Home About this Website About the Exam News Syllabus SAQs and answers Past paper SAQs

s Syllabus SAQs and answers Past paper SAQs by specialty Useful links

Carotid endarterectomy  Search Site

A 56­year­old man is listed for carotid endarterectomy 10 days after suffering a On this page 
cerebrovascular accident.  
a) What are the advantages (4 marks) and disadvantages (4 marks) of performing the Carotid endarterectomy 
procedure under regional anaesthesia?   ­ ©2017 Dr Jonathan Little 

b) What local or regional anaesthetic techniques may be used? (3 marks)   Thoracic outlet syndrome 
c) How can his risk of perioperative cerebrovascular accident be minimised? (6 marks)  ­ ©2015 Dr Nilay Mankad 
d) Following this procedure what other specific postoperative complications may occur?
(3 marks)  Upper limb ischaemia and subclavian
steal 
­ ©2015 Dr Rachel Irwin 
Click for model answer by Dr Jonathan Little
Lower limb amputation 
a) What are the advantages (4 marks) and disadvantages (4 marks) of performing the procedure ­ ©2015 Dr Nauman Iftikhar 
under regional anaesthesia?
Advantages Aortic cross­clamping 
Disadvantages ­ ©2015 Dr Paula Pyper 
Real-time monitoring of neurological condition
Claustrophobia, immobility, and stress leading to myocardial ischaemia Aortic dissection 
No requirement for airway instrumentation ­ ©2015 Dr Ciara Mitchell 
Risks of block – haematoma, infection, intra-vascular injection, intra-thecal/epidural injection, block
inadequacy / failure, phrenic nerve paralysis Critical limb ischaemia and
Avoid myocardial depressant effect of GA drugs and loss of cerebral autoregulation with volatile agents revascularisation 
Airway intervention awkward with patient positioning ­ ©2014 Dr Simon Marcus 
Reduced shunt formation
Requires patient to be able to lie flat Endovascular aneurysm repair 
Reduced hospital stay ­ ©2012 Dr Alison White 
If sedation used then risk of over-sedation
Allows closure at ‘normal’ arterial pressure
Emergency ruptured aortic aneurysm
repair 
Post-operative analgesia
­ ©2012 Dr Caroline Martin 
Post-operative neurological deficits cannot be attributed to post anaesthesia effects
Carotid endarterectomy and deep cervical
plexus block 
b) What local or regional anaesthetic techniques may be used? (3 marks) ­ ©2012 Dr Ciara O'Donnell 
Superficial and/or deep cervical plexus block
- Supplementation at the carotid sheath is commonly required as it has innervation from the cranial nerves Carotid endarterectomy and superficial
Local infiltration cervical plexus block 
Cervical epidural – rarely performed in UK due to high risk of complications ­ ©2012 Dr Bronagh McKay

c) How can his risk of perioperative cerebrovascular accident be minimised? (6 marks)

- Use of antiplatelet agent
- Pre-operative optimization and stabilization of blood pressure
- Institute invasive arterial monitoring prior to induction of anaesthesia
- If GA then use of cardio-stable drugs and suppression of pressor response to laryngoscopy
- Maintain SBP < 170mmHg and ideally within 20% of baseline
- Manage peri-operative hypertension and hypotension judiciously
- If GA then use means to monitor cerebral blood flow – transcranial doppler, EEG, somatosensory evoked
potentials, near infrared spectroscopy
- Minimise cross clamping time if not using shunt
- Avoid hypoxia
- Avoid hyperglycaemia, control blood glucose judiciously
- Avoid hypotension
- Avoid nitrous oxide with shunt due to the risk of air embolism

d) Following this procedure what other specific postoperative complications may occur? (3 marks)
- Wound haematoma formation leading to airway or carotid artery obstruction
- Carotid artery thrombosis
- Cerebral hyper-perfusion syndrome

Thoracic outlet syndrome 

You have been asked to anaesthetise a 48 year old woman for the excision of her first rib
to treat thoracic outlet syndrome. 

a) What is thoracic outlet syndrome (TOS)? 
b) What are the risk factors for the development of TOS? 
c) Describe the (i) intraoperative and (ii) postoperative anaesthetic factors in the care of
this patient. 

Click for model answer by Dr Nilay Mankad

What is Thoracic Outlet Syndrome (TOS)?

