Final Frca Viva _june 2011

8/10/2019 Final Frca Viva _june 2011

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Final FRCA viva questions from June 2011 exam

Coventry collection: Many thanks to the candidates form June 2011 Course 1

Some general feedback for the day for any future candidates:

During the exam, as all candidates take the exam in small booths all in the same room, thenoise levels can be quite high and during pauses to think, it is possible to hear candidates in

the next booth answering their questions! Don't let this put you off! It can be quite

distracting but you really do need to ignore any other conversations.

Some of the radiographs are on computer screens now, and will be shown as such during

the 10 minute prep as well as on paper too. In the examiners booth, the CXR was on acomputer screen not on paper.

Practice the timing for your 10 minute preparation for your long case with a watch you can

wear to the exam. Where I was sat, you couldn't see a clock and so couldn't work out howmuch of the 10 minutes had elapsed. Consequently, even though I had always been well

under the 10 mins prep time in my practices, on the day I just ran out of time.

The examiners may move you on quickly and sometimes want quite 'punchy' answers.Don't let this upset you, go with where they are directing you and be flexible in your

approach with your answer structure. But in general, start broad, classify and work towardsthe details.

The examiners may really push you and come across quite mean! In my science viva, I

thought I was doing badly and nearly felt defeated but picked myself up and pushed on. Atthe end, when I'd passed and was chatting to the examiner with a glass of wine in hand he

said he knew I'd passed and was pushing me to get to the minutiae, and all along I thought

I was failing! You will be a bad judge of how you're doing so keep going, don't getdefeated or angry!

Set1

21 year old 32 weeks pregnant lady presents to Ante natal ward with chest pain and

breathlessness on exertion and rest, she did not receive her antennal appointment as shewas worries that they will advise her to terminate her pregnancy as they did 2 years back,

so she has not been seeing anyone since 3 years, she is known to have a bicuspid Valve(

Aortic Valve)ECG T wave inversion in Lead III and V1 rest all ecg Normal

ECHO - Peak gradient 78 mm of Hg and mean 38mm of Hg

Ejection Fraction 60%, Valve area 1 cm2Good systolic functions

Calcifications on the cusps

X ray- No cardiomegaly but interstitial oedema present characteristic bat winged

appearance with prominent hilum . (Pulmonary HTN)Bloods- Hb 11


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Questions i was asked

Summrise

InvestigationsWhy she is breathless- AS and preg fixed CO state, details of cardiac changes in preg

affecting AS

Managemant She should have a elective LSCS. Examiners happy with answer not tokeep her in DGH , transfer her where facility exists for Valve replacement.

Now in tertiary centre How would you anaesthetise her.

In this i Answered as we tend to answer like , consent , monitoring , invasive , blood loss ,temp , urine output .

GA/ RA . why not Spinal and what are advantages of CSE

What monitorning

Drugs Thio and eximers asked any other drug ( Etimidate ) with TAP Block . Multimodalanalgesia

Now she Bleeds Management Ergometrine avoid Oxytocin as it causes Hypotension

and decreases SVR which is not good for her , also prostaglandins like PGF2a and PGE2

Where will she be after words post op (HDU/ITU) depending on how operation goes.

Management on ITU . FLATHUGWhat about Breast feeding opoids and Benzodiazepine .

Short Cases

1.ECT What is ECT, How is it helpful , how does it works ,Q-What are key in preop management

Answer-Full history, lots of comorbidities , HTN , IHD , COPD , Poor historiens ,

Aspiration risk. Allergies , prev anaesthetic charts impQ- Drugs like litium how does it affect Anaesthetic drugs

Q- what changes does ECT prodA- On saying parasympathetic and Symp , they showed me a ECG where initial

aystole and then tachycardia .

B- I answered making sure that leads are not disconnected and feel for pulse if needed

use glycopyrolate and then atropine.

Q how would u anaesthetise her , what precautions will u take ?

A- Good pre op work up , as done in Isolated conditions if any risk factors i would do itwhere help can arrive and if no risk factors , Machine check , drugs ready , AAGBI

monitoring, trained assistant , Sr help around,and standard....................

Short case 2Pre-assement calls you that a lady has arrived for elective cholecystectomy and

mentions that lady says she suffers with Sickle cell Anaemia and nurse knows nothingabout the disease what will be your advise .

Initially i answered- to do basic check up take blood pressure and bloods for

electrophoresis or Sickeldex test and ECG then it clicked to me that there will be moreto the questions and i answered that i will ask the nurse to wait and i will down myself


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and see the lady ... my examiner almost jumped from her chair ... very happy , more

they were happy more confidence i was getting that things are moving in the rightdirections , KEEP SMILING ( it covers many things as we all think so many things and

so many things going in our minds )

Then questions startedWhat is SCA

Implications

Different haemoglobinsSystems like in college book

Crises Different types, i made a Pneumonic (VASH) Vaso , Aplastic, Sequestration ,

Haemolytic.Usual precipitants

Why stones pigment stones and also crises may mimick surgical emergency

Later she developed Acute chest Syndrome

Short Question 3.

Basic SciencesAnatomy of pherenic nerve.

Relations in the neck, thorax , and insetions on the diaphragmWhen does it get damaged

What happens when it get damaged

Which is longer

Diaphgarm Muscular and tendinious part

Supply (sensory , motor )

Openings

Thyroid hormonesSynthesisMechanism of actions

Effects

Hypo/ hyperthyroidismTreatment

Effects of anaesthetisings hypothyroid/ hyperthyroidism

Treatment of thyroid storm

Hypo/Hyper glycemia

Causes and effects of both hypo and hyper glycemia( Classify)

When on valve is hypoglycaemiaHow do you control stress resp leading to hypoglycaemia ,answer Insulin sliding

scale

Why not tight controlWhich paper

what effects on surgical outcome poor wound healing, dehiscence

drugs for oral hypoglycemics mech of action

-Physics----Scoliosis


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What are the key concern in this case

What are the effects of scoliosis on body systems (Classify )Restrictive diease , CVS , one lung ventilation . what will you see on PFT , Reduced

FVC but normal FEV1 therefore ratio increased

Associations of Scoliosis Muscular DystrophiesDiff positions and effects ( lateral approach and prone approach )

What all can be damaged Spinal cord ischemia

Why spinal cord ischemias , how does it happen and what can be done to minimise it .THEN QUESTION CAME ON PHYSICS

SSEP

How do you monitorWhich one is better

SSEP/MEP effects of NDMR /DMR on each of them

Any other

Epidural MEP.

Set 2

Clinical: Long case

55year old male 174cm, 74Kg. 1 day history of lower abdo pain and vomiting foremergency laparotomy. Smokes 20 day. Has Hx of alcohol excess unknown if still abuses

it. Nil meds.

Apyrexial HR 150 good BP. Bloods: Na 128 K 5.1 normal u&Es and normal LFTs FBCwhite cell counto f 12.4, neutrophilia. ECG AF rate 150, CXR LUZ changes ? old and

RMZ changes.

Discuss differentials: they wanted incarcetated hernia

Discuss how you would opitimis/ when he needs surgery and why

what montioing and why and what would you us e the art line for//tests/ picco etcDiscuss mx of AF and what route you would take/ anticoagulant etcAnaesthetic Mx and whether you would do epidural or not.

Critical incident: profound hypotension 1 hour into surgery

would you extubate him at end?

Short cases:

1.Young child for circumcision. Discuss analgesia...just like the Bricker book

2. 12 Year old for Cholesteatoma surgery. What is cholesteatoma, what makes the tumour,

which nerve is at risk, what are the special anaesthetic implications, how would youanaesthetise and what would you explain to pt: ponv/head bandage.

3.65yr old for carotid endarterectomy, shows you ecg with LBBB, 1st degree HB and

borderline LAD...not sure if it was LAD or not! Discussed anaesthetic implications. Riskbenefits of GA vs LA, Monitoring, how you proceed with each type of surgery.


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Basic Science

Anat:Pleural anatomy, what is in pleural space. How can it be breached. Discussed effusions,

transudate vs exudate analysis, pnumothorax causes and treatment. Anatomy of chest drain

insertion rather than technique specifically.

Physiology:

Alcoholic liver disease pt and why they get admitted to ICU. Then in depth discussion ofall of the systems involved

Measurement:

Breathing circuits. Indications for how you choose which type of circuit you will use.Circle system, advantages and disadvantages, volumes, substances that build up, where

valves are, what happens if exp valve jams open in spont breathing patient.

PharmacologyImmunosuppressants in patient post renal transplant. Why the renal function of the graft

may fail, what function you expect a graft to have and will renal function return to normal.Classes of mmunomodulator and side effects.

