Author: muggerb

FCAI SAQ Past Papers Autumn 2011

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1.Young mechanic, petrol tank explodes in his closed garage.  This results in extensive burns over chest, face and arms. What problems will take place in the next 48 hrs, and what management plan you would formulate in the light of these problems ?

 

2. What are the reasons behind delivering a “hypoxic mixture” to a patient under anaesthesia? How can this be prevented ?

 

3. a) What are the features that would suggest PDPH ?

b) What investigations would confirm your diagnoses ?
c) How would you manage this in general ?
d) Describe in details how you would perform “Blood Patch”

4. a) What types of intraoperative nereve injuries can occur ?
b) What are the mechanism ?
c) How can they be prevented ?

5. Explain the rationale behind using antidepressants and anticonvulsants in managing chronic pain ?

6. Young known Type 1 diabetic comes in labour at 34 weeks.  She is also in DKA.
a) Describe your management

b) Provisions of caesarean section ?

7. Acute pancreatitis.  Causes? Clinical features? Role of imaging? Indications of ITU? Complications?

8. Child in status epilepticus (you are the most senior person on the floor)
a) Define status epilepticus?

b) Most common causes in this age group?

c) Management?

9. MRI.  Briefly describe physical principles? Benefits over CT? Anaesthetic provisions?

10. Non Invasive ventilaion.  Definition. Methods?? Indications? Contraindications?

Myotonic Dystrophy

Multisystem disease with autosomal dominant trait

Presentation in 15-35 year olds

Features:

  • Myotonia – increased muscle tone after contraction, execrbated by cold, stress
  • Cardiomyopathy + conduction defects
  • Respiratory muscle weakness, poor central control of respiration ->leading to respiratory failure
  • Central and obstructive sleep apneoa
  • Cognitive defects
  • weakness in forearm and calf muscles
  • Thyroid and adrenal impairment
  • Poor bulbar function + Delayed gastric emptying
  • Sensitivity to IV anaesthetic agents, opioids, NMBA

 

 

Ventilator Associated Pneumonia (VAP)

Define: Pneumonia as defined by a new infiltrate on chest x-ray plus two or more other factors after mechanical ventilation. These factors include temperature of >38 °C or <36 °C, a white blood cell count of >12 × 109/ml, purulent secretions from the airways in the lung, and/or reduction in gas exchange.

 

Risk factors for MDR pathogens:

  • Hospitalisation > 5 days
  • Antibiotic in preceding 90 days
  • Immunosuppression

Pathogens: Pseudomonas, Klebsiella, Acinetobacter, MRSA

Pathogenesis:

  • Aspiration
  • Leakage around cuff
  • Inhalation
  • Direct incubation
  • Haematogenous spread

Diagnosis:

  • Radiology showing new/progressive lung infiltrate
  • Temperature>38 degree celsius
  • WBC increases/decreased
  • Purulent secretions
  • Blood culture
  • Thoracocentesis of pleural effusion
  • ETT aspirate
  • BAL
  • PSB

 

Treatment

..Even if tracheal colonisation but no sign of systemic infection

Empiric antiobiotic:

  • Monotherapy
    • Nonpseudomonal ceftriaxone OR
    • Ampicillin/sulbactam OR
    • Fluoroquinolone
  • Combination therapy
    • Aminoglycoside OR
    • Antipseudomonal fluoroquinolone PLUS
    • Antipseudomonal penicillin (ceftazidime, cefepime) OR
    • Carbapenem (Meropenem)

 

Evaluate response, followed by trace cultures to narrow within 7 days

 

*Prevention*

Modifiable risk factors:

General

  • infection control
  • surveillance of ICU infection

VAP

  • Avoid ETT/IPPV
  • Aspirate secretions
  • Semirecumbent
  • Cleaning and sterilisation of equipment
  • ?SDD

 