Group of symptoms relating to compression of neurovascular structures (brachial plexus, subclavian artery,
subclavian vein) of upper limb
Compression occurs as structures pass between clavicle and 1st rib
Symptoms depend upon which structure(s) are compressed
Neurogenic TOS: Brachial plexus compression (90% C8 and T1 nerve roots) causing pain, paraesthesia,
muscle weakness and wasting
Arterial TOS: Subclavian artery stenosis, often with post stenotic dilatation producing pulsatile
supraclavicular mass
Symptoms include coldness and arm claudication
Venous TOS: Strenuous upper arm activity produces repeated SC vein compression, activating clotting
cascade producing vein thrombosis
Symptoms include swelling and pain

Risk factors for developing TOS

Most commonly occurs in young adults (aged 20-40)
Females more affected than males (4:1)

Bony/Skeletal Abnormalities

Congenital
Cervical rib (extra rib arising from C7 body – approx. 10% of those with cervical rib develop TOS)
Elongated T7 transverse process
Bifid Clavicle
1st/2nd rib fusion

Acquired
Callous formation following 1st rib or clavicle fracture
Bony tumour of 1st rib/ clavicle
Soft Tissue Abnormalities
Congenital
Fibrous band
Variations in scalene muscle insertion, and extra scalene muscles

Acquired
Fibrous scarring (post operative/ post traumatic)
Large muscle bulk (atheletes using shoulder muscles e.g swimmers, baseball pitchers etc)
Poor posture

(c) 
(i) intraoperative in the care of this patient
IV Induction
Standard oral ETT
Avoid muscle relaxants/ use short acting relaxant (surgeons can use nerve stimulator to identify brachial
plexus)
14G/16G IV access (substantial haemorrhage possibility from subclavian vessels)
Supraclavicular approach: Patient supine
Transaxillary approach: Patient lateral with operative side up
Apical pleura can be breached – monitor for signs of pneumothorax

(ii) postoperative anaesthetic factors in the care of this patient 

Superfical cervical plexus block (if supraclavicular approach) or local anaesthetic infiltration by surgeons
Simple analgesia + PCA
Erect CXR to exclude significant pneumothorax/ haemothorax
Drain usually inserted, however if breach of apical pleura blood may drain into thoracic cavity so blood
loss may be concealed

Upper limb ischaemia and subclavian steal 

You are covering the vascular list. The first patient on the list is a 48 year old woman for a
subclavian transposition. 

(a) Describe the anatomy of the arterial supply to the upper limb. 
(b) What are the causes of upper limb ischaemia? 
(c) What is subclavian steal syndrome? 
(d) What are the anaesthetic considerations in anaesthetising for a subclavian
transposition for subclavian steal syndrome? 

Click for model answer by Dr Rachel Irwin

You are covering the vascular list. The first patient on the list is a 48 year old woman for a subclavian
transposition. 

a. Describe the anatomy of the arterial supply to the upper limb.

the Subclavian artery branches directly from aorta on left and from innominate artery on right; it passes over
first rib posterior to anterior scalene muscle
at the lateral border of the first rib it becomes the axillary artery
at the lower aspect of the trees major muscle it becomes the brachial artery
at the antecubital fossa, it forms the radial, ulnar and interosseous arteries

(b) What are the causes of upper limb ischaemia? 

ACUTE 
thoracic dissection
mural thrombosis following myocardial infarction
iatrogenic injury
atrial fibrillation
trauma

CHRONIC 
atherosclerosis
thoracic aortic aneurysmal disease
thromboembolism
vasculitis ­ Sjogrens, SLE, rheumatoid arthritis
extrinsic compression ­ thoracic outlet syndrome
vasospasm inc. vasopressor therapy
Raynaud’s disease

(c) What is subclavian steal syndrome? 

Clinical syndrome occurring most commonly following exercise of the affected arm, particularly where arm is
lifted above the head. Most common presenting feature is muscle cramps of affected arm.
2 common ‘variations’:
vertebral subclavian steal: retrograde flow in vertebral arteries following exercise of affected side,
causing muscle cramps and NEUROLOGICAL symptoms e.g. vertigo, visual disturbance, transient loss
of consciousness
neuro symptoms develop as result of blood flow being ‘stolen’ from posterior cerebral circulation
coronary subclavian steal: most commonly occurring in patients with history of CABG with internal
mammary grafts
retrograde flow in the IMA graft leads to clinical presentation of angina that can progress to MI,
associated with ipsilateral arm cramps

(d) What are the anaesthetic considerations in anaesthetising for a subclavian transposition for subclavian
steal syndrome? 

