of two 37
such premedicant drugs

4. Neuroanaesthesia

How does concomitant head injury influence your anaesthetic management of an 40


operation for a fracture of the hand?

What monitoring do you consider necessary for a posterior fossa craniotomy? What 40
are the possible sources of error associated with two of the monitors you mention?

Describe the physiological effects of high arterial carbon dioxide tension (10 kpa, 70 41
mmHg.)

What factors affect cerebral blood flow? State briefly their importance in relation to 41
anaesthesia within 12 hours of head injury

How may cerebral bloodflow be affected by general anaesthesia? 42

5. Obstetric anaesthesia

How do obstetric factors affect the management of anaesthesia for the removal of a 44
retained placenta?

Write short notes on ranitidine 44

Describe the anaesthetic management of massive intrapartum haemorrhage requiring 45


emergency operation

Describe the pathophysiological processes of pre-eclamptic toxaemia of pregnancy 45

You are asked to help with a case of severe pre-eclamptic toxaemia of pregnancy. 46
What is your management?
Page x

6. Cardiothoracic anaesthesia

Describe the anatomy of the trachea, including its relations 48

Describe the anatomy of the diaphragm, including its relations 48

Describe the arterial blood supply of the myocardium 49

Describe the venous drainage of the myocardium 49

Describe the conducting system of the heart 50

How may abnormalities of cardiac conduction be revealed by the electrocardiogram? 50

Describe the anatomy of the bronchial tree 51

Describe the nerve supply of the larynx 51

Describe the anatomy of the first rib, including its relations 52

7. Trauma and emergency anaesthesia

What are the effects of an overdose of a tricyclic antidepressant drug? 54

A child of 12 years has been admitted following a road accident. At emergency 54


laparotomy the surgeon announces that the liver is ruptured. Describe your
management of the case up to the end of the operation

Write short notes on Hartmann's solution 55

Describe the adverse effects of blood transfusion. How may they be reduced? 55

Describe the alternatives to donor blood transfusion 56

What are the contents of a unit of transfusion blood? Describe briefly the alternatives 56
which can be used in an emergency haemorrhage situation until transfusion blood
becomes available

Write short notes on Gelatin-based plasma substitutes 57

Describe the features of the Boyle's anaesthetic machine and Bain system which 57
protect the patient from pulmonary barotrauma

What physiological changes follow acute hypovolaemia? 58

What is the physiological response to the rapid loss of 1 litre of blood in the adult? 58

Outline the factors responsible for the maintenance of cardiac output 59

What are the causes and effects of hypothermia? 59

Detail the immediate rescusitation (in the first hour) of an unconscious patient 60
admitted to the A & E department after falling off a ladder
8. Acute and nonacute pain management

What are the medical effects of opioid drugs? 62

Write short notes on pethidine 62


Page xi

Discuss the methods available for the relief of pain following abdominal 63
hysterectomy

Write short notes on tenoxicam 64

Describe the principles involved in prevention and treatment of postherpertic neuralgia 64


in the upper limb

Compare and contrast pethidine and codeine 64

Describe the adverse reactions which may follow the use of non-steroidal anti- 65
inflammatory drugs

Describe the pharmacological effects of paracetamol 65

Describe the pharmacological effects of dextropropoxyphene 66

9. Intensive therapy

A patient is admitted to the intensive care unit with a relapse of myasthenia gravis. 68
How do you cope with the medical problems of this situation?

A patient is admitted to the intensive care unit with Guillain Barre Syndrome. How do 68
you cope with the medical problems of this situation?

Why do some patients develop ARDS following colectomy? What are the 69
pathophysiological processses?

Describe the complications of endotracheal intubation 69

What is the venturi principle? Describe the clinical uses of high frequency jet 70
ventilation

Describe the anatomy of the subclavian vein 70

Describe the anatomy of the internal jugular vein 70

What are the possible complications of internal jugular vein cannulation, and how do 71
you avoid them?

What are the possible complications of subclavian vein cannulation, and how do you 71
avoid them?

Describe the pharmacology of a drug used to relieve severe pulmonary 72


vasoconstriction

List the properties of an ideal inotrope. Compare the properties of dopamine with this 72
ideal

List the factors which determine the supply of oxygen to the tissues of the body. How 72
may these factors be altered by septic shock?

Write short notes on gastric tonometry 73

Write short notes on pulmonary capillary wedge pressure 73


Write short notes on Sucralfate 73

Write short notes on dopamine 74

Discuss the occurrence of metabolic acidosis in patients in the intensive care unit 74

Give a brief account of the pulmonary problems that occur during intermittent positive 74
pressure ventilation of the lungs in ARDS

Write short notes on prostacyclin 75


Page xii

10. Clinical measurement

Describe the physical principles of the pulse oximeter 78

Describe the physical principles of a capnograph. How may it be calibrated? 78

What information can a capnograph give about an anaesthetic? 79

What are the sources of error of the pulse oximeter? 79

What arrangements are required for an adult head-injured patient, during transfer to a 80
neurosurgical unit?

What information can be gained from measuring central venous pressure? 80

11. Regional and local analgesia

What are the dangers and complications of intradural spinal analgesia? 82

Write short notes on ephedrine 82

What are the dangers and complications of extradural analgesia? 83

What are the advantages and disadvantages of the local anaesthetic and epidural 84
anaesthetic techniques for the repair of an inguinal hernia?

Write short notes on prilocaine 85

What factors would influence your decision to choose a regional technique in 86


preference to a general anaesthetic for transurethral resection of the prostate?

Write short notes on midazolam 87

What factors influence the choice of anaesthetic for insertion of arteriovenous shunt 87
for haemodialysis?

Write short notes on naloxone 88

Describe the effects and treatment of bupivacaine overdosage 88

What are the advantages and disadvantages of the supraclavicular and axillary 89
approaches to the brachial plexus block

Write short notes on adrenaline 89

What is the place of local analgesic nerve blocks in the anaesthetic technique for 90
cholecystectomy (excluding ''spinal" and extradural techniques)? State briefly how
they are performed. What are their shortcomings? What are their risks?

Give a brief description of the sensory nerve supply of the thoracic cage and 91
abdominal wall

Write short notes on ropivacaine 91

Briefly describe the anatomical relations of the brachial plexus 92


What are the complications of the supraclavicular and axillary brachial plexus blocks 92
and how do you recognise them?

Describe the anatomy of the sacral canal and its contents 93

Describe the anatomy of the epidural space at the level of the fourth lumbar vertebra 93
Page xiii

12. Medicine and surgery related to anaesthesia

What precautions should you take when anaesthetising a patient known to have 96
suffered from viral hepatitis?

Write short notes on verapamil hydrochloride 96

How would you manage atrial fibrillation which occurs during anaesthesia? What 97
could be done to prevent it?

Write short notes on the diagnosis and treatment of pneumothorax. 97

Write short notes on doxapram 98

Write short notes on aminophylline 98

What problems does hiatus hernia pose for the anaesthetised patient and how would 99
you cope with them?

What is the relevance to anaesthetic management of ankylosing spondylitis? What 99


strategies would you employ to overcome them?

Write short notes on nifedipine 100

How does the presence of aortic stenosis affect the management of an anaesthetic? 100

What would happen if a full dose of thiopentone was given to a patient with acute 101
intermittent porphyria and why?

What is the management of an acute sickle cell crisis? 101

In what ways does Down's Syndrome affect the management of an anaesthetic? 102

What precautions should be taken when anaesthetising a patient with dystrophia 102
myotonica?

How do the intraoperative surgical complications of excision of thyroid goitre affect 103
the management of the anaesthetic?

What are the anaesthetic problems posed by surgical removal of a 103


phaeochromocytoma?

What are the anaesthetic problems posed by surgical removal of a parathyroid 104
adenoma, and how do you cope with them?

What are the complications of mitral valve disease during anaesthesia and how do you 104
prevent them?

A patient's arterial pressure on admission for moderately urgent appendicectomy is 105


170/115 mmHg. Describe your anaesthetic management

A patient with congestive cardiac failure presents for hip replacement. Describe your 106
management for the anaesthetic

A patient presenting for prostatectomy has a pulse rate of 39 beats per minute. 106
Describe the common causes and management of this
How does the common cold influence fitness for anaesthesia? 107

Write short notes on atrial fibrillation 107

How do you judge the significance and plan the management of preoperative 108
anaemia?

A patient with non-insulin-dependent diabetes is to undergo amputation of an infected 109


gangrenous leg. What is the correct peri-operative management of the diabetes?
Page xiv

How would you judge the significance of preoperative jaundice? 110

How do antihypertensive drugs affect the management of anaesthesia? 110

What are the functions of the thyroid gland and how are they controlled? What are the 111
effects of thyroid dysfunction on anaesthesia?

In what circumstances may fluid overload occur during operation? How is it 111
diagnosed and managed?

Name and define the different types of hypoxia. Where are they seen clinically? 112

What is the mode of action of the following, in lowering arterial pressure? 112

Describe all the clinical actions of one anaesthetic agent and two other drugs you 113
might use to lower arterial pressure during anaesthesia

Write short notes on amiodarone 113

Write short notes on adenosine 114

13. Faciomaxillary, ophthalmic and ENT

What complications of operations on the bony structures of the lower half of the face 116
may affect the anaesthetic management, and how do you deal with them?

A patient requires an anaesthetic for removal of an infected molar tooth which is 116
causing severe trismus. Describe the problems and outline the anaesthetic methods

Describe the anaesthetic management for a patient with a perforating eye injury who 117
had a large meal in the last hour

Describe the anaesthetic management for a 5-year-old patient who requires 117
reoperation for haemorrhage an hour after tonsillectomy

How would you perform a block of the maxillary nerve? 118


Page 1

Chapter 1
Advice on Answering Short Answer Questions
Page 2

1. The questions in examinations in Anaesthesia are carefully designed to assess whether you are a safe anaesthetist and whether you
have a good sense of judgement in practising this specialty.

There are many areas in the life of an anaesthetist where there is no single right or wrong answer to a problem, but various
possibilities, depending on the circumstances of the case. The examination is therefore designed to test two aspects of your
professional skill. First, it tests knowledge, which is the "tools" of the professional. Secondly, it tests your judgement, which is
whether you know how to use these "tools". The less knowledge you have, the less equipment you have at your disposal for the
problems of everyday anaesthesia. Knowledge can be gained from books, lectures, and seminars. The more you read and listen, the
better.

A shortage of judgement means that you may be unable to handle problems which are more complex, or "out of the ordinary run of
things". Judgement is gained on the floor of the operating theatre, the intensive care unit and the clinic, in the company of
experienced colleagues who are inclined to teach you. The more experience you have in these areas the better.

Before the Exam

2. In your preparation for this test, read all the exam question books in your subject, including this one!

3. Try to read all the review articles in your subject, published in the last year.

4. Do many practice exam essays beforehand, especially ones from previous papers if you can get them, and ask a sympathetic senior
colleague to mark them for you.

At the Exam

5. Make sure that you have spare pens and possibly coloured pencils in your pocket as well.

You must answer the requisite number of questions. Make sure you know how many this is.

6. Divide the time of the whole examination paper by the number of questions and do not overrun on any one answer by more than a
minute or so. It will probably help to put your watch or clock on the desk in front of you

Use a blank sheet of paper on which to make rough notes for all the questions. You can add to these later as you go along, if you
think of further points.

7. There is very little time for each answer - about 15 minutes. For many candidates this time allows writing only one or two sides of
paper (in the books provided) for each answer.

8. There will probably not be time to write the question out at the start of each answer. This means that you should read the carefully-
worded question at least twice to be sure of what it is asking.

If it is in an area with which you are very familiar, then you will find the answer easy. If it is in an area which you may not personally
have encountered (such as anaesthesia for kyphoscoliosis operations), then you may need to adopt the strategy of paragraph 9
(below).
Page 3

9a. Make notes briefly on what you think is the main answer to the question. (For example, the management of the anaesthetic for
kyphoscoliosis. This would involve general anaesthesia, prone position and all that entails.)

9b. Then think "laterally" about what else might be involved, e.g., why are scoliosis operations performed? (interference with
respiratory function as well as skeletal deformity) Are there preoperative problems? (e.g., some are congenital and may have other
congenital problems, the patients are often teenagers and will be anxious, needing premedication). What operative problems are
likely? (prolonged surgery, patients get cold). What postoperative problems are likely? (pain, respiratory problems).

9c. Then think about the "worst scenario" or "worst case" situation. This may prevent you from missing something big! Remember
that you will gain marks for every correct, relevant fact or opinion.

For example, in kyphoscoliosis, what is the worst thing that could happen preoperatively? (respiratory failure with possible cardiac
problems - this may require preoperative testing).

What is the worst thing that could happen during the operation? (haemorrhage may be profuse - so how much blood needs to be
crossmatched, and what monitoring would be needed; pneumothorax; damage to the spinal cord - the "wake-up test" during the
operation tests for this).

Postoperatively, the pain may be severe - would regional blocks be useful, or should they not be used? (interferes with testing for
damage to the spinal cord). Another "worst scenario" situation in the postoperative period is the occurrence of spinal cord damage.
Don't forget to mention testing for it!

Another question which should cross your mind is, "Do any of these cases need to go to the ITU or HDU?"

10. If the question is about "anaesthetic management", do include preoperative and postoperative care, unless the wording of the
question is specific to one or other area, in which case concentrate on what the question specifically asks.

11. If the question is about clinical anaesthesia, always think about local/regional analgesia as well as general anaesthesia. It might or
might not be appropriate, but you will probably gain marks by saying so.

12. Try to think "clinically" - what actually happens about these types of cases in the hospital where you work? How are the
problems in question coped with in practice? If you can prioritise the points in your answer and put the important points first, so
much the better.

13. If you have time, underline key points. Leave a line between each paragraph of your answer - it makes it clearer, and will also
give a little space for you to insert an extra sentence if you think of another point later on.

14. Where questions on scientific and technical subjects are concerned, there is no substitute for knowledge!

15. Where questions on anatomical subjects are concerned, do read the question carefully a second time, to be absolutely sure of
everything the examiners are asking. E.g., if the question asks for the arterial supply of the forearm and hand. To answer this by
simply writing about the arteries in the wrist and the hand will lose you marks.
Page 4

You may be rather rusty on the anatomical details for which the question asks. However, all is not lost! Put down what you know,
and make an educated guess to fill in the gaps. Diagrams are generally helpful as a part of your answer.

What the Words in Examination Questions Mean

Aetiology = what are the causes

Significance = "reasons for" and "importance of"

Outline = describe briefly

Determine = find out

Management = everything which should be done

Anaesthetic management = preoperative, operative and postoperative unless


otherwise stated.
Page 5

Chapter 2
General Anaesthesia
Page 6

What factors show that intubation of the larynx will be difficult enough to indicate fibroptic intubation?

Notes for an answer:

1. Examination of patient

a) history of rheumatoid arthritis; known history of difficult intubation - Cormack & Lehane scores from previous laryngoscopies;

b) poor mouth opening (< 3fb);

c) low Malampatti score;

d) thyromental distance (< 6cm);

e) small mandible size, inability to protrude jaw;

f) neck stiffness or injury (need to mention neck X-rays), atlanto-occipital distance, atlanto-odontoid distance (> 3mm);

g) Frontal crowns, awkward front teeth.

2. Trismus.

3. Congenital abnormalities of the face or neck.

4. Known or suspected laryngeal obstruction (need to mention soft tissue X-ray of neck).

5. Previous suxamethonium masseter spasm (if rapid sequence induction is needed).

This answer needs a note on whether any of these factors are absolute indications, and how many of the predictive factors need to be
present to indicate fibreoptic intubation.

Serious omissions likely to cause a fail:


Failure to note at least four predictive factors; failure to mention laryngeal obstruction.

<><><><><><><><><><><><>
Page 7

How do you manage the physiological consequences of surgical manoeuvres during abdominal laparoscopy?

Notes for an answer:

Physiological upsets (with management in brackets):

1. Vascular reflexes; bradycardia (atropine 0.2-0.5 mg will correct this).

2. Gas in peritoneum causes diaphragmatic splinting (IPPV is required).

3. Gas in blood vessels causes air embolism (requiring "air embolism drill").

4. Excess absorption of CO2 (moderate hyperventilation).

5. Haemorrhage (you need to state that this can be massive, requiring urgent group-specific transfusion).

6. Gas in pleural cavity causes tension pneumothorax (this requires a comment on how to make the correct diagnosis and the
insertion of a needle in correct side of chest).

7. Surgical emphysema - can cause severe pain.

Serious omissions likely to cause a fail:


Failure to mention diaphragmatic splinting and gas embolism.

<><><><><><><><><><><><>

What are the factors that prolong the action of nondepolarising relaxants?

Notes for an answer:

1. Structure of relaxant - basic scientific knowledge (bonus marks if you state what difference the structure makes).

2. Physiology of patient - hypokalaemia, hypocalcaemia, hypothermia, acidosis, poisons (e.g., botulinus toxin).

3. Volatile anaesthetics.

4. Myasthenia and other rare diseases (bonus marks if you can name any).

5. Other drugs, especially local anaesthetics and aminoglycoside and lincomycin antibiotics in high dosage.

6. Age of patient, very young and very old.

Comment: This is common everyday anaesthetic practice and would be marked severely.

Serious omissions likely to cause a fail:


Failure to mention electrolyte abnormalities, volatile anaesthetics, and age factors.

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Page 8

What are the ''anaesthetic" problems caused by morbid obesity?

Notes for an answer:

1. Definition of morbid obesity in terms of body mass index is required (greater than 30 kg/M2).

Problems:

Respiratory system — increased work of breathing, diaphragmatic splinting, difficult intubation, underventilation, reduced lung
volumes, pulmonary "shunting", hypercapnia, hypoxia (operative and postoperative), slow equilibration with inhaled anaesthetics.

