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Short Answer Questions in Anaesthesia

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© 1997 Greenwich Medical Media 219 The Linen Hall 162-168 Regent Street London W1R 5TB ISBN 1 900151 235 First Published 1997 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the UK Copyright Designs and Patents Act, 1988, this publication may not be reproduced, stored, or transmitted, in any form or by any means, without the prior permission in writing of the publishers, or in the case of reprographic reproduction only in accordance with the terms of the licences issued by the Copyright Licensing Agency in the UK, or in accordance with the terms of the licences issued by the appropriate Reproduction Rights Organization outside the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publishers at the London address printed above. The right of Geoffrey B Rushman to be identified as author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988. The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made. A catalogue record for this book is available from the British Library Distributed worldwide by Oxford University Press Production and Design by Derek Virtue, DataNet Printed in Great Britain by Ashford Colour Press

Page iii Short Answer Questions in Anaesthesia How to Manage the Answers Geoffrey Rushman .

) during a prostatectomy. and how would you manage it? 6 v 2 7 7 8 8 9 9 10 10 11 11 12 .Page vii Contents Preface 1. General anaesthesia What factors show that intubation of the larynx will be difficult enough to indicate fibroptic intubation? How do you manage the physiological consequences of surgical manoeuvres during abdominal laparoscopy? What are the factors that prolong the action of nondepolarising relaxants? What are the "anaesthetic" problems caused by morbid obesity? How would you prevent unplanned awareness during general anaesthesia? How do you detect unplanned awareness during general anaesthesia? What are the advantages and limitations of the laryngeal mask airway? How do you manage total intravenous anaesthesia? Write short notes on ondansetron How do you manage sedoanalgesia? Under what circumstances should general anaesthesia for elective cases be postponed and why? How would you determine the causes of arterial hypotension (80/60 mmHg. Advice on answering short answer questions What the words in examination questions mean 2.

How would you diagnose and manage it once it had occurred? Describe the Bain system and its functions What are the safety devices involved in delivery of oxygen from a cylinder on an anaesthetic machine to an anaesthetised patient through a Bain system? Compare two types of anaesthetic breathing system used for a healthy spontaneously breathing child weighing 20kg Write short notes on desflurane Describe the circle system for anaesthesia. What questions would you ask? What protocol would you construct to guide surgeons on selecting adult patients for day-case anaesthesia? Describe the anaesthetic arrangements involved in a gynaecological day-case list of 15 patients for dilatation and curettage of the uterus Write short notes on rocuronium Give an account of the pharmacology of propofol Compare and contrast halothane and desflurane What are the pharmacological problems presented by a patient taking monoamineoxidase inhibitors (MAOI) who requires emergency anaesthesia for a bleeding duodenal ulcer? Discuss the pharmacological problems presented List the causes of "suxamethonium apnoea". What are its advantages and limitations? What are the features of an anaesthetic machine which are designed to minimise the risk of delivering hypoxic gas mixtures? Write short notes on dantrolene 12 13 14 15 16 17 18 19 20 21 22 22 23 23 23 24 24 25 26 27 27 .Page viii What are the causes and management of hypoventilation immediately following anaesthesia? What causes bradycardia during general anaesthesia and what is the management of this condition? List the causes and briefly note the management of tachycardia (>100 bpm) during general anaesthesia in an adult Why do some patients suffer circulatory collapse at the induction of general anaesthesia and how would you manage it? What signs would lead you to suspect that a patient under general anaesthesia was developing malignant hyperpyrexia? Describe your immediate management What is the pathophysiology of malignant hyperpyrexia? How would you investigate it? You are asked to construct a question sheet for day-case patients to answer on admission to hospital.

Write short notes on ketamine List the physical properties of desflurane. and describe the characteristics of a suitable vaporiser How do you estimate bloodloss during various types of surgery? Write short notes on minimum alveolar concentration Write short notes on propofol Write short notes on mivacurium 28 29 29 30 30 31 .

What is your management? 31 32 34 34 35 35 36 36 37 37 40 40 41 41 42 44 44 45 45 46 . Neuroanaesthesia How does concomitant head injury influence your anaesthetic management of an operation for a fracture of the hand? What monitoring do you consider necessary for a posterior fossa craniotomy? What are the possible sources of error associated with two of the monitors you mention? Describe the physiological effects of high arterial carbon dioxide tension (10 kpa. Paediatric anaesthesia How does the physiology of children aged 1 year differ from that of adults? Write short notes on EMLA cream What psychological factors influence your anaesthesia for children aged 2-3 years? What facilities are required for transfer of a 2-month old baby to a paediatric unit? A 6-week old child has projectile vomiting and is presented for laparotomy.Page ix Write short notes on hyoscine Write short notes on glycopyrronium (glycopyrollate) 3. presenting with cyanosis What are the aims of premedication in children? Describe the pharmacology of two such premedicant drugs 4. Obstetric anaesthesia How do obstetric factors affect the management of anaesthesia for the removal of a retained placenta? Write short notes on ranitidine Describe the anaesthetic management of massive intrapartum haemorrhage requiring emergency operation Describe the pathophysiological processes of pre-eclamptic toxaemia of pregnancy You are asked to help with a case of severe pre-eclamptic toxaemia of pregnancy. 70 mmHg.) What factors affect cerebral blood flow? State briefly their importance in relation to anaesthesia within 12 hours of head injury How may cerebral bloodflow be affected by general anaesthesia? 5. Describe the general anaesthetic problems of this case Describe the management of acute epiglottitis in a child of three years Describe the management of acute laryngotracheitis in a child of three years of age.

Describe your management of the case up to the end of the operation Write short notes on Hartmann's solution Describe the adverse effects of blood transfusion. including its relations Describe the arterial blood supply of the myocardium Describe the venous drainage of the myocardium Describe the conducting system of the heart How may abnormalities of cardiac conduction be revealed by the electrocardiogram? Describe the anatomy of the bronchial tree Describe the nerve supply of the larynx Describe the anatomy of the first rib. At emergency laparotomy the surgeon announces that the liver is ruptured. How may they be reduced? Describe the alternatives to donor blood transfusion What are the contents of a unit of transfusion blood? Describe briefly the alternatives which can be used in an emergency haemorrhage situation until transfusion blood becomes available Write short notes on Gelatin-based plasma substitutes Describe the features of the Boyle's anaesthetic machine and Bain system which protect the patient from pulmonary barotrauma What physiological changes follow acute hypovolaemia? What is the physiological response to the rapid loss of 1 litre of blood in the adult? Outline the factors responsible for the maintenance of cardiac output What are the causes and effects of hypothermia? Detail the immediate rescusitation (in the first hour) of an unconscious patient admitted to the A & E department after falling off a ladder 54 54 48 48 49 49 50 50 51 51 52 55 55 56 56 57 57 58 58 59 59 60 . Cardiothoracic anaesthesia Describe the anatomy of the trachea.Page x 6. including its relations 7. Trauma and emergency anaesthesia What are the effects of an overdose of a tricyclic antidepressant drug? A child of 12 years has been admitted following a road accident. including its relations Describe the anatomy of the diaphragm.

