Hong Kong College of Anaesthesiologists

Final Fellowship Examination Report

August – September 2002

Written examination 2nd August 2002

Viva examination 6th September 2002
OSCE 7th September 2002

General comments
Written
Overall the candidates performed satisfactorily. Quite frequently, the candidates gave a generic answer
to the problem and not relating the answer to the question that was asked. This may demonstrate
knowledge. However, it does not demonstrate the judgement and perspective that is looked for in the
questions asked. Eg.”Discuss the likely causes of an acute fall in SpO2 during placement of a femoral
rod” An exhaustive list of every cause of hypoxemia starting at the oxygen pipeline is not asked for, nor
is it the purpose of the question. Candidates did better on the scenario paper with 92% passing this paper
compared to only 40% passing the short answer paper. Questions usually ask candidates to provide
some explanation in addition to lists and general statements. This is to illustrate understanding. Many
candidates failed to include this in their answers and so scored poorly.
Orals
Overall the candidates performed well in this section
OSCE
The overall standard of the candidates was good with 2 exceptional performances and although the
candidates who failed obviously had deficiencies none of these were bad failures. All of this suggests
that the training and preparation for the examination is of a high standard.

PAPER 1- SCENARIO QUESTIONS

SCENARIO A
30 year old woman with a 10 year history of recurrent supraventricular tachycardia is scheduled
for an elective caesarean section in 3 days time. She requests a regional anaesthetic technique
because she experienced awareness during a previous general anaesthetic for appendicetomy .

1. Describe your pre-operative assessment. (9/13 passed)

This question was reasonably well answered with good answers addressing the following four areas:
assessment related to caesarean section, assessment related to SVT, details on awareness during last GA,
discussion of advantages/ disadvantages of general vs regional anaesthesia.

2. List the regional anaesthetic techniques (central blockade) that can be used for caesarian
section. Discuss their advantages and disadvantages. (13/13 passed)
Again this is a straight-forward questions and most candidates performed well, however, many omitted to
consider the post-operative period. The advantages / disadvantages of subarachnoid, epidural and combined
spinal epidural (CSE) techniques with respect to technical ease of institution, subsequent management, speed of
onset, duration, flexibility, intra-operative conditions, side-effects and complications (cardio-respiratory, degree
of sensori-motor block, post-dural puncture headache- frequency and severity, neurological damage, urinary
retention, specific drug effects etc) and the contribution of feto-maternal factors, obstetrican considerations and
nursing practices together with ability of the technique to provide post-operative pain relief should have been
discussed.

3. What is the incidence of awareness during general anaesthesia for caesarean section. Discuss
how this problem can be minimized. (8/13 passed)
Many candidates failed to address the first part of the question which required an explanation that awareness is
high in this patient group ( .3-10% -a wide range was accepted) but is difficult to measure accurately (due to the
definition encompassing a gradation of recall with the incidence depending on the definition used, the anaesthetic
technique employed and maternal factors present during operation (disease states which may predispose to
awareness because of unpredictable drug handling or difficulty securing and airway, hypotension, haemorrhage
etc).The second part of the question was well answered. Most candidates addressed preoperative assessment (past
medical/smoking/alcohol/ drug history), premedication, equipment and drug check, methods to monitor depth of
anaesthesia as well as considering the use of a regional technique and post-operative follow-up.

SCENARIO B
A 30 year old previously healthy man suffered a fractured left femur and fractures of left 4th and 5th
ribs in a motor vehicle accident. During placement of a femoral rod under general anaesthesia the
oxygen saturation falls from 98 to 90 % .

4. Discuss the likely causes for this fall in oxygen saturation and your management.
(10/13 passed.)
This question was generally well answered. Likely causes include fat embolism syndrome, pneumothorax,
pulmonary contusion, aspiration and pericardial tamponade. General factors such as equipment failure,
endotracheal tube malposition etc. also need to be considered.
Management includes general supportive management such as increasing oxygen concentration and
cardiovascular support while attempting to work out the cause of the problem. Candidates who failed tended to
neglect causes other than the most obvious or did not emphasize the need for supporting the patient before the
cause can be established.