Set 31. Long case

65/M, smoker, alcoholic, one day H/O abdo painO/E HR 150/min, BP 135/70, ht/wt normal, bibasilar crackles

Bloods WCC 12, Na 128, K 5.1, rest wnl

CXR, changes of pulm oedema, L m/z opacity, ECG - A fib

Questions

summarizekey issues

pre op optimisation

when to operateSIRS

comment on bloods

how to treat blood abnormalities

what invasive monitoring, details of oesopahgeal doppler

CXR changes - pulm oedema findingsECG - Mx of A fib

intraop Mx, post op HDU Mx

Short cases

1. 3 yr old male child for circumcisionQ's - entire viva only on pain Mx, including penile/ caudal block techniques


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2. 65/M for carotid end arterectomy with ECG of trifascicular block

Describe ECG, pre/intra op Mx of CEA, GALA trial, adv/disadv of RA/GA in this case

3.3 yr old male child for cholesteatoma

details of cholesteatoma(fortunately I remembered from my USMLE reading but a lot ofpeople said they did not have a clue

pre op issues, complications of cholestatoma

intra/ post op Mx, what will u explain to mother about post op problems

Basic science viva

1. Anatomy of pleura

Pneumothorax

chest drain insertion

2. Alcoholic patient in ICU, physiology of liver injury and sequelae in alcoholic liver

disease, child pugh, encephalopathy, hepatorenal syndrome, varices, etc.(too many detailed

questions asked with unwillingness to move on until answered fully)

3. renal transplant patient for day care procedure

indications of transplantproblems with transplant patients

classification, S/E and anaesthetic effects of immuno suppressants(absolute details, knew it

well, so was OK but lot of people felt it was harsh)

4. anaesthetic breathing circuits, details of Bains and circle systems

Long Case:

42 year old with manic depression for dental clearance. History of multiple ECT

treatments. Lives alone, heavy smoker. On chlorpromazine, flupenthixol, lithium and

amlodipine.Renal failure and HTN, under nephrologist.

Ix: LVH on ECG, cardiomegaly on CXR, polycythaemia, obstructive PFTs, lithium level

upper limit normal.

Asked regards pre op issues (esp lithium).

Intraop Mx.

Post op slow waking, obstruction airway. ?causes and mx.

Short cases:

1) Dural puncture siting labour epidural: options (risks/benefits), PDPH risk andsubsequent Mx.

2) CXR showing NGT off to left, discussed ways to establish NG position. Enteral feeding

on ICU risks and benefits. Nutritional status in critically ill. Requirements of various

components.3) 2year old with stridor: differential and Mx


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Sciences:1) Cross sectional anatomy of T10 level, moved on to CT (meant to show anastamotic

leak). Discussed functional liver anatomy.

2) Na+: body regulation, importance, hyponatraemia differential and management.3) Reasons anaesthetist might prescribe anti-hypertensives, BTS guidelines on HTN,

hypotensive anaesthesia, options infusion therapy to drop BP, focus on nitrates and SNP,

CN toxicity and Mx, brief discussion on phaeo.4) Laser: physics, clinical mx

Set 4

Long Case:

58 year old lady for elective aneurysm repair . 2 week history of hemiparesis.

Known Hypertensive and chronic smoker with COAD.

H/O Complete heart block with Pacemaker insitu.

PFT : Moderate obstructive lung disease.

CXR : Pacemaker.

Short cases:

1) Awareness

2) Downs syndrome with Eisenmenger's disease for fracture NOF3) Sepsis

Clinical sciences:1) Anatomy : Blood supply of spinal cord.

2) Physics: Osmosis

3) Pharmac: VTE Guidelines and anticoagulants4) Physio : Burns / CO & Cyanide poisoning.

Set 5Long Case: Urgent AAA repair

Short cases:1) Bleeding tonsil

2) T2 Spine fracture with autonomic hyperreflexia

3) Lobectomy with PFT of COAD

Clinical Science:

1)Anatomy : Mediastinum

2)Physics : MRI3)Pedicle graft - Hagen Posieulle Law


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4)Pharmac : Antibiotics

Ser 6Long case

RA pt for cervical laminectomy with neurology.Previous MI

Frail with fixed flexion deformities

61 kg

Drugs include atenolol, amlodipine, statin, perdnisolone, azathioprine, lansoprazole and

aspirin

Hb 9

Mcv 96

Na 133

Urea 12

Creat 124

CXR reticulonodular shadowing

Summary?

Went through Ix and ECG ( prev MI)

Why anaemic?Why hyponatraemic?

Can he be optimised pre op?

How would you anaesthetise this pt?

Airway mx with RA?Prone - issues ?

Post op?

Develops SVT in HDU

Management ?

Short cases1. Ruptured AAA in a and e - pacemaker/hypotensive

Periop mx?

2. Obs: SOB / collapse post SVD with epidural.

Causes?

Mx?

3. ECG - complete heart block

Management pre op?

Management if it occurred intra op?


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Science viva

1. Eye pain post non eye surgery( no idea )

2. Adverse effects and benefits of oxygen therapy

3. Latex allergy - types of hypersensitivity. Mx of latex allergy case and presentation ofanaphylaxis

4. Blood pressure measurement

Set 7

Clinical Viva

Long Case

78 yr-old man. For free flap graft of infraorbital defect secondary to radiotherapy for

Maxillary squamous cell carcinoma.

PMHSevere Ischaemic heart disease

Diet-controlled DM

DHx

Ramipril 2.5mg

Carvedilol 12.5mg (?)Furosemide 40mg

Simvastatin 40mg

NKDAs

O/EChest Clear

No murmurs

Investigations

Full Blood Count - Normocytic anaemia (Hb 11.0)

U+EsUrea + Creatinine raised, Urea 10, Creatinine 140 (Approx)

Fasting Glucose 11.0

ECG

SR 80, LBBB

Coronary Angiography

85% stenosis to proximal LAD, 85% stenosis LCx, 80% Stenosis to RCA

EF 40%

Reduced motion of anterior wall


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Questions

How would you assess cardiovascular status / risk?When would you perform surgery?

Would you refer for coronary intervention?

How would you anaesthetise?Would you wake at the end of surgery?

The patient develops chest pain with ST elevation, 12 hours post-opHow would you manage?

Short Cases

25 yr old, Isolated head injury

Management principles for transfer to neurosurgical centre.

Shown CT with Extradural Haematoma.

60 yr old (?) Post-op thoracic Aortic Aneurysm repairHad CSE sited pre-op

Now 6 hours post-op with sensory and motor loss in lower limbs.Epidural infusion stopped 2 hours ago

Differential diagnosis

How would you assess?

How would you manage?Principles of Spinal cord perfusion pressure. (i.e. should maintain adequate MAP to

prevent secondary injury, + discussed possibility of CSF drainage)

16yr old with Learning difficulties for dental corrective surgery (due to last 1 - 2 hours)

What are the issues with this case?What is capacity?Consent issues in adolescents.

How would you anaesthetise this case?

Clinical Science

Radial Artery CannulationAllens Test

Anatomy of radial artery

Describe the path of blood from the heart to the radial artery.

Abnormal HaemoglobinsAbnormal Erythrocytes (Mentioned hereditary spherocytosis, G6PD)

Life cycle of normal erythrocyte

Pathophysiology of Haemolysis


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Magnesium

IndicationsCauses of Hypomagnesaemia

Causes and Management of Hypermagnesemia

A Marathon runner is brought to A+E with a temperature of 40.5 degrees

How would you manage?

How can we measure temperature?

Set 8

1. Long case23 year old lady with 32 weeks pregnant, got admitted to the delivery suite with giddiness,

chest pain and tiredness. Smoker

Investigation - Hb 11.0CXR - seems to be normal

Echo - AV area 1.0cm2, peak pressure gradient 70 mm Hg, mean 35 mm Hg.

Summary?What is the problem?

Grading of AS - different methods? area grades pressure gradient classification.Signs and symptoms of AS?

Changes in pregnancy?

Effects of AS? especially CVS?

Anaesthesia options? Goals? - graded epidural / GA

1. Sickle cell anaemia?

Different types? Physiological effects?Anaesthesia goals/concerns?

2. 45 year old lady for ECT. She is taking lithium.What is ECT? Diseases?

Physiological effects?

Systemic effects?ECG strip at ECT?

Problems associated with Lithium?

3. 22 year old man with fracture mandible for surgery. Brought to hospital from pub.Concerns in this patient - haed injury, c spine, alcohol, drugs

Problems associated with fracture mandible surgery? shared airway, nasal intubation,

difficult intubation

1. Thyroid hormones - physiological effects, systemic effects

2. Perioperative sugar control - hypoglycaemia and hperglycaemia

3. Phrenic nerve anatomy - details

nerve supply, causes of nerve injury


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4. Scoliosis surgey - concerns and problems.

Long surgery, blood loss, nerve injury, spinal cord injurySSEP - principles

Set 9Clinical

Long Case

Middle aged gentleman for emergency laparotomy with one day history of abdo pain andvomiting. He has a mass in right groin.

Past history of alcohol and long term smoker.