8. Acute and nonacute pain management What are the medical effects of opioid drugs? Write short notes on pethidine 62 62 .

How do you cope with the medical problems of this situation? A patient is admitted to the intensive care unit with Guillain Barre Syndrome. and how do you avoid them? What are the possible complications of subclavian vein cannulation.Page xi Discuss the methods available for the relief of pain following abdominal hysterectomy Write short notes on tenoxicam Describe the principles involved in prevention and treatment of postherpertic neuralgia in the upper limb Compare and contrast pethidine and codeine Describe the adverse reactions which may follow the use of non-steroidal antiinflammatory drugs Describe the pharmacological effects of paracetamol Describe the pharmacological effects of dextropropoxyphene 9. Intensive therapy A patient is admitted to the intensive care unit with a relapse of myasthenia gravis. and how do you avoid them? Describe the pharmacology of a drug used to relieve severe pulmonary vasoconstriction List the properties of an ideal inotrope. How may these factors be altered by septic shock? Write short notes on gastric tonometry Write short notes on pulmonary capillary wedge pressure 63 64 64 64 65 65 66 68 68 69 69 70 70 70 71 71 72 72 72 73 73 . Compare the properties of dopamine with this ideal List the factors which determine the supply of oxygen to the tissues of the body. How do you cope with the medical problems of this situation? Why do some patients develop ARDS following colectomy? What are the pathophysiological processses? Describe the complications of endotracheal intubation What is the venturi principle? Describe the clinical uses of high frequency jet ventilation Describe the anatomy of the subclavian vein Describe the anatomy of the internal jugular vein What are the possible complications of internal jugular vein cannulation.

Write short notes on Sucralfate Write short notes on dopamine Discuss the occurrence of metabolic acidosis in patients in the intensive care unit Give a brief account of the pulmonary problems that occur during intermittent positive pressure ventilation of the lungs in ARDS Write short notes on prostacyclin 73 74 74 74 75 .

Regional and local analgesia What are the dangers and complications of intradural spinal analgesia? Write short notes on ephedrine What are the dangers and complications of extradural analgesia? What are the advantages and disadvantages of the local anaesthetic and epidural anaesthetic techniques for the repair of an inguinal hernia? Write short notes on prilocaine What factors would influence your decision to choose a regional technique in preference to a general anaesthetic for transurethral resection of the prostate? Write short notes on midazolam What factors influence the choice of anaesthetic for insertion of arteriovenous shunt for haemodialysis? Write short notes on naloxone Describe the effects and treatment of bupivacaine overdosage What are the advantages and disadvantages of the supraclavicular and axillary approaches to the brachial plexus block Write short notes on adrenaline What is the place of local analgesic nerve blocks in the anaesthetic technique for cholecystectomy (excluding ''spinal" and extradural techniques)? State briefly how they are performed. during transfer to a neurosurgical unit? What information can be gained from measuring central venous pressure? 11.Page xii 10. What are their shortcomings? What are their risks? Give a brief description of the sensory nerve supply of the thoracic cage and abdominal wall Write short notes on ropivacaine Briefly describe the anatomical relations of the brachial plexus 82 82 83 84 78 78 79 79 80 80 85 86 87 87 88 88 89 89 90 91 91 92 . Clinical measurement Describe the physical principles of the pulse oximeter Describe the physical principles of a capnograph. How may it be calibrated? What information can a capnograph give about an anaesthetic? What are the sources of error of the pulse oximeter? What arrangements are required for an adult head-injured patient.

What are the complications of the supraclavicular and axillary brachial plexus blocks and how do you recognise them? Describe the anatomy of the sacral canal and its contents Describe the anatomy of the epidural space at the level of the fourth lumbar vertebra 92 93 93 .

Page xiii 12. Describe your anaesthetic management A patient with congestive cardiac failure presents for hip replacement. Describe the common causes and management of this 96 96 97 97 98 98 99 99 100 100 101 101 102 102 103 103 104 104 105 106 106 . Write short notes on doxapram Write short notes on aminophylline What problems does hiatus hernia pose for the anaesthetised patient and how would you cope with them? What is the relevance to anaesthetic management of ankylosing spondylitis? What strategies would you employ to overcome them? Write short notes on nifedipine How does the presence of aortic stenosis affect the management of an anaesthetic? What would happen if a full dose of thiopentone was given to a patient with acute intermittent porphyria and why? What is the management of an acute sickle cell crisis? In what ways does Down's Syndrome affect the management of an anaesthetic? What precautions should be taken when anaesthetising a patient with dystrophia myotonica? How do the intraoperative surgical complications of excision of thyroid goitre affect the management of the anaesthetic? What are the anaesthetic problems posed by surgical removal of a phaeochromocytoma? What are the anaesthetic problems posed by surgical removal of a parathyroid adenoma. Medicine and surgery related to anaesthesia What precautions should you take when anaesthetising a patient known to have suffered from viral hepatitis? Write short notes on verapamil hydrochloride How would you manage atrial fibrillation which occurs during anaesthesia? What could be done to prevent it? Write short notes on the diagnosis and treatment of pneumothorax. and how do you cope with them? What are the complications of mitral valve disease during anaesthesia and how do you prevent them? A patient's arterial pressure on admission for moderately urgent appendicectomy is 170/115 mmHg. Describe your management for the anaesthetic A patient presenting for prostatectomy has a pulse rate of 39 beats per minute.

How does the common cold influence fitness for anaesthesia? Write short notes on atrial fibrillation How do you judge the significance and plan the management of preoperative anaemia? A patient with non-insulin-dependent diabetes is to undergo amputation of an infected gangrenous leg. What is the correct peri-operative management of the diabetes? 107 107 108 109 .

ophthalmic and ENT What complications of operations on the bony structures of the lower half of the face may affect the anaesthetic management. Describe the problems and outline the anaesthetic methods Describe the anaesthetic management for a patient with a perforating eye injury who had a large meal in the last hour Describe the anaesthetic management for a 5-year-old patient who requires reoperation for haemorrhage an hour after tonsillectomy How would you perform a block of the maxillary nerve? 110 110 111 111 112 112 113 113 114 116 116 117 117 118 . Where are they seen clinically? What is the mode of action of the following.Page xiv How would you judge the significance of preoperative jaundice? How do antihypertensive drugs affect the management of anaesthesia? What are the functions of the thyroid gland and how are they controlled? What are the effects of thyroid dysfunction on anaesthesia? In what circumstances may fluid overload occur during operation? How is it diagnosed and managed? Name and define the different types of hypoxia. Faciomaxillary. and how do you deal with them? A patient requires an anaesthetic for removal of an infected molar tooth which is causing severe trismus. in lowering arterial pressure? Describe all the clinical actions of one anaesthetic agent and two other drugs you might use to lower arterial pressure during anaesthesia Write short notes on amiodarone Write short notes on adenosine 13.

