Short Answer Questions

Mock Exam Answers

Dr Katie Ayyash and Dr Umakanth Kempanna
General Pointers

• Read the question properly and understand what is being asked

• Answer the question asked – NOT what you want to answer about the
topic
• Bullet points
• Classify/categorise
• If question asks for something “specific” – you don’t give general or
superficial answers
• Don’t write extensively for low scoring sections
• Legible and neat writing – if examiner can’t read it, you won’t get the
points!!!!
Question 1

A 56-year-old man is listed for elective surgery. He received an

orthotopic heart transplant 12 years before.
a) What key alterations in cardiac physiology and function
must be considered when planning general anaesthesia? (10
marks)
b) What are the implications of the patient’s
immunosuppressant therapy for perioperative care?
(6 marks)
c) What long-term health issues may occur in this type of
patient? (4 marks)
 Pass rate 27%

“It is not uncommon to have a patient presenting for surgery that has
received a transplanted organ and is on immunosuppressive therapy. A
similar question was asked in October 2001.”
“This question proved to be the most difficult question on the paper.”
“A majority of the candidates demonstrated poor understanding of the
physiology of a transplanted heart and the side effects of
immunosuppressive therapy of relevance to the anaesthetist. “
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Number of Candidates
a) What key alterations in cardiac physiology and function must
be considered when planning general anaesthesia? (10 marks)

• Denervated heart - no autonomic function

1. High resting HR 90-100bpm (loss of vagal tone on SA Node)
2. No response to laryngoscopy, surgical stimulation, hypovolaemia, light anaesthesia.
3. Temporary bradyarrhythmia post transplantation - ? need for a pacemaker
4. Loss of baroreceptor reflex - No response to carotid sinus massage or valsalva
maneouvre
5. Tachycardia in response to physiological stress is blunted and late depending on
circulating hormones
• Cardiac output is preload dependent
• Loss of Sensory Innervation
• Silent MI, hence routine regular angiogram needed.
a) What key alterations in cardiac physiology and function must
be considered when planning general anaesthesia? (10 marks)

• Pharmacology
1. Glycopyrolate and atropine - no effect (no vagal connection), but
reversal of NMB.
2. Ephedrine – No/decreased effect (indirect symp)
3. Adrenaline, Noradrenaline – Augmented Response
4. Dobutamine, Isoprenaline – Normal Response
• Peripheral surgery under regional block well tolerated
• Neuroaxial blockade may cause marked hypotension due to absent
cardiac innervation, but has been successfully used in these patients.
b) What are the implications of the patient’s
immunosuppressant therapy for perioperative care?(6 marks)

• Normally on triple therapy azathioprine, cyclosporin, prednisolone

• General:
1. Important to maintain stable plasma levels – ensure drugs are taken
2. Preop bloods: Hematological, Renal and Elecrolyte impairment.
3. Common agents can cause a degree of nephrotoxicity, hepatotoxicity
• Malignancy – Skin, lymphoproliferative.
• NSAIDS – nephrotoxic
• Steroids:
1. supplementation to account for stress response.
2. Steroid induced osteoporosis or skin fragility necessitate careful handling and
positioning of the patient
• Increased risk of infection – signs maybe masked
• Prophylactic antibiotics
• Strict asepsis
• Hypertension, Cushingoid features, Psychosis, hyperglycaemia, hyperkalemia
b) What are the implications of the patient’s
immunosuppressant therapy for perioperative care? (6 marks)

• Monitor for classical side effects of steroids

• Steroid induced osteoporosis or skin fragility necessitate careful
handling and positioning of the patient

• Cyclosporin:
1. Nephro,
2. Neuro toxic, DM, HTN, Pancreatitis, Enhances NMBs

• Azathioprine:
1. Myelosuppression, Reduces effects of NDMRs
2. Hepatotoxic, GI side effects, Pulmonary infiltrates

• Calcium antagonists increase cyclosporine levels

c) What long-term health issues may occur in this type of
patient? (4 marks)

1. Rejection
• Acute – cellular or antibody mediated, first 3 months,
• Chronic – allograft vasculopathy, immune mediated, arrhythmias, late death.
• 40% of cardiac transplant patients develop one episode of acute rejection within the
1st year
• Features:
• Accelerated coronary artery disease
• Silent myocardial ischaemia/infarction
• Heart failure
• Arrhythmia
c) What long-term health issues may occur in this type of
patient? (4 marks)

1. Difficult arterial and venous access due to repeated use

2. Impaired cough due to phrenic/recurrent laryngeal nerve palsies
predisposes to sputum retention and chronic lung disease
3. Higher incidence of diabetes, pancreatitis, epilepsy and hypertension
4. Higher incidence of malignancies
References

• Anaesthesia for a Patient with a Cardiac Transplant, CEACCP 2002

Question 2

a) List the nuclei of the vagus nerve. (2 marks)

b) Describe the immediate relations of the right vagus nerve
in the neck at C6 (3 marks) and thorax at T4. (3 marks)
c) List the branches of the vagus nerve. (6 marks)
d) Which clinical situations commonly produce vagal reflex
bradycardia? (6 marks)
 Pass Rate 44.4%

“Knowledge of anatomy proved generally very poor.”