Pre­operative 
this cohort of patients are typically older with significant co­morbidities, ‘vasculopaths’ e.g. ischaemic heart
disease, CVA and diabetes mellitus
they therefore should be thoroughly pre­operatively assessed:
cardiac function assessment including ecg, ECHO, appropriate stress testing (exercise or stress ECHO)
carotid doppler assessment to look for contralateral carotid disease ­ may necessitate need for carotid
shunt use during surgery
blood group and hold should be performed, along with FBC/U&E/Coagulation screening
the aim should be to optimise any pre­existing conditions, leasing with specialty MDT where appropriate

Intra­operative 
General anaesthetic: cardiostable induction and maintenance anaesthetic should be chosen given likelihood
of co­morbidities mentioned above; vascular procedure carrying myocardial ischaemic risk
aim to reduce myocardial ischaemic risk by:
maintaining normothermia
maintaining euvolaemia
correct anaemia
provide adequate depth of anaesthesia
provide adequate analgesia
invasive monitoring is required on CONTRALATERAL arm
close discussion required between surgical colleagues as need to balance the need for maintaining adequate
MAP without increasing bleeding risk
the carotid will need to be cross­clamped temporarily so again good communication with surgical team re:
timely management
use of carotid shunt may be required if contralateral carotid disease is present
IV heparin used intra­operatively therefore may proclude regional anaesthetic/analgesic techniques

Post­operative 
Given potential for co­morbidities, planning needed to decide where most appropriate place for post­operative
care e.g. ward level vs. HDU
ensure patient has adequate multi­modal analgesia and address same parameters as above to reduce risk of
myocardial ischaemia
patient will require close monitoring for any neurological disturbance following cross­clamping of carotid

Lower limb amputation 

You are providing emergency anaesthesia for a 69 year old man who has a ruptured aortic
aneurysm. The surgeon has cross­clamped the aorta. 

You have been asked to anaesthetise a 65 year old man for a below knee amputation
(BKA). 

a) What are the potential risk reduction strategies that can be tagged during a pre­
operative assessment? 
b) What are the advantages and disadvantages of a regional technique for anaesthesia in
this group of patients? 
c) What were the key findings with regard to perioperative care of patients undergoing
lower limb amputation in the recent NCEPOD report on lower limb amputation? 

Click for model answer by Dr Nauman Iftikhar

a) What are the potential risk reduction strategies that can be tagged during a pre-operative assessment?
b) What are the advantages and disadvantages of a regional technique for anaesthesia in this group of
patients?
c) What were the key findings with regard to perioperative care of patients undergoing lower limb
amputation in the recent NCEPOD report on lower limb amputation?

a) potential risk reduction strategies that can be tagged during a pre-operative assessment

An targeted assessment is indicated with the aim of preparing individuals for surgery at the earliest
opportunity.
A detailed history of the medical and functional status of the patient
Cardiac symptoms may often be masked due to limited mobility related to claudication, limb ulceration,
and general poor functional capacity.
A clinical examination should be per- formed, with particular attention to the cardio- respiratory systems
and findings used to guide targeted investigations.
Recommended baseline investigations
FBC, U&E,Coagulation screen, BM,12 lead ECG, chest X-ray.
Echocardiography -- in those patients with clinical findings of a murmur or cardiac failure.
ABG, to identify the presence of respiratory failure.
PFTs. A forced expiratory volume in 1 s (FEV1) ,70% of the predicted value or an FEV1/forced vital
capacity ratio ,0.65 indicates a high risk of preoperative complications.
Pharmacological stress testing, for example, dobutamine stress echo, is unlikely to be feasible in the short
preoperative period.

Preop medicine:
Continuation of b-blockers is recommended in patients previously treated for IHD, hypertension, or
arrhythmias
statins be continued perioperatively
Continuation of aspirin in patients previously treated with aspirin should be considered in the pre op
ACE I should be continued perioperatively in patients treated for LV systolic dysfunction Transient
discontinuation of ACE I before non-cardiac surgery in hypertensive patients should be considered
Hypertensive patients should discontinue low-dose diuretics on the day of surgery and resume orally when
possible
Diuretics should be continued in heart failure patients up to the day of surgery, resumed i.v. pre op , and
continued orally when possible

Acute RTI – t/m with Ab, O2, physiotherapy prior to surgery

COPD with infective symptoms—should get corticosteroids in addition

Good glycaemic control with use of insulin if needed

Maintain Hb level of 8–10 g /dl

Withhold LMWH for an appropriate duration where CNB is being considered.

Omit full therapeutic anticoagulation for 24 h before operation
prophylactic anti- coagulation omitted for 12 h before operation.
Omit clopidogrel should be omitted for 7 days before CNB

Avoid prolonged preoperative fasting

Adequate nutrition should be maintained
An appropriate i.v. fluid regime should be commenced to correct preoperative dehydration and electrolyte
imbalances.