Bloods essentially normal except:MCV raised

Low sodium

Mildly raised urea

CXR - Chronic fibrotic changes throughout with apical scarring in left upper zoneECG - Fast AF

Summarise the case

What would be your differential? - strangulated hernia, ischaemic bowel, cancer, appendixmass (in the groin!? - I said you cant rule it out if it was retroperitoneal - they were happy)

Describe the X-ray and ECG - I said I want to repeat the ECG as it wasnt a great trace butI said I would treat - with what? I mentioned beta blockers would not be beneficial in a

respiratory patient and digoxin in sepsis has poor results so I would treat with a loading

dose of amiodarone of 300mg into a large antecubital vein in a HDU environment or

certainly with ECG monitoring and BP measurement. Where would I do this? Either on theward or in my recovery if the ward staff were not available.

What other investigations would you want - ABG and PEFRDo you want an ECHO?? - I said firstly I would ask more about his exercise tolerance in

my history in order to gain a functional status and consider this if his exercise tolerancewas limited or if on auscultation I heard a murmur - however I wont delay surgery for it asit wont change my management - they were really happy with this as I think everyone was

saying just get an ECHO when there was no real clinical indication.

Anything pre-op?- I said get the chest physios to come and show him exercises to do and consider pre-op

nebs

How will you anaesthetise?RSI, Routine stuff, No plan for epidural as WCC high and SIRS - MASTER trial

mentioned and they were happy with my analgesic plan of TAP blocks and PCA

Art line, no CVP, Catheter - aim 0.5ml/kg/hr, consider CVP line intra-op on the table ifhameodynamically unstable but BP had NEVER been a problem.

Post-op - HDU, DVT Gastric prophylaxis and feeding

Relatively straight forward!

Short casesYoung boy for circumcision - methods of pain relief including anatomy - which one would


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you choose for day case and why. Indications for discharge from Day surgery

Elderly male for carotid endarterectomy shown ECG LBBB with 1st degree HB - would

you anaesthetise? I said not without further history and examination and a referral to the

cardiologists - if there was an associated LAD this would be trifascicular block and anincrease risk of periop complete heart block. Brief discusiion of GALA trial - what do I do

and why

12 year old for middle ear surgery - choleasteatoma - diabetic.

What is a cholesteatoma

What are the issues here - child/shared airway/long case/micro surgery requiring minimalblood loss for surgical field/facial nerve monitoring

What would you do?

Pre-op assess/Exam etc

Remi infusion - intubate on remi and avoid NDMR completely - have I done this before -yes - describe!

What sort of tube - South RAE or reinforced ETT NOT AN LMA at all - why- want to

control CO2 and long operation !

Basic Sciences

Tell me about the anatomy of the pleura

- what is it? boundaries, what does it cover- innervation

- how can it be damaged?

exudates/transudates/blood/air- how do you insert a chest drain?

- what is the recommendation regarding ultrasound of the chest before insertion

How do end-stage liver patients present to intensive care

- bleeding - upper GI - varices, ulcer disease, portal hypertension

- ascites and spontaneous bacterial peritonitis- encephalopathy

- physiological changes - I just said things in a very systematic way for each system and

they let me talk for pretty much all of the time and were nodding their heads so I just

carried on until they told me to stop - I related everything I mentioned to anaesthesia andpoor prognostic indicators etc. so tried to show I had experience of these type of patients

and also the fact that sometimes if they are end-stage the decision may be to allow natural

death and supportive palliative care - they actually like that!

You have a patient presenting for elective surgery who has had a renal transplant. What

drugs do these patients take and how will this affect your anaesthetic?- firstly discussed necessity of surgery

- drugs - steroids - in depth! including replacement and equivalent doses perioperatively

- cyclosporin - how it works - t cell associated and what it does - pharmacodynamics

- any newer agents you have heard of - tacrolimus - less side effects


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Who is prone to oxygen toxicity

Mechanism of oxygen toxicity

Pharmacology (?)

Latex allergy - who is proneWhat types of hypersensitivity are encountered intraop

How to treat anaphylaxis

Basic Science

Non invasive BP - how is it measured - mechanisms

Finepres

Set 11

Long Case:

Elderly lady with history of COPD; FEV1 of 0.8 and obstructive lung defect presents withintracranial bleed. 2 weeks later she is booked for elective aneurysm clipping that is not

ameenable to Endovascular repair.

She has a cardiac pacemaker for complete heart block.

Investigations included CXR which showed hyperexpanded lungs, was asked todemonstrate this; pacemaker with atrial and ventricular leads; was asked to explain this.

ECG showed paced rhythm with ventricular pacing spikes; was asked why no atrial pacing

spike; explained this could be related to sensing.

Was asked the significance of Spirometry what does it mean?How would you deal with a pacemaker pre/intra and post operatively?

What other investigations would you like? FBC; Coag: U&E etcThen was asked about introperative management:

TIVA technique with reasoning; avoidance of pressor response; elements of maintainingCPP; seemed very happy with thisWas asked how to manage intraoperative cerebral oedema; started basic upto

pharmacological

Post operative: would I extubate?

what would govern my decision?

Post operative confusion; what is the differential?How would I manage?

All was reasonable; managed to score 10/12

Short cases:Awareness; Standard quest as previously asked ;no problems

Seemed very concerned with medicolegal aspects

Eisenmengers SyndromeAgain standard question; wanted very detailed pathphysiology; questioned mode of


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reversal of the shunt

Anaesthetic managment would you consider a regional?Not the smoothest answer despite knowing the topic well!

SepsisAgain standard question

Definitions/management/targets all fine was very happy; even asked about eveidence in the

literature - no problem

Basic Science

Anatomy of the Spinal Cord Blood SupplyQuestons regarding orgins etc plus wanted veous drainage. Not too bad.

Pathophysiology nonthermal burn injury

Talked about Carbon monxide poisoning and cynanide toxicity. Mode of pathophysiologyetc managment.

Examiner seemed more than happy.

NICE guideance on VTE prophylaxisWanted quite a lot of detail relating to the guideline; mode of action of antiplatelet and

heparin agents.

Osmolality - not the smoothest.

Wanted the equation; could not really remember followed by a discussion on

hyponatraemia causes; managment.

Set 12

67 year old man for a flap repair of maxilla defect second to previous SCC. Given an ECG

(LAD, SR, Q waves), an Angio (triple vessel disease), his U&Es (Chronic renal failure)and FBC. PMH: HTN, IHD, DM

Questions:

Summarise the caseWhat do you think of his blood results?

How can you assess his cardiac function?

What about the Angio? What could be done to optimise him for surgery (Angioplasty,

CABG)How would you anaesthetise him?

What are the important factors for flap surgery? How do you keep the flap warm in

theatre? - warming & Humidifying the theatre environment

Short cases

A: 16 year old with learning difficulties for dental clearanceHow would you asses?

Parental/guardian issues

If no relative/friend - involvement of IMCA - relevance of MHCA.

How would you anaesthetise


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anticoagulate before cardioversion, better to rate control in this case), what can you use and

what will you use (digoxin)Benefit of NG tube

Classes of shock

Risks and benefits of epidural (sepsis- abdo or chest or both but laparotomy, MASTERtrial)

How to GA (RSI and lines +/- epi)

Intraop tachycardia and hypotension causes and managementOn ICU post op with low UO, causes and management

Short cases:

1. Analgesia for circumcision - WHO analgesic ladder (doses in mg/kg), topical LA, penile

block and caudal block and asked how to do them. Armitage formula for caudal bearing in

mind max dose of LA.2. Showed me an ECG and wanted it describing, LBBB (looked, but it wasn't trifasicular)

in a patient for CEA. LA vs GA arguement for CEA and options for LA. Mentioned GALA

trial too.

3. 12 year old for excision of cholesteatoma!! Asked what it was (no idea), examinermentioned it was middle ear surgery (surgical seive and mentioned benign or malignant

tumour). Mentioned that in the 'real world' would discuss surgical needs with surgeon, andask anaesthetic Cons colleague what anaesthetic implications there were (any associated

common syndromes, effects on systems or need for special anaesthetic technique etc),

examiner smiled and nodded and seemed happy with a sensible approach! Also PONV and

facial nerve stimulator. Child was also an IDDM on an insulin pump. Wanted details ofhow an insulin pump worked, what type of insulin it contained and what you would do pre-

op (stop and put on sliding scale or leave in situ).

Science viva

Anatomy - of the pleura (boundaries and visceral/parietal) and PTX and pleural effusions(transudate and exudate and how to classify by protein and LDH levels), what else cancollect in the pleural space? How to insert a ICD.

Physiology - acute liver failure and triggers for admission to ICU. Discusses variceal bleed

and treatment, portal hypertension, ascites and SBP, cerebral odema and encephalopathy.Physics - paediatric breathing systems (inc E, F and circle) and why we can't use the

standard ones. Why we use an Ayres T piece. Problems with circle systems and

advantages. Resistance and work of breathing in paeds.

Pharmacology - Immunosuppressants! Wanted classifications and mechanism of actions,side effects etc.

