Professional Documents
Culture Documents
1995
1995
EXAMINERS?REPORT
PRIMARY EXAMINATION
AUGUST/SEPTEMBER 1995
PLEASE NOTE THAT THIS REPORT IS PREPARED TO PROVIDE CANDIDATES AND
THEIR TEACHERS AND SUPERVISORS OF TRAINING WITH INFORMATION ABOUT THE
WAY IN WHICH THE PERFORMANCE OF CANDIDATES IN THE RECENT EXAMINATION
WAS ASSESSED BY THE EXAMINERS, SO THAT CANDIDATES AND TEACHERS MAY
PREPARE APPROPRIATELY FOR FUTURE EXAMINATIONS. THE INDIVIDUAL REPORTS
ARE NOT INTENDED TO REPRESENT MODEL ANSWERS NOR IMPLY THAT ALL POINTS
MENTIONED ARE NECESSARY IN ORDER TO ACHIEVE A PASS. ALL TEACHERS AND
SUPERVISORS OF TRAINING ARE ENCOURAGED TO DISCUSS THIS REPORT IN
DETAIL WITH CANDIDATES THEY ARE PREPARING FOR FUTURE EXAMINATIONS.
PHYSIOLOGY
QUESTION Define "Venous Admixture". Briefly explain how venous admixture
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Diagrams eg. the haemoglobin oxygen dissociation curve and the iso-shunt
diagram were only useful if accompanied by an explanation.
hypovolaemic shock.
Sixty three percent of candidates passed this question. However, good answers
were uncommon. Few candidates presented the overview that in hypovolemic
shock oliguria results from decreased renal blood flow and increased sodium and
water reabsorption from the renal tubules. Most candidates did not distinguish
between the factors affecting afferent and efferent arteriolar tone. In particular,
they failed to emphasise the importance of neural sympathetic afferent arteriolar
vasoconstriction in diminishing glomerular filtration in hypovolemic shock. Also
most candidates neglected to mention the efferent arteriolar vasoconstriction
produced by angiotensin II which helps to maintain glomerular filtration in this
situation. Many descriptions of the juxtaglomerular apparatus and the stimuli for
renin release were either superficial or contained errors. Glomerulotubular
balance and tubuloglomerular feedback were often confused with each other.
Many candidates produced lengthy descriptions of the cardiovascular responses
to hypovolemia and/or the baroreceptor reflexes. Unfortunately these efforts
gained candidates no additional marks and allowed less time to answer the
question asked.
QUESTION Briefly outline the differences between the pulmonary circulation and the
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systemic circulation
This question was on a topic central to the practice of anaesthesia - fifty seven
percent of candidates passed. A good answer should have mentioned differences
in vessel structure, vascular resistance/impedance, compliance and capacity,
vascular pressures, control of blood flow, and the functions of the two
circulations.
Many candidates correctly quoted vascular pressures and resistances, and fifty
percent discussed structural differences between the two circulations. Although
2/3 of candidates mentioned hypoxic pulmonary vasoconstriction, surprisingly
few discussed other influences on pulmonary vascular resistance such as lung
volume, alveolar pressure, arterial carbon dioxide tension, autonomic receptors
or autacoids. Very few candidates mentioned the non-respiratory functions of the
pulmonary circulation.
Terminology in short-answer questions should be precise. Writing vague
expressions such as "control mechanisms include endocrine, neural and local"
takes valuable time and does not score marks. Several candidates stated that
the pulmonary and systemic circulations were "in parallel".
demonstrated with a diagram (as asked for) in Berne and Levy, Cardiovascular
Physiology, chapter on Electrical Activity and the Heart). The vital relationship
between the slope of Phase 0 (excitability) and the conduction velocity was not
understood by candidates.
Irritability refers to a diminished potential between resting membrane potential
and threshold; the cell membrane is easier to depolarise but there is decreased
gradient of Phase 0 and decreased conduction velocity.
Confusion about the effects of potassium on resting membrane potential was
astonishing.
QUESTION List the physiological factors which determine intracranial pressure and
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posture and intrathoracic pressure. The control areas sought were those of
cerebrospinal fluid volume and control of cerebral blood flow/volume.
The concepts of flow and volume were frequently confused. Many candidates
failed to demonstrate that an increase in intracranial contents would be
accompanied by either an increase in pressure or a displacement of either
cerebrospinal fluid or blood.
Good answers often made use of a compliance/elastance diagram and
commented on the effect of time on the vascular responsiveness to carbon
dioxide.