-Preoperative pain control- -- multimodal analgesic regime ,regular simple analgesic /oral opioids and
agents for neuropathic pain (gabapentin and amitriptyline)/epidural infusions, intrathecal, and i.v. ketamine
-/Opioid-based patient-controlled analgesia (PCA)
modulate pain pathways and reduce chronic pain
reduce the sympathetic stress response and
improve perioperative cardiovascular stability

- Undertake amputation within 48 h of the team decision to operate . major amputation out of hours have a
three- fold increase in mortality compared with those operated on in hours.
- Should be performed by ----senior surgeon, experienced in lower limb amputation procedures, , a
consultant anaesthetist or senior trainee with appropriate consultant supervision
-Antibiotic prophylaxis, guided by local policy, should be given within 60 min before start of surgery.

b)
Advantages of a regional technique :
- improved postoperative respiratory function
-attenuation of the stress response to the surgery.
- Reduction in early postoperative cognitive dysfunction or delirium which may have important
implications for
compliance with medical therapy,
functional recovery, and
length of stay.

DisAdvantages of a regional technique:

Spinal or epidural anaesthesia is relatively contraindicated in
Septic patients
Anticoagulated patient
Hypotension, nausea vomiting
Post Dural puncture headache
High spinal/total spinal – agitation, respiratory compromise
Nerve damage, permanent damage
Epidural abscess, haematoma

C) Key findings with regard to perioperative care in the recent NCEPOD report
- For patients admitted under other specialties , earlier review by a consultant vascular surgeon might
have altered the outcome in some patients
- Deficiencies in note keeping away common.
- Some patients (39.2%)had no formal vascular imaging performed.
- In some (15.1%) ,surgery was unnecessarily delayed.
When surgery was delayed this was thought to affect outcome in some Two-thirds of all delays would have
been avoided if surgery had been performed on a planned operating list.
- Amputation might have been avoided in some (7.7%) patients, in whom they were able to make a
judgment, had limb salvage been attempted.
- The proportion of amputees who underwent pre- operative review by a physiotherapist, a diabetes nurse
specialist and a vascular nurse specialist were poor.
- In some (68.5%) patients there was no pre- operative discussion of discharge planning and
rehabilitation.
- some patients did not have a named individual responsible for co-ordinating discharge planning and
rehabilitation.
- Some (14.4%) patients the quality of the pre-operative care was poor or unacceptable.
- seniority of the person taking consent was not appropriate in some (11.7%) patients and found that the
risks and benefits of surgery were not adequately documented in a third of cases, The risk of death
following the procedure was only included on the consent form in some (21.9%)
- some did not undergo MRSA screening despite national guidelines.

- The level of anaesthetic support for patients undergoing amputation was generally good.
- Deficiency in record keeping were noted in respect of
pre-operative assessment,
administration of peri-operative antibiotics, and
recording the grade of anaesthetist.

Aortic cross clamping 

You are providing emergency anaesthesia for a 69 year old man who has a ruptured aortic
aneurysm. The surgeon has cross­clamped the aorta. 

a) Briefly describe the anatomy of the abdominal aorta and how it gives rise to the renal
circulation (4 marks) 
b) What are the potential sites for aortic cross clamping? (2 marks) 
c) Describe the (i) haemodynamic (ii) metabolic changes that occur with aortic cross
clamping. (5 marks) 
d) What changes may occur with aortic unclamping? How may these be attenuated? (6
marks) 
e) What measures may reduce the likelihood of acute renal failure? (3 marks) 

Click for model answer by Dr Paula Pyper

You are providing emergency anaesthesia for a 69-year-old man who has a ruptured aortic aneurysm. The surgeon has cross-clamped the aorta.

a) Briefly describe the anatomy of the abdominal aorta and how it gives rise to the renal circulation (4 marks)
b) What are the potential sites for aortic cross clamping? (2 marks)
c) Describe the (i) haemodynamic (ii) metabolic changes that occur with aortic cross clamping. (5 marks)
d) What changes may occur with aortic unclamping? How may these be attenuated? (6 marks)
e) What measures may reduce the likelihood of acute renal failure? (3 marks)

a)
Begins at the aortic hiatus of the diaphragm (T12)
Ends at the common iliac bifurcation (L4)

Paired:
Lumbar arteries (usually 4 pairs - posterior)
Inferior phrenic arteries
Middle supra-renal arteries
Renal arteries
Testicular or ovarian arteries