“Candidates performed better in sections (c) and (d) which were most
clinically orientated. “
“Anatomical knowledge is clearly relevant to the invasive procedures
undertaken in anaesthetic practice, and possibly vital to the interpretation
of images generated by ultrasound devices.”
“Candidates must understand that relevant anatomy will be tested
throughout all parts of the Final FRCA examination and should not write
the subject off.”
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Number of candidates
a) List the nuclei of the vagus nerve (2 marks)

Nuclei of Vagus nerve lie in the medulla

1.Dorsal nucleus of the vagus (parasympathetic)
2.Nucleus Ambiguus (motor)
3.Nucleus Tractus Solitarus (sensory)
(Sensory nucleus of the trigeminal nerve - somatic sensory fibres)
b) Describe the immediate relations of the right vagus nerve in
the neck at C6 and thorax at T4.

Within the carotid sheath at C6 (3 marks)

•Anterior – Omohyoid, Right lobe of thyroid gland
•Posterior – Longus cervicis, Anterior scalene muscle, Vertebral artery
•Medial – Common carotid artery, Sympathetic chain, Recurrent laryngeal
nerve
•Lateral – Internal jugular vein, Deep cervical lymph chain,
Sternocleidomastoid muscle, External jugular vein
b) Describe the immediate relations of the right vagus nerve in
the neck at C6 and thorax at T4.

In the thorax at T4 (3 marks)

•Anterior – Phrenic nerve, Brachiocephalic trunk, Manubrium
•Posterior – Right lung
•Medial – Trachea
•Lateral – Right brachiocephalic vein
c) List the branches of the vagus nerve (6 marks)

Jugular foramen
1.Meningeal
2.Auricular

Neck
1.Pharyngeal
2.Superior laryngeal
3.Right recurrent laryngeal
4.Superior cardiac
c) List the branches of the vagus nerve (6 marks)

Thorax
1.Inferior cardiac
2.Left recurrent laryngeal
3.Branches to pulmonary plexus
4.Branches to oesophageal plexus

Abdomen
1.Gastric
2.Hepatic
3.Intestinal
4.Branches to the coeliac plexus
d) Which clinical situations commonly produce vagal reflex
bradycardia? (6 marks)

1. Eye: Traction on extra-ocular muscles (oculo-cardiac reflex)

2. Anus: Dilatation of anal canal/Instrumentation of anorectum
3. Cervix: stretching
4. Peritoneum: Pulling or stretching (laparoscopic surgery)
5. Uterus: Mobilisation or Traction
6. Larynx: Laryngoscopy/Laryngospasm
7. Ovaries, Gallbladder, Liver Hilum: Traction.
8. Regional anaesthesia
9. Haemorrhage
10. IVC compression (during pregnancy)
11. Traction of testes
12. Middle ear surgery
References

• Gray’s Anatomy
• Concise Anatomy for Anaesthesia
Question 3

You are asked to review a woman in the anaesthetic antenatal

clinic. She is 30 weeks pregnant and is a Jehovah’s witness.
She requires an elective caesarean section at 39 weeks due to
a low lying placenta and a fibroid uterus.
a)What specific issues should be discussed with this patient
based on the history outlined above? (10 marks)
b)Give the advantages and disadvantages of using intra-
operative cell salvage during caesarean section? (10 marks)
 Pass Rate 44.6%
22.5% of candidates received a poor fail

“This question was poorly attempted by many candidates.”

“Examiners reported that answers reflected a lack of knowledge or
inaccurate reading of the question.”
“Many candidates described anaesthesia for a Jehovah’s Witness patient
with placenta praevia and fibroid uterus rather than addressing pre-
operative discussions as was asked.”
“Candidates omitted mention of important peri-operative risks such as
haemorrhage, hysterectomy and other significant morbidity and
mortality.”
“Some candidates demonstrated a worrying lack of knowledge of cell
salvage and in particular the disadvantages of this technique.”
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Number of Candidates
a) What specific issues should be discussed with this patient
based on the history outlined above? (10 marks)

1. Elective Caesarian Section + Low placenta + Fibroid

• Anaesthetic plan:
• General anaesthetic due to increased risk of major bleeding
• Post-op analgesia, will be more difficult to manage than for regional
technique- consent for TAP blocks
• Partner will not be present in theatre for birth
• Need for invasive monitoring - arterial line, consider central line.
a) What specific issues should be discussed with this patient
based on the history outlined above? (10 marks)

2. Jehova’s witness
• Is she taking any medication that will impair clotting? Can these be
stopped?
• What blood products will she accept and refuse?
• Would intra-operative cell salvage with a closed loop be accepted?
• Does she have an advanced directive?
• Has she discussed the issues of increased risk of bleeding and blood
products with her religious leader?
• Will need to fill in a specific Trust consent form for Jehovah’s
Witness patients.
• We will respect her wishes
a) What specific issues should be discussed with this patient
based on the history outlined above? (10 marks)

• Can we optimise haemoglobin pre-op? - oral or intravenous iron,

erythropoietin
• Can consider pre-op embolisation of intra-uterine arteries/iliacs
• Senior clinicians from obstetrics and anaesthetics will be present during
the operation.