Page 1 Chapter 1 Advice on Answering Short Answer Questions .

which is whether you know how to use these "tools". then you may need to adopt the strategy of paragraph 9 (below). it tests your judgement. You must answer the requisite number of questions. Secondly. the better. and ask a sympathetic senior colleague to mark them for you. which is the "tools" of the professional. The more you read and listen. There are many areas in the life of an anaesthetist where there is no single right or wrong answer to a problem. Before the Exam 2. You can add to these later as you go along. Divide the time of the whole examination paper by the number of questions and do not overrun on any one answer by more than a minute or so. There will probably not be time to write the question out at the start of each answer.Page 2 1. For many candidates this time allows writing only one or two sides of paper (in the books provided) for each answer. First. but various possibilities. the less equipment you have at your disposal for the problems of everyday anaesthesia. especially ones from previous papers if you can get them. If it is in an area which you may not personally have encountered (such as anaesthesia for kyphoscoliosis operations). or "out of the ordinary run of things". A shortage of judgement means that you may be unable to handle problems which are more complex. including this one! 3. 4. The examination is therefore designed to test two aspects of your professional skill. if you think of further points.about 15 minutes. read all the exam question books in your subject. In your preparation for this test. 8. . If it is in an area with which you are very familiar. Make sure you know how many this is. It will probably help to put your watch or clock on the desk in front of you Use a blank sheet of paper on which to make rough notes for all the questions. depending on the circumstances of the case. the intensive care unit and the clinic. and seminars. then you will find the answer easy. The more experience you have in these areas the better. Make sure that you have spare pens and possibly coloured pencils in your pocket as well. published in the last year. in the company of experienced colleagues who are inclined to teach you. Do many practice exam essays beforehand. At the Exam 5. This means that you should read the carefullyworded question at least twice to be sure of what it is asking. 6. Knowledge can be gained from books. Judgement is gained on the floor of the operating theatre. There is very little time for each answer . The questions in examinations in Anaesthesia are carefully designed to assess whether you are a safe anaesthetist and whether you have a good sense of judgement in practising this specialty. it tests knowledge. The less knowledge you have. lectures. Try to read all the review articles in your subject. 7.

g. . If the question is about "anaesthetic management". Then think "laterally" about what else might be involved. If the question is about clinical anaesthesia. 11.so how much blood needs to be crossmatched.g. 9c. unless the wording of the question is specific to one or other area. if the question asks for the arterial supply of the forearm and hand. What is the worst thing that could happen during the operation? (haemorrhage may be profuse . For example. in which case concentrate on what the question specifically asks. 13. and what monitoring would be needed.. Don't forget to mention testing for it! Another question which should cross your mind is. Postoperatively. Leave a line between each paragraph of your answer .it makes it clearer. This would involve general anaesthesia. "Do any of these cases need to go to the ITU or HDU?" 10. What postoperative problems are likely? (pain. prone position and all that entails. needing premedication). relevant fact or opinion. Where questions on anatomical subjects are concerned. This may prevent you from missing something big! Remember that you will gain marks for every correct. some are congenital and may have other congenital problems. Try to think "clinically" . or should they not be used? (interferes with testing for damage to the spinal cord). Another "worst scenario" situation in the postoperative period is the occurrence of spinal cord damage. damage to the spinal cord .. underline key points. but you will probably gain marks by saying so. the patients are often teenagers and will be anxious. 14.. Then think about the "worst scenario" or "worst case" situation. It might or might not be appropriate. 12. and will also give a little space for you to insert an extra sentence if you think of another point later on.the "wake-up test" during the operation tests for this). always think about local/regional analgesia as well as general anaesthesia.) 9b. there is no substitute for knowledge! 15. so much the better.g. the management of the anaesthetic for kyphoscoliosis. respiratory problems). e. Make notes briefly on what you think is the main answer to the question. in kyphoscoliosis. (For example. to be absolutely sure of everything the examiners are asking. the pain may be severe . What operative problems are likely? (prolonged surgery. Where questions on scientific and technical subjects are concerned.what actually happens about these types of cases in the hospital where you work? How are the problems in question coped with in practice? If you can prioritise the points in your answer and put the important points first. why are scoliosis operations performed? (interference with respiratory function as well as skeletal deformity) Are there preoperative problems? (e. what is the worst thing that could happen preoperatively? (respiratory failure with possible cardiac problems .this may require preoperative testing). do read the question carefully a second time.Page 3 9a. If you have time. do include preoperative and postoperative care. pneumothorax.would regional blocks be useful. To answer this by simply writing about the arteries in the wrist and the hand will lose you marks. E. patients get cold).

Diagrams are generally helpful as a part of your answer. . However. What the Words in Examination Questions Mean Aetiology = Significance = Outline = Determine = Management = Anaesthetic management = what are the causes "reasons for" and "importance of" describe briefly find out everything which should be done preoperative. operative and postoperative unless otherwise stated.Page 4 You may be rather rusty on the anatomical details for which the question asks. and make an educated guess to fill in the gaps. all is not lost! Put down what you know.

Page 5 Chapter 2 General Anaesthesia .

