Hong Kong College of Anaesthesiologists

Intermediate Fellowship Examination

March 2003

Examiners' Report

General

This examination marked the first use of video conferencing technique in the
history of the Hong Kong College of Anaesthetists Fellowship examination. Hong
Kong was hit hardly by the SARS soon after the written examination which was
conducted in the early March. The decision to continue with the examination was
difficult as little was known about the disease at that time. Opinions were sought from
all parties including the candidates, examiners and the Board of the Examinations.
The aim was to strive for the best interest of the candidates and the examiners. The
examination panel felt that it was difficult to estimate the risk for the external
examiners if they had to be physically presented in Hong Kong. With the help of the
PCCW, telephone video conferencing facilities was set up between the HKCA in the
Building of the Hong Kong Academy of Medicine and the ANZCA in Melbourne on
the original date of the oral examination. Due to the time difference between Hong
Kong and London, the RCA examiner was only involved in the marking of the written
paper. As a result, the oral examination for the physiology was conducted by three
local examiners while there were 2 internal examiners and 1 external examiner for
pharmacology. To ensure the candidates were acquainted with the examination format,
notice was sent to all of the candidates prior to the examination and briefing was
conducted before each session of the viva. It was planned to offer compensation time
if the examination was interrupted by poor signals. The oral examination was
conducted in the usual format of 20 minutes for each candidate. Apart from a few
jitters in the first 1 hour of the examination, the rest went smoothly. There were 4
candidates unable to attend the oral examination for various reasons.

Eight out of 21 candidates successfully passed the Intermediate Fellowship

Examination.

The comments in the written section below show the basic requirement for
each question. Additional marks were given to the answers with depth and
applications relevant to the questions. Irrelevant answers will not be given marks.
Values should be given wherever appropriate. Candidates are advised to spend equal
time (10 min or less) on each question and make sure they have answered all the
questions. They should not leave any question unanswered as this may markedly
affect the overall performance of the written paper.

Candidates were examined on a variety of topics during the viva examination.

Usually 4 to 5 topics will be asked in the 20 minutes. Most of these questions were
structured. Only the introductory viva questions are listed in this report. Candidates
are encouraged to use diagrams to help them with their answers. Whenever diagrams
are required, they should be accurate with appropriate proportion and correctly
labelled.

Written Paper:

Q1.

Q2.

Q3.

Q4.
Q5.

Q6.

Q7.

Q8.
Q9.
Q10.
Q11

Q 12

Topics of the Oral Examination

Physiology Section

Six out of 21 candidates achieved a pass mark in the written section and 11
were successful in the oral section. Overall, 9 candidates passed the physiology
section of this examination.

Written Paper

Q 1. What are the essential components of a normal diet? What metabolic

changes occur during a period of starvation?
Eleven candidates passed this question. The first part was generally well-
answered, but essential fatty acids and amino acids were often omitted. The
changes resulting from starvation were less well-understood. Few described
the sequential changes of carbohydrate , fat and protein breakdown, and very
few explained why ketone bodies are formed.

Q2. What determines the contractility of the left ventricle? How may this be
quantitatively assessed in man?
 Seven candidates passed this question. This is an important subject in
intensive care, and the main weakness of those who failed was only a vague
description of measurement techniques. Examiners looked for a discussion on
the position of the Starling curve, effects of the autonomic nervous system,
circulating catecholamines and electrolytes. Assessment can be done by
constructing the ventricular function curve, with an index of mechanical
activity on the y-axis (stroke volume, stroke work, cardiac output), and
preload on the x-axis (end-diastolic volume or pressure), including methods of
measurement. Other methods of assessment includes, e.g. slope of the end-
systolic pressure - volume line, dP/dt max., ejection fraction during
angiography, non-invasive estimates, e.g. radionuclide tests such as
technetium scanning and M-mode echocardiography.