• Further increase in risk due to limitations on blood products that

Jehovah’s witness will accept
• Increased risk of emergency hysterectomy, critical care post-op, death
b) Give the advantages and disadvantages of using intra-
operative cell salvage during caesarean section? (10 marks)

Advantages
1.Reduced use of allogenic blood transfusion (valuable resource) therefore
reduced risk of:
1. ABO incompatibility
2. Infection
3. Haemolytic transfusion reactions
4. Anaphylaxis
2.Transfused autologous blood has normal levels of 2,3-DPG
3.Transfused autologous blood has longer intravascular lifespan than
allogenic blood
4.No pre-operative preparation of patient needed
5.Only >500ml of blood needed for processing - blood loss in Caesarian
section often higher than this
b) Give the advantages and disadvantages of using intra-
operative cell salvage during caesarean section? (10 marks)

Disadvantages
1.Cost of set up and disposables
2.Need for trained personnel to operate equipment
3.Risk of:
1. Infection in processed blood
2. Air embolism
3. Amniotic fluid embolism (should be prevented with leukocyte
depletion filter)
4. Haemolysis and free haemoglobin in transfused blood leading to
nephrotoxicity
5. Micro-aggregates leading to micro-embolism
6. Cell salvage syndrome (dilution of blood in saline can produce
cellular aggregates that activate clotting and increase vascular
permeability)
b) Give the advantages and disadvantages of using intra-
operative cell salvage during caesarean section? (10 marks)

Disadvantages
• Electrolyte imbalance
• Leukocyte activation —> lung damage
• Autologous blood transfusion does not contain platelets or clotting
factors - additional blood products will be required in major
haemorrhage
• Time delay from collection to transfusion due to processing
References

• Perioperative Cell Salvage, CEACCP 2010

• Management of Anaesthesia for Jehovah's Witness, AAGBI 2005
Question 4

A 45-year-old man with a history of ulcerative colitis and

alcohol abuse is admitted to the intensive care unit for
inotropic and ventilatory support following a laparotomy to
excise toxic megacolon. His body mass index is 18kg/m2.
a) Why should this patient receive early nutritional support
and what are the clinical benefits?
(6 marks)
b) What is the specific composition of a nutritional regimen
for this patient? (6 marks)
c) List the advantages and disadvantages of enteral nutrition
(8 marks)
 Pass Rate 44.9%

“This question was answered poorly. “

“The provision of enteral and parenteral nutrition in critically ill patients is
very important and a detailed knowledge of the specific components of a
feeding regimen is essential. The specific components required were:
Water (ml/kg/day)
Calories (kCal/kg/day)
Protein, fat and carbohydrate (g/day) Na/K (mmol/kg/day) and minerals
Vitamins
Immunonutrition “
“Many candidates failed to be specific enough. Leaving the prescribing to
the “nutrition team” or “Intensive Care dietician” are not appropriate
answers.“
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Number of Candidates
a) Why should this patient receive early nutritional support and
what are the clinical benefits? (3 + 3 marks)

Why Nutritional Support

1.He is underweight (< 18.5 kg/m2 as per WHO classification)

2.He has a premorbid chronic inflammatory condition
3.He likely has nutritional deficiencies due to alcohol abuse
4.Early nutritional support following surgery is beneficial
5.He is acutely unwell and therefore is in a catabolic state so will have
increased nutritional requirements
a) Why should this patient receive early nutritional support and
what are the clinical benefits? (3+3 marks)

Clinical Benefits

1. Maintains integrity of gut mucosal barrier

2.Improved wound healing
3.Decreased infectious complications
4.Maintains nitrogen balance
5.Avoids delayed mobilization by promoting muscle mass/bulk and
therefore strength
6.Avoids delayed weaning from mechanical ventilation
b) What is the specific composition of a nutritional regimen for
this patient? (6 marks)
1. Calorie 30 kcals/kg
2. Water 30 mls/kg
3. Protein 1.5 g/kg
4. Remaining calorie requirement must balance between carbohydrate
and fat to avoid increase in lipogenesis and RQ
Fat = 1g/kg/day, Carbohydrate = 7g/kg/day
5. Na = 1 mmol/kg/day
6. K = 1 mmol/kg/day
7. Mg = 1 mmol/kg/day
8. Ca2+ = 0.1 mmol/kg/day
9. Po43- = 0.5 mmol/kg/day
10. Trace elements – fat and water soluble vitamins
11. Vitamin B (due to alcohol abuse)
12. Micronutrients – No evidence of benefit
c) List the advantages and disadvantages of enteral nutrition (4
+ 4 marks)

Advantages

1.Maintains normal physiological digestion and absorption

2.Non-invasive and cheaper
3.Preserves normal gut flora
4.Normal gastric acidity and GI barrier function is preserved
5.Decreased metabolic complications
6.No catheter associated complications
7.Decreased bacterial translocation
8.Prevents mucosal atrophy
9.Decreased stress ulcer
c) List the advantages and disadvantages of enteral nutrition (4
+ 4 marks)

Disadvantages

1.Patient requires a functioning and intact GI tract

2.Diarrhoea (40%)
3.Nausea and vomiting
4.Aspiration and pulmonary injury
5.Direct pulmonary instillation
6.Electrolyte and liver function test disturbance
References

• Parenteral Nutrition in Critical Care, CEACCP 2012

• Nutritional Support in Critical Care: An Update, CEACCP 2007
Question 5

a) What are the cerebral physiological benefits of induced

hypothermia following successful resuscitation from cardiac
arrest? (5 marks)
b) How can a patient be cooled in these circumstances? (4
marks)
c) What adverse effects may occur due to the use of induced
hypothermia? (7 marks)
d) In what other non-surgical clinical scenarios may the use of
induced hypothermia be beneficial? (4 marks)
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a) What are the cerebral physiological benefits of induced
hypothermia following successful resuscitation from cardiac
arrest? (5 marks)

1. Reduces cerebral metabolism by 7% for every 1°C leading to less

oxygen and glucose consumption
2. Promotes cerebral vasoconstriction leading to a decrease in ICP
3. Decreased excitatory neurotransmitter mainly glutamate
4. Decreases calcium flux
5. Prevents neuronal injury leading to apoptosis
6. Decreases neurochemical motor expression
7. Improves ionic homeostatis
8. Decreases free radical formation
b) How can a patient be cooled in these circumstances? (4
marks)