4. and how many of the predictive factors need to be present to indicate fibreoptic intubation. 2.Cormack & Lehane scores from previous laryngoscopies. awkward front teeth. g) Frontal crowns. e) small mandible size.Page 6 What factors show that intubation of the larynx will be difficult enough to indicate fibroptic intubation? Notes for an answer: 1. Trismus. known history of difficult intubation . f) neck stiffness or injury (need to mention neck X-rays). atlanto-occipital distance. Previous suxamethonium masseter spasm (if rapid sequence induction is needed). 5. <><><><><><><><><><><><> . Congenital abnormalities of the face or neck. atlanto-odontoid distance (> 3mm). Known or suspected laryngeal obstruction (need to mention soft tissue X-ray of neck). This answer needs a note on whether any of these factors are absolute indications. d) thyromental distance (< 6cm). b) poor mouth opening (< 3fb). failure to mention laryngeal obstruction. c) low Malampatti score. inability to protrude jaw. Serious omissions likely to cause a fail: Failure to note at least four predictive factors. 3. Examination of patient a) history of rheumatoid arthritis.

hypothermia. and age factors.. 5. <><><><><><><><><><><><> .Page 7 How do you manage the physiological consequences of surgical manoeuvres during abdominal laparoscopy? Notes for an answer: Physiological upsets (with management in brackets): 1. acidosis. very young and very old. botulinus toxin).basic scientific knowledge (bonus marks if you state what difference the structure makes). Gas in pleural cavity causes tension pneumothorax (this requires a comment on how to make the correct diagnosis and the insertion of a needle in correct side of chest). 2.2-0. bradycardia (atropine 0. 3.can cause severe pain. hypocalcaemia.g. Age of patient. 4. 3. Volatile anaesthetics. 4. 6. Other drugs. requiring urgent group-specific transfusion). Haemorrhage (you need to state that this can be massive. especially local anaesthetics and aminoglycoside and lincomycin antibiotics in high dosage. poisons (e. Gas in blood vessels causes air embolism (requiring "air embolism drill"). Gas in peritoneum causes diaphragmatic splinting (IPPV is required). Serious omissions likely to cause a fail: Failure to mention electrolyte abnormalities. Myasthenia and other rare diseases (bonus marks if you can name any). <><><><><><><><><><><><> What are the factors that prolong the action of nondepolarising relaxants? Notes for an answer: 1. 7. Comment: This is common everyday anaesthetic practice and would be marked severely. Surgical emphysema . Serious omissions likely to cause a fail: Failure to mention diaphragmatic splinting and gas embolism. Vascular reflexes.5 mg will correct this). 2. 6. Physiology of patient . 5.hypokalaemia. Excess absorption of CO2 (moderate hyperventilation). volatile anaesthetics. Structure of relaxant .

unless you have thought it out beforehand. Definition of morbid obesity in terms of body mass index is required (greater than 30 kg/M2). 7.Page 8 What are the ''anaesthetic" problems caused by morbid obesity? Notes for an answer: 1. History from patient (previous unplanned awareness. hypoxia (operative and postoperative). reduced lung volumes. difficult intubation. 4. Serious omissions likely to cause a fail: Failure to mention anaesthetic agent monitoring. Use of ear muffs or plugs on patient during surgery. Comment: This is a large answer to complete in 10-15 minutes. Monitoring of patient (this needs a very brief discussion of the value of "clinical" signs. difficult to intubate. 5. Vaporisers are refilled before they become empty. risk of DVT. and regurgitation risks. estimation of drug dosage is difficult. 6. and a few details about the available awareness monitors). Problems: Respiratory system — increased work of breathing. slow equilibration with inhaled anaesthetics. hypertension and coronary disease. difficult venepuncture. 2. surgery is often more prolonged. pulmonary "shunting". Serious omissions likely to cause a fail: Failure to mention respiratory problems. increased cardiac work. especially when using the closed circle system. Monitoring of breathing system — including agent. physiological resistance to anaesthesia. especially when front dental crowns are present. underventilation. 1 MAC of volatile anaesthetic is normally sufficient. regional and local blocks are technically difficult. <><><><><><><><><><><><> How do you prevent unplanned awareness during general anaesthesia? Notes for an answer: 1. Miscellaneous — hiatus hernia. Not placing reliance on opioids to prevent awareness. vaporisers (or syringe drivers if using total intravenous anaesthesia). Technical — difficult to move. Preoperative checks of machine. 3. especially benzodiazepines. lift and nurse — spontaneous respiration restricted. inaccuracy of noninvasive arterial pressure monitoring. etc.). alcoholism. Adequate premedication. Cardiovascular system — blood volume increased. less water per unit of body weight. regurgitation. hypercapnia. diaphragmatic splinting. <><><><><><><><><><><><> .

A brief comment on the usefulness and inadequacies of these monitors is required. Monitoring of patient a) Clinical. this is routine. Serious omissions likely to cause a fail: Failure to mention the monitoring of anaesthetic agents. Monitoring of breathing system — (including anaesthetic agent). good in difficult airway situations. if anaesthesia is too light or the patient wakes up with the laryngeal mask in situ. <><><><><><><><><><><><> . <><><><><><><><><><><><> What are the advantages and limitations of the laryngeal mask airway? Advantages: general ease of use. especially if the cuff is too tightly evacuated. g) Respiratory Sinus Arrythmia analysis. c) Spectral Edge Frequency analysis. logistic difficulties of sterilisation. but it is wonderfully useful. 2. In practice. dental damage. h) Oesophageal contraction rate. occlusion by biting. no airway protection from gastric reflux. Comment: The laryngeal mask does not guarantee anything. allows remoteness from mouth for head and neck operations. can turn. does not require neck movement for insertion.) Limitations: can cause laryngospasm. pharyngeal damage on insertion. bearded patients. b) Cerebral function monitoring. and/or syringe driver system.. d) Bisectral Index.Page 9 How would you detect unplanned awareness during general anaesthesia? Notes for an answer: 1. e) Frontalis EMG etc. kink and obstruct in other ways. (Some comment on sizes is helpful. Serious omissions likely to cause a fail: Failure to mention obstruction of airway. f) Evoked potentials and responses.

and empty syringe. 5HT3 serotonin antagonism Clinical effects: antiemetic Dose. Pharmacokinetics: Routes of administration. IV< IM< oral Metabolism. 3. disconnection.. breathing (anaesthetic bag movements.g. transient visual disturbances Plus other features: especially useful in chemotherapy. propofol) and typical infusion rates (e. minutes Duration. 2.. 10-6 mg/kg/hr for propofol). <><><><><><><><><><><><> . storage (plastic ampoules) preparation. Circulation (ECG. Reliable syringe pump — with battery backup.g. Serious omissions likely to cause a fail: Failure to mention the need for full monitoring. constipation. headache. 8 hrs. flushing. alarms for blockage. SpO2. 4. concentration Pharmacodynamics: Mode of action. arterial pressure. especially respiration. EtCO2). Reliable full monitoring of airway. Reliable IV cannula. <><><><><><><><><><><><> Write short notes on ondansetron This answer needs most of the following headings: Pharmacy: Type of chemical. Use of reliable drugs (e. SpO2) and depth of anaesthesia (details not needed). liver Side effects. 4-8 mg Onset.Page 10 How do you manage total intravenous anaesthesia? Notes for an answer: The following are required: 1.