Cardiovascular system — blood volume increased, increased cardiac work, hypertension and coronary disease, risk of DVT, less
water per unit of body weight;

Miscellaneous — hiatus hernia, regurgitation.

Technical — difficult to move, lift and nurse — spontaneous respiration restricted, difficult to intubate, especially when front dental
crowns are present, difficult venepuncture, estimation of drug dosage is difficult, inaccuracy of noninvasive arterial pressure
monitoring, regional and local blocks are technically difficult, surgery is often more prolonged.

Comment: This is a large answer to complete in 10-15 minutes, unless you have thought it out beforehand.

Serious omissions likely to cause a fail:


Failure to mention respiratory problems, and regurgitation risks.

<><><><><><><><><><><><>

How do you prevent unplanned awareness during general anaesthesia?

Notes for an answer:

1. History from patient (previous unplanned awareness; physiological resistance to anaesthesia; alcoholism, etc.).

2. Preoperative checks of machine, vaporisers (or syringe drivers if using total intravenous anaesthesia). Vaporisers are refilled
before they become empty.

3. Monitoring of breathing system — including agent, especially when using the closed circle system. 1 MAC of volatile anaesthetic
is normally sufficient.

4. Adequate premedication, especially benzodiazepines.

5. Use of ear muffs or plugs on patient during surgery.

6. Monitoring of patient (this needs a very brief discussion of the value of "clinical" signs, and a few details about the available
awareness monitors).

7. Not placing reliance on opioids to prevent awareness.

Serious omissions likely to cause a fail:


Failure to mention anaesthetic agent monitoring.

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Page 9

How would you detect unplanned awareness during general anaesthesia?

Notes for an answer:

1. Monitoring of breathing system — (including anaesthetic agent), and/or syringe driver system.

2. Monitoring of patient

a) Clinical;

b) Cerebral function monitoring;

c) Spectral Edge Frequency analysis;

d) Bisectral Index;

e) Frontalis EMG etc.;

f) Evoked potentials and responses;

g) Respiratory Sinus Arrythmia analysis;

h) Oesophageal contraction rate.

A brief comment on the usefulness and inadequacies of these monitors is required.

Serious omissions likely to cause a fail:


Failure to mention the monitoring of anaesthetic agents. In practice, this is routine.

<><><><><><><><><><><><>

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

Advantages: general ease of use, does not require neck movement for insertion; good in difficult airway situations, bearded patients;
allows remoteness from mouth for head and neck operations. (Some comment on sizes is helpful.)

Limitations: can cause laryngospasm; can turn, kink and obstruct in other ways; no airway protection from gastric reflux, logistic
difficulties of sterilisation, pharyngeal damage on insertion, especially if the cuff is too tightly evacuated, dental damage, occlusion
by biting, if anaesthesia is too light or the patient wakes up with the laryngeal mask in situ.

Comment: The laryngeal mask does not guarantee anything, but it is wonderfully useful.

Serious omissions likely to cause a fail:


Failure to mention obstruction of airway.

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Page 10

How do you manage total intravenous anaesthesia?

Notes for an answer:

The following are required:

1. Reliable IV cannula.

2. Reliable syringe pump — with battery backup, alarms for blockage, disconnection, and empty syringe.

3. Reliable full monitoring of airway, breathing (anaesthetic bag movements, SpO2, EtCO2), Circulation (ECG, arterial pressure,
SpO2) and depth of anaesthesia (details not needed).

4. Use of reliable drugs (e.g., propofol) and typical infusion rates (e.g., 10-6 mg/kg/hr for propofol).

Serious omissions likely to cause a fail:


Failure to mention the need for full monitoring, especially respiration.

<><><><><><><><><><><><>

Write short notes on ondansetron

This answer needs most of the following headings:

Pharmacy:

Type of chemical, storage (plastic ampoules) preparation, concentration

Pharmacodynamics:

Mode of action, 5HT3 serotonin antagonism

Clinical effects: antiemetic

Dose, 4-8 mg

Onset, minutes

Duration, 8 hrs.

Pharmacokinetics:

Routes of administration, IV< IM< oral

Metabolism, liver

Side effects, constipation, headache, flushing, transient visual disturbances

Plus other features: especially useful in chemotherapy.

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Page 11

How do you manage sedoanalgesia?

(This is sedation plus local anaesthesia)

1. Sedative drugs used, benzodiazepines, ketamine, opioids, phenothiazines, the doses required and undesirable side-effects.

2. Methods of local analgesia; e.g., regional/local/topical.

3. Monitoring — you need to state that this is complete as for full general anaesthetic, because the patients selected for this type of
anaesthesia are sometimes very ill.

4. A brief discussion of a strategy for coping with failed local analgesia, e.g., appropriate analgesics.

Serious omissions likely to cause a fail:


Failure to mention full monitoring.

<><><><><><><><><><><><>

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

Notes for an answer:

Uncontrolled hypertension, recent myocardial infarction, colds, URTI, chest infection, head injury, acute pancreatitis, acute LVF,
uncontrolled arrythmia, inadequate preparation or investigations; serious electrolyte abnormality, e.g., hypokalaemia; serious acute
anaemia; uncontrolled shock.

Comment: This is a safety question, and needs only a brief reason for each area noted here.

Serious omissions likely to cause a fail:


Failure to mention shock, myocardial infarction and respiratory tract infections.

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Page 12

How would you determine the causes of arterial hypotension (80/60 mmHg.) during a prostatectomy, and how would you
manage it?

Notes for an answer:

1. Bloodloss — inspection and analysis of bladder washouts — requires a discussi on of difficulty of assessment.

2. TURP syndrome — clinical signs, use of ethanol marker and breathalyser monitoring.

3. Anaesthetic — too deep, severe hypocapnia, severe bradycardia, spinal block too extensive, or made more severe by presence of
significant cardiac disease.

4. Other medical conditions — myocardial infarction, co-existing aortic stenosis, cardiac failure — need comment about usefulness
of monitoring.

Serious omissions likely to cause a fail:


Failure to mention TURP syndrome, bloodloss and myocardial infarction.

<><><><><><><><><><><><>

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

Notes for an answer:

Causes:

1. Obstructed airway.

2. Anaesthetic drugs — especially volatiles and opioids.

3. Incomplete reversal of relaxants.

4. Pain.

5. Shock.

6. CO2 narcosis (caused by, and a cause of, hypoventilation).

7. Obesity and medical problems of the patient, e.g., myasthenia, pulmonary disease, raised intracranial pressure.

Management:

Oxygen, ventilation of lungs, reversal of cause.

Comment: This is a question about everyday anaesthetic practice.

Serious omissions likely to cause a fail:


Failure to mention obstructed airway.

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Page 13

What causes bradycardia during general anaesthesia and what is the management of this condition?

Notes for an answer:

First of all, this needs a comment about what pulse rates constitute bradycardia.

Causes: deep anaesthesia, hypoventilation (e.g., disconnected ventilator), hypoxia, hypotension (which may also be caused by
bradycardia), oculocardiac and other vagal reflexes, drugs (opioids, neostigmine, B-blockers), cardiac ischaemia/failure/
bradyarrythmias, cerebral compression, high spinal blockade.

Management: assess reasons for it and state what limits should provoke action.

Mention use of anticholinergic drugs, e.g., atropine.

Treat cause if possible.

Comment: A common problem.

Serious omissions likely to cause a fail:


Failure to mention opioids and vagal reflexes.

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Page 14

List the causes and briefly note the management of tachycardia (> 100 bpm) during general anaesthesia in an adult

Notes for an answer:

Causes: light anaesthesia, hypercarbia, hypovolaemia, hypotension, tachy-arrythmia, drugs (atropine, adrenaline), endocrine
problems (thyroid crisis, phaeochromocytoma), malignant hyperpyrexia, toxaemia.

General Management:

a) assess significance: (e.g., associated with hyper- or hypotension — pulse rates well above 100 bpm may adversely affect
circulation), state need for experienced help;

b) treat cause if possible. The target pulse rate is 70-100 bpm.

Tachyarrythmias: mention of DC defibrillation shock if hypotensive.

Specific Managements:

Sinus tachycardia — carotid sinus massage; Beta-blockers (and contraindications to these drugs).

Supra Ventricular Tachycardia —carotid sinus massage, adenosine, amiodarone, verapamil is controversial.

Atrial fibrillation or Flutter — digoxin, amiodarone; DC shock may be needed.

Ventricular tachycardia — amiodarone (lignocaine, flecaine and verapamil are used much less).

Serious omissions likely to cause a fail:


Inadequate details of general management; failure to mention malignant hyperpyrexia.

<><><><><><><><><><><><>
Page 15

Why do some patients suffer circulatory collapse at the induction of general anaesthesia and how would you manage it?

Notes for an answer:

Causes:

1. Nature of patient's disease e.g., untreated hypertension, sudden arrythmia, cardiac failure (for example in emergency CABG),
severe aortic stenosis, pacemaker failure, phaeochromocytoma, and other rare syndromes

2. Anaphylaxis (hypotension, bronchospasm, flushing, oedema).

a) Stop injecting the anaesthetic agent.

b) O2/ventilation.

c) Adrenaline 50-100µg.

d) Head down position and 2L colloid volume load.

e) Antihistamines.

f) Steroids.

g) Blood samples.

h) Prevent awareness.

(an d then later. . .

i) Inform patient).

3. Fainting — vasovagal shock. Atropine, and elevation of legs etc.

4. Shock. Prevented by pre-emptive correction of hypovolaemia.

5. Overdose of anaesthetic agent. Prevention is better than cure!

6. Myocardial infarction. ECG will show this.

General Management:

Firstly, diagnosis of the cause, based on knowledge of the patients preoperative medical condition, and full monitoring.

In general, anticipation of the problem, with full monitoring; elevation of the legs and careful use of catecholamines. ACLS plus
control of the cause if the collapse progresses to cardiac arrest.

Comment: There is no simple way of categorising the answer to this one!

Serious omissions likely to cause a fail:


Failure to mention anaphylaxis.

<><><><><><><><><><><><>
Page 16

What signs would lead you to suspect that a patient under general anaesthesia was developing malignant hyperpyrexia?
Describe Your immediate management

Notes for an answer:

Signs:

• high tachycardia; hypercapnia; cyanosis/hypoxia; hypothermia; muscle rigidity; metabolic and respiratory acidosis; initial
hypertension; followed by cardiovascular failure; mottled rash.

Management:

• hyperventilate with oxygen; stop trigger agents; repeatedly measure blood gases; electrolytes and temperature;

• inject dantrolene, 1mg/kg, i.v., repeated (to inhibit sarcoplasmic Ca++ release);

• i.v. sodium bicarbonate, 0.3 mmol/kg;

• active cooling;

• insulin/dextrose to control hyperkalaemia;

• diuresis to prevent renal failure;

• ITU admission.

Serious omissions likely to cause a fail:


Failure to mention dantrolene, and stopping the anaesthetic.

<><><><><><><><><><><><>
Page 17

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

Notes for an answer:

1. Abnormal Ca++ flux with uncontrolled release of Ca++ from sarcoplasmic reticulum on exposure to triggers gives rise in Ca++
pump activity; binding of troponin C causes massive muscle contraction and uncoupling of oxidation from phosphorylation.

2. The role of the ryanodine receptor is central to this process.

3. The condition is inherited as an autosomal dominant.

4. Masseter spasm in children may be associated with it.

5. Triggers: suxamethonium, halothane, physiological stress and many other agents.

Investigation:

• During the crisis: CPK levels > 20,000.

• After the crisis: muscle biopsy (MHSusceptible, MHEquivocal, MHNonsusceptible). MHEcould be exposed to ryanodine.

• Investigate the family.

Serious omissions likely to cause a fail:


Failure to mention calcium and at least some of the triggers.

<><><><><><><><><><><><>
Page 18

You are asked to construct a question sheet for day-case patients to answer on admission to hospital. What questions would
you ask?

Notes for an answer:

• What do you weigh?

• How tall are you?

• Can you do normal activities?

• Is your general health good?

• Have you ever had an operation? If so, please list them.

• Have you ever had an anaesthetic? If so, did you have any problem with it?

• Have your relatives had any problems with anaesthetics?

• Do you have any loose or crowned teeth? If so, which ones?

• Have you had any medical illnesses? If so, which ones?

• Are you taking any sort of medicine, pill or tablet? If so, which ones?

• Are you allergic or sensitive to any medicine?. . . or anything else?

• Do you smoke? If so, how many?

• How many stairs can you climb quickly before you get short of breath?

• Are you short of breath on lying flat?

• Do you have a cough or wheeze? If so, how often?

• Do you get pain in the chest or palpitations? If so, how often?

• Have you had a heart attack or a ''stroke"? If so, when?

• Do you know if you are anaemic?

• Could you possibly be pregnant?

• Are you a "drug user" or homosexual?

• Have you ever been jaundiced? If so, when?

• Have you got someone to take you home and stay with you for the night after the operation?

Comment: This is a question of communication as well as preoperative skills.

Serious omissions likely to cause a fail:


Failure to mention previous anaesthetics, and the need for a responsible adult to take the patient home.

<><><><><><><><><><><><>
Page 19

What protocol would you construct to guide surgeons on selecting adultpatients for day-case anaesthesia?

Notes for an answer:

Operations to Avoid:

• those which are lengthy (more than 30 min), painful, haemorrhagic, enter thorax or abdomen.

Patients to Avoid:

• those with previously bad reactions to anaesthetics;

• those with COAD;

• breathless on ascent of 10 stairs; orthopnoea; breathless at rest, cyanosis;

• myocardial infarction in last year, or multiple or severe previous infarctions with restriction of activity; Angina;

• any degree of left ventricular failure;

• untreated hypertension; severe anaemia;

• electrolyte abnormalities;

• CVA in last year;

• obesity (BMI greater than 30);

• Insulin-dependent diabetes mellitus;

• ASA grades III or more;

• patients with severe congenital abnormalities;

• those with no-one to take them home and look after them;

• patients over the age of 70 years.

Comment: This question includes communication skills with colleagues.

Serious omissions likely to cause a fail:


Failure to mention those with previously bad reactions to anaesthetics.

<><><><><><><><><><><><>
Page 20

Describe the anaesthetic arrangements involved in a gynaecological day-case list of 15 patients for dilatation and curettage of
the uterus

Notes for an answer:

Prior to the Day of the List:

1. There is a need for a selection protocol for surgeons choosing the patients (e.g., patients may be obese).

2. Preadmission questionnaire for patients.

3. Preadmission investigations complete before day of operation.

On the Day of the List:

4. Organisation of the day of operation: preoperative visits, confirmation of the correct order of the list/no waiting for patients/coffee
break for staff! Routine checks of patient identity and expected operation.

5. Anaesthetic techniques for rapid awakening (e.g., sevoflurane, desflurane, or TIVA) and no nausea (routine use of antiemetics).

6. Organisation to avoid "log-jams" in recovery.

7. Discharge protocol — accompanied by responsible adult/no driving/alcohol.

8. Written discharge instructions.

After the List:

9. Postoperative visit.

10. Follow-up audit.

Comment: This is a test of important anaesthetic management skills.

Serious omissions likely to cause a fail:


Failure to mention pre- and postoperative factors.

<><><><><><><><><><><><>
Page 21

Write short notes on rocuronium

This answer needs most of the following headings:

Pharmacy:

Type of chemical, storage (solution in glass ampoules,) preparation, concentration

Pharmacodynamics:

Mode of action, nondepolarising neuromuscular blockade

Clinical effects, relaxation

Dose, 0.5 mg/kg.

Onset, 60 secs.

Duration, 45-60 mins.

Pharmacokinetics:

Routes of administration, i.v.

Metabolism, liver

Interactions, volatile and local anaesthetics, aminoglycoside antibiotics

Plus other features: rapid onset due to low receptor occupancy, with high biophase concentrations.

<><><><><><><><><><><><>
Page 22

Give an account of the pharmacology of propofol

Pharmacy:

Type of chemical (phenol), storage (glass ampoules), preparation (emulsion), concentration (10 mg/ml.).

Pharmacodynamics:

Brain (reduction CMRO2 and anaesthesia), heart, bloodvessels (vasodilator), respiratory depression.

clinical effects: anaesthesia.

Pharmacokinetics:

Doses (1-2 mg/kg.), blood levels (3.5-4.5 µg/ml.), onset (one circulation time), lipid solubility (high), distribution (initially to
extracellular fluid, brain, then other sites, especially fat), short half life; 99% metabolised.

Side effects: extrapyramidal movements, mild relaxation of muscles; depression of pharyngeal reflexes.

Contraindications:

a) Absolute: hypersensitivity, upper airway obstruction.

b) Relative: severe cardiovascular disease, hypovolaemia, aortic stenosis, extremes of age.

Total Intravenous Anaesthesia — infusion rates (10-8-6 mg/kg/hr.).

Interactions with other drugs e.g., alfentanil — (increases duration).

<><><><><><><><><><><><>

Compare and contrast halothane and desflurane.

Notes for an answer:

This should include the following:

An ethane (halothane) compared with a more highly fluorinated ether (desflurane); physical properties, MAC values, rates of onset
and offset, pharmacodynamics, metabolism, side effects, vaporiser design.

Serious omissions likely to cause a fail:


Failure to mention MAC values.

<><><><><><><><><><><><>
Page 23

What are the pharmacological problems presented by a patient taking monoamine-oxidase inhibitors (MAOI) who requires
emergency anaesthesia for a bleeding duodenal ulcer? discuss the pharmacological problems presented.

Notes for an answer:

Problem of cardiovascular support and need for inotropes (with their interactions), place of dopamine in renal support; need mention
of careful volume replacement before and during anaesthesia. This answer needs a mention of strategies for analgesia and the
problem of interaction with pethidine causing hypotension and coma.

<><><><><><><><><><><><>

List the causes of "suxamethonium apnoea". How would you diagnose and manage it once it had occurred?