5. Describe the Fat Embolism Syndrome (including the pathophysiology) associated with trauma.
(9/13 passed)
Fat Embolism Syndrome is a collection of respiratory, cardiovascular, haematological, neurological and
cutaneous symptoms and signs usually associated with major trauma. Good answers described the etiology
including the incidence associated with long bone fractures and covered the possible pathophysiological
mechanisms which include the mechanism of release of marrow fat, effects of intravascular marrow and causes
of pulmonary and cerebral damage. Candidates who failed had poorly organized answers and failed to address
non- pulmonary effects.

6. The patient fails to awaken after the operation. Discuss your management. (10/13 passed)
Successful candidates emphasized the importance of initial cardiorespiratory support (ABC) while the causes are
being ascertained. Major causes could include effects of various drugs, hypoglycaemia, hypoxaemia, hypercapnia,
hypothermia and a range of neurological disorders which should be confirmed/eliminated by various
investigations.

SCENARIO C
An 80yr old man is admitted the day before surgery for repair of an enlarging abdominal aortic
aneurysm.

7. List the anaesthetic implications in the elderly? (13/13 passed)

This is a straight-forward question requiring the candidate to highlight the changes in the many body
systems/organs as a result of their decreasing functional capacity and altered body composition. In particular, the
impact of the effects of nutritional status, cardiorespiratory, CNS, renal, liver, thyroid and adrenal functions as
well as the implications of aging on the pharmacokinetics/dynamics of drug handling, co-morbidities and drug
interaction due to polypharmacy should be addressed.

8. How would you manage the complications associated with aortic cross clamping and
declamping? (13/13 passed)
This is a straightforward question and was generally well answered. Some candidates failed to state the
complications they were managing and proceeded to provide a recipe book approach on how they would conduct
anaesthesia. Good candidates addressed the complication of cross clamping by outline the sequence of events- the
increased afterload, increased myocardial oxygen consumption and decrease cardiac output with the judicious use
of nitroglycerine to return these parameters towards normal, the jeopardized kidney perfusion (worse with
suprarenal cross clamping but also present with infrarenal clamping) by highlighting the importance of
maintaining renal perfusion and urine output and discussed the relative roles of mannitol, frusemide and
dopamine, the lactic acidosis from lower limb ischemia (and the visceral ischemia with clamping above the
celiac and superior mesenteric arteries).
Complicatins of unclamping were reasonably well answered and included the common profound hypotension due
to decrease in preload from blood loss and the large acid metabolite load. Strategies to minimize this unclamping
effects including optimization of blood volume before unclamping, gradual (stepwise) unclamping, correct
pre-existing acidosis before unclamping were well covered.

9. Discuss the use of epidural analgesia for postoperative pain management in this
patient? (13/13 passed)
All candidates passed this question but few performed well. Candidates were required to highlight the risk/benefit
of performing an epidural in someone given low dose systemic heparin for aortic surgery, in particular, the lack of
evidence as to whether there is an increased the risk of epidural haematoma in this setting should have been raised.
Risk is considered minimum when the procedure is done atraumatically by a skilled practitioner. Good candidates
emphasized the following benefits: excellent postoperative analgesia; better perfusion of lower extremities; less
acidosis; increased graft patency and indicated patient participation in the decision as to whether to proceed with
an epidural was essential. Better candidates erred on the side of caution and stated that if difficulty was
encountered, they would abandon the procedure early and switch to PCA rather than risking traumatic puncture.

