AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS

ABN 82 055 042 852

EXAMINATION REPORT
FINAL FELLOWSHIP EXAMINATION
SEPTEMBER 2006

THIS REPORT IS PREPARED TO PROVIDE CANDIDATES, TEACHERS AND

SUPERVISORS OF TRAINING WITH INFORMATION ABOUT THE RECENT
EXAMINATION AND TO ASSIST WITH PREPARATION FOR FUTURE EXAMINATIONS.

GENERAL COMMENTS

In preparing for the examination candidates should be aware that the Objectives of Training guide the
range of content which may be assessed. It is important that candidates allow appropriate time and
resources for preparation for each section of the examination. As this is the Final Fellowship
examination, responses are expected to demonstrate a consultant level of prioritisation, judgement,
integration and decision making.

MULTIPLE CHOICE PAPER

Overall 79%of candidates passed the MCQ paper.
The table below outlines the number of questions in each subject category (noting that an individual
question may have more than one subject). Only subjects represented in 4 or more questions are
listed. The subject spread in the MCQ paper varies from exam to exam, as it is partly determined by
the content of the short answer questions and viva sections of the exam, to ensure that an appropriately
wide range of subjects is covered by the whole examination.
When sitting the MCQ paper candidates should be mindful that marks are not deducted for mistakes,
so every question should be attempted.

Description N % of exam
applied pharmacology 26 17
miscellaneous complications 12 8
paediatric anaesthesia 12 8
cardiac disease 11 7
applied anatomy 10 7
medicine 8 5
pain 7 5
regional anaesthesia 7 5
cardiac investigations 7 5
shock resuscitation 7 5
equipment 7 5
pregnancy obstetrics 6 4
monitoring 6 4
haematological disorder investigation 6 4
infection 5 3
statistics 5 3
rare diseases 5 3
renal disease & investigations 5 3
cardiac complications 5 3
liver disease 4 3
ophthalmic anaesthesia 4 3
applied physiology 4 3
acute trauma 4 3
anaesthetic plan 4 3
endocrine disease 4 3
acute trauma 4 3
equipment 4 3
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Description N % of exam
neuromuscular skeletal 4 3
anaphylaxis 3 2
monitoring 3 2
pre-operative clinical assessment 3 2
pulmonary investigations 3 2
critical care 3 2
DVT and PE 3 2
ENT anaesthesia 3 2
ophthalmic anaesthesia 3 2
orthopaedic anaesthesia 3 2
safety electrical 3 2
cardiac physiology 2 1
malignant hyperthermia 2 1
allergy atopy 2 1
applied physics 2 1
cardiac anaesthesia 2 1
elderly 2 1
neuropathy 2 1
neurosurgical anaesthesia 2 1
surgery 2 1
thoracic anaesthesia 2 1
urological anaesthesia 2 1
vascular anaesthesia 2 1
aspiration full stomach 1 1
difficult airway 1 1
liver disease 1 1
pulmonary disease 1 1
anaesthesia for ECT 1 1
colorectal anaesthesia 1 1
endoscopy imaging monitored care 1 1
ethics 1 1
laparoscopic surgery 1 1
obesity 1 1
postoperative care 1 1

SHORT ANSWER QUESTION PAPER

The overall pass rate for this section of the examination was 42% Candidates are advised to apportion
their time equally amongst the short answer questions as all the questions are worth equal marks.
Candidates are reminded to read the question carefully and answer the question asked. The use of
abbreviations is discouraged as these can be open to different interpretations. Logical, organised
answers with legible handwriting will attract better marks.
Question SAQ subject Pass Rate
1 Equipment 81%
2 Anaesthesia Technique 55%
3 Applied Physiology 57%
4 Chronic Pain 66%
5 Perioperative Medicine 19%
6 Perioperative Medicine 45%
7 Obstetric Anaesthesia 28%
8 Neurosurgical Anaesthesia 45%
9 Pharmacological 686%
10 Anaesthetic Technique 46%
11 Pharmacology 47%
12 Pharmacology 56%
13 Anaesthetic Technique 70%
14 Medicine 36%
15 Pre-anaesthetic assessment 45%
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Question 1: Discuss the risks and benefits associated with intermittent positive pressure
ventilation through proseal ® laryngeal mask airway for a patient undergoing
laparoscopic cholecystectomy.