Set 14Clinical long case:

55 year old woman listed for elective neurosurgery following hemiparesis 2 weeks ago and

scan showing two aneurysms in anterior circulation.SOB at 50-100 yrds, PPM for CHB,

Investigations showed: Bloods (within normal limits from memory - or atleast not grossly

deranged - maybe some renal impairment)

PFTs: FEV1/FVC of 40%CXR: Hyperexpanded and Dual chamber PPM


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ECG: Paced

ABG showed mildly raised PCO2 and Low pO2 on air

General discussion about the case and issues.

Asked about PFT's and would I do the case given COPD and ABG's - discussion re: riskstratification

Details of how I would proceed with anaesthetic. Could I use Isoflurane?Level of monitoring (art line pre-induction)

Post op seizure /differential and treatment of it.

SHORT CASES:

Awareness - risk factors, management of

Lady with sepsis following admission with cholecystitis - from your previous que bank!Downs syndrome with Eisenmengers listed for DHS - Not interested in issues re: Downs.

wanted to know about Congenital heart disease, causes of cyanotic heart disease,

principles of conduct of anaesthesia.

CLINICAL SCIENCE:

Spinal cord blood supply and avoidance of ischaemia.House fire and physiology of Carbon monoxide/cyanide poisoning

Osmolality and measurement and causes of derangement

Anticoagulants/Antiplatelets and recent NICE guidance

Set 15

Long case

72 yr old for aaa repair recently has got discoloured toes (may be embolic) on paracetamol1g for toe pain .he is a smoker.bloods normal u & e,fbc n ,

ecg fast af lad,

echo biatrial enlargementlv and rv normal

exercise tolrance limited by arthritis

Fast AF management,causes,what drugs would u use whycardiac assessment for non cardiac surgery

investigations thalliumscan dipyramidol scan

echoTOE would you anaesthetise for TOE

Dobutamine stress echo

Induction lines drugs gtn,mannitol,vasopressors and inotropes blood products pre op

epidural

clamp onand off physiology

PERI OP RENAL PROTECTION what is the role of mannitol in renal protection


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problems,

flow requirementslaminar flow

formula laminar,turbulant,reynolds number

3.AntibiotiCs prophylaxis

all the questions from reCent guidelines

vague and poorly framed questions

4.MRI

PRINCIPLESPROBLEMS

ECG LEAD PROBLEMS,If non ferrous lead how does it detect signals, contra indications

for MRI

USUAL QUESTIONS.

Set 17

Long Case:

A 60 year old women presents for an oesophagogastrectomy for cancer. She has a pastmedical history of scleroderma & Raynouds disease. Mouth opening is 2 fingers. She has

significant acid reflux. Recently she has been complaining of shortness of breath onexertion. She had an appendicectomy 5 years ago.

dhx:

Prednisolone (no dose given)Sildenafil

Enalapril

LanzoprazoleProstacyclin

Bloods:Urea-10 Creat-130

Rest of bloods ok

CXR: cardiomegaly (? I think it was meant to show enlarged right heart for right sided

failure secondary to lung disease)

ECG: LV Strain and Left Axis Deviation (Axis was -30ish)

Pulmonary Fn Tests: Restrictive Defect with low transfer of CO

Questions:

1. Summarise the key points

2. What is sildenafil for?3. What is prostacyclin for?

4. Talk through the abnormal investigations

5. What is TLCO on the PFTs?

6. Anything you can do to optimise her pre-op? In particular her poor lung function-washappy when I said she was on treatment and there wasn't much you can do because it's


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pulmonary fibrosis.

7. How will you anaesthetise her? I said: Need to fully assess airway as mouth opening 2fingers. If no worse than when had previous RSI then proceed with RSI otherwise AFO

intubation. Needed a rapid sequence but lung isolation. Art line as well as standard

monitoring. Have a DLT and SLT ready-if easy, put a DLT down, if not then a SLT withbronchial blocker or change to DLT.

8. How do you check a DLT position?

9. Where does she need to go post op?10. What criteria do you use to decide whether to extubate or not i.e. HDU or ITU? I said

take ABG at end an if pO2>10 on FiO2


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How do you measure EtCO2? sidesteam vs main stream. Wavelength of CO2 absorbance

from Infrared spectrum

Set 16

Long case59 yr old female scheduled for craniotomy, had hemiparesis secondary to intracerebral

bleed 2/52 ago.

PMHx resp disease with ex tolerance 50-100 yards, hypertension, diagnosed CHB 2 yearsago and has pacemaker

Meds:

Nimodipine 60mg qds, perindopril 4mg, becotide, tiotropium, salbutamol, fluoxetine, PPIand a statin

Pfts:

FEV1 0.84, FVC 2.7, VC 2.8, FEV1/VC ratio 33%

ABG (on air) ph 7.38; PO2 9.4kPa (asked if this was hypoxic or not);PaCO2 6.1 HCO3 28;BE 1

CXR -= pacemaker and hyperexpanded lungs

ECG paced rhythm

Questions:1. Summarise case

2. Comment on PFTs, ECG and ABG

3. Comment on CXR (was there something in the lung fields)

4. How would you anaesthetise?

5. Critical incident post op:

a. Fitting your management

b. Ct head

Short Cases:

1. Awareness as per the blue book, 30yr old patient who you anaesthetised 2 months

ago complains of awareness and GP refers her to you

a. Definitions?

b. Causes?

c. What would you do?

d. Who would you inform?

2. 50yr old male downs syndrome patient with eisenmengers syndrome

a. What is eisenmengers? how would you anaesthetise? What drugs?

3.

30yr female admitted 2/7 ago with acute cholecystitis, you get a call from outreachshe is hypotensive sys bp 70 and tachy 160.

a. What are you going to advise

b. Whats the most likely cause

c. Define severe sepsis (I then talked about sirs, sepsis, severe sepsis and

septic shock)

d. What would be your management


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Clinical science viva

Anatomy: Arterial supply and venous drainage of spinal cordWhat problems?

Spinal perfusion

How would you monitor it? What symptoms?How could you improve spinal perfusion?

Venous drainage

What problems might occur?Which group is particularly at risk

Epidural haematoma

Risk factors?Presentation?

Physiology: Carbon monoxide poisoning and Cyanide poisoning

Mechanisms, treatments

Pharmacology - Anticoagulation

1. NICE guidelines for VTE prophylaxis

2. Risk factors

3. Different drugs and where they act

Clinical Measurement/Physics: Osmalarity and OsmolalityFormula to calculate

Why might you have a reduced osm?

What will it cause?

On same day other group got asked:

Clinical :Alcoholic man with acute abdomen

Sciences:

Anatomy of pleuraRenal transplant pharmacology

Set 1773y man scheduled for an urgent AAA. He has a 6.1cm aneurysm and has recently

developed a black middle toe on the right foot. He has bilateral OA of both hips which are

severely spondylosed. He has no other significant medical history, but has recently been

diagnosed with an irregular pulse. He stopped smoking 10 years ago.

He takes 1g Paracetamol qds.

O/E: Afebrile, BP 140/70. HR 112bpm irreg irreg. Normal chest and heart sounds

Biochemistry: Na 136, K 5.1, Urea 5.0, Creat 67 Glc 5.6Haematology: Hgb 15, WCC 11.1 Plts 278

ECG: Atrial Fibrillation 80-150bpm, one ectopic

Echo: Good LV function, mod dilated RA and LA

Summarise the caseGo through each of the investigations in turn Biochemistry normal


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Haematology WCC upper border normal (though I said it was all essentially

normal so he asked about the WCC so I said at 0.1raised is essentially normal)ECG AF Echo dilated LA probably accounting for AF and no thrombus

So how would you proceed with this case?

More history (he said what Cardiovascular and Respiratory and how todifferentiate between these)

What other investigations would you need?CXR and ABG/Spirometry if chest was bad, and some functional cardiac testing as

poor mobility and these are usually vasculopaths.

What do you mean by functional cardiac testing?These range from exercise ECG which would not be possible in this case to

pharmacological stress methods.

What methods are these?Dobutamine stress test so how do you carry this out I said inject Dobutamine

and watch the heart function with an echo. Ok, good any other tests? Dipyridamole-

Thallium scan how does this work dilation of the arterioles with Dipyridamole andthen watch for cold/hot spots. Ok, any other test? CPEX test but would be challenging

in him with the bike so would opt to use a hand bike.

Tell me about CPEX testing Ran through airy room, standard monitoring and

airway gases, resus equipment, exercise bike/hand bike, metabolic cart (his eyes glazed

over then), pneumotachograph. Measurement of Vo2/VCO2 ratio and AT. That of11ml/kg/min being the defining number for good post op recovery.

What drugs would you have him on?

Statin, didnt need any hypertension or diabetic control but I would consider ratecontrol and need to consider why hes not on Warfarin as per the NICE guidelines.