• Physical:
1. Fans—may increase infection risk
2. Ice packs to the femoral area, major vessels, and armpit
3. Cold fluids via intravascular line
4. Water filled blankets or garments
5. Forced cold air
6. Bypass—specialist (cardiac) areas only
7. Cooling caps (mainly used in neonates and infants)

• Pharmacological:
1. Antipyretics, for example, paracetamol

OR can be classified as passive/active cooling

c) What adverse effects may occur due to the use of induced
hypothermia? (7 marks)

1. CVS
2. RS
3. Neuro
4. Metabolic
5. Renal
6. GI
7. Haematological
c) What adverse effects may occur due to the use of induced
hypothermia? (7 marks)

Cardiovascular
• Decreases cardiac output by 30% at 30°C
• Increases risk of angina, myocardial ischaemia and cardiac arrest
• Increased risk of ventricular arrhythmias at 30°C, VF at 28°C
• Increases SVR and PVR
• Increases catecholamine release
• ECG – prolonged PR interval, wide QRS complex, J waves
c) What adverse effects may occur due to the use of induced
hypothermia?

Respiratory
•Apnoea occurs at 24°C
•Decreases O2 delivery (Left shift of the oxygen-haemoglobin dissociation
curve)
•Decreases O2 demand and CO2 production
•Mild respiratory and metabolic acidosis

Neurological
•Shivering thereby increasing basal metabolic rate
•Confusion <35°C
•Unconsciousness at 30°C
•Cessation of cerebral activity <18°C
c) What adverse effects may occur due to the use of induced
hypothermia?

Metabolic
•Decreases metabolic rate by 6-7% by every 1°C in core temperature
•Decreases enzyme activity
•Hyperglycaemia secondary to fat mobilisation
•Electrolyte shift

Renal
•Decreases GFR by 50% at 30°C
•Diuresis due to inability to absorb sodium and water
c) What adverse effects may occur due to the use of induced
hypothermia?

GI
•Decreases gut motility leading to ileus
•Decreases gut translocation of bacteria

Haematological
•Increases blood viscosity and haematocrit < 30°C
•Thrombocytopenia caused by hepatic and splenic sequestration
•Impaired platelet function
•Immunosuppression
•Increases risk of DVT/PE
d) In what other non-surgical clinical scenarios may the use of
induced hypothermia be beneficial? (4 marks)

1. Post cardiac arrest

2. Traumatic head injury
3. Ischaemia stroke
4. Spinal cord injury
5. Newborn hypoxic–ischaemic encephalopathy
6. Raised ICP seen in hepatic encephalopathy
7. Treatment of malignant hyperthermia and drug overdoses e.g.
serotenergic syndrome
References

• Clinical Implications of Induced Hypothermia, CEACCP 2006

Question 6

a) What characteristic neurological changes occur

immediately and in the first three months following
transection of the spinal cord at the fourth thoracic vertebra?
(5 marks)
b) What other clinical problems may develop following this
type of injury? (8 marks)
c) List the advantages of a regional anaesthetic technique for
cystoscopy in this patient. (4 marks)
d) Why and when may suxamethonium be contraindicated in
a patient with spinal injury?
(3 marks)
 Pass rate 49.4%

“The examiners commented that part (d) about the advantages of regional
anaesthesia for elective lower limb surgery, was not well answered.”
“Candidates tended to give general answers such as “avoids the need for
general anaesthesia” or “maintains cardiovascular stability” rather than
specific advantages such as “reduces the risk of autonomic dysreflexia” or
“avoids postoperative respiratory inadequacy due to general anaesthesia”.
 20

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Number of Candidates
a) What characteristic neurological changes occur immediately
and in the first three months following transection of the spinal
cord at the fourth thoracic vertebra? (5 marks)

Immediate Changes

•Days 0-1: Spinal shock develops where there is loss of reflexes below the
level of T4 resulting in flaccid areflexia. This is usually combined with
hypotension of neurogenic shock
a) What characteristic neurological changes occur immediately
and in the first three months following transection of the spinal
cord at the fourth thoracic vertebra? (5 marks)

Changes in first 3 months

•Days 1-3: Gradual return of reflex activity when the reflex arcs below the
level of the lesion redevelops. Loss of descending inhibitory control leads
eventually to spasticity and autonomic hyperreflexia
•Days 4-28: Early hyperreflexia develops. This results as a stimulation of
the autonomic nervous system which can lead to profound systemic
symptoms, including hypertension, tachycardia, flushing, sweating and
headaches.
•Months 1-12: Development of late hyperreflexia
b) What other clinical problems may develop following this type
of injury? (8 marks)

1. RS
2. Hypotension
3. Autonomic Dysreflexia
4. Haematological
5. GI
6. Skin
7. Musculoskeletal
8. Temperature
9. CNS
b) What other clinical problems may develop following this type
of injury? (8 marks)