Diagrams of cerebrospinal fluid production/absorption versus intracranial
pressure were effectively used to convey information succinctly as were
diagrams of pressure versus cerebral blood flow. Frequently mm Hg and mm
cerebrospinal fluid were erroneously transposed. Physiological intracranial
pressure exceeding arterial pressure was frequently quoted, probably as an error
in units.
A number of answers attempted to display a graph of cerebral flood flow versus
pressure for mean blood pressure, partial pressure of carbon dioxide and partial
pressure of oxygen all on the one set of axes. This was rarely successfully.
Separate axes for each point being made showed fewer errors, was of
comparable speed and is recommended.
Inclusion of clinical examples detracted from answers with resultant omissions in
relevant areas.
QUESTION Briefly differentiate between the terms "heat" and "temperature". explain
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acidosis
Thirty-nine percent of candidates passed this question. The underlining of the
word physiological in the question, was not a formatting exercise. It was a
demand of some relevance in answer to physiological derangements and
principles. yet some candidates managed to ignore this fundamental component.
An unqualified, "the conditions untreated leads to collapse.." does not generate
much enthusiasm in the marker. Few attempted a definition, but those who did
were suitably rewarded. A large number of candidates showed a blatant
ignorance of the condition. One candidates went as far as stating the primary
problem was hypoglycaemia, with a glucose level less than 3 to 5 mmo1/L! The
few good answers opened with an introduction including the relevance of insulin
lack and hyperglycaemia. They went on to explain the derangement including the
hyperosmosis resulting primarily from hyperglycaemia, the acidosis from ketone
bodies, with a short outline of why these come to exist. Then the direct effects of
these derangements, rounding off with a short explanation f compensatory
mechanisms, including the sympathetic output, the hyperventilation secondary to
QUESTION List the physiological factors which increase respiratory rate and include a
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QUESTION Briefly explain the changes that occur in stored whole blood.
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The standard of answer to this question was poor. It is considered that
anaesthetic trainees should have a working knowledge in this core area.
Cardiovascular system
o
Ejection fraction
Head up tilt
Peep
Contractility
Shunts
Renal
Loop of Henley
Metabolism/Cellular
o
Definition of an acid
Buffers
Significance of pKa
Carbonic anbydrase
Cell membrane
Osmotic/oncotic pressure
Glucose metabolism
Lactate formation
Ketone bodies
Respiratory System
o
O2 dissociation curve
Venous admixture
Pattern in pregnancy
Measurement of FRC/RV
Cyanosis
Airway closure
Chemoreceptors
Breath holding
Surfactant
Blood Components
o
Blood coagulation
Platelets - structure
- function
Coagulation factors
Stability in storage
Measurement/Physics
o
Pulse oximetry
Carbon dioxide
Transducers
Humidity
Venturi
Temperature
Neuromuscular transmission
Cholinergic receptors
Intracerebral pressure
Pain pathways
Muscle spindle
Monosynoptic reflex
GIT
- measurement
o
Portal circulation
Formation of bile
Gastric secretions
Endocrine
o
Antidiuretic hormone
Adrenal gland
Most of the above topics were generally answered well. However, the areas where candidates
demonstrated a poor standard of understanding included static and dynamic compliance of
the lung, renal handling of a water load, and the body response to breathing an hypoxic
mixture.
PHARMACOLOGY
QUESTION Describe the clearance of drugs by the kidney.
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The pass rate for this question was eighty-five percent.
The question required the three mechanisms (glomerular filtration, active tubular
secretion and passive tubular reabsorption) to be explained and some examples
of drug clearance via these routes. Examples were necessary for a good mark,
but not a pass. Even in a short answer question simply listing the mechanisms is
not adequate, the description must indicate that the candidate understands the
process. This is best achieved by describing ways in which the process may be
modified. For example, glomerular filtration depends on the free concentration of
a drug and varies with changes in protein binding. Acid or alkaline diuresis will
vary the clearance of an ionised drug.
QUESTION Briefly describe the pharmacological effects of paracetamol. List its clinical
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QUESTION Give a brief account of drug protein binding and outline its significance.
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On the whole the answers to the question were adequate. Sixty-five percent
passed.
The emphasis in the answers to this question on protein binding were directed
towards plasma protein binding as expected, representing the knowledge base.
Those candidates who for completeness briefly mentioned drug binding in other
tissues, for example, the epidural space, cell membranes, receptors and
enzymes were awarded credit.