A brief discussion of a strategy for coping with failed local analgesia.g. Comment: This is a safety question. serious acute anaemia.Page 11 How do you manage sedoanalgesia? (This is sedation plus local anaesthesia) 1. and needs only a brief reason for each area noted here. acute pancreatitis. Serious omissions likely to cause a fail: Failure to mention full monitoring. opioids... <><><><><><><><><><><><> . regional/local/topical. Methods of local analgesia. e. recent myocardial infarction.g. appropriate analgesics. 4. Monitoring — you need to state that this is complete as for full general anaesthetic. acute LVF.. ketamine. hypokalaemia. 2. colds. uncontrolled arrythmia. 3. the doses required and undesirable side-effects. benzodiazepines. chest infection. e. URTI. head injury. Serious omissions likely to cause a fail: Failure to mention shock. Sedative drugs used. because the patients selected for this type of anaesthesia are sometimes very ill. inadequate preparation or investigations. serious electrolyte abnormality. phenothiazines.g. e. <><><><><><><><><><><><> Under what circumstances should general anaesthesia for elective cases be postponed and why? Notes for an answer: Uncontrolled hypertension. myocardial infarction and respiratory tract infections. uncontrolled shock.

severe hypocapnia. ventilation of lungs. 2.. 3.) during a prostatectomy. co-existing aortic stenosis. reversal of cause. 2. 6. Other medical conditions — myocardial infarction. Obesity and medical problems of the patient. 7. TURP syndrome — clinical signs. Pain.g. or made more severe by presence of significant cardiac disease. Serious omissions likely to cause a fail: Failure to mention obstructed airway. 5. CO2 narcosis (caused by. pulmonary disease. e. Comment: This is a question about everyday anaesthetic practice. use of ethanol marker and breathalyser monitoring. and how would you manage it? Notes for an answer: 1. cardiac failure — need comment about usefulness of monitoring. Anaesthetic drugs — especially volatiles and opioids. Serious omissions likely to cause a fail: Failure to mention TURP syndrome. Bloodloss — inspection and analysis of bladder washouts — requires a discussi on of difficulty of assessment.Page 12 How would you determine the causes of arterial hypotension (80/60 mmHg. severe bradycardia. raised intracranial pressure. <><><><><><><><><><><><> . 4. myasthenia. Shock. Anaesthetic — too deep. spinal block too extensive. Obstructed airway. and a cause of. hypoventilation). 3. Management: Oxygen. bloodloss and myocardial infarction. 4. <><><><><><><><><><><><> What are the causes and management of hypoventilation immediately following anaesthesia? Notes for an answer: Causes: 1. Incomplete reversal of relaxants.

oculocardiac and other vagal reflexes. neostigmine. hypotension (which may also be caused by bradycardia). cerebral compression. Serious omissions likely to cause a fail: Failure to mention opioids and vagal reflexes. Mention use of anticholinergic drugs. atropine.Page 13 What causes bradycardia during general anaesthesia and what is the management of this condition? Notes for an answer: First of all. Treat cause if possible..g. hypoventilation (e. Comment: A common problem. high spinal blockade. cardiac ischaemia/failure/ bradyarrythmias. B-blockers). e. this needs a comment about what pulse rates constitute bradycardia.. hypoxia. drugs (opioids. <><><><><><><><><><><><> . Management: assess reasons for it and state what limits should provoke action.g. Causes: deep anaesthesia. disconnected ventilator).

DC shock may be needed. Serious omissions likely to cause a fail: Inadequate details of general management. toxaemia.or hypotension — pulse rates well above 100 bpm may adversely affect circulation). Tachyarrythmias: mention of DC defibrillation shock if hypotensive. <><><><><><><><><><><><> . amiodarone. amiodarone. The target pulse rate is 70-100 bpm. verapamil is controversial. b) treat cause if possible. associated with hyper. phaeochromocytoma). Atrial fibrillation or Flutter — digoxin. Supra Ventricular Tachycardia —carotid sinus massage. Beta-blockers (and contraindications to these drugs). Specific Managements: Sinus tachycardia — carotid sinus massage. hypovolaemia. drugs (atropine. endocrine problems (thyroid crisis. malignant hyperpyrexia. tachy-arrythmia. adrenaline). Ventricular tachycardia — amiodarone (lignocaine. hypotension. hypercarbia. failure to mention malignant hyperpyrexia. General Management: a) assess significance: (e. flecaine and verapamil are used much less). adenosine.g.. state need for experienced help.Page 14 List the causes and briefly note the management of tachycardia (> 100 bpm) during general anaesthesia in an adult Notes for an answer: Causes: light anaesthesia.

oedema). (an d then later. phaeochromocytoma. In general. bronchospasm. e) Antihistamines.. <><><><><><><><><><><><> . Prevented by pre-emptive correction of hypovolaemia. anticipation of the problem. ECG will show this. 5. cardiac failure (for example in emergency CABG). with full monitoring. elevation of the legs and careful use of catecholamines. Prevention is better than cure! 6. c) Adrenaline 50-100µg. . based on knowledge of the patients preoperative medical condition. severe aortic stenosis. 4. Overdose of anaesthetic agent. flushing. Fainting — vasovagal shock. b) O2/ventilation. ACLS plus control of the cause if the collapse progresses to cardiac arrest. Atropine. a) Stop injecting the anaesthetic agent. Anaphylaxis (hypotension. and other rare syndromes 2. sudden arrythmia. General Management: Firstly. g) Blood samples. Shock. 3.Page 15 Why do some patients suffer circulatory collapse at the induction of general anaesthesia and how would you manage it? Notes for an answer: Causes: 1.g. Nature of patient's disease e. pacemaker failure. i) Inform patient). and elevation of legs etc. f) Steroids. and full monitoring. . h) Prevent awareness. untreated hypertension. Myocardial infarction. d) Head down position and 2L colloid volume load. Comment: There is no simple way of categorising the answer to this one! Serious omissions likely to cause a fail: Failure to mention anaphylaxis. diagnosis of the cause.

sodium bicarbonate. initial hypertension. muscle rigidity. • insulin/dextrose to control hyperkalaemia. stop trigger agents. and stopping the anaesthetic. 1mg/kg. mottled rash. • diuresis to prevent renal failure. <><><><><><><><><><><><> .v. repeatedly measure blood gases. hypothermia. • inject dantrolene. • i. • ITU admission.v. metabolic and respiratory acidosis. i. Management: • hyperventilate with oxygen.Page 16 What signs would lead you to suspect that a patient under general anaesthesia was developing malignant hyperpyrexia? Describe Your immediate management Notes for an answer: Signs: • high tachycardia. Serious omissions likely to cause a fail: Failure to mention dantrolene.. • active cooling. hypercapnia. repeated (to inhibit sarcoplasmic Ca++ release). followed by cardiovascular failure. cyanosis/hypoxia. electrolytes and temperature. 0.3 mmol/kg.