1. RS:
• Respiratory function may be compromised leading to:
1. Need for long term mechanical ventilation via a tracheostomy
2. Absent or impaired cough reflex leading to retention of secretions and
increased risk of lower respiratory tract infections
2. Hypotension:
• Incomplete recovery from neurogenic shock leading to postural hypotension that
can be a persistent problem
3. Autonomic Dysreflexia:
• Sympathetic hyperreflexia – a life-threatening condition triggered by somatic or
visceral stimuli below the level of the injury
4. Haematological:
• Risk of thromboembolic events due to immobility and thrombogenicity secondary
to trauma
b) What other clinical problems may develop following this type
of injury? (8 marks)
5. GI:
• Risk of peptic ulceration due to unopposed vagal activity thereby increasing
gastric acid secretion
• Gastroparesis and ileus development leading to nausea, vomiting and risk of
aspiration and abdominal distension impairing respiration
• Constipation is often problematic as sensation of defecation is lost
• May require enteral feeding and therefore glycaemic control is essential to avoid
hypo- and hyperglycaemic episodes
6. Skin:
• Development of pressure sores as a result of immobility, poor perfusion of the
skin and hypoxia
7. Musculo- skeletal:
• Development of contractures from spasticity. Both painful and decrease function,
compromise posture, and reduce functional capacity
• Reduced bone density and increased risk of fractures
b) What other clinical problems may develop following this type
of injury? (8 marks)
8. Temperature:
• Impaired thermoregulation
9. CNS:
• Psychological disturbance – depression, anxiety, confusion
c) List the advantages of a regional anaesthetic technique for
cystoscopy in this patient (4 marks)

1. Completely abolishes the risk of autonomic dysreflexia

2. Avoidance of some of the hazards of general anaesthesia in such
patients
1. Aspiration: Avoidance of risk of aspiration secondary to
gastroparesis
2. Airway: May have a difficult airway (Trache, Spinal Fixation)
3. RS: Avoidance of respiratory complications and post-op
ventilation
4. CVS: Risk of profound hypotension due to loss of sympathetic
response (lesions above T6 and unopposed parasymp)
3. CVS / RS / GI (reduced opioid) / Haematological / Reduced risk of
thrombo-embolism
d) Why and when may suxamethonium be contraindicated in a
patient with spinal injury? (3 marks)

1. Suxamethonium is safe to use in the first 72 hours and after 9months

following the injury
2. Extra-junctional Ach receptors
3. In the intervening period there is a risk of suxamethonium-induced
hyperkalaemia due to denervation hypersensitivity and therefore
should be avoided
References

• Initial Management of Acute Spinal Cord Injury, CEACCP 2013

• Anaesthesia and Acute Spinal Cord Injury, CEACCP 2002
Question 7

A 71-year-old patient requires a rigid bronchoscopy for biopsy

and possible laser resection of an endobronchial tumour.
a) Outline the options available to maintain anaesthesia (4
marks) and manage gas exchange. (6 marks)
b) How will use of the laser change the management of
anaesthesia? (3 marks)
c) What are the possible complications of rigid bronchoscopy?
(7 marks)
 Pass Rate 60.8%

“This question proved discriminatory between candidates who gave a

mature and thoughtful answer and those that did not understand the
implications of “tubeless” ENT / thoracic surgery.”
“Weaker candidates proposed the use of laser-proof endotracheal tubes,
and even double lumen endobronchial tubes and cardiac bypass to
facilitate gas exchange.”
“Part (a) tended to score scored badly whilst parts (b) and (c) were better
known.”
“Focus in part (c) was dominated by traumatic complications with
candidates forgetting “anaesthetic” issues such as; laryngospasm and
bronchospasm, pneumothorax / barotrauma / volutrauma from jet
ventilation, cardiovascular disturbances, pulmonary infection, hypoxaemia,
hypercarbia and awareness.”
 12

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Number of Candidates
a) Outline the options available to maintain anaesthesia and
manage gas exchange. (4 + 6 marks)

Options to maintain anaesthesia: (4 marks)

1.TIVA (Total intravenous anaesthesia)

2.Inhalation: anaesthesia via side arm of bronchoscope with patient
spontaneously breathing (paediatric anaesthesia, typically for inhaled
foreign body)
a) Outline the options available to maintain anaesthesia and
manage gas exchange.

Management of gas exchange: (6 marks)

1.Low frequency jet ventilation (LFJV)

2.Spontaneous respiration through bronchoscope with Mapleson F circuit
attached (ideally for paediatric population)
3.High frequency jet ventilation
b) How will use of the laser change the management of
anaesthesia? (3 marks)

1. Warning sign on theatre door, locking theatre door and blacking out
of all windows
2. Protective goggles for patient and theatre staff members
3. Minimum FiO2 should be used during procedure
4. Saline should be immediately available to deal with airway fire
5. Consideration should be given to using a laser resistant tube instead
of rigid bronchoscope
6. Dexamethasone maybe required to reduce swelling post operatively
7. Requires training on use of Lasers for theatre staff
8. Nitrous oxide must not be used
c) What are the possible complications of rigid bronchoscopy?
(7 marks)

1. Physical:
1. Dental damage
2. Sore throat
3. Hyper-extension of neck can cause basilar artery insufficiency
4. nerve damage to nerves of cervical spine
5. Trauma to the airway leading to swelling or bleeding

2. Physiological:
1. If LFJV or HFJV used then:
1. barotrauma
2. volutrauma
3. pneumothorax
2. Increased risk of awareness
3. Environment:
• Pollution due to inhalational agents
References

• Anaesthesia for Airway Surgery, CEACCP 2006

Question 8

a) What types of infusion control devices are used in clinical

settings? (3 marks)
b) What are the general (4 marks) and specific (7 marks)
characteristics of pumps used for target controlled infusion
(TCI) anaesthesia?
c) What precautions should be undertaken to guarantee drug
delivery when administering total intravenous anaesthesia
(TIVA)? (6 marks)
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8
Mark out of 20

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1 2 3 4 5 6
Number of Candidates
a) What types of infusion control devices are used in clinical
settings? (3 marks)

1. Target controlled infusion pumps e.g Alaris

2. Fluid pumps e.g. Graseby
3. Epidural infusion
4. PCA pumps
5. Syringe drivers
6. Pain busters
b) What are the general and specific characteristics of pumps
used for target controlled infusion (TCI) anaesthesia?