FRCA Past Paper Autumn 2015 SAQ and Examiners’ Report

SAQ

Question 1
a) Outline the production and circulation of cerebrospinal fluid (CSF) and how intracranial pressure affects production and absorption. (5 marks)
b) How does the biochemistry of CSF differ from plasma? (4 marks)
c) List the indications for lumbar puncture. (6 marks)
d) Which factors predispose to the development of a post-dural puncture headache after lumbar puncture? (5 marks)
Question 2
You are asked to sedate a frightened adult patient for insertion of dental implants in an outpatient dental chair.
a) Complete the table in your answer booklet with the four levels of sedation in the American Society of Anesthesiologists (ASA) continuum of sedation (top row) and the clinical features seen at each level (columns below). (8 marks)
b) Outline drugs that may be used and their methods of administration, when providing sedation for this patient (4 marks)
c) What are the best practice principles for providing safe sedation to this patient? (8 marks)
Question 3
A 25 year-old woman who is 37 weeks pregnant and known to have pre-eclampsia is admitted to your labour ward with a blood pressure of 160/110mmHg on several readings.
a) What is the definition of pre-eclampsia (1 mark) and which related symptoms should pregnant women be told to report immediately? (2 marks)
b) How should this patient be managed following admission to your labour ward? (12 marks)
c) What changes would you make to your usual general anaesthetic technique for a pregnant woman, if this woman needed a general anaesthetic for caesarean section? (5 marks)
Question 4
a) How should you manage the perioperative opioid requirements of a patient who is having elective surgery and who takes regular opioids for non-malignant pain? (8 marks)
b) Give the conversion factors for oral tramadol, codeine and oxycodone to the equianalgesic oral morphine dose. (3 marks)
c) What are the perioperative implications of an existing spinal cord stimulator? (6 marks)
d) What additional perioperative precautions should be taken if the patient has an intrathecal drug delivery system fitted? (3 marks)
Question 5
a) Which investigations are specifically indicated in the preoperative assessment of a patient presenting for thyroidectomy for treated thyrotoxicosis? (5 marks)
b) What particular issues must the anaesthetist consider during the induction, maintenance and extubation phases of anaesthesia for a
euthyroid patient having a total thyroidectomy? (11 marks)
c) Describe the specific post-operative problems that may be associated with this operation. (4 marks)
Question 6
A 19 year-old patient has suffered a complete transection of the spinal cord at the first thoracic vertebral level due to a fall, but has no other injuries.
a) Outline the sequence of neurological effects that may develop in the first three months following injury. (6 marks)
b) Which disturbances of the cardiovascular, respiratory and gastrointestinal systems may subsequently occur? (8 marks)
c) When and why may suxamethonium be contraindicated in this patient? (2 marks)
d) Give the advantages of a regional anaesthetic technique for a patient having elective lower limb surgery 2 years after a high thoracic spine transection. (4 marks)
Question 7
a) Which specific nerves must be blocked to achieve effective local anaesthesia for shoulder surgery? (6 marks)
b) What are the possible neurological complications of an interscalene block? (6 marks)
c) Outline the measures available to reduce all types of neurological damage during shoulder surgery. (8 marks)
Question 8
a) List the effects of cigarette smoking on the cardiovascular system and on oxygen delivery, outlining the pathophysiological mechanisms involved. (12 marks)
b) List the effects of cigarette smoking on the respiratory system, other than those you have outlined above, that are relevant to the conduct of general anaesthesia. (4 marks)
c) What advice would you give a smoker 24 hours before a scheduled procedure under general anaesthesia and why? (4 marks)
Question 9
a) What are the central and peripheral neurological complications of coronary artery bypass surgery? (7 marks)
b) What are the risk factors for central neurological complications? (6 marks)
c) How can the incidence of central neurological complications be reduced? (7 marks)
Question 10
You are called to the Emergency Department to see a 2 year-old child who presents with a 4-hour history of high temperature and drowsiness. On examination there is prolonged capillary refill time and a non-
blanching rash. A presumptive diagnosis of meningococcal septicaemia is made.
a) What are the normal weight, pulse rate, mean arterial blood pressure and capillary refill time for a child of this age? (4 marks)
b) Define appropriate resuscitation goals for this child (2 marks) and outline the management in the first 15 minutes after presentation. (7
marks)
c) After 15 minutes, the child remains shocked and is unresponsive to fluid. What is the most likely pathophysiological derangement in this child’s circulation (2 marks) and what are the important further
treatment options? (5 marks)
Question 11

A 26 year-old patient with stage 4B Hodgkin’s disease (spread to lymph nodes and other organs) requires an open splenectomy.

a) List the specific factors that are of importance when planning your anaesthetic management. (10 marks)

b)Outline the options for providing postoperative analgesia for this patient and give a possible disadvantage of each. (6 marks)
c) Which vaccinations should this patient receive and what is the optimal timing of these? (4 marks)
Question 12
a) What is meant by the term ventilator associated pneumonia (VAP)? (3 marks)
b) List the factors that increase the risk of the development of VAP. (10 marks)
c) What measures may reduce the risk of development of VAP? (7 marks)
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Examiners’ Report