If he was on a NSAID would that bother you with putting in an epidural?No

So how would you carry out the anaesthetic if youd had all of the investigations

and optimized fully?Started simply with equipment (cell salvage, invasive monitoring), bair hugger

over upper half why warming? said all patients should be warm as per NICE

guidelines and also coagulation reasons. Drugs, awake epidural. He then asked me how

Id put it in said consent, iv access, trained assistant, monitoring, sitting, full asepsis

and he moved me on! Invasive monitoring.

So you said cell salvage how does that work

Dedicated suction to a reservoir, washed (with what said Im not sure I presume

saline he said yes!) centrifuged and then the packed cells are collected through a filter

20-40nm. What are the cells suspended in - said wasnt too sure.

Ok youre half way through the case and the surgeon releases the clamp and

theres a large amount of bleeding what do you do?

Surgical and anaesthetic things. Start with anaesthetic: give blood that I would havein theatre ready for an AAA, coagulation factors.


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Ok what factors. I said FFP 15u/kg for APTR or PT below 1.5 but as per the massive

haemorrhage AAGBI guidelines more if there is micro vascular oozing, and considercryoprecipitate if fibrinogen under 1g/dl. Also think of tranexamic acid 1g as an

antifibrinolytic. But the tests for APTT and Pt might take a while to come back so need

to treat pre-emptively

What about platelet levels?Aim above 75 as per AAGBI guidelines

But what would you do first get the surgeon to put the clamp back on. He smiled!

What other near bedside tests are there that may guide you?

TEG

So what does the TEG tell you?Platelet function, but gives no indication of actual numbers

Then puts up a normal TEG on the screen (said normal TEG on the icon!) so asked meto run through it.

Little hazy here but said it looks globally normal as has the characteristic port

glass shape, short R time (what does that measure time to initial fibrin) then angle,

then the MA speed of clot strengthShowed abnormal TEG essentially similar at the start but shorter and was a

characteristic picture of fibrinolysis

SHORT CASES:

5 yr old bleeding tonsil.Essentially straight out of any viva book problems, assessment, fluid resuscitation,

blood loss estimation, whats circulating volume of child? Said 70ml/kg. So whatwould his be? Some rapid fire maths said estimate weight of 18kg. Then thoughtnever multiply 70 by 18 so I said Id presume 20kg for now and said 1.4l. She seemed

happy. technique for anaesthetising RSI vs Inhalational (but what would you do RSI),

equipment, ENT surgeon, ant emetics, pain relief.

67yr old female presenting with right lower lobe carcinoma and needs a lobectomy.

Handed a set of pulmonary function tests. Had to go through each one in turn and saywhat they were and what their significance was.

FEV1 (forced expiratory flow in 1s) 1.4FVC reduced

FEV1/FVC 58% - obstructive

FEF 25-75. What is it? Guessed at forced expiatory flow. What does it measure? Small

airways. So its lowered by what: Emphysema, Fibrosis, and Anaemia

TLCO Transfer factor for CO. What does this show surface area of the lung. How dothey measure it. Get patient to breathe in CO. Breathe in CO examiner looked


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horrified, threw me a bit as I was a bit taken by surprise but anyway stuck to my guns

and said yes, but not a lethal amount. So how much I dont know but certainly below10%! yes I think that would be a safe bet!

So how would you asses this ladys fitness for surgery?Cardiovascular and respiratory parameters

Respiratory ones?

BTS guidelines: FEV1 should be more than 1.5 for the lobectomy and this is low sowould need to estimate post op. Ok how do you do this well could V/Q scan. Any

other quicker way?

Lung broken down into bronchopulmonary segment. Right well if youve lost thelower lobe on the right what does that leave you with. Again maths in a stress situation

so I said well there are 3,2,5 on the right side, so that would be five from the 10. She

laughed and pointed out there are two lungs so did they both have the same number of

segments. Oops! Theres 9 on the left so leave 5/19 (thankfully didnt have to work thatout as a number!)

And cardiovascular? CPEX would be gold standard seemed happy with that and

moved on.

43 yr old male spinal cord transaction 2 yrs ago at T2 presents for renal stone surgery.What are the issues. Essentially straight out of a viva book.

Several systems: resp lost intercostals, so diaphragmatic, poor cough,

Cardiovascular bradycardia, postural hypotension

Autonomic Hyperreflexia tell me about this, what happens, what causes itThermal control

Pressure sores

DVTRecurrent UTIs

Hard veins

Bell went. The clinical long case was quite weird really. 2 very stern looking examiners

who were very business like, difficult to get any rapport going at all- We all came out

thinking it was too easy and straight forwards, with not much meat to the question atall. They jumped around quite a bit so keeping your train of thought was difficult.

Short cases very fair 2 straight out of the viva books (so no complaints). The

pulmonary function tests were more iffy, but again they are all in the books and thepre-op resp carcinoma is also in the books. So, on the whole pretty fair.

Clinical Sciences

Anatomy: On the computer screen in the booth a picture of the thorax and neck with

the veins and arteries of the mediastinum.


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Tell me about the mediastinum.I said it was an area of the neck and thorax split in to

4: superior, middle, anterior and posterior.

What structures do each contain and can you point them out.Said thymus in the

neck in the superior ok, what about the vasculature. Went through each in turn

which, as there was a picture on the screen was really straight forwards. They wantedthe Aorta, brachiocephalic, subclavian, common carotids. Then jugular, subclavian,

brachiocephalic, SVC. Wheres the pulmonary veins, pulmonary artery, where would

the ductus venosus run, wheres the thoracic duct ( I said on the left side but I cantactually see it on this screen as it should be draining into Left subclavain he had a

look and agreed it wasnt there!) Name some nerves that traverse through the

neck/chest and abdomen vagus. Where does it lie in the neck T-O groove. Wheredoes the oesphagus start and how long is it.

Why is the oesophagus important to anaesthetists?Mode of feeding so placement of NG

Mode of monitoring: Doppler/ TOE/tempInadvertent injury: bougie, trache

Air into stomach esp in children/LMA regurg risk

Inadvertent intubation

Then he looked as if we had covered what he wanted to so took a few seconds looking

at the paper before askingHow would you anaesthetize for food bolus removal ?Checked it was definitely in the oesophagus. Yes. So history, examination and

investigations. Yes theyre all ok. Well If the airway wasnt difficult would do iv

induction and intubate. Care needed as it will be a shared airway, and need to make

sure patient is fully paralysed if they are going to use a rigid scope.

Physiology: Free flap surgery

What different types of flaps are there, and whats the differences between them

blood supply pedicle flap vs free flap.How do you look after a patient with Free flap.Maintain good oxygenation, MAP but with careful use of vasoconstrictors as these

decrease flow to the flap and actually want to modify the rheology of the blood

haematocrit as per the Pouiselles equation (at which case he switched off), so talkedabout keeping warm, vasodilator drugs, leeches,

Pharmacology:

Antibiotics who would you use antibiotics for pre-operatively?

Essentially a run through of the surgical site infections guidelines about antibiotics.Talked about patient factors and surgical factors (clean, clean-contaminated,

contaminated, dirty.. and wanted examples of these) , implants, at risk patients

diabetics, immunocompromised, IE prophylaxis. Wound dressings. Patient and staffeducation. Taylor therapy to potential pathogens. Wanted examples of what to use for

bowel surgery: need anaerobic cover metronidazole, and orthopaedic? At my hospital

we give gentamycin and Flucloxacillin to cover staphylococci. Ok what about MRSA?

Talked about colonization vs infection. Then education of patients and staff.Handwashing. Aprons and gloves, isolation. Use of specific antibiotics as per


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sensitivities what would you use. Vancomycin. If they had renal failure what would

you use would speak to the microbiologist for advise of sensitivities and what thehospital policy was, but could consider Linezolid!

Physics:

Straight out of a viva book: tell me about the problems of anaesthetizing a patient in an

MRI scanner.Problems with isolated area, magnetism, noise, equipment and monitoring, condition

why needing MRI scan often children.

Basically a run through how it affects all these in turn lots of time on monitoring andequipment, whos contraindicated pacemaker 5 gauss (though now can get MRI safe),

aneurysm clips. Infusion pumps 30Gauss. Different monitoring. Mentioned ear plugs

would you use in an anaesthetized patient. Said yes as anaesthetic doesnt affect

pressure wave (had no idea though!). Quenching, missiles from ferrous material. Thenhow does MRI work in the last minute of the viva. So got to alignment of the atoms

and then apply magnet and the bell went!

Again I thought an extremely fair viva. All the topics were pretty straightforward.

Many found the mediastinum question threw them as it is not in the books howeverthere was the picture on the screen and pointing out the aorta etc shouldnt be too

difficult to work out on your feet. Examiners were much more interactive in this exam

and it was more like a chat between us three as opposed to an actual viva- actually

enjoyed it by the end. However the questions clearly suited me.

Other vivas I heard about on the day for the long case: Scleroderma and CREST

syndrome in the long case. Short cases femoral triangle, pleural anatomy and chestdrains, osmosis/osmolarity, chemotherapy drugs for renal transplantation and the

indications for transplant and side effects of the drugs.