PAPER 2- SHORT ANSWER QUESTIONS

1. Discuss the ventilatory management of an adult with ARDS who requires laparotomy for an
acute abdomen. (5/13 passed)
Despite this being a straightforward question most candidates seemed at a loss as to how to manage such critically
ill patients who not infrequently require emergency surgery. The aim is to keep the patient adequately oxygenated
without increasing lung damage so as to facilitate recovery. The concept of lung damage caused by volutrauma
(related to increased transmural pressure gradient) rather than barotrauma was poorly understood and excessively
large tidal volumes were often wrongly recommended The role of pressure controlled ventilation, inversed I/E
ratios with increased inspiratory times, permissive hypercapnia, and the use of low tidal volumes and PEEP
requiring the use of ICU-type ventilators either were not addressed fully by candidates or were ignored. Better
candidates should have highlighted that overstretch can be minimized by keeping below the upper inflection point
of the pressure/volume curve and that derecruitment be avoided by keeping above the lower inflection point.

2. A patient undergoing an emergency hemicolectomy for carcinoma of the colon aspirates during
induction. What measures can be taken to minimize the possibility of pulmonary aspiration and
its effects should it occur? (8/13 passed)
Many candidates confined themselves to a discussion of the general measures to minimize the possibility of
pulmonary aspiration and did not relate it to the clinical scenario presented. Potential complications such as
intestinal obstruction were rarely discussed. A few candidates recommended cancellation of OT after aspiration
without considering the urgency of the operation. In recommending rapid sequence induction candidates were
expected to describe the pertinent technical details. Discussion on the treatment of aspiration was an essential
part of this answer. Many candidates recommended routine fibreoptic bronchoscopic suctioning of the airway
rather than immediate suction via an endotracheal tube after aspiration. This is usually only justified where there
is evidence of aspiration of particulate substances, airway obstruction or lung collapse and may delay institution
of effective ventilation. Routine use of antibiotic cover after aspiration is not necessary except in the event of
aspiration of faecal material.

3.Describe the principles involved in pulse oximetry.

What are its limitations in clinical practice? (9/13 passed)
In general the principles involved in pulse oximetry were well answered. Common areas of confusion included:
the importance of the pulsatile component of the absorbed light, the two LED have to be illuminated sequentially
as the photodetector cannot distinguish between different wavelengths (i.e absorption of Hb or HbO2 light) and,
the fact that the pulse oximeter does not make a direct calculation of the SpO2 value (it uses empirical in vivo data
which is stored within the microprocessor).
Candidates rarely discussed problems of interpretation of oximetry values in clinical conditions. For example, a
patient may be adequately saturated with supplemented oxygen in the presence of gross hypoventilation or have
profound anaemia but still have poor oxygen delivery. A few candidates highlighted those conditions that can
effect the accuracy of pulse oximetry readings but failed to explain how they affect the value.

4. Describe the techniques available to improve the success rate of a brachial plexus block using
the axillary approach. (2/13 passed)
This question on a common clinical issue pertaining to all regional blockades was surprisingly poorly answered.
Most candidates merely described the technique of brachial block using the axillary approach instead of
discussing techniques which are available to improve the success rate.
A good answer should have addressed the following points: careful selection of operation after discussion with
surgeon, appropriate patient selection, sound knowledge of the relevant anatomy, skilled regional anaesthetic
technique and positioning. The use of a nerve stimulator (short beveled and insulated), a multiple nerve block
technique, tourniquet or distal digital pressure, fast onset local anaesthetic agent (lignocaine > ropivacaine >
bupivacaine), adequate volume of local anaesthetic agent and allowing adequate time for the block onset,
speeding onset time by alkalinising the local anaesthetic agent and the use of additives (clonidine, fentanyl, or
adrenaline) as well as supplementation with systemic analgesics/sedatives agents to enhance blockade needed
considering. Good candidates would have been expected to consider the use of alternative means of identifying
the brachial plexus eg. ultrasound and x- rays.

