Hong Kong College of Anaesthesiologists

Intermediate Fellowship Examination

July 2002

Examiners' Report

Written Paper:
Q 1.

Q 2.

Q 3.

Q 4.

Q 5:

Q 6:

Q 7:

Q 8:
Q 9:
Q 10:

Q 11:
Q 12:
Topics of the Oral Examination
Other therapeutic indications

Physiology Section

Overall 9 out of the 16 candidates passed the physiology section of this examination.
Nine candidates passed the written section while 11 passed the oral section. Of those
who passed the physiology section, all passed the written and oral sections. For the
written section, candidates should read the question carefully, and write relevant
answers only. Irrelevant answers would not be marked. Candidates should understand
the requirements of key words such as outline, describe, and discuss.

Written Section
Q1. Compare and contrast excitation-contraction coupling in skeletal and cardiac
muscles.
Eight candidates (50%) passed this question. Answer relevant to the practice of
anaesthesia includes the duration of action potential, the absolute and relative
refractory period, potential in producing tetanus contraction and a description of how
excitation and contraction coupling occurs.
Occasionally candidates mixed up the duration of action potential with that of
mechanical (contractile) responses and incorrectly mentioned that the twitch response
in muscle was as short as that of the action potential. Indeed the mechanical response
to a single stimulus in the skeletal muscle fibre is about 20 msec.
No one was able to mention correctly how the two types of muscle differ in terms of
the role of T-tubules, sarcoplasmic reticulum and extracellular fluid on the intra-
cellular calcium level. Therefore, the effect of extracellular calcium ion on the force
of contraction was not mentioned by any of the candidates.

Q2. Describe the regulation of liver blood flow.

Eight candidates passed this question. Most candidates were able to correctly point
out the relationship between the hepatic artery and portal vein on the distribution of
hepatic blood flow and oxygen supply. Autoregulation, autonomic nervous supply,
metabolism, meals, reciprocal relationship, and other external factors were commonly
mentioned.

Q3. Compare and contrast measurement of cardiac output by indicator dilution and
thermal dilution.
Only 5 candidates achieved a pass mark. The part on dye dilution technique was
poorly answered by most candidates. Many did not seem to know that the pulmonary
artery catheter is not needed for the dye dilution technique as the dye can be injected
in one of the major veins and serial sampling done at a peripheral artery. The part on
thermodilution was better answered but some candidates had probably never seen
how it is done.

Q4. Describe carbon dioxide transport in blood and explain the Haldane effect.
Nine candidates passed this question. The question was well answered on the whole.
A few candidates mixed up the site of carbonic anhydrase, direction of chloride shift,
and the proportion of carbon dioxide carried in the arterial blood with that of the a-v
difference. A few candidates did not offer any explanations for the Haldane effect.

Q5. Outline the physiological effects of intermittent positive pressure ventilation.

Seven candidates achieved a pass mark. This question is generally not answered
satisfactorily. Most candidates only discussed about the cardiovascular effects of
IPPV in this question. Even then, some forgot to discuss changes in cardiac output
associated with IPPV. Respiratory effects of IPPV were frequently left out. Very few
candidates mentioned the increase in apparatus dead space and the reduction in
anatomical dead space if patient is intubated. Some candidates mentioned increase in
FRC with IPPV. FRC increase only occurs with PEEP. With IPPV per se it may even
decrease depending on the use of muscle relaxation and the posture of the subject.
Renal, CNS and GI effects of IPPV were only mentioned by a few.

Q6. What is glomerular filtration rate? Discuss the use of urinary creatinine
clearance as an estimate of glomerular filtration rate.
Ten candidates passed. This question was generally well handled. Most candidates can
produce a reasonable definition of GFR. A few candidates mixed up GFR and renal
blood flow in the definition. Although not required in the answer, some candidates
provided good and detailed discussion on how the balance of hydrostatic and oncotic
forces determined GFR and received bonus marks. However, change of GFR with age
was not mentioned by any candidate. The equation urinary creatinine clearance =
UcrV/Pcr was important in this question and produced by most candidates.

Q7. Describe the physiological changes of respiratory function in the elderly.

Eight candidates passed. Candidates generally provided sufficient information to pass
comfortably in this question. However, the answers were frequently poorly organized.
Some candidates guessed FRC decreased with age which is not true. FRC actually
increases slightly with age. However, the rate of increase is much slower than the
increase in closing capacity. This leads to the closure of basal alveoli at 44 in supine
and 66 in erect posture. This fact is frequently mentioned by candidates but apparently
some candidates are confused on the mechanism and thought the closure was a result
of decease in FRC. Few candidates produced diagrams which can be very helpful in
presenting the points. Only few candidates mentioned the change in response to
hypoxia/ hypercapnia with aging. Some candidates wasted precious time by
discussing irrelevant information such as changes in disease or measurement of
closing capacity which scored no marks.

Q8. What is surfactant? What are the physiological roles of surfactant?

Twelve candidates passed. The question was generally very well answered. There
were a few excellent answers in which the candidates can describe the detail
constituent of surfactant. The role of surfactant in causing hysteresis in lung
compliance was not mentioned by most candidates. A few poorer candidates failed to
apply Laplace’s Law to explain why small alveoli are unstable without surfactant.

Q9. Briefly describe the structure and functions of endoplasmic reticulum.

Eight out of sixteen candidates passed this question. Most candidates illustrated the
answer with an appropriately labelled diagram. Candidates were better with the
structure and functions of rough ER. Many candidates did not realise the importance
of smooth ER in drug metabolism and intracellular storage of calcium.

Q10. Discuss the role of skin as an effector in the regulation of body temperature.
Eight out of sixteen candidates passed this question. Most candidates described the
roles of skin in thermoregulation in general, with discussing its roles as an effector.
Subcutaneous fat does not play any role as an effector in thermoregulation, as its
insulating effects do not change in response to a change in body temperature. Few
candidates discussed skin as the primary organ for removal of metabolic heat and
sweating as the only mechanism of heat loss when ambient temperature is higher than
the body temperature. However, most candidates did realised piloerection to increase
insulation was not important in humans.

Q11. Describe the unique features of the coronary circulation (anatomy of coronary
arteries NOT required). List the determinants of myocardial oxygen supply and
demand. Eight out of sixteen candidates passed this question. Candidates in general
were better with the first part of the question. Most candidates were aware of the
phasic effects of ventricular contraction on coronary blood flow. Common omissions
included maximal oxygen extraction and metabolic control of coronary circulation. In
the second part of the question, candidates were expected to give headings only.
However, some candidates wasted time on discussion of the details.

Q12. Explain the physiologic effects of drinking 1 litre of water in a normal subject.
Nine out of sixteen candidates passed this question. Better candidates were able to
follow the sequence of physiologic events, and explain the physiologic homeostatic
changes. Some candidates were confused about the distribution of body water, leading
to the wrong conclusion of haemodynamic changes following the drinking of 1 litre of
water. Other common mistakes included the sites of water absorption, osmoreceptors,
and ADH secretion. Most candidates were aware the role of ADH in controlling the
renal excretion of free water.

Oral Questions:
Cerebral blood flow: measurement
Cardiac cycle: change in LV pressures
Lung volumes and spirometry
Functional residual capacity: measurement and factors affecting
High altitude: physiologic adaptation
Starvation
Exercise: respiratory changes
Resting membrane potential
Renal medullary blood flow and counter-current multiplier mechanism
Arterial pressure: control and baroreceptor reflex
Alveolar gas equation
Dead space and alveolar ventilation
Preload: effect of heart rate
Valsalva manoeuvre
Haemoglobin-Oxygen dissociation curve
Thyroid function