September 2019

Question 1

A 74- year old man is going to have a total hip replacement. On preoperative assessment is found to have a pan-systolic murmur and is being investigated for aortic stenosis.

a) List 3 worrying symptoms of aortic stenosis that you should screen for in your preoperative assessment. (3 marks)

b) What 3 measurements are used in echo and what values would be deemed as severe aortic stenosis (6 marks)

c) Describe the pathophysiology of aortic stenosis on the left ventricle (5 marks)

It is found to be mild aortic stenosis on echocardiography so is scheduled for his total hip replacment.

d) Name 4 key haemodynamic goals you would aim for perioperatively (4 marks)

e) Name 2 treatment options that are available for severe aortic stenosis (2 marks)

Question 2

A 63 year old man has had an elective laparotomy and removal of intestinal tumour in an enhanced recovery setting. He has had a single shot spinal with an intrathecal (IT) opioid.

a) Name 3 other methods that could be used to control postoperative pain in this patient? (3 marks)

b) Describe the mechanism of action of IT opioids. (5 marks)

c) List 6 side effects of IT opioids. (6 marks)

d) Name 6 factors may increase the risk of postoperative respiratory depression following administration of IT opioids? (6 marks)

Question 3

A 24 year old woman is having a laparoscopic appendicectomy. Soon after teh start of the anaesthetic you start to suspect possible malignant hyperthermia.

a) Define malignant hyperthermia (MH) (2 marks)

b) Name 2 possible triggers for MH (2 marks)

c) Name 4 different signs that would make you suspect MH (4 marks)

d) Outline how you would manage this case (7 marks)

e) What blood test would you measure serially (1 mark)

The patient recovers and you are following the patient up

f) Where in the UK would you refer the patient for further testing (1 mark)

g) What tests are done to confirm MH (3 marks)

Question 4

A 66-year-old man is listed for carotid endarterectomy (CEA) 10 days after suffering a cerebrovascular accident

a) Name 4 advantages of performing the procedure under regional anaesthesia (4 marks)

b) Name 4 disadvantages of performing the procedure under regional anaesthesia (4 marks)

c) Name 3 local or regional anaesthetic techniques tha may be used? (3 marks)

d) Why is cardiovascular instability common during CEA (3 marks)

e) Following this procedure name 6 specific postoperative complications that may occur? (6 marks)

Question 5

A 65 year old patient on ICU has had a percutaneous tracheostomy inserted 3 days ago you are called to the ICU overnight as there is concern over the tracheostomy.

a) Name 3 indications for tracheostomy placement (3 marks)

b) Describe 3 different types of tracheostomy (3 marks)

c) Name four immediate complications of tracheostomy insertion (4 marks)

On initial assessment there is concern that the tracheostomy may be blocked

d) How do you check if a tracheostomy is patent (3 marks)

e) Outline your immediate management of a blocked tracheostomy (3 marks)

f) The patient then develops worsening hypoxia what you do? (4 marks)

Question 6

a) In a patient with diabetes mellitus, name 4 clinical features that may indicate autonomic involvement? (4 marks)

b) Name 3 other microvascular and 3 macrovascular complications of diabetes mellitus (6 marks)

c) What is the recommended upper limit of HbA1C for elective surgery (1 mark)

d) What is the association of Anaesthetists of Great Britain and Ireland (AAGBI) guidance for perioperative blood glucose monitoring in diabetic patients (3 marks)

e) List 3 classes of oral hypoglycaemic agents that are available (3 marks) and describe the mechanism of action of each (3 marks)

Question 7

You are assessing a five year old for an elective ENT case. The parents describe how she has had a recent cough.

a) Name 2 social factors that may preclude paediatric daycase surgery (2 marks)

b) List 3 reasons why might you proceed with surgery ( 3 marks)

c) Outline 6 features in the history that you gather from the patients family that might cause a cancellation (6 marks)

d) Outline 4 features in your examination that might cause a cancellation ( 4 marks)

You discuss with a consultant and decide to go ahead with the theatre case. After securing IV access and on insertion of the airway the patient goes into laryngospasm

e) Outline how would you manage this (give doses of drugs if indicated)? (5 marks)

Question 8

This question regards cardioplegia solution

a) Name 3 reasons cardioplegia is used in cardiac surgery? (3 marks)

b) What is the typical composition of cardioplegia solution? (4 marks)

c) Name 5 physiological effects of cardioplegia solution on the myocardium? (5 marks)

d) Name 2 routes by cardioplegia solution be administered? (2 marks)

e) Name 6 possible complications of cardioplegia solution administration? (6 marks)

Question 9

A 33 year old woman who has myasthenia gravis is due to have a thymectomy. You have been asked to see her in preoperative assessment.

a) What are the clinical features of myasthenia gravis? (2 marks)

b) What is the pathophysiology of myasthenia gravis? (2 marks)

c) Name 3 treatment options available for myasthenia gravis? (3 marks)

d) What scorings system is used to grade for myasthenia gravis (1 mark)

e) Name 2 factors correlate with need for prolonged ventilation following a thymectomy (2 marks)

f) What would preoperative assessment focus on and what advice might you give to the patient about their medications? (5 marks)

g) How do patients with myasthenia gravis respond to depolarising and non-depolarising muscle relaxants ?(2 marks)

h) What would your postoperative plan for this patient be? (3 marks)

Question 10

The recent Mothers and Babies: reducing risk through Audit and Confidential Enquiries across the UK (MBRRACE-UK) report was released in 2018.

a) What are the two commonest causes of direct maternal death (occurring within 42 days of the end pregnancy) in the latest Mothers and Babies: reducing risk through Audits and Confidential Enquiries

across the UK (MBRRACE-UK) report 2018? (2 marks)

b) What is the leading cause of indirect death in the latest MBRRACE-UK report 2018?(1 mark)

c) Amniotic fluid embolism (AFE) is a direct cause of maternal mortality. How does AFE present clinically? (8 marks)

d) What are the possible obstetric (3 marks) and non-obstetric (4 marks) differential diagnoses of AFE?

e) State two possible theories about the pathophysiology of AFE (2 marks)

Question 11

A 74-year-old man with osteoarthritis, known CVD and AF who is on rivaroxaban is booked in for a revision hip replacement. He is found to be anaemic in preoperative assessment.

a) What are the 3 pillars of patient blood management? (3 marks)

b) What strategies can be used to treat this patient’s anaemia preoperatively? (4 marks)

c) How long before the operation should the patient be assessed? (1 mark)

d) Name 4 intraoperative changes would you make (4 marks)?

e) The patient starts to bleed, how would 1L blood loss differ physiologically to a whole blood volume loss (3 marks)?

f) What point of care testing do you know of? (1 mark)

g) What other laboratory targets would you use to manage his bleeding? (4 marks)

Question 12

a) List the implications of an inadvertent wrong-sided peripheral neve block (5 marks)

b) Summarise the recommendations of the “Stop before you block” campaign (4 marks)

c) List the factors that have been identified as contributing to a wrong side block being performed (5 marks)

d) Define the term “never event” (2 marks) and list four drug related never events (4 marks)