Most candidates could list the main risks and benefits. A good answer required a
comprehensive list of risks and benefits specifically for a proseal mask in this
procedure. Most candidates realised the proseal provided a more effective seal with
IPPV but the pressure limits quoted varied from 20-50 cmH2O. Most also
acknowledged the presence of an oesophageal lumen but many did not mention passing
an orogastric tube to empty the stomach. Other common errors included describing the
Trendelenburg position for laparoscopic cholecystectomy rather than the reverse
Trendelenburg, which is usual. Many candidates suggested that the proseal is useful if
the patient is a known difficult intubation. This is considered inappropriate for an
elective case where a definitive airway could be established by other means. Many
candidates were not clear about the use of muscle relaxants. Many stated that muscle
relaxants would not be required with a proseal however it was unclear whether they
were suggesting the patient breathes spontaneously or have their ventilation suppressed
by other means. Overall this question was poorly answered considering it asked about
a common airway device in a common procedure.

Question 2: Describe your technique for performing a continuous paravertebral block in a 50

year old man with fractured 5th – 10th left ribs. Include possible complications and
relevant anatomy.

Few candidates scored very high marks and the better answers had a logical layout with
some good anatomical diagrams. Legible handwriting is always appreciated. Many
candidates’ description of the block were inaccurate and incorrect. The optimum
insertion site was often too low and too wide. Better candidates indicated the depth
they would expect to strike the lateral process. Loss of resistance is an imprecise sign
and better candidates noted this and then indicated a depth of advancement beyond the
lateral process. The technique and anatomy is well described on the NYSORA.com
website. Some confused the interpleural block with the paravertebral block. Some
wasted time writing on thoracic epidurals and thoractomoy. Pneumothorax was
mentioned by most but is relatively rare. Many did not identify block failure as a
problem.

Question 3: Describe the cardiovascular changes which occur during clamping and
unclamping of the supra-renal aorta during repair of an abdominal aortic
aneurysm in a patient with normal ventricular function and outline your strategies
to maintain critical organ perfusion during these times.

Many candidates gave a good account of the cardiovascular changes which occur with
cross clamping of the supra-renal aorta. Unfortunately, a large number of answers were
incomplete in the other areas of the question ie. description of the cardiovascular
changes which occur with aortic unclamping and description of strategies for
maintaining critical organ perfusion during clamping and during unclamping. Such
incomplete answers generally scored poorly. Pharmacological and non-pharmacological
therapies which may have efficacy in protecting organ function but which do not
influence perfusion were not relevant.

Question 4: Describe the features and management of phantom limb pain.

Few answers were of a high standard despite phantom limb pain being a common
postoperative problem. There was confusion between phantom limb pain, phantom
sensations and stump pain. Some candidates did not appreciate this was a type of
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neuropathic pain and therefore did not select the correct treatment. Some candidates
confused phantom limb pain with CRPS.

Question 5: Describe and justify an appropriate strategy for the use of low molecular weight
heparin in a patient undergoing knee replacement surgery with an epidural block.

The pass rate for this question was poor. Since there is little in the way of data on the
subject of neuraxial anaesthesia and anticoagulation, knowledge of the expert
consensus view is vital to the safe management of this technique in this common
setting. Candidates should not use unexplained or uninterpretable abbreviations.
Writing must be legible. Answers with an identifiable structure are easier to follow and
will aid candidates in providing more comprehensive answers. Elements of strategy
were rarely directly linked to justifications as the question asked.

Good answers reflected an awareness of the issues raised by the ASRA consensus
statement relating to this topic. These included:

• How strategy may be altered if a patient has used or is likely to be given other drugs
that affect haemostasis intra and post operatively
• Nomination of a drug, dosage, timing in relation to epidural insertion, dosage
interval
• Nomination of the type and concentration of epidural solution used to enhance the
early detection of epidural haematoma
• Strategy for catheter removal
• The critical place of staff education in post procedural monitoring (frequency and
duration and nature), specifically with the aim of early detection of signs associated
with epidural haematoma
• How the management plan might be altered if epidural insertion is traumatic
• The place of monitoring anti-Xa levels

Question 6: List and explain the typical electrolyte abnormalities of chronic renal failure.

This question required factual knowledge all too often missing in candidates responses.
• in many responses the only correct electrolyte abnormality correctly identified was
hyperkalaemia
• explanations were even more deficient
• confusion regarding serum sodium was widespread
• confusion regarding serum calcium and the role of parathyroid hormone was
widespread
• no marks were awarded for descriptions of blood chemistry abnormalities other than
electrolytes

Question 7: While performing an epidural for labour analgesia in an otherwise healthy

primigravida in first stage you inadvertently cause a dural puncture with the
Touhy needle. Describe and justify your management of this complication.