binding of troponin C causes massive muscle contraction and uncoupling of oxidation from phosphorylation. Abnormal Ca++ flux with uncontrolled release of Ca++ from sarcoplasmic reticulum on exposure to triggers gives rise in Ca++ pump activity. 2. 4. • After the crisis: muscle biopsy (MHSusceptible. <><><><><><><><><><><><> . MHEcould be exposed to ryanodine. 5.000. • Investigate the family. physiological stress and many other agents. Triggers: suxamethonium. MHEquivocal. halothane. 3. The role of the ryanodine receptor is central to this process. Investigation: • During the crisis: CPK levels > 20. Serious omissions likely to cause a fail: Failure to mention calcium and at least some of the triggers.Page 17 What is the pathophysiology of malignant hyperpyrexia? How would you investigate it? Notes for an answer: 1. Masseter spasm in children may be associated with it. MHNonsusceptible). The condition is inherited as an autosomal dominant.

pill or tablet? If so. which ones? • Are you taking any sort of medicine. <><><><><><><><><><><><> . Serious omissions likely to cause a fail: Failure to mention previous anaesthetics. . how often? • Have you had a heart attack or a ''stroke"? If so. • Have you ever had an anaesthetic? If so. What questions would you ask? Notes for an answer: • What do you weigh? • How tall are you? • Can you do normal activities? • Is your general health good? • Have you ever had an operation? If so. how many? • How many stairs can you climb quickly before you get short of breath? • Are you short of breath on lying flat? • Do you have a cough or wheeze? If so. or anything else? • Do you smoke? If so. . please list them. when? • Have you got someone to take you home and stay with you for the night after the operation? Comment: This is a question of communication as well as preoperative skills.Page 18 You are asked to construct a question sheet for day-case patients to answer on admission to hospital. how often? • Do you get pain in the chest or palpitations? If so. when? • Do you know if you are anaemic? • Could you possibly be pregnant? • Are you a "drug user" or homosexual? • Have you ever been jaundiced? If so. which ones? • Are you allergic or sensitive to any medicine?. did you have any problem with it? • Have your relatives had any problems with anaesthetics? • Do you have any loose or crowned teeth? If so. and the need for a responsible adult to take the patient home. which ones? • Have you had any medical illnesses? If so.

breathless at rest. <><><><><><><><><><><><> . • breathless on ascent of 10 stairs. cyanosis. enter thorax or abdomen. • myocardial infarction in last year. • obesity (BMI greater than 30). • untreated hypertension. orthopnoea. Serious omissions likely to cause a fail: Failure to mention those with previously bad reactions to anaesthetics. • patients over the age of 70 years. • Insulin-dependent diabetes mellitus. • CVA in last year. painful. • any degree of left ventricular failure. • patients with severe congenital abnormalities. severe anaemia. Comment: This question includes communication skills with colleagues. or multiple or severe previous infarctions with restriction of activity. • those with COAD.Page 19 What protocol would you construct to guide surgeons on selecting adultpatients for day-case anaesthesia? Notes for an answer: Operations to Avoid: • those which are lengthy (more than 30 min). haemorrhagic. Angina. Patients to Avoid: • those with previously bad reactions to anaesthetics. • those with no-one to take them home and look after them. • electrolyte abnormalities. • ASA grades III or more.

6.. or TIVA) and no nausea (routine use of antiemetics). 10. After the List: 9. 2. 7. On the Day of the List: 4. Preadmission investigations complete before day of operation.. Discharge protocol — accompanied by responsible adult/no driving/alcohol. 3. Serious omissions likely to cause a fail: Failure to mention pre. confirmation of the correct order of the list/no waiting for patients/coffee break for staff! Routine checks of patient identity and expected operation. Comment: This is a test of important anaesthetic management skills. 8. There is a need for a selection protocol for surgeons choosing the patients (e. Anaesthetic techniques for rapid awakening (e.g. Follow-up audit.Page 20 Describe the anaesthetic arrangements involved in a gynaecological day-case list of 15 patients for dilatation and curettage of the uterus Notes for an answer: Prior to the Day of the List: 1. 5. Postoperative visit. sevoflurane. Written discharge instructions.and postoperative factors. patients may be obese). Organisation of the day of operation: preoperative visits.g. Preadmission questionnaire for patients. Organisation to avoid "log-jams" in recovery. <><><><><><><><><><><><> . desflurane.

i. volatile and local anaesthetics. <><><><><><><><><><><><> . aminoglycoside antibiotics Plus other features: rapid onset due to low receptor occupancy. storage (solution in glass ampoules. Duration. 0. Onset. concentration Pharmacodynamics: Mode of action.) preparation.v. Metabolism. Pharmacokinetics: Routes of administration.Page 21 Write short notes on rocuronium This answer needs most of the following headings: Pharmacy: Type of chemical.5 mg/kg. with high biophase concentrations. 60 secs. 45-60 mins. nondepolarising neuromuscular blockade Clinical effects. liver Interactions. relaxation Dose.

preparation (emulsion). physical properties. blood levels (3. distribution (initially to extracellular fluid. <><><><><><><><><><><><> Compare and contrast halothane and desflurane.). Notes for an answer: This should include the following: An ethane (halothane) compared with a more highly fluorinated ether (desflurane).. Pharmacodynamics: Brain (reduction CMRO2 and anaesthesia). especially fat). brain. alfentanil — (increases duration). hypovolaemia.).Page 22 Give an account of the pharmacology of propofol Pharmacy: Type of chemical (phenol). Interactions with other drugs e.). short half life. extremes of age. lipid solubility (high). then other sites. pharmacodynamics. Contraindications: a) Absolute: hypersensitivity. MAC values.5-4. Serious omissions likely to cause a fail: Failure to mention MAC values.). bloodvessels (vasodilator). metabolism. <><><><><><><><><><><><> . aortic stenosis. 99% metabolised. storage (glass ampoules). concentration (10 mg/ml.5 µg/ml. vaporiser design. Side effects: extrapyramidal movements. respiratory depression. heart. rates of onset and offset. Pharmacokinetics: Doses (1-2 mg/kg.g. mild relaxation of muscles. Total Intravenous Anaesthesia — infusion rates (10-8-6 mg/kg/hr. b) Relative: severe cardiovascular disease. side effects. onset (one circulation time). depression of pharyngeal reflexes. upper airway obstruction. clinical effects: anaesthesia.