Interestingly when talking to the examiners afterwards I said I thought that had I got

the science viva with pleura/chemotherapy/osmolarity it would have been much harder

however 70% of candidates passed the exam that day. 57% passed with the questionswe had which is interesting as I thought they were more middle of the road questions.

The Monday cohort had a 50% candidate pass- so I am glad I didnt sit then!

Set 19

57 male, scheduled for emergency laparotomy

24 hour history of abdominal pain & vomiting.

Red mass in right groin

Nil PMH

Smokes 20 / dayPrevious alcohol excess, unclear about current intake


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HR 150BP 137/86

Reduced air entry at both bases, with bilateral crepitations

ECG Fast AF

CXR Bilateral pulmonary oedema, sail sign & RUL scarring

Bloods

Na 128

K 5.1

U+Es normalLFTs normal

Hb 14.6

WCC 12.9Plts 306

Summarise the case

Differential diagnosis

Explain ECG & CXR findings

Pre-op optimisation where, how?

Goal directed fluid therapy

How long willing to wait given likelihood of strangulated hernia?

Management of fast AF chemical vs electrical cardioversion, importance ofknowing old or new AF.

Profound hypotension intraop causes & management

When would you extubate? On table or not?

Post op analgesia epidural vs PCA & TAP blocks

Develops hypoxia post op in HDU, CXR shows basal atelectasis, how would youmanage?

Short Cases

8 year old boy for circumcision methods of analgesia

Simple analgesics

Local anaesthetic (instillagel)

Caudal vs penile block

Anatomy of caudal space, how performed, complication & doses

How a penile block is performed

57 year old male pre-op assessment clinic for CEA


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Shown ECG Rate 66bpm, SR, normal axis, 1stdegree heart block & LBBB

What further information would you want to obtain

Would you be happy to anaesthetise?

What further investigations?

Biggest concern? (recent silent MI)

How would you anaesthetise cervical plexus block vs GA

Advantages & disadvantages of each

GALA trial

12 year old boy for cholesteatoma

What is a cholesteatoma

How long is the operation?

What are the considerations?

Hypotensive anaesthesia (I only had time to discuss increased volatile conc & remibefore being moved on)

What nerves may be damaged?

How are they monitored?

How does this affect the anaesthetic technique?

Basic Sciences

Anatomy of the pleura Describe the anatomy of the pleural space

Why is it important to anaesthetists?

What accumulates in it?

Why does the lung collapse in pneumothorax?

Pleural effusion types (transudates & exudates protein content & causes)

Chest drain insertion where? How?

Physiology Alcoholic Liver Disease

Pathophysiology of ALD

Relevance to anaesthetists

Problemso Protein synthesis (protein binding)

o Clotting factor synthesis

o Hypoglycaemia

Blood result derangements

Encephalopathy definition & presentation

Hepato-renal syndrome (implications)


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Pharmacology Immunosuppressants

Assessment of the post renal transplant patient for theatre

Cause of their renal failure

Function of the transplanted kidney

Difficult vascular access

Types of immunosuppressants

Azathioprine / ciclosporin how do they work?

Steroids how do they work?

What will you do in your anaesthetic?

HPA axis & supplementation

Conversion doses

Long term problems GVHD, nephrotoxicity of immunospressants

Physics & Equipment Breathing systems

How do you choose which one to choose?

Which ones do I regularly ues?

What would you use for MRI / for children?

Efficiency of the Bain for SV / IPPV? Circle system draw it adv / disadv

Components of soda lime

Set 20

74 year old male for elective C3/4 C4/5 decompression. PMH: RA, prev MI x2 over two

years ago, has had PCI.

Presents as generally frail, weak upper limbs and lower limbs, with altered sensation inupper arms.

On statin, B blocker, azathioprine, prednisolone, lansoprazole, aspirinBloods

Normocytic anaemia, low Na 133

CXR

? increase fibrotic lung markings

ECG

? partial LBBB, evidence of lateral ischaemia

Questions:

Why normocytic anaemia?

Why anaemic?

Why Na low?Comment on ECG:


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What other investigations would you like?

How would you anesthetise?Problems with intubation ?AFOI

Problems with proneing

Where would you send him post op?Would you extubate him? I said yes totally forgot about potential for phrenic nerve

involvement!!!

80 year old chap presents to pre assessment clinic for SCC removal on his forehead. He

complains of dizzy spells.

They show you his ECG

It was CHB but I messed that up and said it was trifascicular block

80 year old chap comes to A/E with abdo pain, CT confirms AAA his BP is 60/40, HR 85,he is conscious.

What are you going to do? Stay in A\E or take to theatre?

What fluids , how much?Consent issues

You get to theatre, how are you going to induce him?What agent are you going to use?

Multiparous lady has given birth normally and has an epidural in situ. You are asked to see

her as she is complaining of shortness of breath.

What are you going to do?

ABC, Hx and examination etc

DD? high epidural, ?AFE ? CVS vs RespiratoryManagement of AFE

Science Viva

Pt wakes up with sore eye post op

Causes, reasons, what are you going to do.

Examine eye, possible findings on exam.

What are you going to do if it is abrasion?

Eye signs in anaesthesia and critical care?

Talk about light reflex, afferent and efferent pathways.

Talk about nerve supply to eye muscles

Talk about SNS and PNS supply to eye


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Oxygen toxicity

What happens if you give someone too much O2.

Symptoms of toxicity, how much is too much?

CNS and respiratory symptomsWho gets O2 toxicity

What is the mechanism behind O toxicity????

Anaphylaxis

Latex sensitivity, type of reactions Type 1 vs type 4

Mechanism of reactions.

Symptoms and signs of reaction

Who gets latex reactionsHow would you know under GA?

Management of anaphylaxis, ABC etc

BP measurement

How do we measure NIBP?Explain syphgomanometer and korotkoff sounds

Explain mechanism

Other types of Non invasive measurement. Eg Finapres

How does it work? What else does it tell us (PCA)Why dont we use Finapres?

Set 21Long Case

1. 76 Yrs male H/o 12 months weakness of arms now progressing to legs having C3-

4, C4-5 cervical laminectomy.

PMH: MI *2 , 3 yrs ago Dec& JanRheumatoid arthritis for 10 years

On Examination:

BP 145/60 mmHg, HR 60/minFBC: Hb 10g%, Plt 136, others normal

U&E: Na 133 , K 4.5, U 9.0, Creatine 80

ECG: Q in L1 , aVL, V4-6, T inversion Q in L1, aVL, V4-6CXR: Trachea deviated to Right due to? Aortic unfolding

DH: Azathioprine, B blocker, statin, Aspirin

Summarise the case

What Hx would you ask

Comment on FBC and U&E


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Causes of low sodium

Causes of high ureaDescribe chest x-ray, Features in RA

Describe ECG

What other investigations?Airway examination and findings in RA

Goals for anaesthetising

Intraoperative: MonitorsGA options: AFOI, GA with manual in line stabilisation

Induction drugs

How to anaesthetise airway

Maintenance

Pain management intraop

Post op pain management( cant use PCA morphine due weakness of arms)Post op goes to ( ECG shown Atrial flutter ) management

Bell rang!!!!!!

Short Cases

1. 80 years male, who is reasonably independent, diagnosed with confirmed

Ruptured aortic aneurysm is with surgeon. BP 60/40 mmHg, Just arousable, HR

120/min, H/O pacemaker, working well.

How would you manageWhat resuscitation fluid would you give

What other instructions would you give to your team ?

How would you manage pain?Investigations?

How would you induce and where?What monitors will you useDo you need a line and cvp pre induction?

2. 30 yrs had normal vaginal delivery, epidural in situ for delivery. In 20 min post

delivery Pt. becomes short of breath

Differential diagnosis for SOB

They were expecting huge list

Can she have PET post delivery? I said yesThey wanted Drug induced Pulmonary embolism

Mechanism of pulmonary edema in pre eclampsia( leaky capillary and

decreased oncotic pressure)Mechanism of ergo metrine

3. You see a pt. for pre assessment with complete heart block( had to diagnose

with ecg) for elective surgery( dont remember)

How would you approach?

What is your immediate managent?


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PPM for future

Other ways of treating CHB( drugs)Causes of CHB

BASIC SCIENCES

1. Pt. C/o pain in one eye after non ocular surgery

What is your differential diagnosis?

Causes of pain in eye?What drugs are used to treat glaucoma?

What drugs precipitate glaucoma?

How would you examine eye and what INVT would you do?Tell me the pupillary light reflex pathway in detail

Tell the corneal reflex pathway in detail

2. Oxygen Toxicity

What are the ways of oxygen toxicity?

How does it affect various system

Where would you use 100% ( not hyperbaric) O2?

% FiO2 and duration of treatment relation (safely)How does it cause retrolental fibroplasia ?

Who are prone to get retrolental fibroplasia apart from prematurity?Group of patients who will deteriorate with 100 % O2

3. NIBP

What are the ways of measuring NIBP non invasively?How does the sphygmomanometer work?