Unpaired (superior to inferior - anterior):

Coeliac trunk (left gastric, common hepatic and splenic)
Superior mesenteric artery
Inferior mesenteric artery

Renal circulation:
Lateral branches of the abdominal aorta
Arise just inferior to the origin of the superior mesenteric artery
between L1 and L2

b)

Infrarenal (most common site)

Suprarenal
Supraceliac

c)

(i) Haemodynamic changes with aortic cross-clamping:

Increased afterload (may cause hypertension proximal to the clamp)
Decreased BP below the clamp
Increased ventricular wall tension
Decreased ejection fraction
Decreased CO
Decreased RBF
Increased pulmonary occlusion pressure
Increased CVP
Increased coronary blood flow

(ii) Metabolic changes with aortic cross-clamping:

Decreased total body oxygen consumption
Decreased total body carbon dioxide production
Increased mixed venous oxygen saturation
Decreased total body oxygen extraction
Metabolic acidosis

d)
UNCLAMPING:
Sudden decrease in afterload
Ischaemic-reperfusion injury
Hypotension (can be profound)
Lactic acidaemia
Decreased myocardial contractility and decreased CO
Myocardial ischaemia
Cardiovascular collapse
Decreased temperature
Increased body oxygen consumption
Activated complement

Attenuated by:
Maintaining MAP and organ perfusion
Expanding the circulating volume (vasodilators during cross-clamping application weaned and fluid load)
Maintaining oxygenation
Vasoconstrictors and positive inotropic drugs available

e)

Maintain adequate perfusion pressure

Limit the duration of supra-renal clamping
No convincing evidence for mannitol, dopamine or furosemide
Maintaining an adequate extracellular fluid volume intra- and postoperatively is the priority

Aortic dissection 

(a) What are the main types of aortic dissection ­ pick a popular classification. How does
this affect management? 
(b) What are the risk factors for aortic dissection? 
(c) What are the clinical features? 
(d) What are the radiological features? 
(e) What are the main principles of anaesthesia for emergency surgery for an aortic
dissection? 

Click for model answer by Dr Ciara Mitchell

(a) What are the main types of aortic dissection - pick a popular classification. How does this affect management?

Stanford Classification
Type A – ascending aorta +/- descending aorta. Requires surgical Management.
Type B – descending aorta only, distal to left subclavian artery. Managed medically.

DeBakey Classification
Type I – ascending aorta, aortic arch and descending aorta. Requires surgery.
Type II – ascending aorta only. Requires surgery.
Type III - descending aorta distal to left subclavian artery. Medical management.
IIIa – extends to diaphragm
IIIb – extends beyond diaphragm

(b) What are the risk factors for aortic dissection?

Patient Factors
Male
Age 50-70
Pregnancy
Smoking
Cocaine use
Hypercholesterolaemia
Family history
Structural Factors
Hypertension
Connective tissue diseases - Marfan’s syndrome, Elhers- Danlos
Vascular inflammation – giant cell arteritis, syphilis, takayasu arteritis
Congenital vascular abdnormalities – bicuspid aortic valve, coarctation aorta
Aortic dilation
Aortic aneurym
Trauma
Iatrogenic
Catherisation/ instrumentation/ cannulation
Aortic surgery / graft/ cross clamp

(c) What are the clinical features?

- Initially pain due to tearing of intima- sharp, tearing, ripping, stabbing sudden onset
- Chest pain more common type A, abdominal pain more common type B.
- Anxiety
- Loss of pulse volume. Differential/ absent pulses.
- Tachycardia, hypertension
- Depending on site, evidence of –
- pericardial tamponade – muffled heart sounds, raised JVP, hypotension, small complexes on ECG
- myocardial ischaemia – ischaemia on ECG, pain, clammy, sweaty aortic valve regurgitation – diastolic murmur, acute
LVF, widening aortic root CXR
- Finally rupture resulting in hypotension.
- Neurological signs are common – decreased level of consciousness, syncope, CVA, acute paraplegia

(d) What are the radiological features?

CXR – 90% acute aortic dissection have abnormality

Aortic knuckle
Widened/ bumpy/ humped
displaced calcification, more than 6mm from edge of knuckle
Widened mediastinum – compare with previous CXR
Widens to right in ascending dissection
Widens to left in descending dissection
>8cm is significant on AP view
Loss of costophrenic angles due to haemothorax, left > right
Cardiomegaly if pericardial tamponade – globular shaped heart

(e) What are the main principles of anaesthesia for emergency surgery for an aortic dissection?