which prevents barotrauma. the outlet valve usually has an airway pressure limiting device. a. 3. ecothiopate. neostigmine. e.. need mention of careful volume replacement before and during anaesthesia. Notes for an answer: Problem of cardiovascular support and need for inotropes (with their interactions). d) Later — investigation of patient and relatives. This answer needs a mention of strategies for analgesia and the problem of interaction with pethidine causing hypotension and coma. Dibucaine no. IPPV and sedation for about 1-2 hr.Page 23 What are the pharmacological problems presented by a patient taking monoamine-oxidase inhibitors (MAOI) who requires emergency anaesthesia for a bleeding duodenal ulcer? discuss the pharmacological problems presented. breaks of central tube gives high deadspace — safety check before use. small deadspace.. fluoride no. f. <><><><><><><><><><><><> List the causes of "suxamethonium apnoea". until muscle power returns. myxoedema. <><><><><><><><><><><><> Describe the Bain system and its functions Notes for an answer: Bain system — modified Mapleson D.g. Diagnosis: a) history from patient. with homo. 2. Management: Oxygenation. <><><><><><><><><><><><> . serum cholinesterase levels. s. Serious omissions likely to cause a fail: Failure to mention both congenital and acquired forms. not antistatic. Antagonism — anticholinesterases. How would you diagnose and manage it once it had occurred? Notes for an answer: Causes: 1. but not pressure effects on pulmonary circulation. Acquired — pregnancy. b) Failure of suxamethonium to wear off within 5-10 minutes.. outlet valve by machine. and drug-induced. c) Neuromuscular monitoring. always some rebreathing except at very high flows.. plasmapheresis. lupus.and heterozygotes. coaxial. place of dopamine in renal support. malnutrition. the newborn. set at 50-60 mm Hg. sterilising procedures. Inheritance as dominant. Congenital — genotypes e.

machine pressure relief valve. mask. filter. needle valve. • Fresh Gas Flows — requires figures for the systems you describe. <><><><><><><><><><><><> . rotameter (on the left in UK). prevention of pulmonary barotrauma). Serious omissions likely to cause a fail: Failure to mention the safety factors. antistatic protection. • Economy. tap on cylinders. flow restrictor. vaporiser with adequate gas seals. • Humidification and warming. Heidbrink exit valve with airway pressure limiting device (50-60 mm Hg).Page 24 What are the safety devices involved in delivery of oxygen from a cylinder on an anaesthetic machine to an anaesthetised patient through a Bain system? Notes for an answer: Pin-index on cylinders. • Ease of sterilisation and crossinfection. ease of disconnections. • Safety for patient (valves (or lack of them). Serious omissions likely to cause a fail: Failure to mention pin index and the airway pressure limiting device. bag. • Likelihood of rebreathing at various gas flows. • Simplicity of use. pressure reducing valve. coaxial pipes. <><><><><><><><><><><><> Compare two types of anaesthetic breathing system used for a healthy spontaneously breathing child weighing 20kg Notes for an answer: Issues for discussion (any descriptions of the systems should be very brief). standardised 22mm outlet. Comment: The size of the patient in question here has been chosen to allow you the maximum choice of breathing systems. risks of hypoxia.

Page 25

Write short notes on desflurane This answer needs most of the following headings: Pharmacy: type of chemical (fourinated ether), storage (glass bottles) Pharmacodynamics: Mode of action, inhalation volatile anaesthetic Clinical effects, anaesthesia Dose, MAC = 6% Onset, very rapid, due to low solubility Duration, N/A Pharmacokinetics: Routes of administration, inhalation Metabolism, very small Excretion, rapidly, via lungs Side effects, coughing, laryngospasm, excitement on inhalation induction Plus other features (low solubility, blood/gas partition coefficient 0.4, oil/gas 18.7; high SVP (88 @ 20° C; MAC50 6%; Boiling point 22.8° C; vaporiser designed to run above boiling point).

<><><><><><><><><><><><>

Page 26

Describe the circle system for anaesthesia. What are its advantages and limitations? Notes for an answer: Corrugated tubes, soda lime, low-resistance, NON-stick valves, gas entry port on inspiratory limb. Advantages Economy, low pollution, warming of gases, humidification. Soda lime — 90% Ca(OH)2, 5% NaOH, 1% KOH, silicates and water. Used to absorb CO2 (up to 20% of its own weight). Granule size, air spaces important, Colour indicator change on exhaustion. Limitations 1. Risk of • hypoxia • hypercapnia • awareness due to slow equilibration with large volumes • overdose of anaesthetic, disconnections • deadspace problems (a sticking valve causes a large dead-space) • carbon monoxide generation during rest, if very dry • degradion of sevoflurane by heat 2. Needs monitoring of: • O2 • CO2 • anaesthetic agents
Serious omissions likely to cause a fail: Failure to mention the soda-lime; monitoring of gases.

<><><><><><><><><><><><>

Page 27

What are the features of an anaesthetic machine which are designed to minimise the risk of delivering hypoxic gas mixtures? Notes for an answer: The features which should be mentioned are: colour coding of cylinders, pin-index, pressure gauge, Schrader valves and colourcoded pipe for pipelines, flow control by rotameters, O2/N2O interlock, O2 failure warning device, O2 monitor, safety checklist card. Issues for discussion — effectiveness, proof against operator failure, areas of failure of reliability, need for audible alerts for operator, operator involvement in safety checks, effect of electrical failure.
Serious omissions likely to cause a fail: Failure to mention the pin-index and Schrader valves.

<><><><><><><><><><><><>

Write short notes on dantrolene This answer needs most of the following headings: Pharmacy: Type of chemical, storage (powder, with mannitol), i.v. preparation is very highly alkaline Pharmacodynamics: Mode of action, muscle fibre relaxant, acting at excitation-contraction coupling zone, preventing Ca++ release from sarcoplasmic reticulum Clinical effects, treatment of malignant hyperpyrexia (and other spasm) Dose, 1 mg/kg., repeated Onset, rapid Duration, 10-30 mins. Pharmacokinetics: Routes of administration, i.v., oral Metabolism, liver Interactions, with veapamil in anaesthetised animals Plus other features: difficult to dissolve

<><><><><><><><><><><><>

vasoconstrictor — hypertension. increased muscle tone and movements. 10-30 mins. epidural Metabolism. dreams and hallucinations.. Prolonged hypnosis with barbiturates.Page 28 Write short notes on ketamine This answer needs most of the following headings: Pharmacy: Type of chemical (a cyclohexanone). <><><><><><><><><><><><> . one circulation time. PONY. NMDM receptor agonist Clinical effects.m.m. for sedoanalgesia Onset.) Pharmacodynamics: Mode of action. Duration. storage (aqueous solution in glass ampoules) preparation. analgesia.. liver Side effects. 0. i.5mg/kg.. dreams and hallucinations prevented by low dose benzodiazepines. concentration (10. Pharmacokinetics: Routes of administration. 50. Has been used in patients with full stomachs without regurgitation.v. mild rises of ICP and IOP. Interactions. i. 2mg/kg. salivation. Plus other features: low-dose use in sedoanalgesia. 5mg/kg i.v.v. i.. oral.v. anaesthesia Dose.. 5 mins i. and 100 mg/ml.m. i. i.