Notes for an answer:

Causes:

1. Congenital — genotypes e, f, s, a; with homo- and heterozygotes. Inheritance as dominant.

2. Acquired — pregnancy, malnutrition, plasmapheresis, myxoedema, the newborn, lupus, and drug-induced.

3. Antagonism — anticholinesterases, e.g., neostigmine, ecothiopate.

Diagnosis:

a) history from patient;

b) Failure of suxamethonium to wear off within 5-10 minutes;

c) Neuromuscular monitoring;

d) Later — investigation of patient and relatives. Dibucaine no.; fluoride no.; serum cholinesterase levels.

Management:

Oxygenation; IPPV and sedation for about 1-2 hr. until muscle power returns.

Serious omissions likely to cause a fail:


Failure to mention both congenital and acquired forms.

<><><><><><><><><><><><>

Describe the Bain system and its functions

Notes for an answer:

Bain system — modified Mapleson D, coaxial, outlet valve by machine, small deadspace, always some rebreathing except at very
high flows, breaks of central tube gives high deadspace — safety check before use, not antistatic, sterilising procedures. the outlet
valve usually has an airway pressure limiting device, set at 50-60 mm Hg., which prevents barotrauma, but not pressure effects on
pulmonary circulation.

<><><><><><><><><><><><>
Page 24

What are the safety devices involved in delivery of oxygen from a cylinder on an anaesthetic machine to an anaesthetised
patient through a Bain system?

Notes for an answer:

Pin-index on cylinders, tap on cylinders, pressure reducing valve, filter, flow restrictor, needle valve, rotameter (on the left in UK),
vaporiser with adequate gas seals, machine pressure relief valve, standardised 22mm outlet, bag, coaxial pipes, mask, Heidbrink exit
valve with airway pressure limiting device (50-60 mm Hg).

Serious omissions likely to cause a fail:


Failure to mention pin index and the airway pressure limiting device.

<><><><><><><><><><><><>

Compare two types of anaesthetic breathing system used for a healthy spontaneously breathing child weighing 20kg

Notes for an answer:

Issues for discussion (any descriptions of the systems should be very brief).

• Simplicity of use.

• Safety for patient (valves (or lack of them); ease of disconnections; antistatic protection; risks of hypoxia, prevention of pulmonary
barotrauma).

• Economy.

• Fresh Gas Flows — requires figures for the systems you describe.

• Humidification and warming.

• Likelihood of rebreathing at various gas flows.

• Ease of sterilisation and crossinfection.

Comment: The size of the patient in question here has been chosen to allow you the maximum choice of breathing systems.

Serious omissions likely to cause a fail:


Failure to mention the safety factors.

<><><><><><><><><><><><>
Page 25

Write short notes on desflurane

This answer needs most of the following headings:

Pharmacy:

type of chemical (fourinated ether), storage (glass bottles)

Pharmacodynamics:

Mode of action, inhalation volatile anaesthetic

Clinical effects, anaesthesia

Dose, MAC = 6%

Onset, very rapid, due to low solubility

Duration, N/A

Pharmacokinetics:

Routes of administration, inhalation

Metabolism, very small

Excretion, rapidly, via lungs

Side effects, coughing, laryngospasm, excitement on inhalation induction

Plus other features (low solubility, blood/gas partition coefficient 0.4, oil/gas 18.7; high SVP (88 @ 20° C; MAC50 6%; Boiling point
22.8° C; vaporiser designed to run above boiling point).

<><><><><><><><><><><><>
Page 26

Describe the circle system for anaesthesia. What are its advantages and limitations?

Notes for an answer:

Corrugated tubes, soda lime, low-resistance, NON-stick valves, gas entry port on inspiratory limb.

Advantages

Economy, low pollution, warming of gases, humidification.

Soda lime — 90% Ca(OH)2, 5% NaOH, 1% KOH, silicates and water. Used to absorb CO2 (up to 20% of its own weight). Granule
size, air spaces important, Colour indicator change on exhaustion.

Limitations

1. Risk of

• hypoxia

• hypercapnia

• awareness due to slow equilibration with large volumes

• overdose of anaesthetic, disconnections

• deadspace problems (a sticking valve causes a large dead-space)

• carbon monoxide generation during rest, if very dry

• degradion of sevoflurane by heat

2. Needs monitoring of:

• O2

• CO2

• anaesthetic agents

Serious omissions likely to cause a fail:


Failure to mention the soda-lime; monitoring of gases.

<><><><><><><><><><><><>
Page 27

What are the features of an anaesthetic machine which are designed to minimise the risk of delivering hypoxic gas mixtures?

Notes for an answer:

The features which should be mentioned are: colour coding of cylinders, pin-index, pressure gauge, Schrader valves and colour-
coded pipe for pipelines, flow control by rotameters, O2/N2O interlock, O2 failure warning device, O2 monitor, safety checklist card.

Issues for discussion — effectiveness, proof against operator failure, areas of failure of reliability, need for audible alerts for
operator, operator involvement in safety checks, effect of electrical failure.

Serious omissions likely to cause a fail:


Failure to mention the pin-index and Schrader valves.

<><><><><><><><><><><><>

Write short notes on dantrolene

This answer needs most of the following headings:

Pharmacy:

Type of chemical, storage (powder, with mannitol), i.v. preparation is very highly alkaline

Pharmacodynamics:

Mode of action, muscle fibre relaxant, acting at excitation-contraction coupling zone, preventing Ca++ release from sarcoplasmic
reticulum

Clinical effects, treatment of malignant hyperpyrexia (and other spasm)

Dose, 1 mg/kg., repeated

Onset, rapid

Duration, 10-30 mins.

Pharmacokinetics:

Routes of administration, i.v., oral

Metabolism, liver

Interactions, with veapamil in anaesthetised animals

Plus other features: difficult to dissolve

<><><><><><><><><><><><>
Page 28

Write short notes on ketamine

This answer needs most of the following headings:

Pharmacy:

Type of chemical (a cyclohexanone), storage (aqueous solution in glass ampoules) preparation, concentration (10, 50, and 100
mg/ml.)

Pharmacodynamics:

Mode of action, NMDM receptor agonist

Clinical effects, analgesia; anaesthesia

Dose, 5mg/kg i.m.; 2mg/kg. i.v.; 0.5mg/kg. i.v. for sedoanalgesia

Onset, one circulation time, i.v.; 5 mins i.m.

Duration, 10-30 mins.

Pharmacokinetics:

Routes of administration, i.v.; i.m.; oral; epidural

Metabolism, liver

Side effects, dreams and hallucinations, vasoconstrictor — hypertension, mild rises of ICP and IOP, salivation, PONY, increased
muscle tone and movements.

Interactions, dreams and hallucinations prevented by low dose benzodiazepines. Prolonged hypnosis with barbiturates.

Plus other features: low-dose use in sedoanalgesia. Has been used in patients with full stomachs without regurgitation.

<><><><><><><><><><><><>
Page 29

List the physical properties of desflurane, and describe the characteristics of a suitable vaporiser

Notes for an answer:

1. Molecular wt: 168 Daltons.

2. Boiling point 22.8° C.

3. SVP @ 20° C: 88.5 kPa.

4. Oil/gas Sol.: 18.7.

5. MAC: 6%.

6. Blood/gas partition coefficient 0.4.

Vaporiser characteristics:

Splitting of gas inflow, temperature controlled @ 39° C, calibration independent of flow, electronic vapour injection with differential
pressure transducer system, electronic monitoring of liquid content with alarm, keyed filling ports and bottles, spill-proof device,
easily mounted and demounted from machine, interlocks to allow only one in use, at any one time.

<><><><><><><><><><><><>

How do you estimate bloodloss during various types of surgery?

Notes for an answer:

1. Clinical condition of patient e.g., capillary refill, warm periphery, quality and volume of pulses in various parts of body.

2. Monitoring CVP; arterial pressure — invasive and noninvasive (with comment on pressures needed for production of urine) (MAP
70 mm Hg.).

3. Visual assessment of swabs, drapes and sucker bottle, allowing for volume of saline washouts.

4. Other weigh swabs.

5. Hb estimation of TURP irrigation fluid and calculation of bloodloss.

<><><><><><><><><><><><>
Page 30

Write short notes on minimum alveolar concentration

Definition: a measure of the potency of volatile anaesthetics. MAC50 is the minimum alveolar concentration required to prevent
physical reaction to skin incision in 50% of subjects.

Isoflurane 1.15%; enflurane 1.7%; desflurane 6%; sevoflurane 2%; halothane 0.75%.

It varies with age, greatest at one month; lowest in premature babies and old age.

Increased by: adrelaline, severe surgical stimulus.

Decreased by: sedation, analgesia, pregnancy.

MAC95 is the minimum alveolar concentration required to prevent reaction to skin incision in 95% of subjects.

Other features: in mixtures of anaesthetic gases, the various MAC's are additive.

<><><><><><><><><><><><>

Write short notes on propofol

This answer needs most of the following headings:

Pharmacy:

Type of chemical (phenol) storage (emulsion in soybean oil, in glass ampoules) concentration (10mg/ml.)

Pharmacodynamics:

Mode of action, hypnosis via GABA receptors

Clinical effects, anaesthesia

Dose, 1-2 mg/kg; infusion 10-6 mg/kg/hr. effective blood level is 3.5-4.5 µg/ml.

Onset, one circulation time

Duration, 1-5 mins.

Pharmacokinetics:

Routes of administration, i.v.

Metabolism, liver

Side effects, vasodilation, hypotension, respiratory depression, relaxation

Interactions, prolongs action of alfentanil

Plus other features: long infusion leads to green urine colour

In low dosage it is used as a sedative

Note the similarity to the question and answer on p22

<><><><><><><><><><><><>
Page 31

Write short notes on mivacurium

This answer needs most of the following headings:

Pharmacy:

Type of chemical (benzylisoquinoline), storage, (aqueous, in glass ampoules) preparation, concentration 10mg/ml

Pharmacodynamics:

Mode of action, nondepolarising neuromuscular drug

Clinical effects, relaxant

Dose, 0.1-0.2 mg/kg.

Onset, 3 mins.

Duration, 10 mins.

Pharmacokinetics:

Routes of administration, i.v.

Metabolism, serum cholinesterase

Side effects, histamine release

Interactions, volatile and local anaesthetics, aminoglycoside antibiotics, other relaxants

<><><><><><><><><><><><>

Write short notes on hyoscine

This answer needs most of the following headings:

Pharmacy:

Type of chemical, storage, preparation (aqueous, tablet or syrup), concentration (400 µg/ml.)

Pharmacodynamics:

Mode of action, anticholinergic

Clinical effects, parasympathetic blockade; sedative; antiemetic; locally acting mydriatic

Dose, 7 µg/kg.

Onset, one circulation time

Duration, 3hrs

Pharmacokinetics:

Routes of administration, oral, i.m.; i.v.

Metabolism, liver

Side effects, central anticholinergic syndrome, tachycardia, dry mouth

<><><><><><><><><><><><>
Page 32

Write short notes on glycopyrronium (glycopyrollate)

This answer needs most of the following headings:

Pharmacy:

Type of chemical, storage (aqueous solution in glass ampoules,) preparation, concentration 200 µg/ml.

Pharmacodynamics:

Mode of action, anticholinergic

Clinical effects, parasympathetic blockade

Dose, 7 µg/kg.

Onset, one circulation time

Duration, 4-6 hrs.

Pharmacokinetics:

Routes of administration, i.v; i.m.

Metabolism, liver

Side effects, Tachycardia, dry mouth

Plus other features: does not cross blood brain barrier

<><><><><><><><><><><><>
Page 33

Chapter 3
Paediatric Anaesthesia
Page 34

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

Notes for an answer:

Infants have:

1. More increased heart and respiratory rates in response to demands than adults. The ribs are more horizontal, and the respiration is
more diaphragmatic.

2. Higher metabolic rate — more rapid onset of cyanosis.

3. Reduced renal concentrating function — need more water.

4. Greater risk of hypothermia due to relatively larger surface area.

5. Greater sensitivity to opioids, partly due to nervous system immaturity, partly to hepatic clearance.

6. Larger volume of distribution for water-soluble drugs.

Comment: the question sounds complex, but the answer is quite simple!

Serious omissions likely to cause a fail:


Failure to mention sensitivity to opioids.

<><><><><><><><><><><><>

Write short notes on EMLA cream

This answer needs most of the following headings:

Pharmacy:

Type of chemical (eutectic mixture of local anaesthetics), storage (cream in a tube), preparation, concentration (2.5% lignocaine;
2.5% prilocaine)

Pharmacodynamics:

Mode of action, local analgesia

Clinical effects, to make venpuncture painless

Dose, 5 ml.

Onset, 1 hr.

Duration, as long as applied

Pharmacokinetics:

Routes of administration, topical

Metabolism, liver

Side effects, Risk of being eaten (with its dressing) by a child

<><><><><><><><><><><><>
Page 35

What psychological factors influence your anaesthesia for children aged 2-3 years?

Notes for an answer:

1. Very easily frightened — need to be seen with parents and spoken to kindly; need discussion of place of premedication, including
day cases.

2. Highly dependent on parents — development of rapport with them is a high priority.

3. Tolerate pain badly

a) need EMLA or similar cream for venepuncture and discussion of management of gaseous induction

b) need careful analgesia (but sensitive to opioids and not able to control own PCA) — need discussion of pro's and con's of the main
techniques for pain relief.

Comment: The question sounds complex, but the answer is quite simple!

Serious omissions likely to cause a fail:


Failure to mention fear and pain.

<><><><><><><><><><><><>

What facilities are required for transfer of a 2-month old baby to a paediatric unit?

Notes for an answer:

A trolley which is easily mobile and physically secure, warm, with O2 supply, humidification, IPPV available (secure tracheal tube if
appropriate), good IVI. Monitoring which is portable, shakeproof, battery powered (need SpO2, EtCO2, ECG, pulse meter,
thermometer; laryngoscopes, spare tracheal tubes and i.v. cannulas.)

Drugs and other facilities for CPR. Easy access to the patient.

Trained assistants/facilities for, and rapport with, accompanying parent.

<><><><><><><><><><><><>
Page 36

A 6-week old child has projectile vomiting and is presented for laparotomy. Describe the general anaesthetic problems of this
case.

Notes for an answer:

1. Alkalosis (needs treatment to lower the serum bicarbonate below 30 mmol/L).

2. Dehydration (needs IVI and full rehydration).

3. Hyponatraemia (need IVI with half strength saline).

4. Hypokalaemia.

5. Full stomach (regurgitation risk — need for preoperative nasogastric tube with clear washouts and rapid sequence induction of
anaesthesia).

6. Small size of patient, with special paediatric problems — risk of hypothermia, risk of overventilation, risk of fluid overload,
sensitivity to opioids, narrow cricoid ring, short trachea, more difficult intubation. If the patient is a premature baby, extra risk of
intracranial haemorrhage.

Comment: This is a safety question.

Serious omissions likely to cause a fail:


Failure to mention alkalosis and regurgitation risk.

<><><><><><><><><><><><>

Describe the management of acute epiglottitis in a child of three years.

Notes for an answer:

Rapport with parents. Minimum interference with child prior to careful transfer to theatre with humidified O2, ENT surgeon standing
by, careful O2/halothane or sevoflurane induction, difficult intubation (with possible use of steroid cream), throat swab; then — need
for IV infusion, blood tests for bacteria and RSV, antibiotics (usually cephalosporin for Haemophilus A), IPPV, sedation,
humidification, transfer to ITU, fluid management, protocol for eventual extubation.

Comment: This condition is rapidly becoming rare.

Serious omissions likely to cause a fail:


Failure to mention careful gas induction and difficult intubation.

<><><><><><><><><><><><>
Page 37

Describe the management of acute laryngotracheitis in a child of three years of age, presenting with cyanosis

Notes for an answer:

Rapport is established with parents.

Humidified O2 therapy; cyanosis makes this case severe enough to require intubation; induction of anaesthesia (gas or iv), potentially
difficult intubation, throat swab; need for rehydration by i.v. infusion, blood cultures for bacteriology and virology, antibiotics (broad
spectrum in the first instance), ITU, IPPV, sedation, humidification, paediatric fluid management, protocol for eventual extubation.

<><><><><><><><><><><><>

What are the aims of premedication in children? Describe the pharmacology of two such premedicant drugs

Notes for an answer:

1. Needs a comment on sedation, analgesia, drying secretions, routes of administration; and about which patients need greater and
which need lower dosage.

2. Needs comment on selection criteria for premedication in children and influence on dosages of premedicants in children with
relevant concomitant diseases, e.g., effect of Downs syndrome on dosages of sedatives.

3. Details about two drugs, e.g., benzodiazepines, atropine, hyoscine, trimeprazine; using the format described for answers on ''write
short notes on" questions.

Comment: An easy answer for those who premedicate children. In answer to the first part of the question, it would also be acceptable
to argue the case against premedicating children!

<><><><><><><><><><><><>
Page 39

Chapter 4
Neuroanaesthesia
Page 40

How does concomitant head injury influence your anaesthetic management of operation for a fracture of the hand?

Notes for an answer:

Monitoring of head injury required as it may be getting worse — monitoring of GCS. The intracranial critical volume/pressure
compliance point may be reached suddenly.

If the head injury is unstable, cerebral oedema would be worsened by coughing, straining, vomiting, and jugular venous obstruction.
Hypoxia, and hypercapnia may critically compress brain, and hypotension would carry risk of cerebral hypoxia. Operation may need
to be postponed.

If head injury is stable and improving, brachial plexus and wrist blocks and local infiltration are OK, Biers block OK, but care is
needed with dosages of local anaesthetics because of side effects.

Serious omissions likely to cause a fail:


Failure to mention intracranial pressure, and regional blockade.

<><><><><><><><><><><><>

What monitoring do you consider necessary for a posterior fossa craniotomy? What are the possible sources of error
associated with two of the monitors you mention?

Notes for an answer:

List of monitors (with sources of error in brackets).