The SAQ paper is written to contain questions with varying levels of difficulty;
2 questions adjudged to be difficult (pass mark 10-11/20)
8 questions adjudged to be moderately difficult (pass mark 12-13/20)
2 questions adjudged to be easy (pass mark 14/20 or more)
The overall pass rate for this paper was 49.5%
Question 1: CSF Physiology and lumbar puncture
Pass rate 50.9%
This was one of the easy questions in the paper so we would have expected the pass rate to have been a little higher. Some candidates did not answer the question asked in part (d) so lost marks.
Question 2: Dental Sedation
Pass rate 62.1%
This is an important topic and was generally well answered despite some confusion caused by the inclusion of a table that required completion. It had the highest pass rate of all the questions.
Question 3: Pre-eclampsia and severe pre-eclampsia
Pass rate 16.1%
The poor pass rate for this important subject is of concern as pre-eclampsia is a common condition that all candidates should have encountered. Severe pre-eclampsia is an emergency for which the principles of management should be known. Surprisingly few candidates could give an acceptable definition of pre-eclampsia and even fewer knew that control of systolic hypertension is of prime importance in preventing intracerebral bleeding in women with severe pre-eclampsia.
Again, as mentioned above, failure to read the question in part (c) meant that some candidates lost marks by not answering what was asked.
Question 4: Chronic opioid use and analgesia conversion
Pass rate 25.0%
It was anticipated that candidates would find this question difficult and this proved to be the case. Some candidates lost marks because they wrote exclusively about the drugs they would use to manage opioid requirements for this patient but did not mention more general measures such as involvement of the pain team. Very few candidates gave any information about management of transdermal pain patches in the peri-operative period. There are differing opinions as to whether patches should
be continued, particularly in the case of buprenorphine, but candidates were able to gain marks for either opinion provided they showed that they were aware of the potential problems of altered absorption and partial antagonism.
Question 5: Thyroidectomy
Pass rate 31.9%
The first and last parts of this question on pre-operative tests and postoperative considerations were well answered. The majority of the marks were lost in the middle section on issues to be aware of during anaesthesia for elective thyroidectomy. Many of candidates concentrated on management of thyroid storm or difficult airway, both of which are relatively rare during such surgery. It is likely that some candidates failed to read the question correctly because it was clearly stated
that the patient was euthyroid making thyroid storm very unlikely.
Question 6: Spinal injury
Pass rate 49.4%
This question had the highest correlation with overall performance i.e. candidates who did well in this question performed well overall in the SAQ. 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”.
Question 7: Shoulder block
Pass rate 48.3%
This question also correlated well with overall performance. The anatomy was not well known to a lot of the candidates so quite a few marks were lost here. This is a recurring theme in the Final exam-remember that anatomy relevant to clinical practice is likely to be included. Failure to read the question again caused some candidates to lose marks. Part (b) asked specifically for possible neurological complications of an interscalene block and quite a few candidates wrote about non-neurological complications.
Question 8: Smoking and anaesthesia
Pass rate 55.5%
The relevance of this question to everyday practice makes the fact that it was well answered all the more pleasing. Candidates who lost marks generally did so because they did not know the pathophysiological mechanisms involved in the difficulties caused by smoking. Remember that applied physiology is also part of the syllabus.
Question 9: Neurological complications of coronary artery bypass grafting
Pass rate 54.6%
Candidates who did well in this question tended to do well overall. There was quite a spread of scores with some candidates having a very clear idea of the answers and others seemingly not very much idea at all. Whether this reflects the fact that some candidates sitting the exam have no experience of cardiac anaesthesia is not clear. However, as stated in previous reports, candidates who have no exposure to the mandatory units of training should endeavour to spend a few sessions gaining first hand experience prior to sitting the SAQ paper.
Question 10: Paediatric meningitis
Pass rate 56.9%
The pass rate for this question was the second highest in the paper but the
examiners still felt that it was not particularly well answered. Many candidates lost marks because they wrote similar answers for parts (b) and (c), despite the fact that in part (c) they were asked to comment on what they would do if the measures used in (b) were not successful in resuscitating the child. Incorrect dosages of drugs, particularly antibiotics were often quoted.
Question 11: Splenectomy in a patient with Hodgkin’s lymphoma