Causes of erroneous reading?

Is mercury open to atmosphere or closed?Korotkoff sounds describe

Von Recklinghausen oscillotometer- How does it work?Draw the Oscillations for MAP, SBPCan you show for DBP

DINAMAP Principles

Causes of erroneous readingsFinapress:

Principles

4. Pt. has H/O allergy to Latex.

What is Latex?

What types of hypersensitivity reaction it causes?

Which other types of hypersensitivity reaction do you see duringanaesthesia?

How would you manage Pt. with latex allergy under anaesthesia?

What substances in theatres and anaesthetic room has latex?Where would you anaesthetise?

Where would you shift pt post treatment?

Who would you refer later?


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Set 22

Long case:72 years, h/o hip arthritis with reduced mobility presenting with 6.2 cm AAA. 2/52 of right

leg discoloration and 1/52 of black right big toe.

Now in AF ~122, BP: 135/75.Drug Hx: Paracetamol

CXR: nil

ECG: AF; ECHO: Good LV function. Dilated LA, RV, RA. Mildly impaired RV function.Valves- normal.

Bloods: Normal FBC, K 5.4, urea 9, normal creatinine

Quest: summary, preop optimise. Is this case emergency? What drug for rate control? Is

high Potassium alarming? Comment on ECG, ECHO.

Anaesthesia- your technique? Intraop monitoring? Shown a TEG with fibinolysis...what

Mx?

Short cases:

1. 5 years post-tonsillectomy bleed. Standard questions.

2. 78 years with FEV1 1.48L, FEV25-75: 50% of predicted. Lowish Diffusion

capacity. Posted for pneumonectomy.Risks? Suitability for lobectomy?

3. 30+ young man 2years after T5 complete transection of sp cord now listed for renal

stone retrieval. Risks? Conduct of anaes? Intraop brady....why? how do you

manage?

Anatomy:Mediastinum: boundaries? Structures from neck to thorax? Trace major vessels and

thoracic duct on the image? Oesophagus- anatomy- relevance to anaesthetists.

Physiology:

Physiological goals for a flap plastic neck surgery? Free vs pedicle? Post-op goals? If lowperfusion, how do you manage?

Pharmacology:

Antibiotic prophylaxis: indications/ types of surgeries routinely given/ commonly useddrugs/ timing/ disadvantages. It is part of .......campaign? what are the other points in this

campaign?

Physics:

MRI- standard questions- challenges to anaesthetists/ principles of monitoring, equipment/

what is MRI/ contra-indications

Set 23

CLINICAL VIVA

Long Case

History

Elderly man with neurological symtoms of upper limbs for 12 months, scheduled for C3/4and C4/5 posterior decompression.

History of RA, 2 previous MI 3 years ago and has a stent insitu

Drugs: azathioprine, atenolol, ISMN, aspirin, ACEI


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No allergies

Examination:

Height 169cm, weight 61kg, BP 140/80

Thinning of skin and fixed flexion deformities

Investigations:

FBC: Hb 9.1 normochromic normocytic anaemia, platelets 136, WCC 7, low lymphocytecount

Biochem: Na 133, ur 13 and creat 125

CXR no obvious abnormalityECG: SR 80. Q waves I and v5/6 with TWI in same leads

Questions:Summarise case

Comment on FBC and biochem. Discuss possible causes of then derangements.

Comment on ECG, possible causes, consistent with previous infarct? Significance of Q

wavesComment on CXR: what possible changes might you expect on see. Asked about changes

seen with RA/CCFThen asked about anaesthetic technique. Discussed Fibreoptic intubation. Other options for

intubation. What tube would I use.

Then intra op management prone position discussed issues with positioning,

physiological changes, which nerves can be at riskThen post op management analgesia.

Critical incident shown ECG - ? flutter /? SVT. Causes and management.

Short cases

1) Elderly man with ruptured triple AAA management (standard questions)

2) Shown ECG with CHB asked about managgment and them about management ofpatient with pacemaker

3) Pregnant lady postpartum with SOB asked about differential diagnosis, then asked

about features of amniotic fluid embolism and features and management of PET with

pulmonary oedema.

SCIENCE VIVA

1) Asked about abnormalities of the pupil, what happens when light shone in pupil(follow impulse to brain and back)

2) Oxygen toxicity when it occurs, what happens, why it occurs, how free radicals

cause harm. why premature infants get retinopathy/retrolental fibroplasia. How

much oxygen and for how long.


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3) Latex allergy which patients, management of patient with latex allergy. Types of

hypersensitivity reaction. What occurs with each/what reacts with what (seemed toask for quiet some detail) Recognition of anaphylaxis and management

4) Methods of measuring BP non invasively. Sources of inaccuracy. Just managed to

get on to talk about Finapres.

Set 24

Clinical sciences

AnatomyHow do you get pain in the eye?

How do u get pain in eye intra operative and post operatively?

How do u get pain in the eye with non operative surgery?What is the nerve supply to eye?

What is the anatomy of the sns to the eye?

What is the ganglion associated with thisWhat eye nerves are tested in bsdt

What is the efferent pathway of the PLRHow does one get blindness in the eye with pressure

What drugs act on the ans to the eyeWhich drugs cause miosis and mydriasis

PhysiologyOxygen

How do u get problems with oxygen

Wanted thorough details on adults and children including mechanismsWhich age groups most susceptible

Wanted quite specific details

Im not sure I provided them

PharmacologyLatex allergy

Medications used in this

Types of reactionTesting

Patient on table symptoms ad signs of anaphylaxis

What to do

Drugs doses

Short cases1

AAA in resus shocked gcs 6/15Management

How to control BP


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To intubate or not. Where

Do in theatre?Renal failure how to reduce renal failure

Post op metabolic acidosis

CausesManagement

What to tell relatives about bowel ischemia

What other stuff to prepare forI said blood loss, vasopressors

lines maybe post induction

Cell salvage. Urinary Catheter cvp

2

Sob post partum multiple aged epidural in situ

Causes if sobWanted a long list

Wanted preeclampsia and effects of epidural

Little about amniotic fluid bolus

Wanted to know about drugs. How they cause fluid overload

3Third degree heart block

What to do pre op

What to do intraop

Drugs usedHow to cardiovert

Long case76 cervical cord compression for posterior laminectomy

RheumatoidAzothioprineNa 133

Renal impairment

HaloFibrotic lung disease

ECG - anterolateral ischaemia

Anaemia thrombocytopenia

Summarise

Main problems

BloodsECG

Cxr

Management planPost op location

Post op analgesia

Components of prone

WhyAbdominal compression


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Bleeding

Why post op hdu Itu

Set 25Long Case

76 yr male paraesthesia and weakness in arms for posterior cervical decompression C2/3

+ C3/4

PMH 2x MI with primary PCI to LCA, Rheumatoid arthritis

DH atenolol, amlodipine, ISMN, statin, aspirin, prednisolone 7.5mg od, azathiopine,

lasnoprazole, codydramol NKDA

Examination deformities of arms and skin, cachectic (weight 60kg)

Bloods Na 133, Cr 124, Ur 9.8 Hb 9.1 MCV normal, WCC 7.29 Plt 136

ECG sinus rhythm, normal axis rate 75, borderline 1stdegree heart block

CXR unremarkable

QUESTIONS

- summary- how would you anaesthetise him

- talk through the normal chest x-ray

- discuss his MI and problems associated with this intraoperatively- how would you further investigate his cardiac history

- what cardiac meds would you continue and why, which ones would you stop, are

there any he is not on you would like to stop and why!- other investigations ie/ pulmonary functiontests- discussion about risks related to rheumatoid arthritis and airway, then c spine and

airway

- steroid and azathiopine effects and whether I would replace steroids- issues with prone position padding, physiology

- post operatively he has SVT management

Short Cases

70yr, PPM for complete heart block, ruptured AAA

- immediate management in A&E - who available / who would you inform /

resuscitation bp aims and why / consent / discussion about why heart rate not

useful parameter in this case- in theatre anaesthetic management, lines

- physiology of problems in AAA repairs including cross clamp and letting it off, use

of GTN / noradrenaline in relation to cross clamping / site of cross clamp / mannitoland frusemide for renal protection and evidence for this


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Preop assessment, Complete heart block, rate 40

- how would you manage this immediately / long term- different types of pacing available

- what would you do if this happened intraoperatively (drugs / pacing)

- guidelines for preop insertion of pacing wires

Primip, epidural for labour, just delivered, sudden onset SOB

-

causes- ergometrine and effects of drug

- high block and identification

- amniotic fluid embolism pathophysiology

Science Viva

Anatomy - EYE- causes of unilateral red eye post non-opthalmic surgery

- anatomy of papillary reaction

- effect of drugs on the pupil

-

clinical conditions cause pupil abnormalitiesPhysiology OXYGEN TOXICITY

- disadvantages of high flow oxygen- exact mechanism of neonatal retinal problems / length of oxygen treatment required

/ concentration of oxygen required

- COPD patients and hypoxic drive

- Pathophysiology in lungs of oxygen toxicity- Oxygen and carbon monoxide poising (brief they moved me off this fast)

- Neurological effects of oxygen toxicity

- Cellular mechanism of oxygen toxicityPharmacology

-

Types of latex allergy- Types of allergy, how each is mediated- Anaphylactoid vs anaphylaxis

- People at risk of anaphylaxis to latex

- How you plan your list around latex allergy- ?premed

- Management of anaphylaxis

Physics

- different methods of measuring non invasive blood pressure- DINAMAP, principles behind how it works, diagram of oscillations with MAP and

diastolic BP on

-

Sphig / stethoscope and how it works, turbulent flow- Finipress

- Causes for error in DINAMAP

Set 25

Long case

29-year-old male for dental clearance. Recent referral to nephrologist for renal impairment.