This question asked the complication of epidural (dural puncture) specifically in a

primagravida in the first stage of labour. Candidates were asked to describe and justify
the management.

Many answers gave a list of options with little clinical interface, some made a choice
from the options and fewer justified their choice.

Good answers divided the question into

a) the management (with options, choices and justification) of the immediate problem
- provision of analgesia in labour, and
b) the nature and treatment of a post dural puncture headache if it occurs.
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Some answers did not mention this significant after effect of a dural puncture at all, or
gave scant emphasis to this debilitating problem. Much time was spent in detailed
issues with regard to the safe use of an intrathecal catheter, but few gave any insight
into the practical issues of such management in private practice (with no onsite medical
staff) or a busy hospital setting which may preclude this as an ongoing alternative.
Emphasis on explanation to the patient and ongoing communication and review was
laudable. A detailed description of the performance of an epidural blood patch was not
required.

Question 8: Describe the principles of cerebral protection in a patient with an isolated closed
head injury.

Most candidates did not provide a systematic approach towards maintaining adequate
cerebral oxygenation. They tended to provide a discussion just around cerebral
perfusion pressure. Several candidates gave an account of anaesthesia for head injured
patients which was not required. Surgical approach to reduce intracranial pressure was
mentioned by very few candidates.

Question 9: Nitrous oxide should not be used routinely as a component of general anaesthesia.
Discuss.

Most candidates were able to supply a list of good and bad features of Nitrous Oxide
and this formed a suitable introduction to the question. Better answers commented on
the critical importance of the agent’s features, and discussed the importance of newer
evidence as to nausea, immune suppression, and outcome to give a balance as to which
features should be regarded as most important to continue to use N20 in general
anaesthesia.

Candidates are reminded this is a clinically oriented exam, so that presentation of

pharmacological facts alone is insufficient when the question asks for a discussion.

Question 10: Discuss in detail the technique of rapid sequence induction with cricoid pressure in
a child. Include the reasons for your choice of relaxant.

Discussion of rapid sequence induction and cricoid pressure was generally well
handled. However, candidates who did not mention the specific issues relevant to
children did not pass the question. Justification of choice of muscle relaxant was
adequate in most answers.

Question 11: Critically evaluate the use of Beta blockers in the perioperative period to prevent
myocardial infarction.

A number of candidates failed to identify which patient groups should receive this
treatment. Many failed to assess the evidence for the use of these drugs despite the
question requiring candidates to critically evaluate their use.

Question 12: Discuss the role of ketamine in current anaesthesia practice.

Ketamine is a very popular drug at the moment and a high standard of answer was
expected and generally most answers were of adequate standard.

A good answer required the candidate to apply part one knowledge to the current
clinical climate. Candidates must remember to read the question and legible hand
writing is useful.

Question 13: List the risks associated with the placement of a central venous catheter? Discuss
the ways in which these risks may be modified.
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This question was generally well answered. Candidates had a good understanding
of the common risks (and the appropriate risk mitigation strategies) associated with the
placement of central lines. Good candidates recognised the risk of needlestick injury to
the operator and the risk of anaphylaxis with antibiotic or Chlorhexidine impregnated
lines.

Question 14: Critically evaluate the role of recombinant factor VIIa in blood loss requiring
massive transfusion in the trauma patient.

In general this question was poorly answered, despite many candidates knowing a lot of
information on the topic of Recombinant Factor 7a. The information was not organised
into a form that answered the question. The question as written asked for a critical
evaluation of the role of RF7a in major blood loss associated with trauma which should
involve a weighing of Pro’s and Con’s on the topic and a summary opinion on the role
of the drug.
Many candidates presented details that did not specifically answer the question as set,
such as: a description of RF7a, with detailed facts on the origin and makeup of the drug
or a full description of the coagulation pathway.