5. A 64 yr old woman with chronic obstructive airways disease presents for microlaryngoscopy and
excision of a vocal cord lesion with the possible use of a laser. Describe the techniques of ventilation
available to you for this procedure and the factors you will consider in deciding on your choice of
technique. (7/13 passed)
Candidates who performed poorly confined themselves to a description of only a couple of techniques of ventilation
and failed to highlight factors limiting/recommending these techniques. Candidates were expected to consider the the
following techniques: endotracheal tube / paralysis / IPPV, microlaryngoscopy tube (laser protected ETT if laser
used), apnoeic ventilation, intermittent intubation / IPPV, intermittent bag and mask IPPV, jet ventilation
(supraglottic, infraglottic), spontaneous ventilation with TIVA.
Factors for consideration in choice of technique include: discussion with surgeon, surgical factors (site of lesion –
posteriorly placed are not ideal for ETT techniques and size of lesion – larger lesions are less suitable for jet
ventilation), duration of surgery (if prolonged IPPV via ETT may be a better technique), requirement to proceed to
laser surgery (need for laser protected ETT or, if using jet ventilation- use infraglottic technique to reduce risk of fire),
patient factors (COPD–barotrauma risk with jet ventilation, gastroesophageal reflux – unprotected airway in non ETT
techniques)

6. Discuss how the ulnar nerve could be damaged perioperatively and how you would manage this
problem should it occur. (9/13 passed)
This question was generally well answered. Better candidates arranged the answer into pre-operative,
intra-operative, and post-operative phases. History, examination and documentation of pre-existing/ predisposing
risk factors (diabetes, alcohol abuse etc), proper positioning/padding and regular inspection of vulnerable areas,
proper application of BP cuff / tourniquet, avoid stretching the brachial plexus (arm abduction < 90 degrees,
minimizin head rotation) and maintainance perfusion by avoiding hypotension and hypothermia were covered
by good candidates. Management issues including careful documentation and examination after the event, good
patient rapport and explanation, consult neurologist / orthopaedic surgeon for investigation (EMG and
neurophysiological studies), referral to occupational or physical therapist for intensive physiotherapy, informing
the local insurance carrier were well addressed. Most candidates failed to emphasize that most injuries can expect
to recover over 6 to 8 months and that regular follow-up is required to monitor progress and to identify those
patients who might develop a chronic pain syndrome

7. A patient with Idiopathic Hypertrophic subaortic stenosis (IHSS) develops hypotension

and tachcardia during the induction of anesthesia. Briefly describe the pathophysiology of
IHSS and list the measures you would take to stabilize the cardiovascular system?
(10/13 passed)
Most candidates were not aware of the dynamic nature of the obstruction caused by hypertrophy of the left
ventricle, mainly at the septum and aortic region, and that the obstruction may be reduced by increased volume,
decreased contractility and increased systemic vascular resistance. Many candidates gave lists of therapy
without adding explanation- this approach scored poorly.

8. Outline measures you would employ to ensure the adequacy of cerebral perfusion during
carotid enarterectomy. (10/13 passed)
A satisfactory answer would have included a description of the risk and possible mechanisms of impaired cerebral
perfusion during carotid clamping, how to monitor cerebral perfusion, the limitation of this monitoring and the
measures one can take to avoid cerebral ischaemia. Many candidates failed to cover all these aspects

9. Describe how you would provided anaesthesia if you felt intravenous access could not be
obtained without considerable difficulty and patient distress, for closed reduction of an
acutely fractured radius in a 4 year old child who last ate 6 hours ago. (6/13 passed)
Many candidates struggled with this question and were unable to provide a “plan of action” for a very pertinent
paediatric anaesthesia management problem. Most candidates recognized the desirability of rapid sequence
induction due to the possibility of aspiration. However, some candidates failed to explore the possibility of
obtaining IV access via patient rapport, EMLA, vasodilatation of potential IV access sites by the use of gravity
and heating and the role of pre-medication. Other candidates omitted to discuss a contingency plans if
intravenous access failed eg. consideration of delaying surgery after discussion of surgical considerations, the
possibility of giving drugs by the intramuscular route (suxamethonium and ketamine) and the desirability of
recruiting a “second pair of skilled hands”.