Q3. Draw a simple diagram to illustrate the emetic neural pathways. Describe
effects of vomiting and list risk factors contributing to development of
postoperative nausea and vomiting.
Nine candidates passed this question. Most drew an adequate diagram.
Additional sensory input like that of pregnancy, raised ICP and knowledge of
the neurotransmitters were often omitted. Those who failed were
disadvantaged by not adopting a systematic approach to the effects of
vomiting and the risk factors. Effects of vomiting include electrolyte
disturbance, dehydration, mechanical damage to oesophagus, vagal effects (e.g.
bradycardia) and aspiration. Risk factors include patient factors (e.g. female
gender, motion sickness, vestibular disease, obesity, early pregnancy, anxiety,
ingestion of food, delayed gastric emptying), anaesthetic factors (e.g. volatiles,
nitrous oxide, ketamine, etomidate, opioids), operative factors (type of surgery
e.g. laparoscopy, lithotripsy, squint, tonsillectomy, middle ear, orchidopexy)
and postoperative factors (e.g. pain, hypotension, premature ambulation,
forcing oral fluids).such as that outlined above. This led to important
omissions.

Q4. Define innate immunity and describe how they protect the body against
infections.
Eight candidates passed this question. Most gave a reasonable definition of
innate immunity. However those who failed usually demonstrated little
knowledge of the 4 mechanisms. Anatomic: includes skin and mucous
secretion. Physiologic: include temperature, pH, lyzozymes, interferons,
complements. Phagocytosis: description of what it is and the cell types
 involved. Last one is inflammation.

Q5. What are the differences between anatomical, alveolar and physiological
dead space? Describe how may each of these be measured, and the values
you would expect in a normal man?
Twelve candidates passed this question. Those who passed generally answered
it well. The main weaknesses in the remaining candidates were poor
understanding of alveolar dead space, and the physiological principles behind
Fowler’s method and the Bohr equation.

Q6. Describe the physiological responses of a normal subject who receives a

rapid intravenous infusion of one litre of normal saline, and the
mechanisms by which the saline is excreted.
Eight candidates passed this question, which seemed to cause some candidates
considerable difficulty. Several made elementary mistakes about the
distribution of sodium in the body, gave incomplete mechanisms by which
saline is excreted, and did not describe the renin-angiotensin-aldosterone
system. None provided a full explanation of the juxtaglomerular apparatus.
After saline administration, there will be a rise in atrial pressures, and a small
rise in arterial pressure. The former causes secretion of atrial naturietic factor
(ANF) - vasodilator, increases GFR and inhibits renin secretion. The latter
increases GFR (and thus sodium delivery to the distal tubules), and also (via
the baroreceptors) inhibits sympathetic outflow and the renin-angiotensin-
aldosterone system.

Q7. Discuss the physiological mechanisms governing coronary blood flow in

the normal heart.
Nine candidates passed this question. Common errors were incorrect or vague
diagrams attempting to show the changes in coronary blood flow during the
cardiac cycle, little understanding of anatomy as it relates to function e.g.
relationship of aortic valve leaflets to coronary ostia, the epicardial arteries,
the intramuscular arteries (entering at right-angles to the heart wall) and the
sub-endocardial plexus, and poor descriptions of autoregulation. Nervous
control was omitted by some candidates.

Q8. Give an account of calcium metabolism in the body.

9 out of 21 candidates passed this question. Common problems were an
inadequate understanding of the actions of vitamin D, PTH and calcitonin. Gut
 absorption of Ca was often omitted, as was the distinction between free and
protein-bound Ca in plasma. Very few candidates attempted to explain the
relationship between Ca and PO4 as well as the effects of other hormones
(steroids, GH, thyroxine, estrogens).

Q9. What are the mechanisms by which arterial hydrogen ion concentration is
controlled?
Fourteen candidates passed this question. The three mechanisms needed
discussion: buffers, ventilation, and renal control were well covered. The
weakest part was on the kidneys. The maximum excretory capacity of the
kidneys (300 mmol H+ per day) can only be reached after 7 to 10 days. In
acute acid load, if the amount of hydrogen ion excretion is higher than the rate
of ammonia formation, urinary pH will fall. Urinary buffers are important to
remove free hydrogen ion, permitting more acid to be secreted. Bicarbonate is
the most important buffer in the proximal tubules because of the presence of
carbonic anhydrase; HPO42- reacts with the hydrogen ion to form H2PO4-
happens to the greatest extent in the distal tubules and collecting ducts; the
reaction with ammonia to form ammonium ion occurs in the proximal and
distal tubules. Hydrogen also combines to a minor degree with other buffer
anions. Hydrogen excretion is largely an energy expenditure as it needs to be
excreted against a concentration gradient.