Noninvasive BP (inaccurate on large arms).

Invasive arterial pressure (damping, clotting in cannula, zero errors, height of transducer).

Pulse oximetry (mechanical and electrical interference; digit too large or too small for transducer; abnormal haemoglobins; venous
pulsation; delay in alerting hypoxia).

Capnography (sampling site too far from lungs, blocked sample tube, interference by N2O, leak in sample tube, monitor wrongly
calibrated).

Agent monitoring (interference by N2O).

FiO2 (blocked sample tube, leak in sample tube, monitor wrongly calibrated, fuel cell dead).

Pulse (if counting from ECG, a high T wave can apparently double the rate, if counting from a digit, electrical and mechanical
interference).

Air embolus doppler (errors due to wrong direction).

CVP (catheter tip peripheral — reading is too high, catheter tip in right ventricle — reading is too high; damping, clotting in cannula,
zero errors, height of transducer).
Page 41

Describe the physiological effects of high arterial carbon dioxide tension (10 kpa, 70 mmHg.)

Notes for an answer:

Effects of high CO2:

On general circulation — increased arterial pressure; raised arteriolar tone, dilation of skin blood vessels.

On cerebral circulation — vasodilation, increase in flow and volume of vessels. Raising of ICP.

On respiration — stimulation of rate and depth.

On oxygen dissociation curve — move to the right.

On coronary flow — increase.

On heart — arrythmias; increased force of myocardial contraction,

On muscle — increased tone.

On pH — reduction

On adrenal — secretion of adrenalin.

Rise of intraocular pressure.

CO2 narcosis may supervene.

Serious omissions likely to cause a fail:


Failure to mention cerebral circulation.

<><><><><><><><><><><><>

What factors affect cerebral blood flow? State briefly their importance in relation to anaesthesia within 12 hours of head
injury

Control Factors

• a rise of CO2, increases it;

• a rise of venous pressure reduces it;

• arterial pressure (autoregulation controls it between MAP of 40-140);

• extracellular pH (acidaemia increases it);

• PO2 (hypoxia increases it);

• temperature (cold reduces it);

• neurogenic factors — various effects.

Pathological Factors

• raised intracranial pressure, due to vomiting coughing and straining reduces it;

Drugs

• examples are thiopentone, propofol, mannitol.

Serious omissions likely to cause a fail


Failure to mention effects of drugs.
Page 42

How may cerebral bloodflow be affected by general anaesthesia?

Notes for an answer:

General anaesthesia — disruption of controlling factors by the anaesthetic; e.g., cardiovascular instability, raised jugular venous
pressure (coughing, vomiting, fluid loading, hypoxia, intubation, IPPV, cardiac failure) hypercapnia, hypocapnia, hypothermia;
hyperventilation with low CO2 tension causes cerebral vasoconstriction;

• drugs — induction agents e.g., propofol, thiopentone (reduce it);

• anaesthetic volatile agents (increase it);

• Other drugs, for example fentanyl, ketamine.

Comment: This answer also needs a little discussion of the significance to the anaesthetist of raised intracranial pressure.

<><><><><><><><><><><><>
Page 43

Chapter 5
Obstetric Anaesthesia
Page 44

How do obstetric factors affect the management of anaesthesia for the removal of a retained placenta?

Notes for an answer:

1. A retained placenta can cause severe blood loss, therefore good IV access essential, and that potential hypovolaemia is as
dangerous in regional block as in general anaesthesia.

2. Acid gastric juice — with risks of severe pneumonitis from regurgitation and aspiration.

3. Pre-partum narcotic drugs may have been given, which will accentuate responses to anaesthesia.

4. The possible presence of an existing epidural for obstetric analgesia, which can be used for the anaesthetic.

5. The sensitivity of the postpartum uterus to the relaxing effect of halothane.

6. Oxytocic-induced vomiting and the need for antiemetics.

Serious omissions likely to cause a fail:


Failure to mention haemorrhage and shock; and risk of aspiration of gastric acid.

<><><><><><><><><><><><>

Write short notes on ranitidine

This answer needs most of the following headings:

Pharmacy:

Type of chemical, storage (glass ampoules, tablets)

Pharmacodynamics:

Mode of action, H2 antagonist

Clinical effects, reduction of volume and acidity of gastric juice

Dose, 150 mg.

Onset, 1 hr.

Duration, 4 hrs.

Pharmacokinetics:

Routes of administration, oral, i.m., i.v.

Metabolism, liver

Excretion

Side effects, cardiovascular disturbances, bradycardia, AV block, asystole; CNS disturbances — mental confusion, headache
dizziness; anaphylaxis, nosocomial pneumonia

Interactions, in porphyria and phenylketonuria

Plus other features: no effect on cytochrome P450


Page 45

Describe the anaesthetic management of massive intrapartum haemorrhage requiring emergency operation

Notes for an answer:

1. Give oxygen.

2. Stop haemorrhage — need for oxytocics; immediate delivery and even emergency hysterectomy. Need for large, fast infusion to
replace bloodloss.

3. Anaesthetic for severely shocked patient (hypovolaemia, acute anaemia, oxygen carriage problems), who may have a full stomach
with acid gastric juice.

4. Organisation for massive transfusion.

5. Risk of DIC — organisation for fresh frozen plasma.

6. Preservation of renal and splanchnic function with dopamine, dopexamine, diuretics.

7. Later — ARDS or MSOF or ileus may require intensive care.

Serious omissions likely to cause a fail:


Failure to mention massive transfusion; renal and other organ function.

<><><><><><><><><><><><>

Describe the pathophysiological processes of pre-eclamptic toxaemia of pregnancy

Notes for an answer:

Pre-eclamptic toxaemia arises from changes in the placenta which lead to:

• hypertension;

• albminuria;

• DIC, with coagulopathy;

• low platelets (function may be reduced by aspirin);

• intrauterine haemorrhage;

• convulsions (exact process not clear) with hypoxia;

• placental failure (baby at risk);

• sodium retention;

• patients are waterlogged, yet hypovolaemic;

• HELLP syndrome may occur.

Serious omissions likely to cause a fail:


Failure to mention abnormalities of haemostasis, convulsions and placental failure with risk to baby.
Page 46

You are asked to help with a case of severe pre-eclamptic toxaemia of pregnancy. What is your management?

Notes for an answer:

1. Assessment: hypertension, proteinuria, weight gain. How serious and how acute is it?

2. Monitoring the baby. Is there temporary or continuous bradycardia?

3. Clinical monitoring of the mother. Is there hyper-reflexia or incipient convulsions?

4. Monitoring: arterial pressure, blood gases, platelet levels, coagulation screen, CVP, urinalysis.

5. Treatment: there should be a continuous attempt to make all abnormal parameters normal. Arterial pressure control is a high
priority (IV colloid, epidural, hydrallazine, alphamethyldopa), magnesium sulphate to prevent convulsions.

FFP for coagulopathy, attempt at early delivery. If general anaesthetic is required, upper airway oedema may make intubation
difficult.

The risks to mother may continue after operation.

Serious omissions likely to cause a fail:


Failure to mention magnesium sulphate or to consider the baby.
Page 47

Chapter 6
Cardiothoracic Anaesthesia
Page 48

Describe the anatomy of the trachea, including its relations

Notes for an answer:

Origin (cricoid, C6); termination (carina, T4); tubular midline structure of horseshoe-shaped cartilages (keep airway open), fascia and
muscle; lined by ciliated epithelium, which moves mucus. Innervated by recurrent laryngeal nerves and vagi; blood supply from
thyroid arteries, draining to inferior thyroid plexus.

Relations:

Neck – pretracheal fascia, strap muscles, thyroid, platysma; laterally – carotid sheath, recurrent nerves and vagi, posteriorly –
oesophagus.

Chest – anteriorly innominate artery, vein, aorta; laterally subclavian arteries, recurrent nerves and pleura on right side; posteriorly
oesophagus. Carina is related to pulmonary artery bifurcation.

Comment: In an anatomy question, extra marks can often be gained by noting the function of the structure in question. In this case it
is simply the airway!

<><><><><><><><><><><><>

Describe the anatomy of the diaphragm, including its relations

Notes for an answer:

A sheet of muscle, arising from the lower 6 costal cartilages, the xiphisternum, arcuate ligaments and crura; inserted into central
tendon. There are three main openings – for oesophagus, aorta, and inferior vena cava. (Also perforated by thoracic duct and
hemiazygos vein).

Function:

Rhythmic respiration and abdominal straining. Innervated by phrenic nerve (C345); blood supply from surrounding vessels, e.g.,
internal mammary artery.

Relations:

Above – pleura, pericardium, lungs, heart, ribs, spine, oesophagus (passing through hiatus) aorta, inferior vena cava; below –
stomach, spleen, liver, kidneys, arcuate ligament.
Page 49

Describe the arterial blood supply of the myocardium

Notes for an answer:

1. R coronary (dominant in 50%) from right coronary sinus, between aorta and right auricle, goes down right atrioventricular groove
(marginal branch down right ventricle), to posterior atrioventricular groove, to anastomose with left coronary, with posterior
interventricular and posterolateral branches. Supplies SA node, AV node, Bundle of His, pulmonary conus.

2. L coronary (dominant in 20%) from left (posterior) sinus between left auricle and pulmonary trunk, gives left anterior descending
(anterior interventricular) branch which supplies anterior left ventricle, septum and bundle branches. It continues as circumflex in
atrioventricular groove, with obtuse, marginal and left lateral branches.

<><><><><><><><><><><><>

Describe the venous drainage of the myocardium

Notes for an answer:

1. Thebesian veins (venae cordis minimae) drain into the cavities of the heart. Anterior cardiac veins open into right atrium.

2. The coronary sinus drains 90% of left ventricular blood supply from five tributaries (great, middle and small cardiac veins;
posterior vein of left ventricle, and oblique vein of left atrium).

3. It lies in the atrioventricular groove, and drains into the right atrium to the left of the opening of the inferior vena cava.
Page 50

Describe the conducting system of the heart

Notes for an answer:

This system is specialised myocardial tissue and has pacemaker activity and conduction functions.

SA node on right side of SVC root, near the top of the crista terminalis and the right auricle. There are 3 internodal pathways
(anterior, middle, posterior).

Function:

It contains P cells which generate impulses.

Other (pathophysiological) pathways: Bundle of Kent bypasses AV node, James fibres go to Bundle of His.

AV node on right side of central fibrous body (has labyrinthine structure which delays conduction and limits number of impulses
coming through), has atrionodal, nodal and nodal-His regions. Bundle of His is inferoposterior to membranous portion of septum. left
bundle (below posterior cusp of aortic valve) has 2 branches which ramify in the muscle of left ventricle and interventricular septum.
right bundle goes under base of anterior papillary muscle of tricuspid valve (as the moderator band) and ramifies in the muscle of the
right ventricle.

Serious omissions likely to cause a fail:


Sinuatrial and atrioventricular nodes.

<><><><><><><><><><><><>

How may abnormalities of cardiac conduction be revealed by the electrocardiogram?

Notes for an answer:

• Atrial fibrillation;

• Heart block;

• Bundle branch block;

• Re-entry arrythmias, and their significance (usually ischaemic). Mention of oesophageal and intracardiac leads;

• Sick Sinus Syndrome.

Comment: Each one needs a small description of what the abnormality looks like.
Page 51

Describe the anatomy of the bronchial tree

Notes for an answer:

1. The bronchial tree extends from the carina to the bronchioles.

2. It is a branching tubular structure, stiffened by small rings and plates of cartilage. Lined by pseudostratified columnar ciliated
epithelial cells with goblet and serous cells. Bronchial artery supply from aorta (and third right posterior intercostal artery), to
pulmonary and azygos veins.

3. Nerve supply from the pulmonary plexus — vagus is constrictor, adrenergic is dilator; nonadrenergic, noncholinergic (NANC)
system is bronchodilator and mucus secreting.

4. R main 15mm x 2cm from carina to intermediate bronchus. Branches — upper — APA, middle — LM, lower — AMALP. (Each
letter represents the name of a branch)

5. L main 13mm x 5cm, Branches: left upper APA (lingular SI), lower-APAL.

6. Lower bronchi down to 16th division end as terminal bronchioles.

<><><><><><><><><><><><>

Describe the nerve supply of the larynx

Notes for an answer:

Branches of vagus nerve:

Superior laryngeal nerves — external — motor to cricothyroid; internal — sensory from mucosa above cords.

Recurrent laryngeal nerves — sensory below cords and motor to the other small muscles. They arise in the chest, curve round the
aorta and subclavian artery, and return to the neck alongside trachea and oesophagus. They enter the larynx behind the cricothyroid
joints, beneath the lower part of the pyriform recess.

Comment: This is an easy question!


Page 52

Describe the anatomy of the first rib, including its relations

Notes for an answer:

First rib has upper and lower surfaces (lower surface featureless), curves downwards and forwards, sickle shaped, head articulates
with body of T1, and tubercle with transverse process, muscle insertions: scalenus anterior inserted into scalene tubercle (vein in
front, artery behind), lev. costae and serratus anterior inserted into lateral border. Function: formation of rib cage and respiration.

Relations:

• lower surface — pleura;

• medially — pleura, thoracic duct;

• neck of rib — root of T1, vagus, phrenic nerves and sympathetic chain;

• laterally — posterior triangle of neck;

• inferiorly — first intercostal space, with intercostal muscles vessels and nerves;

• superiorly — clavicle, subclavius, the brachial plexus crosses from superomedial to inferolateral, the subclavian artery and vein
cross the medial end of the first rib and join the brachial plexus.
Page 53

Chapter 7
Trauma and Emergency Anaesthesia
Page 54

What are the effects of an overdose of a tricyclic antidepressant drug?

Notes for an answer:

1. Autonomic; sympathetic stimulation and anticholinergic effects.

2. Brain; sedation, convulsions, coma.

3. Cardiac; tachyarrythmias; cardiac failure (most inotropes make tachyarrythmias worse).

4. Drug overdose effects in general; often overdosed with other drugs and alcohol, loss of airway control, regurgitation risk, skin
necrosis, hypothermia, retention of urine.

Comment: It helps to categorise these effects.

Serious omissions likely to cause a fail:


Failure to mention convulsions and tachyarrythmias

<><><><><><><><><><><><>

A child of 12 years has been admitted following a road accident. At emergency laparotomy the surgeon announces that the
liver is ruptured. Describe your management of the case up to the end of the operation

Notes for an answer:

This is severe road trauma and needs a comment about search for, and possible presence of, other injuries, especially head injury.

• organise massive blood crossmatch, and supplies of fresh frozen plasma;

• circulatory support (drugs and colloids and crystalloids in severe haemorrhage), citrate problems;

• diagnosis of blood clotting abnormalities, with intraoperative coagulation screening;

• keeping the patient warm;

• blood glucose support;

• organisation of ITU;

• keeping parents informed of progress;

• perhaps consider secondary transfer to liver unit.

Serious omissions likely to cause a fail:


Failure to mention managing massive transfusion.

<><><><><><><><><><><><>
Page 55

Write short notes on Hartmann's solution

This answer needs most of the following headings:

Pharmacy:

type of chemical (intravenous electrolyte solution) storage (glass or plastic) preparation, concentration (isotonic) Na+ 131; K+ 5; Cl-
111; Ca++ 2; Lactate 29; mmol/l.

Pharmacodynamics:

mode of action, water and electrolyte replacement

clinical effects, rehydration

dose, appropriate to clinical situation — e.g., 500ml/4-6 hrs

onset, immediate

duration, N/A

Pharmacokinetics:

routes of administration, i.v.

excretion, kidney

interactions, lactate load is unsuitable for diabetic patients

Plus other features: same electrolyte concentrations as plasma

<><><><><><><><><><><><>

Describe the adverse affects of blood transfusion. How may they be reduced?

Notes for an answer:

1. Acute and delayed haemolytic reaction, circulatory overload, hypothermia, embolism, hyperkalaemia, citrate intoxication,
crossinfection, ARDS, immunosuppression, hypomagnesaemia, hypocalcaemia, coagulopathy.

2. Reduction of adverse effects:

a) Set up a good transfusion service! (the administrative side, including correct labelling is as important as the technical side);

b) Warm the blood during transfusion;

c) Ca++ and fresh frozen plasma are given to correct coagulopathy. Platelet transfusion may be needed;

d) Autotransfusion, cell savers and predonation solve many of these problems;

e) Monitor the patient for overload and transfusion reactions.

Serious omissions likely to cause a fail:


Most of the complications.

<><><><><><><><><><><><>
Page 56

Describe the alternatives to donor blood transfusion

Notes for an answer:

1. Colloid infusion (which will be limited by progressive anaemia).

2. Autologous transfusion — predonation/perioperative haemodilution cell savers/salvage with reinfusion.

3. Fluorocarbons—fluosol emulsion 5ml/dl. O2 carriage @ FiO2 1.0.

4. Haemoglobin infusion with 2,3 DPG analogue (nephrotoxicity of red cell stroma).

Comment: The above items should be described in detail.

<><><><><><><><><><><><>

What are the contents of a unit of transfusion blood? Describe briefly the alternatives which can be used in an emergency
haemorrhage situation until transfusion blood becomes available

Notes for an answer:

Contents:

350 ml. blood, 150 ml. CPD adenine or SAGM. (Most is plasma-reduced and therefore low in albumin and globulins). It becomes
progressively more hyperkalaemic and acidotic during storage, with lower clotting factors and low platelets.

Alternatives:

Colloids: dextran 70, gelofusine, hespan, haemaccel, hetastarch, albumin.

Crystalloids: normal saline, Hartmann's solution, 5% dextrose.