Preoperative
ABC approach, 100% oxygen
Rapid assessment, call for help
Time is of the essence – mortality rate is 1-2% per hour pre operative management. Operative mortality is 5-10% reaching
70% in complicated cases eg tamponade, aortic valve regurgitation, ostia involvement.
Intravenous access – bloods for FBP, U&E, LFTs, Coag screen, GXM
Analgesia – IV morphine
ECG – exclude acute MI although ischaemic changes often present in acute dissection if involve ostia
Control of blood pressure – aim systolic 110-120 mmHg
Aim to reduce left ventricular contraction
Give beta-blocker prior to vasodilator to avoid reflex tachycardia
Titrate beta-blocker to effect – esmolol, metoprolol, labetalol
Calcium channel blocker is contraindications to beta-blocker
Consider sodium nitroprusside/ GTN/ hydralazine if BP not controlled
Imaging – if stable
CXR
ECHO – TTE readily available but TOE better images of aortic arch
Aortography – time consuming
CT is rapid
MRI – only if haemodynamically stable
Transfer to cardiothoracic centre
Inform theatres that patient is coming

Intraoperative
Aim to reduce sympathetic response and force of left ventricular contractility.
Requires excellent analgesia and ongoing BP control
Monitoring – AAGBI, left radial arterial line (right sided may be inaccurate due to involvement of innominate artery),
CVC, catherter, TOE
Dudicious fluid administration and monitoring of input, output, acidosis, temperature, coagulopathy
Emergency situation therefore likely full stomach requiring a RSI
Maintenance of anaesthesia with volatile, sevoflurane, isoflurance or propofol and NMBD
Require cardiopulmonary bypass or deep hypothermic circulatory arrest
Normal bypass considerations – management of coagulation with heparin and protamine, use of tranexamic acid, ensure
normothermia, normoglycaemia, normoxia, normocapnia, normal Hb prior to coming off bypass

Post operative
Ventilate in intensive care post operatively
Opioid based analgesia
Avoid hypertension

Endovascular aneurysm repair 

A 79­year­old patient presents with a leaking abdominal aortic aneurysm. The vascular
surgery/radiology team decide to undertake an endovascular aneurysm repair (EVAR)
procedure. 

What are the main preoperative anaesthetic considerations for this procedure? (55%) 
Describe options for providing anaesthesia for this case and give the advantages
/disadvantages of each. (45%) 

Click for model answer by Dr Alison White

(a)
• Consider senior support
• AAA is leaking therefore cardiovascular stability must be assessed
• Aggressive preop fluid resuscitation contraindicated
• Limited time to optimise patient before surgery
• Preop assessment should be no different from that of a patient listed for open AAA repair
- include all things as in standard anaesthetic assessment e.g. medical history, anaesthetic history, medications,
examination, airway assessment, drug allergies etc
• Patient may be unfasted
• High incidence of co-morbidities are seen in patients requiring vascular surgery which must be taken into
consideration and include:
- coronary artery disease, impaired ventricular function, HTN, pulmonary disease, renal impairment, diabetes
• Investigations that may be required include bloods, ECG, CXR and cross-match 6-10 units
• Discuss with patient anaesthetic technique, inform of possibility of conversion to open and possible requirements
for blood transfusion
• Require invasive arterial pressure monitoring (usually right radial as radiological access to left axillary artery
sometimes required) and urinary catheter
• Require large bore IV access x 2 (preferably right side)
• May require central venous line if unstable
• Request rapid fluid infusor and cell salvage
• Surgery is usually performed in a combined radiology-surgery suite often separate from theatres - therefore
involves risks of remote anaesthesia
• Ensure standard anaesthetic drugs and intropes and vasopressors available
• Require bed in HDU (or possibly ICU) post op and discuss this with patient also

(b)
• Local anaesthesia
- adequate topical analgesia can be achieved using local infiltration
- greater risk of poor patient compliance
- avoids complications of GA in a potentially unstable patient with a full stomach
- some studies show a lower incidence of renal failure
• Regional anaesthesia (+/- sedation, e.g. TCI propofol)
- subarachnoid (single shot and continuous), CSE or epidural anaesthesia. CSE and epidural allow block to be
topped up during long cases and can be used for post op analgesia
- may not have time to site in an emergency situation
- avoids complications of GA
- beware of hypotension in unstable patient
- peri-op anticoagulation is required during EVAR which poses a theoretical risk of central neuraxial haematoma
formation
- patient compliance is important as patient must remain still and hold breath when screening for endoleak
- may be a challenge to maintain compliance for extended cases (> 3 hours)
• General anaesthetic
- significant cardiorespiratory comorbidity in this cohort makes RA preferable; thorough pre-op assessment for
suitability for GA is required
- avoids patients being awake and distressed by procedure
- no constraints on surgical time
- requires additional post-op analgesia to be addressed

Emergency ruptured aortic aneurysm repair 

A patient presents to the Emergency Department with a suspected ruptured abdominal
aortic aneurysm. 