Pass rate 38.8%
Many examiners marking this question felt that either the candidates had not read the question as carefully as they should have done, or they lacked knowledge of the implications of Hodgkin’s lymphoma and its treatment for anaesthesia. Rather than focusing on specific factors of importance many ca ndidates wrote about general problems when anaesthetising for a splenectomy. This was reflected in the pass rate.
Question 12: Ventilator associated pneumonia (VAP)
Pass rate 44.3%
This is a common condition that candidates should have seen so it was sur
prising that it was quite poorly answered. Very few candidates were able to give a definition of VAP or to give details of the care bundles used in its prevention and treatment. Merely stating “a care bundle would be used“
suggests inadequate depth of knowledge.
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FRCA Final SAQ Questions Spring 2014
Question 1
A 68-year-old patient attends the Pain Management Clinic with a history of intractable low back pain.
a) What symptoms and signs would alert you to the need for urgent investigation and referral? (50%)
b) List recommended treatment options that may be considered (with examples) if a magnetic resonance imaging (MRI) scan has excluded significant pathology. (50%)
Question 2
b) How might surgical diathermy affect the ICD? (20%)
c) A patient with an ICD is listed for elective surgery; what preparations are necessary preoperatively,intra-operatively and postoperatively? (45%)
d)How does the management differ if this patient requires emergency surgery? (15%)
Question 3
A 45-year-old patient is reviewed in the preoperative assessment clinic prior to surgery for excision of a phaeochromocytoma.
a) What are the characteristic symptoms (15%) and signs (30%) of a phaeochromocytoma?
b) Which specific biochemical (10%) and radiological (5%) investigations might confirm the diagnosis of a phaeochromcytoma?
c) What therapeutic options are available to optimise the cardiovascular system prior to surgery? (40%)
Question 4
a) What are the indications for (20%) and possible contraindications to (25%) elective percutaneous tracheostomy (PCT)?
b) List the potential early (40%) and late (15%) patient complications of PCT.
Question 5
A 64-year-old man is scheduled for a stereotactic brain biopsy. He is taking dual antiplatelet therapy following the insertion of a drug-eluting coronary artery stent six months earlier.
a) Explain the issues that may arise from antiplatelet therapy in this patient. (30%)
b) Summarise the perioperative strategies to minimise the above issues. (40%)
c) What are the specific contraindications (15%) and complications (15%) of a stereotactic brain biopsy
under sedation?
Question 6
A 5-year-old patient presents for a myringotomy and grommet insertion as a day case. During your pre-operative assessment you notice that the patient has a nasal discharge.
a) Why would it be inappropriate to cancel the operation on the basis of this information alone? (25%)
b) List the features in the history (35%) & examination (25%) that might cause you to postpone the operation due to an increased risk of airway complications in this patient.
c) What social factors would preclude this child’s treatment as a day case? (15%)
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 (20%) and manage gas exchange. (30%)
b) How will use of the laser change the management of anaesthesia? (15%)
c) What are the possible complications of rigid bronchoscopy? (35%)
Question 8
An adult patient is to receive a target controlled infusion (TCI) of propofol.
a) Detail how TCI devices ensure a steady state blood concentration. (50%)
b) What additional pharmacokinetic data is required to allow effect-site targeting? (20%)
c) What are the advantages of a TCI device compared to a manual propofol infusion regime? (30%)
Question 9
A 27-year-old woman is 13 weeks pregnant. In the antenatal clinic she is found to have an asymptomatic heart murmur. A subsequent echocardiogram shows moderate to severe mitral stenosis.
a) List the causes of mitral stenosis. (15%)
b) How do the cardiovascular changes in pregnancy exacerbate the pathophysiology of mitral stenosis? (45%)
c) Outline the specific management issues when she presents in established labour. (40%)
Question 10
a) Which human factors contribute to intravenous drug administration errors in theatre-based anaesthetic practice? (30%)
b) Outline the organisational strategies that might minimize intravenous drug administration errors. (70%)
Question 11
a) List the nuclei of the vagus nerve. (10%)
b) Describe the immediate relations of the right vagus nerve in the neck at C6 (15%) and thorax at T4. (15%)
c) List the branches of the vagus nerve. )30%)
d) Which clinical situations commonly produce vagal reflex bradycardia? (30%)
Question 12
An elderly patient has sustained a fractured neck of femur following a fall and is scheduled for surgery.
a) Which aspects of this patient’s care have a significant impact on outcome? (45%)
b) Outline the recommendations of best practice for the management of pain in this patient. (30%)
c) What causes of a fall in this patient might impact on the anaesthetic management? (25%
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