A suitable method to answer this question would have been:

A listing of the Pro argument – points that could be discussed include : (but did not
necessarily have to completely include) were:
• A good theoretical basis for it’s usage
• Encouraging results from Case Reports
• It is quick and easy to use, with no storage problems.
• It may avoid many of the problems of continuing transfusion, such as
hypothermia, acid/base disturbance, volume overload etc.
• It does not carry a risk of infectious diseases transmission
• It may be of use in Jehovah Witness patients
1. A Listing of Con Arguments
• No evidence for it’s use
• Possibly a publication bias, as there is a tendency not to report bad outcomes.
• Off Licence product - problems of consent, paediatric use? etc
• Cost
• Availability.
• Agreement on usage between interested parties such as Haematology,
Anaesthesia.
• Side Effects?
• No real agreed protocol for it’s use
2. An Appreciation of the Practical Issues Involved, such as:

• The importance of other methods of haemorrhage control such as surgical

methods, ? role of drug therapy such as aprotonin etc
• A rational approach to transfusing blood and blood products to allow RF 7a a
“substrate” to work on.
• Importance of improving general aspects of coagulation such as temperature
control, acid/base status.

3. A summary Opinion on the place of RF7a

Question 15: Discuss the usefulness of the ASA grading as a measure of perioperative risk.

The ASA classification was grossly incorrectly reproduced in many cases. A

comprehensive discussion could be achieved without reproducing the classification.
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The role of the “E” (emergency) modification was infrequently discussed.
Comments relating to anaesthetists’ remuneration and increased ASA grading were not
appropriate. Good answers discussed “usefulness” comprehensively by reviewing both
positive and negative aspects.

MEDICAL CLINICAL VIVAS

80% percent of candidates passed this section.

Although there was a good overall pass rate, there was a wide range of performance in this section of
the examination. Examiners attempt to set a task for candidates that can be completed in the given time
frame. Candidates who performed poorly in this section did not have a systematic approach to a
focused history and examination or frequently missed vital information because they did not listen to
the patient’s answers to their questions. This is an important section of the examination as it is the only
opportunity examiners get to see candidates interact with patients.

Marks are allocated for:

• Interviewing skills i.e. obtaining relevant and accurate information, listening to the patient and
responding to their non-verbal cues

• Examination technique i.e. follows efficient, logical sequence, informs patient

• Professionalism i.e. shows respect, compassion to patient and is sensitive to patient comfort,
modesty

• Organisation, efficiency i.e. prioritises, is succinct and timely

ANAESTHESIA VIVAS

92% of candidates passed this section.

The aim of this section of the examination is to assess the candidates’ ability to:

• Apply principles of acceptable, safe practice

• Apply clinical experience with a knowledge of potential pitfalls

• Interpret complex situations

• Demonstrate clinical judgement

• Plan and prioritise clinical actions and anticipate sequelae

Some scenarios may contain co-morbidities or diseases that some candidates have not had experience
with e.g. cystic fibrosis but which is reasonably considered part of the curriculum i.e. chronic
respiratory disease (module 5). It is expected that a consultant anaesthetist will have a systematic way
of thinking about this content which achieves the desired safe anaesthesia practice.

The introductory scenarios and initial questions were as follows:

1. A 3yr old girl presents for resection of a Wilms tumour.

She has no other significant medical history and no allergies. She weighs 15 kg.

She has been receiving vincristine and doxorubicin prior to her planned nephrectomy.

How would you assess the potential side effects of this chemotherapy?
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Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Deal with anxious child and family for major surgery.
• Describe the impact of preoperative chemotherapy on anaesthesia management.
• List the DD and describe the management of intraoperative hypotension.
• Discuss major blood loss and perioperative fluid management in children, including
allowable blood loss, transfusion thresholds etc

2. You are requested to anaesthetize a woman who is 32 weeks pregnant with a suspect acute
appendicitis. She is febrile 38.2C, tachycardic, tachypnea and looks unwell. The surgeon
plans to perform a laparoscopic appendenctomy.

What are the anaesthetic implications of the physiologic changes of pregnancy in this
lady?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Discuss the induction and management of general anaesthesia in pregnancy
• Discuss the maintenance of uteroplacental flow and foetal monitoring.
• Manage foetal bradycardia intraoperatively
• Describe neonatal resuscitation

3. 63 year old male presents with headache, sweating, chest pain, palpatations. BP 220/120 and
pulse of 65. Past history of hypertension controlled on enalapril, myocardial infarction 3 yrs
ago. Smokes 20 cigarettes/day. A left adrenal phaeochromocytoma is confirmed by 24 hour
urine catecholamine levels and MRI. The patient is scheduled for laparoscopic adrenalectomy
in 2 weeks.