<><><><><><><><><><><><>
Page 57

Write short notes on Gelatin-based plasma substitutes

This answer needs most of the following headings:

Pharmacy:

Type of chemical (high molecular weight colloids 30-70 K.Daltons) storage (glass or plastic), preparation, concentration (frequently
slightly hypertonic)

Pharmacodynamics:

Mode of action, expansion of the plasma compartment

Clinical effects, resuscitation from shock and haemorrhage

Dose, appropriate to clinical situation

Onset, immediate

Duration, hours

Pharmacokinetics:

Routes of administration, i.v.

Metabolism, very little

Excretion, via kidneys

Side effects, allergy, risk of overinfusion

Comment: This answer will also need details of the various types of product.

<><><><><><><><><><><><>

Describe the features of the Boyle's anaesthetic machine and Bain system which protect the patient from pulmonary
barotrauma

Notes for an answer:

The following items need to be addressed:

1. Reducing valve and flow restrictor for cylinders, needle valves on flowmeters to restrict flow, thin-walled bag, which limits
pressure rises, heidbrink valve (the pressure relief valve protects the machine, not the patient).

2. Airway pressure limiter (and its limitations).

<><><><><><><><><><><><>
Page 58

What physiological changes follow acute hypovolaemia?

Notes for an answer:

Definition: imbalance between circulating volume and capacity of circulation.

1. Blood volume falls causing reduced venous return; reduced RA pressure, CO.

2. Reduced cardiac output causes systolic and pulse pressure fall.

3. Baroreceptors firing reduced, leads to tachycardia, vasoconstriction, adrenaline secretion, Cortisone secretion, redistribution of CO
from skin, muscle and viscera to heart and brain. BP maintained till loss of 20% volume.

4. Atrial receptors cause ADH secretion (resulting in oliguria and water retention). Aldosterone secretion (causes Na+ retention),
thirst, endorphin secretion, water transfer from ECF to circulation, resulting in dilutional anaemia.

5. Carotid chemoreceptors stimulation causes hyperventilation.

6. Cold periphery, pallor, cyanosis, reduced capillary refill.

Serious omissions likely to cause a fail:


Baroreceptors, ADH, shift of water into circulation.

<><><><><><><><><><><><>

What is the physiological response to the rapid loss of 1 litre of blood in the adult?

Notes for an answer:

1. General description of the clinical picture in the hypovolaemic patient with fall of cardiac output, vasoconstriction and
hypotension. Some indication of signs—reduced capillary refill, tachycardia, oliguria, distress, loss of muscle tone.

2. Compensation:

a) baroreceptors—arteriolar resistance, venoconstriction, cardiac effects (tachycardia, raised diastolic) respiratory effects
(hyperventilation);

b) pituitary renal/adrenal axis, renin, angiotensin, ACTH, ADH;

c) fluid shifts from ECF to blood, with timescale.

Comment: This is similar to the previous question, and demonstrates that any subject may be asked in several different ways.

<><><><><><><><><><><><>
Page 59

Outline the factors responsible for the maintenance of cardiac output

Notes for an answer:

1. Venous return, myocardial contractility (Starling's Law of the heart).

2. Sympathetic and parasympathetic activity.

3. Diastolic coronary blood flow and PaO2, supplying the substrates for muscle action.

4. Inotropic hormones, PaCO2 levels, and heart rate (especially in children)—Bowditch effect.

Serious omissions likely to cause a fail:


Failure to mention Starling's law, inotropic hormones and nerve control of heart.

<><><><><><><><><><><><>

What are the causes and effects of hypothermia?

Notes for an answer:

Causes:

Conduction, convection, radiation, and cooling of the blood.

radiation to cold surroundings (note the importance of ambient temp),e.g., drowning;

convection: evaporation of skin prep or water vapour from exposed serous cavities during operation, especially when there is
vasodilation, loss of hypothalamic control, absent shivering response (due to anaesthesia or alcohol intoxication); dry, cold inspired
gases;

conduction of heat to cold surroundings, as when a limb is packed in snow, or a donor organ transported in melting ice;

cooling of the blood: cold IV infusions, deliberate hypothermia during cardiopulmonary bypass.

Effects:

Dysrythmias at < 31° C. Prolonged action of general anaesthetics and relaxants, slow metabolism of drugs and citrate, increased Hb
oxygen affinity, fall in CBF, reduced O2 consumption, peripheral vasoconstriction, acidosis, coagulation problems, shivering and
hypoxia on recovery.

<><><><><><><><><><><><>
Page 60

Describe the immediate rescusitation (in the first hour) of an unconscious patient admitted to the A & E department after
falling off a ladder

Notes for an answer:

Primary survey—the main elements of ATLS. Airway, Breathing, Circulation—pulse, BP, capillary refill (hypotension is likely to be
due to extracranial bleeding or spinal injury); Disability of cerebrum (level of consciousness, pupils, GCS monitoring is
commenced); Exposure (other injuries).

Cervical support collar is placed until cervical spine is known to be stable.

Resuscitation.

IV access is established.

O2 is given.

Items A and B; O2, intubation (with care of cervical spine); cricoid pressure (because of the vomiting risk); note of the appropriate
anaesthetic drugs; and IPPV.

C: volume replacement as necessary with monitoring of arterial pressure, capillary refill, urine output and CVP.

Monitoring: ECG, arterial pressure, CVP, pulse oximetry, capnography.

Investigations: FBC, Cross-match, ABG's. Blood sample for drug levels if history indicates this.

X ray: chest, skull, neck, pelvis.

Secondary survey: more detailed examination and repeated further assessments.

Serious omissions likely to cause a fail:


Cervical collar, oxygen, the vomiting risk, and the main elements of ATLS.

<><><><><><><><><><><><>
Page 61

Chapter 8
Acute and Nonacute Pain Management
Page 62

What are the medical effects of opioid drugs?

1. Analgesia

2. Addiction

3. Respiratory depression

4. Nausea and vomiting

5. Bradycardia

6. Miosis

7. Sedation

8. Hallucinations

9. Bronchospasm

10. Biliary spasm

11. Renal colic

12. Slowing of premature labour

13. Itching

14. Histamine release

15. Muscle rigidity

Serious omissions likely to cause a fail:


Failure to mention respiratory depression and addiction.

<><><><><><><><><><><><>

Write short notes on pethidine

This answer needs most of the following headings:

Pharmacy:

Type of chemical, (phenylpiperidine) storage (aqueous in glass ampoules), preparation (synthetic) concentration

Pharmacodynamics:

Mode of action opioid agonist

Clinical effects, analgesia, respiratory depression, nausea and vomiting, sedation, addiction, relaxation of smooth muscle

Dose, 1 mg/kg.

Onset, minutes

Duration, 2-4 hrs.

Pharmacokinetics:

Routes of administration, oral, im., i.v., epidural

Metabolism, liver

Side effects, respiratory depression, nausea and vomiting, addiction, histamine release,
Interactions, MAOI's—collapse and coma

Plus other features: related to atropine, synthesised in 1939.


Page 63

Discuss the methods available for the relief of pain following abdominal hysterectomy

Notes for an answer:

Advantages:

• NSAID's (reasonably powerful, no respiratory depression or vomiting).

• Other oral analgesics: very safe but most are not so powerful.

• IM opiates (powerful and safe).

• PCA (powerful, swift reaction to pain, patients can customise dosage to their own needs).

• Epidural catheters (superb, powerful analgesia).

This answer needs a note about customising treatment for the individual patient and discussing patient preferences!

Complications:

• NSAID's (haemorrhage, ulcers, renal failure and bleeding).

• IM opiates (nausea, vomiting and delay in action).

• PCA (needs common sense, reasonably strong fingers and may cause vomiting and hallucinations. Serious overdose has occurred.).

• Epidural catheters (weak, numb legs and risk of unrecognised apnoea from opiates; and hypotension).

Serious omissions likely to cause a fail:


Failure to mention PCA, and the dangers of epidural opiates.

<><><><><><><><><><><><>
Page 64

Write short notes on tenoxicam

This answer needs most of the following headings:

Pharmacy:

Type of chemical (nonsteroidal anti-inflammatory drug), storage (powder or tablet), preparation, concentration

Pharmacodynamics:

Mode of action, local prostaglandin inhibition

Clinical effects, analgesia

Dose, 20-40 mg.

Onset, minutes

Duration, 10-12 hrs.

Pharmacokinetics:

Routes of administration, oral, i.m., i.v.

Metabolism, liver

Side effects, platelet inhibition, gastric irritation, tendency to renal failure

Interactions, other NSAIDs

<><><><><><><><><><><><>

Describe the principles involved in prevention and treatment of postherpertic neuralgia in the upper limb

Notes for an answer:

Place of preventive analgesia of herpes zoster, acyclovir cream. This is neuropathic pain and is self-limiting; may be helped by
tricyclic drugs and other coanalgesics, local analgesics, capsaicin cream, IV guanethidine block.

<><><><><><><><><><><><>

Compare and contrast pethidine and codeine

Notes for an answer:

Both Controlled Drugs, analgesics and constipators; but codeine doesn't sedate and has less respiratory depression by IM route. The
examiner also needs to see the usual pharmacological details e.g., using the answer format for questions which start ''Write short
notes on. . .".

Serious omissions likely to cause a fail:


Respiratory depression.

<><><><><><><><><><><><>
Page 65

Describe the adverse reactions which may follow the use of non-steroidal anti-inflammatory drugs

Notes for an answer:

PGE1 synthase inhibition causing (reversible) gastric irritation, renal failure, exacerbation of asthma, angioedema, rashes, water
retention, aseptic meningitis in patients with SLE, hepatic damage. Thromboxane A inhibition causes irreversible loss of the
adhesiveness of existing platelets.

Serious omissions likely to cause a fail:


Renal failure.

<><><><><><><><><><><><>

Describe the pharmacological eeffects of pparacetamol

Notes for an answer:

This answer needs most of the following headings:

Pharmacy:

Type of chemical (simple analgesic drug), storage (powder or tablet)

Pharmacodynamics:

Mode of action, central prostaglandin inhibition

Clinical effects, analgesia

Dose, 10-15 mg/kg.

Onset, minutes

Duration, 4-6 hrs.

Pharmacokinetics:

Routes of administration, oral

Metabolism, liver

Side effects, overdose causes serious hepatic damage

Interactions, potentiates other analgesics

<><><><><><><><><><><><>
Page 66

Describe the P0armacological effects of dextropropoxyphene

Notes for an answer:

This answer needs most of the following headings:

Pharmacy:

preparation (tablet), it is an opiod

Pharmacodynamics:

Mode of action, simple analgesia

Clinical effects, analgesia

Dose, 30-65 mg.

Onset, minutes

Duration, 6-8 hrs.

Pharmacokinetics:

Routes of administration, oral

Metabolism, liver

Side effects, respiratory depression and acute heart failure; overdose convulsions

Interactions, potentiates other analgesics

<><><><><><><><><><><><>
Page 67

Chapter 9
Intensive Therapy
Page 68

A patient is admitted to the intensive care unit with a relapse of myasthenia gravis. How do you cope with the medical
problems of this situation?

Notes for an answer:

1. Identification of what caused relapse and treatment of infections if appropriate.

2. Problems of inability to swallow and excessive secretion of saliva due to anticholinesterases; nasogastric tube and enteral nutrition
will be required.

3. Respiratory failure (and how it is diagnosed) would indicate intubation and IPPV, with risk of chest infections. Antibiotics may be
needed for this.

4. Protection of the eyes because of inability to blink.

5. Prevention of bedsores and use of physiotherapy.

6. Plasmapheresis may be needed.

7. Steroid cover may be required.

Comment: The mention of ITU indicates that this relapse is severe, and the answer should address this.

Serious omissions likely to cause a fail:


Failure to mention anticholineserases and respiratory failure.

<><><><><><><><><><><><>

A patient is admitted to the intensive care unit with Guillain Barre Syndrome. How do you cope with the medical problems of
this situation?

Notes for an answer:

1. Identification of the degree of disability.

2. Problems of inability to move and the unhappiness this causes.

3. Intubation and IPPV for respiratory failure, with risk of infections. Antibiotics may be needed.

4. Prevention of bedsores and use of physiotherapy.

5. Steroid cover may be required.

6. Will this be a short- or long-term case? How will nutrition be provided?

<><><><><><><><><><><><>
Page 69

Why do some patients develop ARDS following colectomy? What are the pathophysiological processses?

Notes for an answer:

The sequence of events may be:

gut wall ischaemia — endotoxinaemia — eicosanoid secretion — endothelial damage — capillary closure — tissue hypoxia and
oedema — destruction of type I cell — proliferation of type II cells — hyaline membrane formation — shunting, hypoxia —
deadspace, hypercapnia—barotrauma (due to IPPV)—lung destruction.

Serious omissions likely to cause a fail:


Failure to mention endotoxin and generalised endothelial damage.

<><><><><><><><><><><><>

Describe the complications of endotracheal intubation.

Notes for an answer:

Short Term:

• cardiovascular—reflexes due to intubation;

• bronchospasm;

• endobronchial intubation resulting in one-lung ventilation;

• oesophageal intubation by mistake;

• kinking of tube with respiratory obstruction;

• obstruction of tip against tracheal wall;

• herniation of cuff;

• laryngospasm on extubation;

• sore throat;

• subglottic oedema and stenosis in children;

• throat packs left in, causing obstruction.

Longer Term:

• candida/haemorrhage/crusting/dilation of trachea/stenosis of trachea.

Serious omissions likely to cause a fail:


Failure to mention obstruction and nosocomial infection in the longer term.

<><><><><><><><><><><><>
Page 70

What is the venturi principle? Describe the clinical uses of high frequency jet ventilation

Notes for an answer:

Principle:

High speed gas jet causes suction on surrounding areas with entrainment of surrounding gas.

Rates: 1-1.5 Hz. 1.5-5 Hz. 5-10 Hz. (high frequency oscillation).

Uses:

• rigid bronchoscopy and intratracheal surgery;

• for the development of intrinsic PEEP in the intensive care case;

• reduction of pulmonary barotrauma in ARDS;

• to allow reduced requirement for sedation during IPPV;

• reduction of pulmonary leak during IPPV in cases of bronchopleural fistula.

<><><><><><><><><><><><>

Describe the anatomy of the subclavian vein

Notes for an answer:

The subclavian is the continuation of the axillary vein, from lower border of first rib. Arches up across rib, then medial, downwards
and forwards, across scalenus anterior insertion to enter thorax, and join internal jugular vein behind sternoclavicular joint. Anterior
is clavicle, postero-laterally lies subclavian artery and pleura, posteriorly is vagus and phrenic nerves.

<><><><><><><><><><><><>

Describe the anatomy of the internal jugular vein

Notes for an answer:

Jugular—large thin-walled vein, traverses the neck from jugular bulb to subclavian vein; in carotid sheath with artery and vagus.
From above lies posterior, then lateral, then anterior to artery. The lower part is behind sternomastoid. It lies in front of prevertebral
fascia, vertebral muscles, transverse processes, and lower down, subclavian artery, phrenic, vagus, and cupola of pleura.

<><><><><><><><><><><><>
Page 71

What are the possible complications of internal jugular vein cannulation, and how do you avoid them?

Notes for an answer:

Complications:

Air embolism, pneumothorax, carotid or vertebral artery puncture with cerebral damage, haematoma, sepsis, sympathetic trunk
damage, surgical emphysema.

Avoidance:

a) position of patient, head down;

b) careful preparation of skin;

c) landmarks; (midpoint between mastoid and manubrium, lateral to carotid artery);

d) use of seldinger wire system and careful direction of insertion;

e) avoidance of unwanted damage to other structures in neck by good knowledge of anatomy and inserting needle in upper half of
neck to avoid pleura;

f) aspiration test for position of cannula tip;

g) chest X-ray for position of cannula tip.

Serious omissions likely to cause a fail:


Failure to mention pneumothorax and carotid artery puncture.

<><><><><><><><><><><><>

What are the possible complications of subclavian vein cannulation, and how do you avoid them?

Notes for an answer:

Complications:

Air embolism, pneumothorax, artery puncture, haematoma, sepsis, thoracic duct injury on left, surgical emphysema.

Avoidance of Complications:

a) position of patient — head down;

b) careful preparation of skin;

c) landmarks; 1 cm below midpoint of clavicle;

d) use of seldinger system and careful direction of insertion towards suprasternal notch;

e) avoidance of unwanted damage to other structures e.g., pleura by not allowing needle to go between ribs;

f) aspiration test for position of cannula tip;

g) chest X-ray for position of cannula tip.

Serious omissions likely to cause a fail:


Failure to mention pneumothorax.

<><><><><><><><><><><><>
Page 72

Describe the pharmacology of a drug used to relieve severe pulmonary vasoconstriction

Notes for an answer:

An example would be: prostacyclin (inhibits platelet aggregation, half life 3 min., infusion 2-5 µg/kg/min, side effects — pulmonary
and systemic vasodilation, bradycardia, flushing, headaches hypotension, pallor, sweating, severe anticoagulation with heparin);
thrombocytopenia.

a description of nitric oxide is also appropriate

<><><><><><><><><><><><>

List the properties of an ideal inotrope. Compare the properties of dopamine with this ideal

Notes for an answer:

Effective in normal and abnormal hearts, doesn't raise myocardial VO2; raises renal and splanchnic perfusion, preventing
endotoxinaemia; no side effects, no alpha effects, no arrythmias. Dopamine comes out quite well!

<><><><><><><><><><><><>

List the factors which determine the supply of oxygen to the tissues of the body. How may these factors be altered by septic
shock?

Factors:

• O2 supply to lungs;

• respiratory drive and adequacy of ventilation;

• pulmonary O2 transfer (shunting and V/Q mismatch);

• Hb level and O2 affinity of haemoglobin, including shifts of the O2 dissociation curve;

• cardiac output and blood distribution;

• capillary function;

• body temperature.

Alteration by Septic Shock:

• reduction of lung function, cardiac output, arterial pressure;

• unbalanced blood distribution;

• endothelial swelling, capillary closure;

• tissue oedema;

• bypass of capillaries via arteriovenous anastomoses.