Drug binding in the plasma, usually a reversible process due to weak bonds eg.
ionic and van der waal , occurs between drugs and albumin, -1acidglycoprotein, and to some extent lipoproteins and red blood cells. Albumin
has a high binding capacity and possesses multiple binding sites mainly for
acidic drugs. -1-acidglycoprotein has a low binding capacity and few binding
sites, mainly for basic drugs. The extent of protein binding is determined by the
QUESTION Outline the chemistry of heparin. Describe its mechanism of action and list
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Heparin is used to prevent clotting of lines during bypass and in intensive care
(NO candidates mentioned this).
QUESTION Briefly outline the effects of the volatile agents on muscle tissues. Include
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blocking agents was often discussed well, as was the change in the epidural
space and the consequent effect on local anaesthetics. Pregnancy has a variable
effect on the metabolism of drugs, any effect depending very largely on the drug.
The increased metabolism of phenytoin is well recognised and dosage generally
should be reduced after delivery. The effect of the increased renal blood flow on
the renal clearance of drugs was correctly included in most answers.
QUESTION Outline the factors that determine recovery (offset of effect) after ceasing a
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interactions, and a correct answer to the relevance of the drug elimination halftime. Very few candidates mentioned anything about pharmacodynamics and
most candidates were not correct in their answer to the relevance of elimination
half-time.
Pharmacokinetic factors included the rate of transport of the drug from the
biophase to the plasma (including the affinity of the drug for its receptors) which
in turn could be influenced by the rate of redistribution and elimination. The
plasma concentration at cessation of infusion is also relevant. The majority of
candidates focussed mainly on factors affecting the rate of decline of plasma
concentration, dealing mainly with factors affecting metabolism, but this was only
one component of the answer. Quite a few candidates discussed nonlinear
elimination, but this is a rarity. Very few indicated that the elimination half-time is
largely irrelevant for most drugs, because it usually describes the slow decline in
plasma concentrations at levels too low to have any effects. The so-called
context-sensitive half-time is relevant as it describes the apparent half-time for
decline of plasma concentrations after cessation of infusion and it depends on
the dose administered and the duration of the infusion.
Pharmacodynamic factors included interactions which may increase or decrease
the effects of the drug, the use of antagonists, synergism, hypothermia and
tachyphylaxis.
QUESTION Using opioids as examples, describe and illustrate with graphs what you
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better approach.
Marks were not deducted for considering codeine a partial agonist as this was
such a commonly held view. Interestingly, Codeine is metabolised to morphine
and so one would expect it to be rather a less potent full agonist. However,
references to support either view have not been found.
In summary this question illustrated the importance of reading past examiner
reports as a part of each candidate preparations.
during the first half hour of administration for nitrous oxide, isoflurane, and
halothane. Outline the reasons for the observed differences between the
agents and indicate the effects of non concurrent increases in alveolar
ventilation and cardiac output.
It was encouraging that this basic pharmacology question was attempted by most
candidates and 52% attained a satisfactory pass. A majority of candidates were
able to draw a reasonable graphical illustration of wash-in curves that related
alveolar and inspired concentrations of halothane, nitrous oxide and isoflurane to
time. Unfortunately, a significant number of candidates incorrectly labelled the
ordinate with a wash-out ratio and then constructed wash-in curves. Marks were
deducted for inadequate detail and labelling of both axes. Some candidates
positioned the three curves in incorrect order. The majority managed to ascribe
differences in rate of uptake to relative differences in blood/gas partition
coefficients, however, few mentioned the lesser importance of other tissue/blood
partition coefficients Although the second-gas and concentration effects were
included in many answers, only a minority of candidates understood the
mechanisms of how these two effects enhanced uptake of anaesthetic agents.
Effects of the agents themselves on ventilation and cardiac output were rarely
included. Metabolism and non-pulmonary excretion as factors were largely
ignored. Most candidates demonstrated an adequate understanding of the
effects of non concurrent increases in alveolar ventilation and cardiac output on
the uptake of the three agents.
Classification of anti-emetics
Adenosine
Explain clearance
Haemmaccel
Infusion kinetics
Tests of significance
Bias
Pharmacogenetics
Structure of opioids
Uptake of nitrous-oxide
2 agonists
Bioavailability
Action of warfarin
Classify vasodilators
Vecuronium infusion
Pentazocine
EMLA
Diuretics
Clonidine
Tolerance - tachyphylaxis
Steady state
Correlation
X2 test