What are the management goals for this patient before they come to theatre?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Discuss the perioperative management of Phaeochromocytoma.
• Describe and manage the problems with laparoscopic surgery
• Discuss the DD and management of tension pneumothorax intra op

4. A 35 year old female with metastatic breast cancer is admitted with a pathological femur
fracture and is booked for a femoral nail. She is significantly short of breath. Her last course
of chemo was 4 months ago, and she is currently on various ‘alternative therapies’ under the
guidance of her naturopath.

You assess her the night before her scheduled surgery.

What specific issues will you focus on at the pre-operative visit?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Describe the preoperative assessment and management of dyspnoea
• Discuss the implications of Alternative therapies for anaesthesia
• Describe the DD and management of Fat/Tumour embolism

5. A 57 year old man presented to the emergency department with 4 hour onset of severe back
pain, leg weakness and faecal incontinence.

What is the differential diagnosis for the cause of his symptoms?

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Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Discuss the diagnosis and management of a spontaneous epidural haematoma
• Describe the perioperative management of anticoagulation in emergency spinal cord
decompression.
• Discuss the risks of ceasing anticoagulation in this patient.
• Can discuss the issues anaesthesia for this patient including maintenance of spinal cord
perfusion in this context

6. You are called to the Emergency Department to assist the medical staff there who are
struggling to analgese a 54 year old male involved in a pedestrian accident leaving him with a
compound fracture of his left tibia and fibula. He has been given 45mg intravenous morphine
and as you approach the ED he is still screaming in pain.

What are your immediate plans?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Discuss the Anaesthetic management of patient on naltrexone
• Manage the issues for Alcoholism and anaesthesia
• Diagnose and manage compartment syndrome in a patient with regional anaesthesia

7. A 55 year old man presents to the Emergency Department following a 1 metre fall from a
ladder whilst painting his house.

He is complaining of pain in his lower neck and his right wrist.

He has a fractured right radius which the ED staff would like reduced under an intravenous
regional anaesthetic technique. He was diagnosed with Ankylosing Spondylitis at the age of
35.

His current medications include prednisone 10mg, methotrexate and diclofenac. A lateral spine
x-ray was taken because of the pain.

How does this x ray affect your preoperative assessment?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Plan anaesthesia for C spine stabilization and fusion including intubation issues
• Discuss the issues for prone surgery positioning especially in patient with unstable C spine
• Discuss the role of spinal cord monitoring
• Discuss a plan for safe extubation of this patient

8. You are on call.It is 2200 hrs.

A surgeon calls and advises that he has a patient on the ward who has just been transferred
from a local nursing home. He feels she needs urgent laparotomy. He tells you she’s not in
good shape and he’s worried she may have dead gut. He has a theatre organized for a half hour
from now.

What would you ask the surgeon?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Interpret ABG’s (severe metabolic acidosis) and manage fluid resuscitation
• Discuss ethical issues around operation or not.
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• Describe the management of rapid AF.

9. You are the retrieval anaesthetist at a factory where a 30 yr old man is trapped by his partially
severed and obviously fractured Right forearm under heavy machinery. He is screaming in
pain and continues to bleed freely from his arm wound. His head is just under the machine
giving you no access to his airway other than to deliver oxygen via nasal cannula. Amputation
may be the only option to free him.

How will you manage this situation?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Describe a safe plan for Anaesthesia/analgesia for safe extrication from machine
• Discuss issue involved in anaesthesia for reimplantation of forearm
• Describe the safe use/risks/benefits of Continuous brachial plexus block.

10. A 2 year-old presents for bilateral ueteric reimplantation, she weighs 14 kg and is otherwise
well. Her parents are very anxious about pain post operatively.

The parents ask what the options are for post-operative pain management for this child
for this procedure. Explain their risks and benefits.

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Describe a sensitive approach to parental presence or absence at induction
• Describe the safe use of caudals
• Detect and manage LA toxicity
• Describe the use of desflurane and a circle system in children

11. You are telephoned and asked to urgently attend the emergency department to assist with the
management of a 25 year old woman who has been brought in following a high speed motor
vehicle accident. She is confused and hypotensive. Her husband, who has suffered minor
injuries in the crash, has informed staff that his wife is 28 weeks pregnant with their first child.

On arrival in the resuscitation room how will you conduct you initial assessment?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Conduct the initial assessment and resuscitation of pregnant trauma patient
• Discuss management of hypotension, utero-placental blood flow and foetal protection in off
the floor/out of theatre environment
• Describe a safe anaesthesia plan for laparotomy/LSCS
• Manage major blood loss and discuss the use of cell saver in this situation

12. A 47 year old female is booked on your next morning list for resection of liver tumour. The
biopsy reveals carcinoid tumour.