<><><><><><><><><><><><>
Page 73

Write short notes on gastric tonometry

Need a description of how pHi is derived and measured (catheter with a balloon, completely filled with saline. CO2 from gastric
mucosa diffuses into this, and a sample is withdrawn and measured. At the same time, serum bicarbonate is measured, and pHi
derived from the Henderson-Hasselbalch equation) and in which situations it is deranged (pHi is reduced in shock, sepsis and
hypotension).

<><><><><><><><><><><><>

Write short notes on pulmonary capillary wedge pressure

Notes for an answer:

Need comment on:

• method of inserting the flotation catheter, e.g., via internal jugular line;

• pressures during insertion, in the superior vena cava, right atrium, right ventricle, and pulmonary artery;

• interpretation of readings;

• complications of technique (e.g., infection, arrythmias, damage to pulmonary vessels).

<><><><><><><><><><><><>

Write short notes on Sucralfate

This answer needs most of the following headings:

Pharmacy:

Type of chemical, storage (liquid), preparation, concentration

Pharmacodynamics:

Mode of action, physical protection of gastric mucosa

Clinical effects, at pH < 4 polymerises and adheres to ulcer craters, preventing peptic ulceration

Dose, 2 g. twice daily

Onset, immediate

Duration, hours

Pharmacokinetics:

Routes of administration, oral

Excretion, via GI tract

Side effects, no effect on gastric pH

Plus other features: the name means sucrose (aluminium) sulphate — it increases gastric production of mucus, and does not cause
nosocomial pneumonia.

<><><><><><><><><><><><>
Page 74

Write short notes on dopamine

This answer needs most of the following headings:

Pharmacy:

Type of chemical (catecholamine), storage (aqueous solution in coloured glass ampoules), preparation, concentration

Pharmacodynamics:

Mode of action, stimulation of adrenergic and dopamine receptors

Clinical effects, inotrope, renal vasodilator

Dose, 1-10 µg/kg/min.

Onset, immediate

Duration, very transient unless infused

Pharmacokinetics:

Routes of administration, i.v.

Metabolism, liver

Side effects, vasoconstriction in high dosage

<><><><><><><><><><><><>

Discuss the occurrence of metabolic acidosis in patients in the intensive care unit

Notes for an answer:

1. Causes — tissue hypoxia, renal failure, insulin antagonism (with the various acids involved).

2. Prevention — The methods of preventing the above, and their considerable limitations.

3. Treatment — need discussion of the problems of bicarbonate.

<><><><><><><><><><><><>

Give a brief account of the pulmonary problems that occur during intermittent positive pressure ventilation of the lungs in
ARDS

Notes for an answer should include the following aspects:

misplacement of tracheal tube, crusting, deadspace problem due to capillary blockage, shunting problem due to hyaline membrane,
diffusion problem due to oedema, barotrauma due to hyperventilating normal lung in juxtaposition to areas of stiff diseased lung.
Secondary nosocomial infection.

<><><><><><><><><><><><>
Page 75

Write short notes on prostacyclin

This answer needs most of the following headings:

Pharmacy:

Type of chemical (natural hormone), storage (aqueous solution in glass ampoules)

Pharmacodynamics:

Mode of action, inhibits platelet aggregation

Clinical effects, pulmonary and systemic vasodilation, used in haemofiltration

Dose, infusion 2-5 µg/kg/min.

Onset, immediate

Duration, half-life 3 min.

Pharmacokinetics:

Routes of administration, i.v.

Metabolism, liver

Side effects, pulmonary and systemic vasodilation, bradycardia, flushing, headaches hypotension, pallor, sweating

Interactions, severe anticoagulation with heparin

Plus other features: used in haemofiltration

<><><><><><><><><><><><>
Page 77

Chapter 10
Clinical Measurement
Page 78

Describe the physical principles of the pulse oximeter

Notes for an answer:

Hb and HbO have different absorption spectra. Light absorbed depends on their concentrations and the thickness of the medium.

(Beer-Lambert Law; there is some doubt about the relevance of this.) Comparison of absorption at different wavelengths (not
necessarily the isobestic point) gives relative concentrations of HbO and Hb, the SpO2. Infrared light from diode emitter passes
through or is reflected from skin to a photodetector. The steady (DC) component is rejected. The pulsing (AC) component is
amplified and displayed digitally or graphically. Calibration of each model (at the top end of the SpO2 scale) is done using volunteers.

<><><><><><><><><><><><>

Describe the physical principles of a capnograph. How may it be calibrated?

Notes for an answer:

Principle of the infrared device: two different atoms in a molecule cause infrared absorption; infrared beam splits and passes through
a reference and sample gas chambers. CO2 absorbs the infrared and emergent beams are compared by photoelectric cells. Analyser
sites may be direct (instream) or indirect via withdrawn sample.

Calibration: electronic/physical; zero = air; span — using accurately known CO2 sample from machine, cylinder or reference cell

Serious omissions likely to cause a fail:


Failure to mention zeroing the calibration.

<><><><><><><><><><><><>
Page 79

What information can a capnograph give about an anaesthetic?

Notes for an answer:

End-tidal carbon dioxide monitoring may indicate:

• adequacy of ventilation;

• oesophageal intubation (no CO2 in gas);

• rebreathing (graph does not return to zero on inspiration);

• sodalime exhaustion (rising CO2);

• fall of cardiac output (falling CO2);

• PE; air embolism (sudden fall of CO2 excretion);

• MH (fast rising CO2);

• shock (low CO2 production);

• disconnection of anaesthetic system (sudden fall of CO2 to zero), emphysema, airtrapping (sloping plateau);

• wearing off of relaxants (notching of capnograph plateau);

• death (cessation of CO2 production).

Serious omissions likely to cause a fail:


Failure to mention oesophageal intubation.

<><><><><><><><><><><><>

What are the sources of error of the pulse oximeter?

Notes for an answer:

1. Sources of error: interference; mechanical (fingers too large for probe, movement artefacts), electrical, light, nail polish and dirt.

2. COHb counted as HbO, so SpO2 falsely high.

3. Methylene blue, methaemoglobin and bilirubin counted as Hb, so SpO2 falsely low. Inaccurate in presence of venous congestion
(venous pulsation) or low SpO2 (not calibrated in this range).

4. Warning of central hypoxia may be delayed.

5. Fails during poor tissue perfusion (a useful sign of poor perfusion).

6. Inaccurate during cardiopulmonary bypass.

Comment: In spite of these sources of error, pulse oximetry is an excellent monitor!

<><><><><><><><><><><><>
Page 80

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

Notes for an answer:

1. Identification tag for patient.

2. Clear notes of injuries, with investigations (e.g., X-rays), and ongoing Glasgow Coma Score chart.

3. Hard collar if cervical spine injury is suspected.

4. Intravenous infusion (or central line).

5. Intubation and ventilation of patients who are comatose, depressed conscious level, or who have fitted; with added oxygen.

6. Monitoring, pulse oximetry, capnography, arterial pressure.

7. Administration of analgesic and relaxant.

8. Administration of mannitol or frusemide, if not already given.

9. Smooth slow journey, head-up position, trained escort.

<><><><><><><><><><><><>

What information can be gained from measuring central venous pressure?

a) Normal range: (with variations erect/supine/head down; spont./IPPV; and effect of tachycardia and bradycardia);

b) Diagnosis and subsequent management of shock;

c) Managing fluid and blood transfusion;

d) Monitoring cardiac performance, esp. right side of heart, and acute left ventricular failure; note also assessment of venous waves a,
c, v.

Serious omissions likely to cause a fail:


Failure to mention treatment of shock.

<><><><><><><><><><><><>
Page 81

Chapter 11
Regional and Local Analgesia
Page 82

What are the dangers and complications of intradural spinal analgesia?

Notes for an answer:

Immediate: inappropriate dosage causing total spinal; hypotension, respiratory depression, apnoea; bradycardia; intravascular
injection of local anaesthetic; headache, itching, incontinence, retention of urine, paralysis of legs preventing ambulation.

Later complications: arachnoiditiis, meningitis, backache, epidural haematoma and abscess; neurological damage from inadvertent
injection of toxins; spinal artery syndrome; foreign body left in dural space.

Comment: There is still a widespread misconception that spinals are always safe!

Serious omissions likely to cause a fail:


Failure to mention apnoea and hypotension.

<><><><><><><><><><><><>

Write short notes on ephedrine

This answer needs most of the following headings:

Pharmacy:

Type of chemical (catecholamine), storage (aqueous solution in glass ampoules), concentration (30mg/ml.).

Pharmacodynamics:

Mode of action, alpha and beta agonist

Clinical effects, rise of arterial pressure, bronchodilation, relief of nasal congestion

Dose, 3-30 mg.

Onset, seconds

Duration, 3-30 mins.

Pharmacokinetics:

Routes of administration, i.m., iv., topical

Metabolism, liver

Side effects, increases awareness during light anaesthesia

Interactions, other catecholamines potentiated

Plus other features: a very safe and effective drug

<><><><><><><><><><><><>
Page 83

What are the dangers and complications of extradural analgesia?

Notes for an answer:

The hazards of epidural anaesthesia:

• Inadvertent spinal or total spinal. Subdural injection, with effects similar to total spinal.

• Systemic toxicity from local anaesthetic absorption,

a) cardiovascular; low arterial pressure; low cardiac output; low systemic vascular resistance; bradycardia

b) convulsions followed by depression.

• Cardiovascular — hypotension, bradycardia.

• Respiratory — respiratory depression, apnoea; impaired cough and tidal volume.

• Other systems — Urinary retention or incontinence.

• Increased gut tone and relaxation of sphincters.

• Nausea, vomiting, headache, restlessness.

• Backache.

• Abducens palsy.

• Neurological damage, spinal artery syndrome, arachnoiditis, radiculitis, sepsis (meningitis or abscess).

• Broken needle or catheter.

• Epidural or spinal haematoma, spinal abscess.

• Inadequate block (failed, unilateral, missed segment, patchy).

Comment: It is difficult to know where to stop with this list! These are only the main complications.

Serious omissions likely to cause a fail:


Failure to mention total spinal, systemic toxicity, hypotension.

<><><><><><><><><><><><>
Page 84

What are the advantages and disadvantages of the local anaesthetic and epidural anaesthetic techniques for the repair of an
inguinal hernia?

Notes for an answer:

Ilioinguinal

Advantages:

• simple;

• no hypotension;

• no resp. depression in patients with respiratory failure;

• control of own airway;

• conscious;

• no IPPV;

• avoids use of opioids.

Disadvantages:

• does not always work, especially on the hernia sac;

• ilioinguinal nerve may be damaged;

• moderate failure rate.

Epidural

Advantages:

• control own airway;

• conscious, avoids IPPV in patients with respiratory failure;

• catheter for longer analgesia;

• avoids systemic opioids.

Disadvantages:

• more complex technique;

• hypotension;

• hypovolaemia;

• backache;

• infection;

• drug toxicity;

• total spinal;

• haematoma;

• foreign body may be left in spinal canal.

Serious omissions likely to cause a fail:


Failure to mention value in patients with respiratory failure; failure to list the disadvantages of epidural
analgesia.
Page 85

Write short notes on prilocaine

This answer needs most of the following headings:

Pharmacy:

Type of chemical (amide), storage (aqueous solution in glass ampoules).

Pharmacodynamics:

Mode of action, blockade of nerves

Clinical effects, local analgesia

Dose, up to 8 mg/kg. of 0.5-2% solution

Onset, minutes

Duration, 1-2 hours

Pharmacokinetics:

Routes of administration, infiltration, epidural, intravenous regional block

Metabolism, liver, to orthotoluidine (causes methaemoglobinaemia)

Excretion, kidney

Side effects, methaemoglobinaemia

Plus other features: one of the safest local analgesics.

<><><><><><><><><><><><>
Page 86

What factors would influence your decision to choose a regional technique in preference to a general anaesthetic for
transurethral resection of the prostate?

Notes for an answer:

Indications for Regional Analgesia (RA):

Patient preference in favour of RA, COAD, good postoperative analgesia; reduction of haemorrhage due to parasympathetic
blockade.

Contraindications of RA:

Patient preference against RA, uncooperative patient, untreated hypertension, ischaemic heart disease, fixed cardiac output, physical
abnormalities (spinal deformity), local sepsis, disorders of haemostasis, e.g., anticoagulants.

The following are also relevant to this answer:

Advantages (Reasons for Choosing) of Regional Analgesia:

• Avoidance of respiratory depression in the obese and in respiratory failure; easier recognition of TURP syndrome, less bleeding,
easier recovery as patient is fully awake.

Disadvantages (Reasons for not Choosing) of Regional Analgesia:

• Immediate: inappropriate dosage causing total spinal; hypotension, respiratory depression, apnoea, bradycardia, intravascular
injection of local anaesthetic, headache itching, incontinence, retention of urine, paralysis of legs preventing ambulation.

• Later complications: arachnoiditis, meningitis, backache, epidural haematoma and abscess; neurological damage from inadvertent
injection of toxins; spinal artery syndrome; foreign body left in dural space.

Comment: It is very helpful in an answer like this to categorise your points.

Serious omissions likely to cause a fail:


Failure to mention advantage of regional analgesia in respiratory failure and morbid obesity.

<><><><><><><><><><><><>
Page 87

Write short notes on midazolam

This answer needs most of the following headings:

Pharmacy:

Pharmacodynamics:

Mode of action, benzodiazepine receptor agonist

Clinical effects, sedation, amnesia

Dose, 1-10 mg.

Onset, minutes

Duration, 1-2 hours

Pharmacokinetics:

Routes of administration, i.m., i.v., oral

Metabolism, liver

Excretion, kidney

Side effects, overdose causes unconsciousness, with loss of airway control, and hypoxia

Interactions, reversed by flumazenil

<><><><><><><><><><><><>

What factors influence the choice of anaesthetic for insertion of arteriovenous shunt for haemodialysis?

Notes for an answer:

The effect of general anaesthetics on renal function (risks of hypoxia and hypotension; the effect of NSAIDS on renal function).

Effect of renal failure on general anaesthetics — the following are relevant:

• anaemia;

• hyperkalaemia (suxamethonium, cardiac arrythmias — not a problem if patient has been dialysed very recently);

• many nondepolarising relaxants greatly prolonged.

Thus regional blocks are ideal, for example plexus block may dilate blood vessels and make the operation easier; and they avoid the
problems of general anaesthetics, but some patients may prefer general anaesthesia in addition. Furthermore, brachial plexus block
would be contraindicated if the patient were anticoagulated.

Comment: There is no right or wrong technique here, there are merely advantages and disadvantages.

Serious omissions likely to cause a fail:


Failure to mention anaemia and hyperkalaemia

<><><><><><><><><><><><>
Page 88

Write short notes on naloxone

This answer needs most of the following headings:

Pharmacy:

Type of chemical, (oxymorphone derivative), storage (aqueous solution in glass ampoules), preparation, concentration

Pharmacodynamics:

Mode of action, opiate antagonist with receptor affinity but no receptor stimulation

Clinical effects, reversal of respiratory depression caused by natural and synthetic opioids

Dose, 7 µg/kg.

Onset, rapid

Duration, 30 mins-6hrs (i.m.)

Pharmacokinetics:

Routes of administration, i.m, i.v.

Metabolism, liver

Side effects, reverses nitrous oxide anaesthesia

<><><><><><><><><><><><>

Describe the effects and treatment of bupivacaine overdosage

Notes for an answer:

Effects:

1. Vascular — hypotension, cyanosis.

2. Cardiac — arrythmias, negative inotropy, arrest.

3. Cerebral — convulsions, hypoxia.

Treatment:

Oxygen, IPPV, ACLS for cardiac arrest; diazepam, anticonvulsants. Careful volume loading, needs mention of dangers of inotropes
in worsening of arrythmias, and dangers of some anticonvulsants, e.g., thiopentone in worsening of cardiac failure.

Comment: This is a question of safety and omissions would be marked severely.

Serious omissions likely to cause a fail:


Failure to mention cardiac arrest and convulsions. Failure to mention the need for oxygen in treatment.

<><><><><><><><><><><><>
Page 89

What are the advantages and disadvantages of the supraclavicular and axillary approaches to the brachial plexus block

Notes for an answer:

Supraclavicular:

Advantages:

wider area of block.

Disadvantages:

pneumothorax risk, vessel damage (inc. thoracic duct); risk of intravascular injection; location of plexus may be difficult.

Axillary:

Advantages:

much less risk of pneumothorax; location of plexus is usually easier.

Disadvantages:

inadequate block above elbow unless large volumes of analgesic are used; vessel damage; axillary skin may be infected; risk of
intravascular injection.

Comment: An easy question for those who have performed these blocks!

Serious omissions likely to cause a fail:


Failure to mention pneumothorax.

<><><><><><><><><><><><>

Write short notes on adrenaline

This answer needs most of the following headings:

Pharmacy:

Type of chemical (amine), storage (aqueous solution in glass ampoules or syringes).

Pharmacodynamics:

Mode of action, stimulates sympathetic receptors, alpha 1 and 2; beta 1 and 2

Clinical effects, rise of pulse rate and atrerial pressure, redistribution of circulation, dilate bronchus and pupil raise central excitatory
state, quieten gut

Dose, 0.1 mg for anaphylaxis; 1mg for CPR; 1/200,000 vasoconstrictor for local anaesthetics

Onset, rapid

Duration, 10 mins

Pharmacokinetics:

Routes of administration, i.v. and infiltration

Metabolism, catechol-o-methyl transferase and monoamine oxidase

Side effects, feelings of panic!

Interactions, monoamine oxidase inhibitors, cocaine

<><><><><><><><><><><><>
Page 90

What is the place of local analgesic nerve blocks in the anaesthetic technique for cholecystectomy (excluding ''spinal" and
extradural techniques)? State briefly how they are performed. What are their shortcomings? What are their risks?