Anaesthesia vivas
10/13 passed

A 35 year old male with “ hyper-reactive airway disease” is scheduled for emergency laparoscopic
examination and appendectomy. He has been on regular cromolyn spinhaler and salbutamol.
Anaesthetic management, management of severe bronchospasm at induction.

A 55 year old lady was admitted to the hospital for sudden severe headache, followed by transient loss of
consciousness and neck stiffness. On the second day of admission, she has a GCS 13/15, mild
right-sided weakness, BP is 180/100, pulse rate 85/min. CT scan shows a subarachnoid haemorrhage
with midline shift, ECG- sinus rhythm with ST depression, Hb 12gm%, platelet 280, Na 129 mmol/litre.
Perioperative management and complications.

A 3 year old boy presenting with listlessness, sore throat, drooling of saliva and a high temperature
airway establishment. The anaesthetist is consulted for airway management.

An adult falls 20 feet. GCS is 7/15 in A&E . Management plan, physiology of ICP, CBF,
pathophysiology, effects of opioids

ICU patient with septic shock. Monitoring, use of monitors to guide treatment, PA catheter-
risks/benefits/limitations, fluid balance, use of colloids and crystalloids, nitric oxide.

Patient with coronary angioplasty done three month ago, now on plavix, aspirin, B blocker for hernia
operation requesting for regional anaesthesia. Management considerations.

Laparoscopic surgery under general anaesthesia, sudden onset of cardiac decompensation. Crisis
management

Clinical use of bispectral index.

Latex allergy, management
Airway assessment , Mallampati airway classification.
Intraoperative hyperthermia –causes
Malignant hyperthermia- features and management
A 2 year old child with acute epiglottitis requiring intubation, His cousin has a documented history of
MH.
Capnogram – waveform and explanations.

OSCE
Ten out of 13 candidates passed the OSCE overall. The highest and the lowest average marks were in the
Physical Examination stations, and the Equipment station respectively.

Station 1: Physical Examination 11/13 passed

Candidates were asked to examine the cardiovascular system of a patient with mitral regurgitation and
congestive cardiac failure. Eleven candidates passed this station.
Station 2: Investigations 6/13 passed
Candidates were asked to interpret 2 blood tests and 4 ECG. The abnormalities included DI, respiratory
acidosis, acute MI, pulmonary embolism, hyperkalaemia, and ventricular fibrillation. Six candidates
passed this station.

Station 3: Physical Examiantion 12 /13 passed

Candidates were asked to examine the respiratory system of a patient with pleural effusion.

Station 4: Anatomy/ Regional Anaesthesia 8/13 passed

Candidates were asked to demonstrate the techniques and complications of intravenous regional
anaesthesia in a patient undergoing carpal tunnel release.

Station 5: Crisis Management 11 /13 passed

Candidates were asked to demonstrate the skills in resuscitation of patient undergoing caesarean section
under spinal anaesthesia complicated by massive haemorrhage. Eleven of 13 candidates passed this
station.

Station 6: Equipment 5/13 passed

Candidates were asked about the use of various airway humidification and filtering devices such as heat
and moisture exchanger, bacterial and viral filters, and heated humidifier.

Station 7: X-rays 9/13 passed

Candidates were asked to interpret eight CXR showing features such as left lung collapse, fractured ribs,
pulmonary interstitial infiltrates, and malpositoned central venous.

Station 8: Patient Communication 10/13 passed

Candidates were asked to give preoperative explanation to 30yrs old woman scheduled for left ovarian
cystectomy at 20 weeks gestation. The patient preferred regional anaesthesia.

Station 9: Practical Procedure 12/13 passed

Candidates were asked to demonstrate the skills of central venous catheterisation through the right
subclavian vein, and management of pneumothorax as a complication.

Station 10: Resuscitation (ACLS/ATLS) 11/13 passed

Candidates were asked to resuscitate a motor vehicle accident victim with severe head and
thoraco-abdominal injuries.