What issues will you look for?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Discuss the Perioperative Management of carcinoid
• Discuss the perioperative management of patient for major liver resection
• Discuss the management of a patient with tricuspid incompetence in this context including
appropriate cardiovascular monitoring. CVP vs Swan vs TOE

13. A 65 yr old lady requires surgery for revision hip arthroplasty. She has longstanding atrial
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fibrillation and a history of transient ischaemic attacks prior to being put on
warfarin therapy. Currently she is on warfarin 3 mg daily. You are consulted one week prior to
the planned surgery.

What further details of her history are relevant to planning your anaesthetic?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Identify the issues with respect to re-do THR in this patient
• Discuss the perioperative management of anticoagulant therapy in the context of atrial
fibrillation and potential blood loss
• Describe appropriate perioperative blood conservation strategies
• Describe the management of a Post-operative nerve palsy

14. A 52 year old female presents for coiling of a left anterior communicating artery aneurysm.
She is a smoker with a known history of hypertension and ischaemic heart disease.

BP 180/110
HR 100
ECG: ST elevation, T wave inversion, QT prolongation.

What are the issues in the anaesthetic management of this patient?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Discuss the issues of out-of-theatre/off the floor neurovascular procedures
• Conduct safe anaesthesia in a patient with ischaemic heart disease
• Demonstrate an understanding of the effects of rebleeding

15. A 26 year old male presents for laparotomy and bowel resection for Crohn’s disease. The
patient takes prednisone 20 mg and oxycontin 120 mgs daily. He has no other co-morbidities.
The patient requests an epidural for post-operative analgesia.

What are the advantages and disadvantages of an epidural for post-operative analgesia
in this patient ?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Discuss the perioperative management of patient on steroids
• Discuss the advantages and disadvantages of an Epidural for post op analgesia
• Manage epidural problems/failure
• Describe the risk management required for an institutional policy on minimising epidural
risk/consequences of epidural haematoma and infection

16. You are the anaesthetist working on a retrieval team in a major metropolitan hospital. You take
a call from a GP in a remote town 60 min away by helicopter.

She requests retrieval of an 18 year old male who has been trapped in a house fire. The patient
is estimated to have 50% burns, including airway and facial burns. The GP states that the
patient has stridor.

What further information do you want from the GP?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Describe the safe management of airway and intubation issues to GP and issues for safe
retrieval of patient
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• Describe the other acute management of 50%burns: analgesia and fluids
• Discuss the management of change of dressings in the ward some time after acute episode

17. A 77 year old from a nursing home presents with an acute abdomen; the surgeon are concerned
she has a perforated viscus and want to perform a laparotomy.

She has a past history of

- PVD [fem-pop bypass] and CVD [mild CVA]
- COAD and long history of smoking
- Episodes of heart failure
- Diverticular disease
- R renal staghorn calculus
- osteoarthritis

What are your priorities in perioperative assessment?

Aims of the Viva:

The aim of this viva is to ensure that candidates can:
• Describe appropriate Preoperative resuscitation
• Discuss a safe choice for anaesthesia
• Discuss the possible causes for inadequate reversal in this patient including the role of
monitoring neuromuscular response
• Formulate a plan for situation of no available ICU bed

18. You are the consultant anaesthetist on call . The hospital anaesthesia registrar is an Emergency
Medicine Trainee with 7 months anaesthesia experience. He rings you for advice regarding
the induction of anaesthesia for the following case. An intoxicated 18 year old male has had
his right leg run over after a push bike accident. He has sustained compound fractures to both
tibia and fibula with significant soft tissue loss. There are no other injuries. He is
cardiovascularly stable. He has no apparent head injury and his cervical spine has been cleared.
He refuses any regional techniques. His initial orthopaedic surgery will take 2 hours.

What advice do you give the registrar regarding the induction of anaesthesia?

Aims of the Viva:

The aim of this viva is to ensure that candidates can
• Describe a safe plan for anaesthesia in this patient for prolonged initial surgery
• Discuss the safe use of tourniquet
• Discuss principles of maintaining graft perfusion perioperatively
• Describe how they would teach trainee RSI and safely manage failed intubation

M.A. JOSEPH
CHAIRMAN
FINAL EXAMINATION

DISTRIBUTION College Council Supervisors of Training

Regional Education Officers Panel of Examiners
Registered Trainees