Notes for an answer:

Place: very helpful for supplementary and postoperative analgesia, using long-acting agents.

Shortcomings: Note that these blocks by themselves are inadequate for surgery, because the gall bladder is often innervated by vagus
and/or phrenic nerves.

Performance: Clean skin first, have i.v. access and available resuscitation equipment.

Subcostal block: infiltrate subcostal area of abdominal wall in both subcutaneous and muscle layers, with local analgesic.

Risk: peritoneal, pleural or pericardial puncture.

Intrapleural block: insert i.v. or special cannula into pleural space at angle of rib, taking care to avoid pneumothorax and intercostal
artery puncture.

Risk: pneumothorax, and volumes of local analgesic required are close to toxic doses.

Intercostal block: short bevel needle inserted just below rib, posterior to angle, into subcostal groove.

Risk: haematoma and pneumothorax. The problem of overlap of innervation from adjacent intercostal nerves is solved by blocking
multiple spaces.

Comment: There is a great risk of over-running your allotted time. Keep this answer in note form.

Serious omissions likely to cause a fail:


Failure to mention at least two of these blocks.

<><><><><><><><><><><><>
Page 91

Give a brief description of the sensory nerve supply of the thoracic cage and abdominal wall

Notes for an answer:

Supraclavicular nerves in pectoral region.

The thoracic intercostal nerves T1-T12; each one has sensory input to dorsal horn; these nerves cross intra- and extradural spaces,
and traverse intervertebral foramina, T1 goes via brachial plexus, other anterior divisions travel in subcostal grooves. Cutaneous
branch given off in midaxillary line; intramuscular branch continues, both cross the costal cartilages, and enter abdominal wall (in
subcutaneous and intramuscular layers respectively), and proceed to midline, where intramuscular branch surfaces. T4 to sternum,
T10 to umbilicus. Lumbar nerve of L1 supplies inguinal region, scrotum and labia.

Comment: A diagram would be helpful here.

Serious omissions likely to cause a fail:


Failure to mention the cutaneous branch.

<><><><><><><><><><><><>

Write short notes on ropivacaine

This answer needs most of the following headings:

Pharmacy:

Type of chemical (amide), storage (aqueous solution in glass ampoules), concentration (0.5-1%).

Pharmacodynamics:

Mode of action, inhibition of nerve conduction

Clinical effects, local analgesia

Dose, 0.5-1%

Onset, 20 mins.

Duration, 8-9 hrs.

Pharmacokinetics:

Routes of administration, infiltration, epidural

Metabolism, liver

Side effects, less toxic than bupivacaine

Plus other features: better motor block than bupivacaine

<><><><><><><><><><><><>
Page 92

Briefly describe the anatomical relations of the brachial plexus

Notes for an answer:

Relations:

Transverse processes of C5-T1; scalenus anterior and medius, whose fascia helps to form its sheath.

In the posterior triangle of the neck, it lies on the upper surface of the first rib. Under the clavicle and subclavius it joins the
subclavian vessels, and lies on the second rib and first intercostal space, which separate it from the pleura. The shoulder joint and
humerus lie laterally as it traverses the axilla.

Comment: It is a great help to have thought this answer out before meeting it in an examination!

Serious omissions likely to cause a fail:


Failure to mention the neck, the first rib and the axilla.

<><><><><><><><><><><><>

What are the complications of the supraclavicular and axillary brachial plexus blocks and how do you recognise them?

Notes for an answer:

Complications (with signs for recognition in brackets):

1. Nerve damage (pain on injection, involuntary movement of arm, failure to recover function after block wears off).

2. Vessel damage (intravascular injection, with immediate toxic effects; later, haematoma and ensuing thrombosis).

3. Pleural damage with pneumothorax (cough, collapse, cyanosis, hypoxia, seen on chest X-ray).

4. Thoracic duct damage (development of chyloma).

5. Infection (heat, redness, swelling, pain, loss of function).

6. Toxic effects of local analgesic (hypotension, arrythmias, convulsions, hypoxia).

Comment: Extra marks for identifying major and minor complications and their frequency.

Serious omissions likely to cause a fail:


Failure to mention pleural damage or pneumothorax.

<><><><><><><><><><><><>
Page 93

Describe the anatomy of the sacral canal and its contents

Notes for an answer:

Extends from the lower border of L5 to sacral hiatus, S4-5; bounded posteriorly by fused laminae, anteriorly by fused vertebral
bodies, laterally by pedicles and sacral intervertebral foraminae. It is lined with periosteum. Contents—fat, cauda equina with pia
mater, filum terminale, veins, lymphatics and minor arteries, dura (to lower border of S1 or upper border of S2 (S3 in small children).

Comment: This is essential anatomical knowledge for anaesthetists.

Serious omissions likely to cause a fail:


Failure to mention cauda equina and dura.

<><><><><><><><><><><><>

Describe the anatomy of the epidural space at the level of the fourth lumbar vertebra

A canal formed anteriorly by body of vertebra and discs; posteriorly by neural arch (laminae), laterally by pedicles with neural
foraminae. Lined by periosteum with posterior longitudinal ligament anteriorly, ligamentum flavum posteriorly.

Contents: epidural space—fat veins lymphatics, nerves with dural cuff.

Traversed by dural sac—dura and arachnoid maters, subarachnoid space and CSF. This is traversed by cauda equina with pia mater
(cord ends at L2), and filum terminale.

Comment: This is essential anatomical knowledge for anaesthetists.

Serious omissions likely to cause a fail:


Failure to mention cauda equina and dura.

<><><><><><><><><><><><>
Page 95

Chapter 12
Medicine and Surgery Related to Anaesthesia
Page 96

What precautions should you take when anaesthetising a patient known to have suffered from viral hepatitis?

Notes for an answer:

1. Protect staff and other patients—assessment of infectivity of patient (HBAge, Hepatitis A, Hepatitis C and other infective
diseases), information to all staff, use of disposable equipment and safe disposal. Use of gloves etc., practice of correct "sharps drill".
Check Hepatitis B immunisation status of all staff.

2. Protect patient—liver function tests to assess hepatic reserve, and appropriate care with dosages of drugs.

Comment: It would be difficult to know how much detail to give in this answer. This would have to be dictated by the time available.

Serious omissions likely to cause a fail:


Failure to mention protection of staff.

<><><><><><><><><><><><>

Write short notes on verapamil hydrochloride

This answer needs most of the following headings:

Pharmacy:

Type of chemical, storage (tablets, aqueous solution), preparation, concentration

Pharmacodynamics:

Mode of action, Ca++ channel blocker, mainly slow channel cardiac effects

Clinical effects, class 4 antiarrythmic; increases refractory period, reduces excitability and dilates arterioles

Dose, oral—100-500 mg/day, adult; 2.5 mg i.v.

Onset, minutes

Duration, hours

Pharmacokinetics:

Routes of administration, oral

Side effects, constipation

Interactions, digoxin, volatile anaesthetics, beta blocking drugs

<><><><><><><><><><><><>
Page 97

How would you manage atrial fibrillation which occurs during anaesthesia? What could be done to prevent it?

Notes for an answer:

ECG monitoring is essential for recognition.

1. Management:

a) Use of adenosine, 3mg i.v.—for diagnosis;

b) Use of DC shock (bonus marks for management of this during regional analgesia);

c) digoxin 0.5mg i.v. to control ventricular rate if > 100bpm;

d) amiodarone 1g infusion to prevent recurrence;

e) use of beta blockade in thyrotoxicosis;

f) need for notes about the care of resulting cardiac failure and embolism problems.

2. Prevention:

a) recognition of the at-risk patients (thyrotoxicosis/myocardial ischaemia/ mitral stenosis/previous atrial fibrillation/Sick sinus
syndrome/elderly with hypokalaemia). Preoperative ECG is essential for this;

b) Avoidance of hypotension at induction in the elderly;

c) Preoperative correction of hypokalaemia.

Serious omissions likely to cause a fail:


Failure to mention the ECG and the resulting cardiac failure

<><><><><><><><><><><><>

Write short notes on the diagnosis and treatment of pneumothorax

Notes for an answer:

1. Diagnosis:

The answer needs comments about when this is likely to confront the anaesthetist, and the difficulty of locating the side.

a) symptoms: pain, dyspnoea, cyanosis, cardiovascular collapse, especially in tension pneumothorax or bilateral pneumothorax;

b) signs: abnormal breath sounds, abnormal chest movement, coin test;

c) tests: CXR—mediastinal shift, loss of lung markings in periphery.

2. Treatment:

This may be a major life-threatening emergency. IPPV may make the condition worse! Need for (i.v.) cannula in third ribspace
anteriorly, and chest drain techniques, after which IPPV will be safer.

<><><><><><><><><><><><>
Page 98

Write short notes on doxapram

This answer needs most of the following headings:

Pharmacy:

Type of chemical, storage (aqueous solution in glass ampoules and plastic bags), preparation, concentration (2 mg or 20 mg/ml.)

Pharmacodynamics:

Mode of action, peripheral chemoreceptor stimulant

Clinical effects, nonspecific respiratory stimulant

Dose, 1 mg/kg., better given as infusion

Onset, minutes

Duration, 1 hour

Pharmacokinetics:

Routes of administration, i.v.

Metabolism, liver

Side effects, tachycardia, dizziness, sweating, muscle fasiculations.

Interactions, MAOI's; aminophylline (agitation)

<><><><><><><><><><><><>

Write short notes on aminophylline

This answer needs most of the following headings:

Pharmacy:

Storage (aqueous solution in glass ampoules)

Pharmacodynamics:

Mode of action, cyclic AMP inhibition

Clinical effects, bronchodilator and stabiliser of cardiac rhythm

Dose, 100-250 mg.

Onset, rapid

Duration, 4-6 hrs.

Pharmacokinetics:

Routes of administration, oral, i.v.

Side effects, gastric irritation, CNS stimulation, hypokalaemia

Interactions, Ephedrine (in children); phenytoin, carbamazepine, barbiturates, doxapram

Plus other features: regular monitoring of theophylline levels required

<><><><><><><><><><><><>
Page 99

What problems does hiatus hernia pose for the anaesthetised patient and how do you cope with them?

Notes for an answer:

1. Regurgitation and aspiration of highly acidic juice causes pulmonary airways burn; if this occurs, it is managed by tracheal
washout, IPPV, possibly steroids and antibiotics.

2. Haemorrhage from peptic ulcer, if present; oesophagitis; resultant anaemia.

3. The giant hiatus hernia may interfere with lung function.

4. Managed by premedication with H2 antagonist and metoclopramide. Cricoid pressure is needed during induction, with tracheal
intubation to protect lungs.

Needs discussion of difficulty of insertion of nasogastric tube and pHi estimation.

Serious omissions likely to cause a fail:


Failure to mention cricoid pressure, and H2 antagonists.

<><><><><><><><><><><><>

What is the relevance to anaesthetic management of ankylosing spondylitis? What strategies would you employ to overcome
them?

Notes for an answer:

Problems:

Stiff neck and jaw—intubation difficulty; reduced pulmonary function needs assessment, esp. if kyphotic.

Strategies:

1. Use of regional blocks; spinal blocks are desirable but difficult!—spinal X -ray is needed.

2. Elective fibreoptic intubation or tracheostomy may be needed if general anaesthesia is unavoidable, especially if there is:

a) known history of difficult intubation—Cormack & Lehane scores from previous laryngoscopies;

b) poor mouth opening (< 3fb);

c) low Malampatti score;

d) short thyromental distance (< 6cm);

e) small mandible size and inability to protrude jaw;

f) neck stiffness (you would need to mention neck X-rays here). This is perhaps the most critical of these features.

Serious omissions likely to cause a fail:


Failure to mention difficult intubation and reduced lung function.

<><><><><><><><><><><><>
Page 100

Write short notes on nifedipine

This answer needs most of the following headings:

Pharmacy:

Storage (liquid in capsules)

Pharmacodynamics:

Mode of action, calcium channel antagonist

Clinical effects, percentage lowering of arterial pressure in hypertension; coronary vasodilation.

Dose, 10 mg.

Onset, minutes

Duration, 4-8 hrs.

Pharmacokinetics:

Routes of administration, oral, sublingual

Side effects, headaches dizziness and flushing

Interactions, potentiated by cimetidine

Plus other features: fast onset; no rise of intraocular pressure

<><><><><><><><><><><><>

How does the presence of aortic stenosis affect the management of an anaesthetic?

Notes for an answer:

Fixed cardiac output, with risk of severe hypotension on induction; vasodilation is to be avoided. Coronary flow reduced, risk of
endocarditis (need for antibiotic cover) and subendocardial ischaemia if inotropes are given in large dosage. (Bonus marks for stating
that HOCM is worsened by inotropes).

Comment: It is particularly important to mention that coronary flow is dependent on diastolic pressure, and that tachycardia is to be
avoided as it shortens diastolic interval.

Serious omissions likely to cause a fail:


Failure to mention fixed cardiac output, with risk of severe hypotension on induction.

<><><><><><><><><><><><>
Page 101

What would happen if a full dose of thiopentone was given to a patient with acute intermittent porphyria and why?

Notes for an answer:

The patient would become anaesthetised, but:

Thiopentone stimulates hepatic delta ALA synthase, giving excess porphyrins, causing:

a) neuropathy, epilepsy, psychiatric symptoms;

b) abdominal pain and vomiting;

c) tachycardia, hypertension, acute LVF;

d) red urine.

This is a dose-related effect.

Neuropathy may last for weeks, needing IPPV, and intensive care.

Serious omissions likely to cause a fail:


Failure to mention delta ALA synthase, and neuropathy.

<><><><><><><><><><><><>

What is the management of an acute sickle cell crisis?

Notes for an answer:

1. Remove precipitating factor, e.g., cannabis, hypoxia, cold, acidosis.

2. Give oxygen and rehydrate the patient.

3. Prevent cold, hypoxia and acidosis occurring during treatment.

4. Control very severe pain with large doses of opiates.

5. Prevent joint and organ damage which can be fatal.

6. Exchange transfusion has been used with success.

Serious omissions likely to cause a fail:


Failure to mention pain and need for oxygen.

<><><><><><><><><><><><>
Page 102

In what ways does Down's Syndrome affect the management of an anaesthetic?

Notes for an answer:

1. Resistance to sedatives.

2. Large size and difficult veins.

3. Excess salivation and large tongue.

4. Associated ASD and VSD, with risk of intracardiac shunting and endocarditis (need for antibiotics).

5. Immune deficiency with risk of infection and cross infection.

6. Communication problems resulting in fear and failure to comply with instructions (rapport with parents essential).

Comment: Anaesthetists should be professionally competent in these situations.

Serious omissions likely to cause a fail:


Failure to mention the cardiac complications.

<><><><><><><><><><><><>

What precautions should be taken when anaesthetising a patient with dystrophia myotonica?

Notes for an answer:

1. Prevention of aspiration of stomach contents.

2. Prevention of prolonged apnoea by avoiding thiopentone.

3. Prevention of cardiovascular depression and dysrhythmias by being sparing with volatile agents.

4. Prevention of severe myotonia by avoiding suxamethonium.

5. Awareness that nondepolarising relaxants do not stop myotonia.

6. Awareness that anticholinesterases may worsen myotonia.

7. Dantrolene may reduce myotonia and should be available.

8. Central neural blockade is useful (if appropriate).

9. Postoperative IPPV may be required.

10. Preparedness for these patients to be very heavy for their age.

Comment: This is rare but important.

Serious omissions likely to cause a fail:


Failure to mention the risks of thiopentone and suxamethonium.

<><><><><><><><><><><><>
Page 103

How do the intraoperative surgical complications of excision of thyroid goitre affect the management of the anaesthetic?

Notes for an answer:

1. Stimulation of carotid baroreceptors by surgical manipulations may destabilise arterial pressure. Surgery may cause haemorrhage,
pneumothorax; splitting of sternum would require IPPV; recurrent laryngeal palsy and external laryngeal palsy may cause
postoperative airway obstruction; concomitant parathyroidectomy may cause early postoperative tetany.

2. Damage to the trachea (including tracheomalacia) may occur with postoperative airway obstruction.

3. Finally—the surgical elbow in the patient's eye!

Serious omissions likely to cause a fail:


Failure to mention need for IPPV; postoperative airway obstruction.

<><><><><><><><><><><><>

What are the anaesthetic problems posed by surgical removal of a phaeochromocytoma?

Notes for an answer:

1. Preoperative unstable arterial pressure requiring alpha and (later) beta blockade with restoration of circulating blood volume.

2. Avoid histamine releasers in premed and anaesthetic—they may cause a crisis.

3. Vasodilators may be needed for operative hypertension.

4. Vasoconstrictors (adrenaline, noradrenaline, angiotensin) needed for post-removal hypotension.

5. Requires full-scale monitoring (details needed).

6. Secondary phaeochromocytomas may be missed at operation, with postoperative ongoing symptoms.

Serious omissions likely to cause a fail:


Failure to mention unstable arterial pressure; histamine releasers and need for full-scale monitoring.

<><><><><><><><><><><><>
Page 104

What are the anaesthetic problems posed by surgical removal of a parathyroid adenoma and how do you cope with them?

Notes for an answer:

1. Excessively high Ca++ would pose a risk of serious arrythmias (may need emergency lowering of Ca++, antiarrythmic drugs and K+
infusion).

2. Pneumothorax (prevention by IPPV, treatment by chest drain).

3. Air embolus (prevention by avoiding too steep head-up tilt, treatment by turning patient on side and evacuation by central line).

4. Haemorrhage (treated by infusion and transfusion).

5. Recurrent nerve damage (with postoperative obstruction, requiring reintubation).

6. Postoperative tetany requiring Calcium injection (needs details of preparations and doses).

Comment: This is an easy question.

Serious omissions likely to cause a fail:


Failure to mention postoperative tetany requiring Calcium.

<><><><><><><><><><><><>

What are the complications of mitral valve disease during anaesthesia and how do you prevent them?