General (4 marks)

1.Battery or mains operated

2.User interface to enter patient details
3.Display screen for information regarding protocol and infusion data
4.Alarm for power failure or low battery
5.Alarms for syringe disengagement, end of infusion, occlusion or high
resistance
b) What are the general and specific characteristics of pumps
used for target controlled infusion (TCI) anaesthesia?

Specific (7 marks)
1.Can set and adjust target plasma or effect-site concentration of drug
2.Software with pharmacokinetic model validated for specific drug to
control infusion rate
• Models are derived from previously performed pharmacokinetic
studies
• Computer continuously calculates the patient’s expected drug
concentration and adjusts drug infusion rate
3.Communication between ‘control unit’ and pump hardware
• Computer-controlled motor turning screw that pushes syringe
plunger
4.Specific Drugs: Propofol (Marsch / Schneider), Remifent (Minto)
5.Pumps themselves do not provide depth of anaesthesia monitoring
c) What precautions should be undertaken to guarantee drug
delivery when administering total intravenous anaesthesia
(TIVA)? (6 marks)

1. Dedicated intravenous line

2. Regular monitoring of cannula site checking for disconnection or
tissuing – cannula should be easily visible
3. Non-return valve should be used on any intravenous fluid line (when
multi-lumen IV connectors used)
4. Anti-siphon valve prevents siphonage into pump-controlled
medication lines
5. Ensure all infusion devices are fit for purpose – systematic checks of
all pumps
6. Ensure all staff trained in how to operate infusion pumps
7. Depth of Anaesthesia Monitoring – Clinical / Equipment – BIS,
Entropy, etc.,
References

• Safe Anaesthesia Liaison Group - Guaranteeing Drug Delivery in Total

Intravenous Anaesthesia
Question 9

a) What are the site of action and the intra and extracellular
mechanisms of analgesic effect within the spinal cord
following the administration of intrathecal (IT) opioids? (6
marks)
b) List the principal side effects of IT opioids. (7 marks)
c) What factors may increase the risk of postoperative
respiratory depression following administration of IT opioids?
(7 marks)
 Pass rate 31.7%

“It was anticipated that candidates would find this question difficult, and
this proved to be the case.”
“Intrathecal opioids are used widely in anaesthetic practice but
candidates’ knowledge of their use was poor.”
“Advanced sciences are part of the intermediate curriculum so knowledge
of applied pharmacology is expected.”
“Some candidates failed to read part (b) of the question and gave the side
effects of intravenous opioids or intrathecal local anaesthetic in their
answer.“
 12

10

8
Mark out of 20

0
1 2 3 4 5 6
Number of Candidate
a) What are the site of action and the intra and extracellular
mechanisms of analgesic effect within the spinal cord following
the administration of intrathecal (IT) opioids? (6 marks)

1. After injection – slow cephalad and circumferential spread.

2. G-protein: Intrathecal opioids bind to G-protein-linked pre- and
postsynaptic opioid receptors
3. Site: Laminae I and II of the dorsal horn
4. Receptor activation leads to G-protein- mediated potassium channel
opening (mu and delta) and calcium channel closure (kappa)
5. This results in a reduction in intracellular calcium
6. This reduces the release of excitatory transmitters (glutamate and
substance P) from presynaptic C fibres, but not A-fibre terminals
7. This causes a reduction in nociceptive transmission
8. Other possible target sites: C fibres (fentanyl), increase in adenosine
(morphine), post synaptic receptor sites in dorsal horn – K channel
opening – indirect activation of descending inhibitory pathways.
b) List the principal side effects of IT opioids. (7 marks)

1. RS: Respiratory depression

2. GI:
• Delayed gastric emptying
• Nausea and vomiting
3. Pruritus (mechanism not understood)
4. CNS: Sedation
5. Urinary retention
6. Sweating
7. Shivering
c) What factors may increase the risk of postoperative
respiratory depression following administration of IT opioids? (7
marks)

1. Administration of high dose intra-thecal opioids

2. Increasing age
3. Concomitant use of long acting sedatives
4. Positive pressure ventilation
5. Co-existing respiratory depression
6. Co-administration of opioid analgesics during the first 12-24 hours
after intra-thecal administration
(? Others: OSA, Obesity, Premature / very young)
References

• Intrathecal Opioids in the Management of Acute Postoperative Pain

Relief, CEACCP 2008
Question 10

A one-day old term neonate has arrived at your regional

paediatric intensive care unit. A congenital diaphragmatic
hernia has been diagnosed. The baby is already intubated and
receiving artificial ventilation.
a) What is congenital diaphragmatic herniation? (2 marks)
b) How may it present and how may it be diagnosed? (4
marks)
c) What are the anaesthetic implications, including ventilator
strategy when anaesthetising these patients? (6 marks)
d) What problems may occur intra-operatively and post-
operatively? (8 marks)
 12

10

8
Mark out of 20

0
1 2 3 4 5 6
Number of Candidates
a) What is congenital diaphragmatic herniation? (2 marks)