What are the priorities in your preoperative management? (40%) 

The consultant vascular surgeon would like to repair the ruptured aortic aneurysm.  
Describe your anaesthetic management in the operating theatre. (50%) 

Click for model answer by Dr Caroline Martin

(a)
- Surgical emergency therefore rapid evaluation required
- Consider appropriateness of surgery
o Hardman index helps predict mortality; two or more factors indicate likely mortality >80% (age >76, CKD stage III,
anaemia [Hb <9], ischaemic ECG, LOC after arrival to hospital)

- Get expert help; two anaesthetists are most often required

- Brief and targeted history and airway assessment
- Wide-bore intravenous cannulae
- Baseline blood tests including coagulation
- Preparation of drugs, theatre and availability of blood products (at least 10 units PRC)
- Avoid fluid resuscitation unless patient unconscious or displaying signs of myocardial ischaemia
- Analgesia: IV morphine; consider an epidural if patient haemodynamically stable and not coagulopathic
- Alert ICU

(b)
- Patient monitoring: 5-lead ECG, CVP, arterial line, temperature and urine output (CVP may be deferred until patient
asleep if necessary)
- Warmed fluids ready
- Assuming open repair:
o Induction of anaesthesia only when patient prepped for surgery and blood available in theatre
o No induction agents shown to be preferable, therefore aim for rapid sequence induction with titrated dose of induction
agent and suxamethonium (or rocuronium) with an opioid to reduce induction dose in an effort to maintain cardiovascular
stability
o Thermoregulation of air, fluids and operating table
o Maintenance: usually with volatile, opioid and relaxant
o At cross-clamping: manage resultant hypertension with increasing depth of anaesthesia or vasodilators
o Fluid loading prior to release of cross-clamp and vasoconstrictors or inotropes if necessary
o Infusion of blood and blood products as appropriate, guided by Hb and elastography if available
o Consider cell salvage if available
o Maintain circulating volume in an attempt to protect renal function
o Care to continue in intensive care setting
- Endovascular repair:
o Imaging necessary prior to and during repair, therefore preparation for anaesthesia in a remote location likely
o Discussion with surgeon / radiologist as to whether local or regional anaesthesia is possible (epidural or groin infiltration
with sedation)
Regional / local requires a co-operative patient
o Preparation for possible conversion to general anaesthesia (1%)

Carotid endarterectomy and deep cervical plexus block 

(a) Briefly describe your technique for performing deep cervical plexus block for carotid
endarterectomy under LA. (35%) 
(b) List the complications associated with deep cervical plexus block. (30%) 
(c) List the advantages and disadvantages of carotid endarterectomy under regional
anaesthesia (35%) 

Click for model answer by Dr Ciara O'Donnell

(a)
To achieve anaesthesia the cervical dermatomes C2-C4 must be blocked. There are 2 techniques described. In both the
patient is positioned supine, slightly head up and turned to contra lateral side. Full Monitoring and asepsis throughout.

Moore 3 needle technique:

- Palpate transverse processes behind posterior border of sternocleidomastoid
- Palpate Chassaignac's tubercle (C6) at level of cricoid and mastoid process (C1)
- Draw a transverse line C1 and C6 and a line along posterior border of sternocleidomastoid
- Mark equidistant intervals 1.5cm from C1 down so marks are opposite C2 C3 C4
- Inject 1%lidocaine to skin at each point
- Introduce a short bevelled 22/25G needle caudad and perpendicular to skin and advance until transverse process is
encountered (depth 1-2cm)/paraesthesia elicited in distribution of cervical plexus/or pop felt as needle exits post part of
sternocleidomastoid
Inject 3ml 0.5% bupivacaine into each needle (if all left insitu LA will be seen flowing from hub of other needles)

Winnie Approach:
- Simpler and equally effective and may be performed at C3 or C4.
- Identify the interscalene groove at the level of the superior curnu of thyroid cartilage C4 by moving fingers laterally from
the sternocleidomastoid
- A short bevelled regional block needle is inserted medial caudal and dorsal toward the contra lateral elbow (minimises
advancement between transverse process and inadvertent vertebral artery/intrathecal injection)
- Advance the needle until contact with C4 transverse process and inject 10-20ml LA. The plexus is superficial only 10-
20mm deep to skin

