The Hong Kong College of Anaesthesiologists

Intermediate Fellowship Examination

Feb - Mar 2001

Examiners’ Report

PHARMACOLOGY PAPER

Written Section
Oral Section

PHYDSIOLOGY PAPER
Written Section

Q 1: Explain the functions, formation and absorption of cerebrospinal fluid (CSF).

Thirteen candidates passed this question. Candidates are reminded to use words as intended- e.g.
writing “haemostatic” when “homeostatic” was meant. Very few candidates could provide the rate of
formation of CSF, and not many appreciated that ↑ICP had different effects on formation and
absorption of CSF. Many stated that CSF was an ultra-filtrate of plasma, then gave differences in
composition, without understanding that this required active transport mechanisms.

Q2: Briefly outline the physiological consequences of a rapid blood loss of 1 litre in a pregnant
lady (60 kg) at 32 weeks of pregnancy.
Eighteen candidates passed this question. Almost all candidates stated that blood volume was increased
in pregnancy, but not all pointed out that this enabled the pregnant lady to tolerate greater blood loss
(up to 1.5L) before vital signs changed. Most proceeded to discuss response to haemorrhage with little
further reference to pregnancy. Potential aortocaval compression with ↓ ability to compensate for
hypovolaemia was mentioned only by some, and potential ↓uterine flow/foetal distress with occult ↓
cardiac output was seldom mentioned. Many candidates still make the common mistake of confusing
baroreceptors in the carotid sinus with the carotid bodies.

Q3. Describe the normal plasma level and function of magnesium in the body. Briefly outline the
causes of magnesium deficiency.
Thirteen passed this question. This was a straightforward factual question and most candidates
provided satisfactory answers. Those who did not do well confused Serum Mg levels with Serum Ca (2
mmol/L), gave wrong units (ng/dl and even g/dl), and did not describe the functions beyond saying it
was “important for many enzymes”.

Q4: Describe the compensatory changes that occur with acute normovolaemic haemodilution
resulting in a drop of haematocrit from 0.45 to 0.20.
Only ten candidates passed this question. Candidates could not differentiate between O2 carrying
capacity/content and O2 delivery. Many provided the O2 flux equation, then stated that ↓ O2 content
leads to ↓O2 delivery without appreciating that O2 delivery can in fact be maintained by compensatory
↑cardiac output (CO). No candidate pointed out that a Hct of 0.2 was at the limit of compensation,
with little further reserve. Many candidates wrongly attributed the increased CO to sympathetic
activation as the major mechanism, rather than ↓viscosity and peripheral vasodilatation, capillary
recruitment with increased tissue perfusion, leading to ↑ venous return and stroke volume. Many
candidates stated that the peripheral chemoreceptors were activated- these respond to hypoxia, rather
than ↓ O2 content (Nunn). Some candidates in fact said that patients became hypoxic, and others
provided an answer to haemorrhagic shock, rather than normovolaemic haemodilution.

Q5: What is 2-3 Diphosphoglycerate (DPG)? How is it produced in the red blood cells? Briefly
describe the physiological role of 2-3 DPG and its relevance in altitude exposure, anaemia, and
blood transfusion?
Fifteen candidates passed this question. Most candidates failed to support their answers with relevant
data. Only one candidate mentioned 2,3-DPG is a strong anionic substance present inside the RBC.
Some candidates stated the effect of 2,3-DPG level on the P50 of haemoglobin wrongly. There were
inadequacy in how 2,3-DPG is produced, the roles of 2,3-DPG in foetal haemoglobin and the time
course for change of 2,3 DPG level before and after transfusion.

Q6: Outline the control of body water by the kidneys

Fifteen candidates passed this question. Examiners expected a brief statement on the amount,
mechanisms and factors affecting reabsorption of water in different parts of the kidney. A common
mistake was wrongly linking the water reabsorption in the distal tubules to that of solute reabsorption
as the tubules are relatively water impermeable and small water reabsorption only occurs via passive
reabsorption.

Q7: Describe the function, distribution and turnover of the albumin in the body.
Ten candidates passed this question and good answer was lacking. Common omissions included
antithrombotic, free radical scavenging and buffering effects of albumin. The distribution of plasma
albumin in the intravascular and interstitial compartment was not known by many. Normal plasma
contains 120 g albumin compared to 165 g in the interstitial tissue. However, the interstitial
concentration is lower (15 g/L) than plasma (40 g/L). Albumin is constantly leaving the intravascular
compartment by pinocytosis at a rate estimated to be about 5% per hour and is returned to it via the
lymphatic system. There is no storage of albumin in liver that is the site of synthesis and breakdown.
Half life is about 2-3 weeks.

Q8: Outline the control of arginine vasopressin secretion.

Fifteen candidates passed this question with a few good answers. Most candidates mentioned about the
feedback control loop and recognized the relative difference in sensitivity and potency of the osmotic
and volume stimuli. However, sites of osmoreceptors (in relation to blood brain barrier), low and high
pressure receptors and the pathway to the hypothalamus were often inaccurate. Normal plasma
osmolality value was given by a few. Stress, atrial natriuretic peptides, angiotensin II, drugs and
alcohol also play a role in the secretion of the vasopressin.
Q9: A 70 years old man (70 kg) has a gastric cancer causing outlet obstruction with nasogastric
losses of 1000 mL per day for 7 days. He develops metabolic alkalosis. Describe the electrolyte
changes and explain how the metabolic alkalosis develops in this man. Justify the choice of
replacement fluid.
Only 8 candidates passed this question. A disappointing result considering that anaesthetists need to
optimize the fluid and electrolytes status of patients with gastric outlet obstruction before surgery. Most
candidates knew the electrolytes content in gastric juice. However, explanation about the causes of
metabolic alkalosis in gastric outlet obstruction was deficient, particularly the “paradoxical” loss of H+
in the distal renal tubules. A few candidates even stated wrongly that Hartmann’s solution was the
replacement fluid of choice.

Q10: Explain how blood gases and acid-base status is measured in modern blood gas analyzers.
Ten candidates passed this question. Most candidates were able to explain the oxygen and pH
electrodes and that the CO2 electrode was a special type of pH electrode. However, a number of
candidates did not realize that the values of bicarbonate, base excess and oxygen saturation were
calculated.

Q11: Describe how the pulmonary circulation differs from the systemic circulation.
Eleven candidates passed this question. Of the 4 areas, candidates were better with the anatomy and
haeomodynamic differences. Candidates were able to include more points by tabulating the
differences of the systemic and pulmonary circulation.

Q12: Explain the factors that affect resistance to gas flow in the respiratory tract.
Twelve candidates passed this question. The question was handled well overall. Candidates in general
realized the importance of airway diameter in affecting resistance to gas flow. However, a number of
candidates stated the Hagen-Poiseuille equation wrongly. Candidates failed mainly because they
omitted the discussion of laminar vs. turbulent flow, and physical properties of the gas in affecting
resistance to gas flow in the respiratory tract.

Oral Section
The introductory topics for the oral examination include:
Oxygen cascade
Oxygen flux
Red blood cell production
Bilirubin metabolism
Calcium
Thyroid hormones
Complement system
Basal metabolic rate
Cerebral blood flow
Intracranial pressure-volume
Coronary blood flow
ECG
Capnograph
Pressure transducer
Ventricular pressure volume loop
Clotting cascade