1. Diaphragm fails to close properly during fetal development. The

resulting defect allows the abdominal contents such as bowel to enter
the thoracic cavity.
2. It is more common on the left side via the foramen of Bochdalek
3. Lung development on the affected side is abnormal and displays
hypoplasia with poorly developed airways, fewer type 2 pneumocytes
and highly reactive pulmonary vasculature
b) How may it present and how may it be diagnosed?(4 marks)

• CDH can be diagnosed antenatally and postnatally

Antenatally

• Ultrasonographic features that suggest CDH include polyhydraminos,

visualization of the stomach or bowel in the thorax and mediastinal shift
away from the hernia
• Average gestational age at diagnosis is 24 weeks
b) How may it present and how may it be diagnosed?(4 marks)

Postnatally

• History / Presentation:
•CDH often presents as respiratory distress with tachypnea and cyanosis in the neonatal
period. This is due to associated pulmonary hypoplasia and pulmonary hypertension.
• Examination:
• Abdomen is scaphoid and the thorax barrel-shaped.
•Breath sounds are absent on the affected side (most commonly the left side) and the
heart sounds are shifted to the opposite side (most commonly the right)
•Bowel sounds on the affected side are an uncommon finding.
•Investigation:
•Diagnosis is made by chest radiograph showing abdominal contents in the thoracic
cavity after birth.
c) What are the anaesthetic implications, including ventilator
strategy when anaesthetising these patients? (6 marks)

Anaesthetic Implications specific to CDH

1.Surgical correction of the defect is not an emergency as it will not

improve ventilation.
2.At delivery bag mask ventilation should be avoided as it inflates the
stomach and impairs ventilation
3.The trachea is intubated and a ‘gentle ventilation’ strategy is used. This
strategy encompasses:
• Limiting inspiratory pressures to < 25cm H2O
• Low tidal volumes
• Permissive hypercapnia
• Allowing spontaneous respiration.
• This reduces barotrauma and further damage to the hypolastic lung
•High frequency oscillator/ECMO may be required
c) What are the anaesthetic implications, including ventilator
strategy when anaesthetising these patients? (6 marks)

Anaesthetic Implications specific to CDH

1. FiO2 adjusted to preductal arterial saturations >85%

2.A large orogastric tube is inserted to deflate the stomach
3.Neoenate is stabilised in NICU where arterial and central venous access
can be gained
4.Ongoing management is focused on trying to reduce pulmonary vascular
resistance (PVR) as these neonates have pulmonary hypertension.
5.Inhaled nitric oxide is a selective pulmonary vasodilator that reduces
PVR
6.After 24-48hrs and a period of stabilisation with falling PVR surgery is
performed
c) What are the anaesthetic implications, including ventilator
strategy when anaesthetising these patients? (6 marks)

Anaesthetic Implications specific to CDH

•Key anaesthetic considerations in theatre are:

• To prevent any rise in PVR by adequate oxygenation
• Avoiding acidosis
• Avoiding hypothermia
• Continue any pharmacological infusions from NICU to reduce PVR
•Inhalational agents with the exception of nitrous oxide can be used
•Often there is cardiovascular instability so opioids and muscle relaxants
are the key drugs used
d) What problems may occur intra-operatively and post-
operatively? (8 marks)

Intra-operatively

Specific to CDH General to Neonate

1.Pneumothorax particularly 1.Hypothermia

contralateral side if pressures exceed 2.Hypoglycaemia
40cmH2O. Can be life threatening and 3.Bradycardia
requires immediate decompression 4.Hypovolaemia with what appears to
2.Pulmonary hypertension impairs be low blood loss
oxygenation and reduces cardiac output
d) What problems may occur intra-operatively and post-
operatively? (8 marks)

Post-operatively

Specific to CDH General to Neonate

3. Difficulty weaning from ventilation 5. Risk of apnoea

4. Pulmonary hypertension can worsen 6. Respiratory failure
oxygenation and ventilation and ECMO
may be required
5. Chronic lung disease
6. Hernia recurrence
7. Nutritional problems and GORD
8. Neurodevelopmental delay
References

• Congenital Diaphragmatic Hernia in the Neonate, CEACCP 2005

Question 11

a) List the key principles of consent for anaesthesia. (12

marks)
b) Which patients may be unable to give consent (2 marks)
and how is this situation approached? (6 marks)
 12

10

8
Mark out of 20

0
1 2 3 4 5 6
Number of Candidates
a) List the key principles of consent for anaesthesia.(12 marks)

1. Autonomy: Patient has the right to refuse or choose their treatment

2. Beneficence: Act in the best interest of the patient
3. Non-maleficence: “first, do no harm”
4. Justice: fairness and equality. Concerns about distribution of scarce
health resources, and the decision of who gets what treatment.
a) List the key principles of consent for anaesthesia.(12 marks)

• No actual ‘form’ but verbal with brief documentation of risk

• Written patient information
• Patient given time to take away information, read and understand
• Given chance to ask questions
• Informed
• Risk/ benefit explained
• No coercion- given freely
• Below 15
• Gillick competence- patient can consent for treatment but not
refuse
• Child under 15 with competence can go against parents’ wishes
a) List the key principles of consent for anaesthesia.(12 marks)

• Capacity
• Able to understand information, retain information long enough to
weigh risk and benefit then communicate decision
• All patient assumed to have capacity unless proven otherwise
• Apparently unwise decision does not imply patient does not have
capacity
• Patient can have capacity for one decision but not another
• Patients need to be given as much assistance as required to help
them make decisions for themselves
a) List the key principles of consent for anaesthesia.(12 marks)

• Lack capacity
• In emergency- decision in patient’s best interest
• Family can be consulted but not necessary followed (evidence of
patient’s wishes but not in themselves determinative)
• Lasting power of attorney (LPA)- must register with the court of
protection to be valid
• If dispute between clinician and LPA and concerns that LPA not
acting in best interest return to court of protection
a) List the key principles of consent for anaesthesia.(12 marks)

• Language issues
• Always aim to get interpreter- in person/ by phone
• Written information
• Advance directive/ living will
• Done when patient has capacity for use in the event that they lose
capacity
• For specific condition/ treatment only
• Mental Capacity Act
• Protects patients who lack capacity
b) Which patients may be unable to give consent (2 marks) and
how is this situation approached (6 marks)?