(b)
- Phrenic nerve palsy (60%) - tolerated well unless respiratory disease
- Recurrent laryngeal nerve palsy
- Stellate ganglion block- Horners syndrome
- Discomfort from retractor under the jaw as mandibular branch of the trigeminal contributes to innervation (especially
problem in patient with high carotid bifurcation)
- >50% patients need supplementation of LA around the carotid sheath despite block due to pain fibres running with
sympathetic nerves
- IV injection - unconsciousness/seizures
- Subarachnoid injection- total spinal
- Local haematoma/airway compromise

(c)
Advantages
Allows real time neuro monitoring
Avoids GA/airway intervention
Reduced shunt rate
Preserves cerebral autoregulation
Reduced BP fluctuations
Reduced postop haemorrhage/haematoma locally
Allows arterial closure at normal pressure

Disadvantages
Complications with block
Discomfort/pain/stress/higher risk MI
Restricted access to airway
Need patient cooperation
Risk of conversion to GA
GALA trial showed no difference in primary outcomes at 30 days

Carotid endarterectomy and superficial cervical plexus block 

(a) Describe the anatomy of the cervical plexus. (40%) 
(b) How would you perform a superficial cervical plexus block? (25%) 
c) A carotid endarterectomy is being performed using a superficial cervical plexus block.
A few minutes after clamping the carotid artery the patient becomes unresponsive to
verbal command. Describe your management of this situation. (35%) 

Click for model answer by Dr Bronagh McKay

(a)
• The cervical plexus is formed from the anterior rami of C1, C2, C3 and C4.
• It has sensory and motor components
• Motor supply to
- Paravertebral muscles
- Infrahyoid and thyrohyoid
- Some of the motor supply to the trapezius (most of the motor supply to trapezius is from the accessory nerve)
- The diaphragm (phrenic nerve C3, 4 and 5)
• Cutaneous branches- these all emerge at the midpoint of the posterior border of sternocleidomastoid
- Lesser occipital nerve- sensory supply to sternocleidomastoid and posterior to the ear
- Greater auricular nerve- sensory supply to skin of the ear, mastoid and angle of mandible
- Transverse cervical nerve- sensory supply to the middle of the neck
- Supraclavicular nerve- sensory supply to the lateral neck, upper thorax and shoulder
• Nerve blocks- can be blocked at the level of the transverse processes in a deep cervical nerve block or at the level of the
cutaneous branches in a superficial cervical nerve block

(b)
• Detailed pre-operative assessment- patient is likely to have significant co-morbidities
• Consent for block
• Ensure patient empties bladder before coming to theatre
• Ensure correct side before marking skin and performing block
• Ensure resuscitation equipment and drugs are available
• Ensure assistant is trained
• Obtain IV access
• Monitors- ECG, BP, pulse oximeter
• Apply oxygen
• Position patient supine with head on pillow and head turned to contralateral side
• Clean skin with alcohol based solution
• Use aseptic technique
• Identify landmarks- posterior border of sternocleidomastoid
• Infiltrate in the subcutaneous plane along the posterior border of sternocleidomastoid with 10ml 0.5% bupivicaine
The surgeon may need to infiltrate more local anaesthetic in the distribution of the trigeminal nerve if the retractor causes
pain and in the carotid sheath.

(c)
• Begin assessment and treatment using ABC approach while simultaneously informing the rest of the theatre team about
the situation and calling for help
• Open airway- head tilt, chin lift, jaw thrust
• Apply face mask
• 100% oxygen
• Manually ventilate via facemask if patient not breathing or if not breathing sufficiently
• Check SpO2
• Auscultate chest
• Check heart rate and blood pressure
• If hypotensive consider fluid bolus and/or vasopressors e.g phenylephrine
• Check surgical site and suction for excessive bleeding
• Surgeon should be inserting shunt- if they are not suggest that they insert one
• On shunt insertion consciousness should be regained
• If patient does not regain consciousness then patient will need either intubation or LMA- Assess to airway is likely to be
restricted due to surgery
• Once airway more secure then continue to look for other causes of loss of consciousness
• Check blood glucose and administer glucose if low
• Send ABG, FBC and U&E
• Check pupils
• If patient fails to regain consciousness then will need CT brain and transfer to Intensive care unit

Back To Top ↑

Home About this Website About the Exam News Syllabus SAQs and answers Past paper SAQs by specialty Useful links

Page last updated: 10/01/2018 
©2012­17 Claire Shevlin Contact Me