Q10. How is the PO2 of venous blood prevented from falling too low when man
ascends to high altitude?
Six candidates passed this question. Not many of the candidates gave a logical
presentation of the problem. Probably best to describe the influence of
acclimatization on alveolar PO2 and arterial PO2, and show how these
determine venous PO2. As arterial PO2 falls, this stimulates peripheral
chemoreceptors, increasing ventilation and lowering PCO2. As acclimatization
proceeds, the kidneys excrete bicarbonate, providing metabolic compensation
for the respiratory alkalosis, and tending to restore pH towards normal. This
allows further hyperventilation, which can be extreme at very high altitude
(PCO2 as low as 7.5mmHg - 1kPa). Venous PO2 derived from the Fick
equation: CvO2 = CaO2 - (oxygen consumption / cardiac output). This shows
that the fall in venous PO2 is limited by an increase in cardiac output, and also
by polycythaemia.
Q11. Describe the principles of compatibility testing performed on donor and
recipient blood samples prior to homologous (allogenic) red cell
transfusion.
Four candidates passed this question - the least well performed question for
the whole paper. Compatibility testing refers to the ABO-Rh type, cross-match,
and antibody screen. ABO-Rh is determined by testing the patient blood with
commercially available anti-A, anti-B and Rh antibodies. Antibody screening
is carried out in three phase. It is a trial transfusion between the recipient
serum and commercially available red blood cells that are specifically selected
to contain optimal numbers of red cell antigens. It is done for both the donar
(performed shortly after withdrawal of blood from the donor) and recipient
blood. The first phrase is conducted at room temperture and takes 1 to 5
minutes (saline agglutination). The second phrase involves incubation of the
first-phrase reaction at 37 degree Celsius in albumin or low-ionic strength salt
solution to detect incomplete antibodies primarily Rh system (incubation
phrase). The third phrase involves the addition of antiglobulin sera to the
incubated test tubes. This detects most incomplete incomplete antibodies in
the blood group systems, including the Rh, Kell, Kidd and Duffy blood group
system (Indirect Coomb’s test or antiglobulin phase). In many hospitals, a
complete cross match between the donar and recipient’s blood is not needed
unless immune antibodies are found in the recipient’s blood. A cross-match is
a trial transfusion within a test tube in which donar’s blood is mixed with
recipient serum to detect a potential for serious reaction. The cross match like
the antibody screening, can be completed in approximately 45 to 60 minutes.

Q12. What is a thermometer? Discuss the principles, advantages and

disadvantages of the different types of electrically-operated
thermometers.
Eleven candidates passed this question. Descriptions needed for thermistors,
thermocouples, infra-red thermometers and resistance coils. Thermistors were
mentioned by all candidates but not many were aware of the potential
problems associated with its use. Knowledge on infra-red thermometers,
resistance coils and thermocouples were not sufficient.

Topics of the Oral Examination

Oxygen-haemoglobin dissociation curve
Frank-starling law and assessment of preload
Fluid compartments
Storage lesions of blood
Functions of kidney and assessment of kidney function
Serum osmolality and regulation
Effect of heart rate on cardiac output
End tidal carbon dioxide
Flow: laminar and turbulent
Intracranial pressure
Humidification
Preoxygenation and exponential function
Factors affecting cardiac output and measurement
Carriage of carbon dioxide in blood
Countercurrent mechanism
Isovolaemic haemodilution
Resting membrane potential
Pneumotachograph
Spirometry, measurement of lung volume, FRC, closing capacity
Starvation
Starling’s forces