Notes for an answer:

1. Fixed cardiac output, with risk of serious vascular instability (avoidance of cardiac depression, vasodilation and tachycardia).

2. Acute left ventricular failure, with pulmonary oedema, requiring diuresis with frusemide.

3. Bacterial endocarditis, (requiring antibiotic cover).

4. Atrial fibrillation (requiring control of rate and treatment of left ventricular failure). This may cause:

a) arterial thromboembolism, prevented by anticoagulation;

b) cardiac failure, requiring careful use of inotropes.

Serious omissions likely to cause a fail:


Failure to mention atrial fibrillation and bacterial endocarditis.

<><><><><><><><><><><><>
Page 105

A patient's arterial pressure on admission for moderately urgent appendicectomy is 170/115 mmHg. Describe your
anaesthetic management

Notes for an answer:

The anaesthetist checks it for himself! (It can be due to pain, a full bladder, and the answer requires a brief discussion of hypertension
due to fear.)

Investigation of Causative Conditions:

a) generalised vascular disease, possible renal and other rare causes of hypertension (e.g., phaeochromocytoma);

b) is the patient's abdominal pain due to another, medical, cause? Could it be angina due to hypertensive crisis?

Management:

Prevention of risks;

• hypotension under anaesthesia;

• myocardial infarction;

• cerebral haemorrhage;

• ECG required;

• this diastolic pressure is too high for safety. The operation is postponed for emergency medical treatment, involving relevant
specialists.

Relevant Drugs:

• nifedipine;

• beta blockers;

• ACE inhibitors;

• Ca channel blockers;

• clonidine, with rapid and carefully monitored intravascular volume replacement.

Antibiotics are required to cope with a short period of postponement of operation. Spinal anaesthesia not advisable because of
cardiovascular instability.

Comment: The answer to this is longer than many in this book.

Serious omissions likely to cause a fail:


Failure to mention emergency medical investigation and treatment of hypertension; and risk of severe
hypotension under anaesthesia.

<><><><><><><><><><><><>
Page 106

A patient with congestive cardiac failure presents for hip replacement. Describe your management for the anaesthetic

Notes for an answer:

Postpone the operation and control the cardiac failure.

Problems:

1. The implication is that the patient has serious cardiac and possibly other organ disease, and requires full investigation, e.g., by
ECG, echocardiography and relevant blood tests.

2. Cardiac depression by anaesthetics, and

3. uncontrolled vasodilation from cement are the notable risk points, with the emphasis on prevention.

4. Haemorrhage may be considerable with need for accurate volume replacement with monitoring.

Comment: This is not an uncommon scenario.

Serious omissions likely to cause a fail:


Failure to mention postponement of operation.

<><><><><><><><><><><><>

A patient presenting for prostatectomy has a pulse rate of 39 beats per minute. Describe the common causes and
management of this

Notes for an answer:

This answer needs a comment on what pulse rates are acceptable and what the target pulse rate would be.

Causes:

1. Heart block (will need anticholinergics and possibly pacing).

2. Treatment with beta blockers (reduce the dose and/or use other drugs; premedicate with anticholinergics).

3. Sick sinus syndrome (common in this patient population with risk of atrial fibrillation, supraventricular tachycardia, ventricular
tachycardia and ventricular fibrillation).

4. Failure of implanted pacemaker (needing referral to cardiologist).

This all implies serious cardiovascular disease.

ECG and full drug history is essential (esp. beta blockade). Specialist medical advice is helpful. Operation will need to be postponed
until the pulse rate is normal.

Risk of further bradycardia during and after anaesthetic.

Serious omissions likely to cause a fail:


Failure to mention that this sign usually indicates serious cardiovascular disease.

<><><><><><><><><><><><>
Page 107

How does the common cold influence fitness for anaesthesia?

Notes for an answer:

1. A genuine cold presents a risk of postoperative chest infection, which depends on severity of cold and need for intubation.

2. Risk of laryngeal spasm/bronchospasm/cyanosis during operation.

3. Risk of cardiac arrest in children—up to 4-6 weeks after infection.

This answer requires a brief discussion about difficulty in diagnosis because of fast onset of colds in children, and differentiation
from teething, and blocked nose due to adenoid hypertrophy—the presence of pyrexia is a useful sign.

Tonsillectomy during a cold may cause marked haemorrhage and local infection.

Serious omissions likely to cause a fail:


Failure to mention the risk of laryngospasm and cardiac arrest in children.

<><><><><><><><><><><><>

Write short notes on atrial fibrillation

Notes for an answer:

Causes: ischaemia, rheumatic heart disease, thyrotoxicosis; triggers: hypotension and hypokalaemia.

Diagnosis: irregularly irregular pulse (including deficit), and cannon waves. The ECG makes the diagnosis. The answer needs a
comment on the significance of uncontrolled rate.

Complications: poor cardiac output, left ventricular failure, emboli (requiring anticoagulation).

Treatment: need to mention adenosine, DC shock, amiodarone, digoxin, and the indications for anticoagulation.

Serious omissions likely to cause a fail:


Failure to mention cardiac failure.

<><><><><><><><><><><><>
Page 108

How do you judge the significance and plan the management of preoperative anaemia?

Notes for an answer:

Significance: What has caused it? How severe is it? (When the Hb is below 10g/dl. it will cause reduced oxygen carriage). Is it acute
or chronic (with compensation by raised 2.3 DPG)?

Does the patient have chronic renal failure (high blood urea and creatinine)/ carcinomatosis (skeletal X-ray survey)/leukaemia (blood
film)/malnutrition (red cell volume)/coagulopathy (coagulation profile, drug history)/chronic bloodloss from gut, bladder or uterus
(microcytosis)/aspirin or NSAID usage? There will be reduced O2 flux and possibly high output cardiac failure if severe.

Investigations: The medical history will have indicated which lines should be further investigated.

Management: The relevant issues are:

a) how severe;

b) how acute the anaemia is and whether it is ''renal" (accept Hb of 7-8g/dl); and how urgent surgery is (emergency indicates
transfusion, and possibly urgent need to stop cause of bleeding if possible).

The non-urgent situation calls for discussion of Fe++ therapy, erythropoeitin, and correction of haemostasis factor levels.

Comment: This is a common problem but not an easy question to answer.

Serious omissions likely to cause a fail:


Failure to mention oxygen carriage.

<><><><><><><><><><><><>
Page 109

A patient with non-insulin-dependent diabetes is to undergo amputation of an infected gangrenous leg. What is the correct
peri-operative management of the diabetes?

Notes for an answer:

You need to state that this diabetes will be out of control.

Issues to mention include:

a) History of patients previous diabetic status.

b) Involvement of diabetologist.

c) Assessment of current biochemical status plus awareness of possible loss of control due to gangrene—danger of hyper- and
hypoglycaemia—requiring assessment of blood glucose, electrolytes, hydration status (Hartmann's solution is avoided because of
lactate load).

d) Preoperative management—antibiotics, rehydration urine output, hourly blood glucose and electrolyte monitoring, insulin
prescription (sliding scale/Alberti regime: K+, insulin, glucose infusion).

e) Operative management—maintain diabetic regime, monitor blood sugar (intervals of 1 hour on average).

f) Postoperative management—Awareness of rapid improvement in diabetes, use of sliding scale, timing of return to preoperative
regime.

Comment: This is quite a common clinical situation.

Serious omissions likely to cause a fail:


Failure to mention diabetes will be out of control, with need for insulin.

<><><><><><><><><><><><>
Page 110

How would you judge the significance of preoperative jaundice?

Notes for an answer:

Causes:

Is there infective hepatitis?—need to test for HBAge, Hepatitis A, Hepatitis C, and enquire about malaria, glandular fever. Would
there be a crossinfection risk for staff?

Is it due to; drugs (paracetamol, halothane), with risk of fulminating hepatic failure (what is the drug history?); gallstones; Gilbert's
syndrome; haemolysis; cirrhosis; Ca pancreas; pancreatitis (Serum amylase and blood glucose levels are required)?

Effects:

Has it affected blood coagulation, and therefore jeopardise haemostasis? Is there hepatic failure (function tests needed)? Is there
concomitant renal failure (electrolyte tests)?

Are there cerebral effects, e.g., in the neonate?

Serious omissions likely to cause a fail:


Failure to mention the appropriate tests.

<><><><><><><><><><><><>

How do antihypertensive drugs affect the management of anaesthesia?

Notes for an answer:

1. They reduce raised arterial pressure (this needs a little discussion of the limits, and target pressures at different ages).

2. They commonly vasodilate the patient, which requires care in the use of vasodilating anaesthetics.

3. They commonly increase circulating volume, which is a safety factor, and the indication for continuing medication through the
perioperative period.

4. Beta blockers may limit changes of cardiac rate and output and cause severe bradycardia.

5. Some cause renal failure in certain situations, with problems of anaemia, hyperkalaemia, acidosis and prolongation of relaxants.

6. Clonidine will potentiate anaesthetics and analgesics.

7. Thiazides lower the serum K+, prolonging and potentiating nondepolarising relaxants.

8. Withdrawal of some antihypertensives cause excessive rebound of arterial pressure.

Comment: This is common clinical scenario.

Serious omissions likely to cause a fail:


Failure to mention lowered arterial pressure.

<><><><><><><><><><><><>
Page 111

What are the functions of the thyroid gland and how are they controlled? What are the effects of thyroid dysfunction on
anaesthesia?

Notes for an answer:

Functions: production of thyroxine and T3 to control metabolic rate, growth, cerebral activity. They interact with other hormones.

Control: TSH from anterior pituitary; negative feedback control.

Effect of Dysfunction:

a) myxoedema—sensitivity to anaesthetics and cold, instability of circulation;

b) thyrotoxicosis—atrial fibrillation, thyroid crisis.

Serious omissions likely to cause a fail:


Failure to mention myxoedema and atrial fibrillation.

<><><><><><><><><><><><>

In what circumstances may fluid overload occur during operation? How is it diagnosed and managed?

Notes for an answer:

1. Overestimation of the operative losses (e.g., in laparoscopic operations), with overinfusion.

2. TURP syndrome, with absorption of irrigant.

3. In severe toxaemia with capillary hyperpermeability, causing pulmonary oedema.

4. Where the patient has inappropriate ADH secretion, renal failure, acute left ventricular failure.

5. During and after cardiopulmonary bypass.

Diagnosis: onset of hypoxia, rise of ventilation pressures, auscultation of crepitations in the lungs, froth in tracheal tube.

Management: diuretics, treatment of acute heart failure, oxygenation, fluid restriction, triple strength albumin if appropriate.

Comment: CEPOD have emphasised the importance of this.

Serious omissions likely to cause a fail:


Failure to mention TURP syndrome and overinfusion.

<><><><><><><><><><><><>
Page 112

Name and define the different types of hypoxia. Where are they seen clinically?

Notes for an answer:

1. Hypoxic—PaO2 is low (inadequate respiration, low FiO2).

2. Anaemic—Hb and O2 carriage is low (anaemia; Hb < 10g/dl).

3. Stagnant—bloodflow is slow (poor cardiac output, obstruction of peripheral vasculature).

4. Histotoxic—tissues are unable to utilise delivered O2 (CO poisoning, cyanide poisoning).

Comment: This is basic physiology upon which anaesthetic practice is based.

Serious omissions likely to cause a fail:


Failure to mention all four types.

<><><><><><><><><><><><>

What is the mode of action of the following in lowering arterial pressure?

• Isoflurane — vasodilation

• Halothane — negative inotropy and vasodilation

• Propofol — vasodilation

• Lignocaine — negative inotropy

• Enflurane — negative inotropy and vasodilation

• Desflurane — vasodilation

• Thiopentone — negative inotropy and vasodilation

• GTN — vasodilation

• Pulmonary embolism — physical obstruction of circulation

• Ruptured aortic aneurysm — reduction of bloodvolume and afterload

• Septic shock syndrome — negative inotropy, pulmonary vasoconstriction, opening of A-V anastomoses

• Ventricular fibrillation — no cardiac output

• Spinal anaesthesia — vasodilation

• Anaphylactic shock — vasodilation

<><><><><><><><><><><><>
Page 113

Describe all the clinical actions of one anaesthetic agent and two other drugs you might use to lower arterial pressure during
anaesthesia

Notes for an answer:

Many drugs can do this, e.g., halothane, enflurane, isoflurane, desflurane, alpha and beta blockers, ganglion blockers, direct
vasodilators (SNP and nitrates), hydrallazine clonidine.

Comment: Space forbids a full treatment of all the possibilities for this answer. The pharmacodynamics and side-effects should all be
mentioned as in the answers to the "Write short notes on. . ." questions).

<><><><><><><><><><><><>

Write short notes on amiodarone

This answer needs most of the following headings:

Pharmacy

Pharmacodynamics:

Mode of action, a K+ channel blocker which uncouples beta receptors from the regulatory unit of the adenylate cyclase complex

Clinical effects, class 3 antiarrythmic, control of ventricular and supraventricular arrythmias

Dose, 100-250 mg.

Onset, rapid

Duration, months

Pharmacokinetics:

Routes of administration, oral, i.v.

Metabolism, liver (halflife 26-107 days)

Side effects, mild negative inotrope; microdeposits of drug in cornea; pulmonary interstitial infilatration.

Interactions, prolongs life of digoxin; potentiates other antiarrythmics;

Plus other features: affects thyroid function; avoid in porphyria, contains iodine.

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Page 114

Write short notes on adenosine

This answer needs most of the following headings:

Pharmacy:

Type of chemical (endogenous nucleoside)

Pharmacodynamics:

Mode of action, stimulation of A1 receptors

Clinical effects, negative chronotropy on sinus node, negative dromotropy on atrioventricular node; termination of supraventricular
tachycardias

Dose, 3 mg.

Onset, one circulation time

Duration, 1 minute

Pharmacokinetics:

Routes of administration, i.v.

Interactions, alteration of potency of anaesthetics

Plus other features: avoid in sick sinus syndrome, heart block, and asthma

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Page 115

Chapter 13
Faciomaxillary, Ophthalmic and ENT
Page 116

What complications of operations on the bony structures of the lower half of the face may affect the anaesthetic management,
and how do you deal with them?

Notes for an answer:

1. "Oculocardiac" reflex — bradycardia — atropine needed.

2. Interference with tracheal tube, the nasal route may be preferable, and armoured tube may be required.

3. Massive haemorrhage, requiring massive crossmatch and massive transfusion, with CVP monitoring.

4. Postoperative airway problems, due to swelling and pre-existing abnormalities.

5. Postoperative vomiting problems when the jaws have been wired together, requiring antiemetics, awake extubation and strategy
for emergency unwiring.

Comment: This is another example of demonstrating your skills in an important clinical scenario.

Serious omissions likely to cause a fail:


Failure to mention bradycardia, massive haemorrhage and airway problems.

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A patient requires an anaesthetic for removal of an infected molar tooth which is causing severe trismus. Describe the
problems and outline the anaesthetic methods

Notes for an answer:

1. Problems — woody swelling in pharynx, unable to open mouth, severe local infection and toxaemia, pus in pharynx. Local
anaesthesia is unhelpful. Relaxants will not usually relax trismus, because the spasm arises in the muscles of mastication themselves.

2. The airway should be secured, and needs a brief discussion of four methods: General anaesthesia; awake fibreoptic intubation;
blind nasal (not easy because of swollen tissues); tracheostomy (difficult if the neck is also swollen); induction of general
anaesthesia: the safest is inhalation induction, using high O2, spontaneous breathing, e.g., with halothane or sevoflurane; not IV
induction.

3. Trismus relaxes under general anaesthesia and cords may be visualised in the usual way. There is still the problem that pus may be
in the pharynx.

4. Awake extubation is safest for the airway.

Comment: This question is about a safety issue.

Serious omissions likely to cause a fail:


Failure to mention trismus not releasing with relaxants; and three of the above approaches to intubation,
with problems.

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Page 117

Describe the anaesthetic management for a patient with a perforating eye injury who had a large meal in the last hour

Notes for an answer:

1. Postpone the operation if possible; if not possible:

Premedication with metoclopramide and H2 antagonist.

2. The use of suxamethonium is controversial as it raises intraocular pressure.

3. The use of intubation is controversial as it also raises intraocular pressure. Opiates are important here.

4. If intubation is essential, cricoid pressure is required, and a very careful laryngeal spray with lignocaine.

5. Laryngeal mask has been used successfully, after a period of saturation.

6. Postoperatively, prevention of coughing and vomiting is important.

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Describe the anaesthetic management for a 5-year-old patient who requires reoperation for haemorrhage an hour after
tonsillectomy

Notes for an answer:

1. Assessment and resuscitation: intravenous infusion of colloids and blood until the patient is clinically not shocked (details needed).
Oxygen is required.

2. Premedication: not usually required for tonsillar haemorrhage in the first six hours after operation.

3. Induction of anaesthesia: rapid sequence induction with cricoid pressure and intubation.

4. Maintenance of anaesthesia: light anaesthetic, a nasogastric tube is passed and the stomach emptied.

5. Postoperative care: further assessment of shock, anaemia, and analgesia. Oxygen is required.

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Page 118

How would you perform a block of the maxillary nerve?

Notes for an answer:

1. Preoperative: assess patient (details required, including anticoagulation); gain consent.

2. Operative: availability of resuscitation equipment, i.v. access, clean skin. Full monitoring is applied.

3. Short-bevel needle is inserted below mid point of zygoma, above mandible, and advanced towards contralateral eyeball until it
meets pterygoid plate. It is then angled upwards and forwards and advanced 1 cm. to enter the pterygomaxillary fissure, close to the
maxillary nerve. Aspiration is performed:

a) nothing aspirated — inject 2 mls of local analgesic;

b) blood is aspirated — move needle slightly to exit bloodvessel;

c) air is aspirated — withdraw needle 0.5-1cm — the tip is in the nasal cavity!

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Page 119

NOTES