Patients unable to give consent Approach

Acute • Wait for capacity to return
•intoxication • If emergency/ life threatening- treat
•GA in best interest. Treatments in this
•Head injury (concussion) situation must cause least
disruption to patient
Long term conditions • Treat in best interest
•Degenerative (Parkinson’s, dementia) • Lasting power of attorney
•Mental health issues • Independent mental capacity act
•Head injury/ permanent brain damage (IMCA)
• Advanced directive
• Court order
Children • Gillick competence in older patient
• Parental consent in younger
children
• If clinician feels parents not acting
in child best interest court order can
be sought
References

• General Medical Coucncil

Question 12

a) What airway, respiratory and cardiovascular problems may

follow the removal of a tracheal tube? (10 marks)
b) List the patient and surgical factors that may contribute to a
high-risk extubation. (6 marks)
c) Outline the strategies used to prevent airway complications
if a difficult extubation is anticipated in the operating theatre.
(4 marks)
 20

18

16

14

12
Mark out of 20

10

0
1 2 3 4 5 6
Number of Candidates
a) What airway, respiratory and cardiovascular problems may
follow the removal of a tracheal tube? (10 marks)

Airway
1.Airway obstruction
1. Laryngospasm (most common)
2. Tongue obstructing airway
3. Laryngeal oedema, haemorrhage
4. Decrease in muscle tone
5. Trauma to airway
6. Vocal cord paralysis/dysfunction (in head & neck / thoracic
surgery)
7. Airway compression (expanding haematoma)
2.Pulmonary aspiration
3.Tracheomalacia (certain surgical pathology, prolonged intubation)
a) What airway, respiratory and cardiovascular problems may
follow the removal of a tracheal tube? (10 marks)

Respiratory
1.Coughing
2.Central respiratory depression due to residual anaesthetic drugs, opioids
3.Early postoperative hypoxaemia –
• Range of causes - inadequate MV, airway obstruction, increased
V/Q mismatch, diffusion hypoxia, post-hyperventilation
hypoventilation, shivering, inhibition of hypoxic pulmonary
vasoconstriction, mucociliary dysfunction, decreased cardiac
output
4.Bronchospasm – smokers, COPD pts, children with URTI
5.Residual neuromuscular blockade may cause respiratory difficulties
6.Post-obstructive pulmonary oedema (respiratory distress, haemoptysis,
CXR changes consistent with pulmonary oedema)
a) What airway, respiratory and cardiovascular problems may
follow the removal of a tracheal tube? (10 marks)

Cardiovascular
1.10-30% increase in arterial pressure and heart rate, lasting 5-15 minutes
2.Decreased ejection fraction (40-50% in patients with CAD)
3.Myocardia ischaemia in high risk patients
b) List the patient and surgical factors that may contribute to a
high-risk extubation. (6 marks)

Patient factors : (Predictors of difficult intubation imply potential for

difficult extubation)
1.Airway pathology – congenital or acquired
2.Known/previous difficult airway
3.MP 3 or 4
4.Limited neck movements/cervical spine instability (RA, Downs, OA,
Ankylosing Spondylitis, surgical fixation)
5.Morbid obesity
6.OSA
7.Severe gastroesophageal reflux
8.Multiple attempts at intubation
9.Airway deterioration – trauma, bleeding, oedema
10.Severe cardiorespiratory disease
b) List the patient and surgical factors that may contribute to a
high-risk extubation. (6 marks)

Surgical factors
1.Neck immobilisation (C-spine surgery)
2.Intermaxillary fixation
3.Presence of Halo/traction limiting access to mouth
4.Head & Neck surgery - Haematoma, oedema and distorted anatomy
5.Posterior fossa surgery
6.Drainage of deep neck and dental abscesses
7.Thyroid surgery – risk of tracheomalacia, recurrent laryngeal nerve
damage
c) Outline the strategies used to prevent airway complications if
a difficult extubation is anticipated in the operating theatre. (4
marks)

Follow DAS Extubation Guidelines

Step 1: Plan
Assess Airway and general risk factors
Step 2: Prepare
Optimisation patient and other factors
(patient – CVS, respiratory, metabolic / temperature, neuromuscular)
(other factors – Location, skilled help and assistance, monitoring,
equipmen)
c) Outline the strategies used to prevent airway complications if
a difficult extubation is anticipated in the operating theatre. (4
marks)

Step 3: Perform Extubation

Safe to remove tube – Awake extubation, Advanced Techniques (LMA,
Remifentanil technique, Airway Exchange Catheter)
Not safe to remove tube – postpone extubation, Tracheostomy
Step 4: Postextubation Care
Recovery / HDU / ICU (Safe transfer, handover/communication, O2 and
airway management, Observation and monitoring, analgesia, staffing,
documentation)
References

• Tracheal Extubation, CEACCP 2008

• DAS Extubation guidelines