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PMH:Manic depression

Obesity

Renal impairmentHTN

Smoking

DH:

Lithium

FluphenthixoleAmlodipine

Chlorpromazine

O/EBMI 35-40 bp 130/90 bilateral wheeze

FBC: Hb 16.5 High PCV

Bichemistry: Cr 135 Ur 8.5 Lithium 1.0 (upper limit of normal)

ECG: SR with signs of right atrial hypertrophy

CXR: Clear

PFTs: Obstructive ventilatory defect with reversibility

Questions

Summarise the case

How do you know the renal impairment is chronic?What does his ECG show?What does his CXR show?

What do you think about his PFTs?

What would explain the ECG and PFT findings?What are the anaesthetic implications of lithium?

Does anything need to be done about his lithium?

How would you anaesthetise him?Are you sure a GA is the best option for him?

How about a throat pack?

Talked about safety concerns with a throat pack

Develops airway obstruction in recovery

How would you manage it?What are the possible causes?

What is the likely cause in this patient and how is it best managed?

Airway obstruction resolves and now the patient is insisting he wants to go home

How would you manage this?Would you involve anyone else?


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Would you get him to sign anything?

Short cases

1)PDPH

How do you diagnose PDPH?

What would you do if you perform a dural-tap whilst placing an epidural catheter?What are the advantages and disadvantages of your approach?

How would you manage a PDPH?

Regarding epidural blood patch:

What would you explain to the patient?How would you perform it?

What is the optimum time to perform it?

Would you perform it in the first 24 hours?

If not why?

2) Paediatricians request your help with a 2-year-old with stridor

How would you approach this situation?

What are the possible causes?

Interested in inhalational injuryPatient deteriorates and requires intubation

How would you manage this?

Who would you want present?

1)Shown CXR of NG tube sitting in left lung

What is this?

How do you check the position of an NG tube?

What would you do with this one?What are the nutritional requirements of a normal person (Kcal, carbohydrate, fat, protein,

electrolytes)?

How does this change with critical illness?

What are the complications of enteral feeding?What does enteral feed contain and what is the base solution?

Science

1)Anatomy

What do you understand by the term T10?

Shown a diagram of a cross section of abdomen/thorax at T10 and asked to name as many

structures as possible.

Shown a CT slice at level of T10 with peritoneal free air and asked to identify structuresWhat is the diagnosis?


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Asked about macroscopic anatomy of the liver

What is the blood supply?Where do the portal vein and hepatic artery meet?

1)Physiology

Define hyponatraemia

What are the causes of hyponatraemia?How is sodium regulated by the body?

What are the clinical features of hyponatraemia?

What is TURP syndrome?How would you manage it?

Why are we seeing less of it recently?

1)Pharmacology

Name some drugs we use to reduce the arterial blood pressure

In what clinical situations would you use them?

How does GTN act?Does it act more on the venous or arterial system?

What would you do if asked to reduce the blood pressure during middle ear surgery?What is the mechanism of action of sodium nitroprusside?

What are the problems associated with its use?

Is cyanide toxicity common?

How do you treat it?

1)Physics

Tell me about the different types of lasers you are aware ofIn what situations are the different types used?

How is laser generated?What safety precautions would you take when using laser for upper airway surgery?What would you do if the surgeon said a laser resistant tube would impair his vision?

What are the problems with transglottic jet ventilation?

Are there any other options other than transglottic jet ventilation?What is the name of the tracheal catheter that can be used?

Set 26Clinical long case

Lady with CREST syndrome (didnt say CREST, said Reynauds and Scleroderma, but shehad oesophageal disease and mildly elevated Ca2+ on bloods), symptomatic reflux disease,

presenting for oesophagectomy for oesophageal Ca. Exactly like case on Coventry course

same clinical details. Same issues: needs RSI but limited mouth opening and Double-Lumen Tube (I talked about awake FOI and then tube exchange or using bronchial blocker

not sure they were that impressed). Asked which sided DLT and why.

Also, she had pulmonary hypertension Right ventricular bump on CXR and increased

lung vascularity. ECG showed left axis deviation (?). Was taking Sildenafil and Iloprost.We had a brief discussion about diagnosis (above signs), further investigations (Echo),


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causes (2ry to pulmonary complications of connective tissue disease and its treatments)

Anaesthetic implications (avoid hypoxia, ??role for pulmonary artery catheter),pharmacology of Sildenafil and Iloprost.

Clinical short cases

1) Young lady for laparoscopic sterilization. Had PONV with previous operations.- What will you tell her (in lay language)

- Why is she at risk (discussion of risk factors: Patient, surgical and anaesthetic)

- What can you do to decrease risk (non-pharmacological Vs pharmacological)

- Tell me about pharmacological which receptors can you block (+example), howdoes ondansetron work, whats the incidence of PONV, how is this affected by

ondansetron (I happened to know of one study in gynae patients where incidencereduced from about 50% to about 26% with addition of Ondansetron). Any side

effects or contra-indications

- So whats youre plan with this lady?

2) Trauma call to a young man (no further details given). CXR showed a pneumothorax- Discussion of simple versus tension pneumothorax (clinical signs on tension

pneumo)

- Treatment of pneumothorax

- Talk me through putting in a chest drain. Which type? Which site?

- Treatment differences with tension pneumothorax

- Treatment differences with spontaneous pneumothorax (BTS guidelines)

- He also has a dislocated shoulder on the other side and the trauma surgeon asks youto give him a quick GA so he can reduce it [High risk case, needs transfer to

theatre and GA in safe environment. Avoid N2O. Wanted to hear that IPPV can

convert a simple pneumothorax to a tension. LMA +SV not fasted. Avoid

brachial plexus blocks phrenic nerve block (interscalene) or pneumothorax(infraclavicular/subcoracoid) on other side to existing pneumothorax would be

disastrous.]

3) 70yo man for ENT microlaryngoscopy for hoarse voice

- discussion of causes Direct vocal chord pathology, extrinsic airway compressionor nerve lesion.

- Which nerves involved? Describe motor nerve supply to larynx and effect of partial

and complete lesions.

- What are the issues anaesthetizing this man [Patient factors (commonly smokerswith other pathologies, particularly respiratory and vardiovascular, ?airway

difficulties) and surgical factors (shared airway, head end distant from anaestheticmachine, need for airway that allows surgery]

- Any other investigations (flexible nasendoscopy, CT)? What do you want to know

from nasendoscopy (cord movement)

- Whats your plan? Discussion of benefits of microlaryngoscopy tube Vs Huntsakirjet ventilator (definitive airway with airway protection. Difficult for posterior

comissure pathology)

- The surgeon now says he wants to use the laser. What are the implications [staff(warning signs, goggles) and patient


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- What would you do? What would you have done if youd known beforehand youwould use laser (metal tube, saline-filled cuff etc)

- What would you do in an airway fire? [Bell rang!]

Clinical Science Viva

Anatomy

- Venous drainage of the lower limb. They wanted this in detail course of long and

short saphenous, point of insertion to femoral, distinction between deep andsuperficial veins, where does the popliteal vein arise, where does the popliteal vein

become the femoral?

- Where does femoral vein lie in femoral triangle. Describe borders and floor offemoral triangle.

- Indications for cannulation of femoral vein

Physiology

Discussion of physiology of ageing, going through each system and its relevance toanaesthetics. Wanted reasonable detail and typical figures (eg for closing volume, rate of

decline of GFR)

Pharmacology

- What drugs are used in the treatment of malignancy?

- Symptom control. Spent a couple of minutes discussing analgesia. Emphasis onopiates, especially alternative routes of delivery (transdermal, sublingual, sub-cut in

terminal care). Typical doses (point seemed to be that they can have very highopiate requirements). Brief mention of alternatives (gabapentin/pregabalin,

amitriptylline, SSRIs. SNRIs like duloxetine) and very brief mention of nerve

blocks/celiac plexus blocks- Other symptoms: anti-emetics (not in any detail), steroids (very briefly how do they

act on the cell), anxiolytics and antisialogogues in end-of-life care

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Final Frca Viva _june 2011

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