2. keyed filling ports and bottles. calibration independent of flow. capillary refill. Vaporiser characteristics: Splitting of gas inflow. electronic vapour injection with differential pressure transducer system. 5.8° C. at any one time. <><><><><><><><><><><><> How do you estimate bloodloss during various types of surgery? Notes for an answer: 1. Hb estimation of TURP irrigation fluid and calculation of bloodloss. temperature controlled @ 39° C. Boiling point 22.4. allowing for volume of saline washouts.7. 4. Oil/gas Sol.5 kPa. warm periphery. MAC: 6%. SVP @ 20° C: 88.g. arterial pressure — invasive and noninvasive (with comment on pressures needed for production of urine) (MAP 70 mm Hg.: 18. Monitoring CVP. 6. 3. Clinical condition of patient e. easily mounted and demounted from machine. 4. 3. Other weigh swabs. interlocks to allow only one in use. Molecular wt: 168 Daltons. 5.Page 29 List the physical properties of desflurane. Visual assessment of swabs. and describe the characteristics of a suitable vaporiser Notes for an answer: 1. electronic monitoring of liquid content with alarm. spill-proof device.. Blood/gas partition coefficient 0.). quality and volume of pulses in various parts of body. <><><><><><><><><><><><> . drapes and sucker bottle. 2.

7%. infusion 10-6 mg/kg/hr. Other features: in mixtures of anaesthetic gases. 1-2 mg/kg.) Pharmacodynamics: Mode of action. It varies with age. effective blood level is 3. MAC95 is the minimum alveolar concentration required to prevent reaction to skin incision in 95% of subjects. prolongs action of alfentanil Plus other features: long infusion leads to green urine colour In low dosage it is used as a sedative Note the similarity to the question and answer on p22 <><><><><><><><><><><><> .Page 30 Write short notes on minimum alveolar concentration Definition: a measure of the potency of volatile anaesthetics. severe surgical stimulus. Increased by: adrelaline.15%. one circulation time Duration. pregnancy. desflurane 6%. vasodilation. i. Pharmacokinetics: Routes of administration. Decreased by: sedation. lowest in premature babies and old age.75%. hypnosis via GABA receptors Clinical effects.5 µg/ml. greatest at one month. Isoflurane 1. the various MAC's are additive. respiratory depression. <><><><><><><><><><><><> Write short notes on propofol This answer needs most of the following headings: Pharmacy: Type of chemical (phenol) storage (emulsion in soybean oil. liver Side effects. relaxation Interactions. 1-5 mins. Onset. analgesia. MAC50 is the minimum alveolar concentration required to prevent physical reaction to skin incision in 50% of subjects. hypotension.v. Metabolism. halothane 0. in glass ampoules) concentration (10mg/ml. sevoflurane 2%.5-4. enflurane 1. anaesthesia Dose.

tachycardia. anticholinergic Clinical effects. Onset. i. 0. tablet or syrup). sedative. preparation (aqueous. Duration. nondepolarising neuromuscular drug Clinical effects. 7 µg/kg.m. 3hrs Pharmacokinetics: Routes of administration. Metabolism. (aqueous. central anticholinergic syndrome. concentration (400 µg/ml.) Pharmacodynamics: Mode of action. one circulation time Duration. serum cholinesterase Side effects. dry mouth <><><><><><><><><><><><> .2 mg/kg.v. volatile and local anaesthetics. 3 mins.1-0. aminoglycoside antibiotics. histamine release Interactions. storage.Page 31 Write short notes on mivacurium This answer needs most of the following headings: Pharmacy: Type of chemical (benzylisoquinoline). in glass ampoules) preparation. i.. 10 mins. liver Side effects.v. Onset. oral. Pharmacokinetics: Routes of administration. relaxant Dose. other relaxants <><><><><><><><><><><><> Write short notes on hyoscine This answer needs most of the following headings: Pharmacy: Type of chemical. locally acting mydriatic Dose. parasympathetic blockade. concentration 10mg/ml Pharmacodynamics: Mode of action. storage. antiemetic. i. Metabolism.

Tachycardia.m. Onset. storage (aqueous solution in glass ampoules. 7 µg/kg. concentration 200 µg/ml. parasympathetic blockade Dose. liver Side effects. i. i. dry mouth Plus other features: does not cross blood brain barrier <><><><><><><><><><><><> . Metabolism. 4-6 hrs.v. one circulation time Duration.) preparation. Pharmacodynamics: Mode of action.Page 32 Write short notes on glycopyrronium (glycopyrollate) This answer needs most of the following headings: Pharmacy: Type of chemical. anticholinergic Clinical effects. Pharmacokinetics: Routes of administration.

Page 33 Chapter 3 Paediatric Anaesthesia .

preparation. 4. Onset. The ribs are more horizontal. Greater sensitivity to opioids.5% lignocaine. Higher metabolic rate — more rapid onset of cyanosis. as long as applied Pharmacokinetics: Routes of administration. partly due to nervous system immaturity. 5 ml. concentration (2. <><><><><><><><><><><><> Write short notes on EMLA cream This answer needs most of the following headings: Pharmacy: Type of chemical (eutectic mixture of local anaesthetics). 2. local analgesia Clinical effects. 3. 5. but the answer is quite simple! Serious omissions likely to cause a fail: Failure to mention sensitivity to opioids. liver Side effects. 2. Duration. partly to hepatic clearance. Comment: the question sounds complex. to make venpuncture painless Dose.5% prilocaine) Pharmacodynamics: Mode of action. Reduced renal concentrating function — need more water. storage (cream in a tube). More increased heart and respiratory rates in response to demands than adults. and the respiration is more diaphragmatic. Greater risk of hypothermia due to relatively larger surface area. Larger volume of distribution for water-soluble drugs. topical Metabolism. Risk of being eaten (with its dressing) by a child <><><><><><><><><><><><> . 6.Page 34 How does the physiology of children aged 1 year differ from that of adults? Notes for an answer: Infants have: 1. 1 hr.

) Drugs and other facilities for CPR. with O2 supply.v. IPPV available (secure tracheal tube if appropriate). thermometer. shakeproof. accompanying parent. Easy access to the patient. Very easily frightened — need to be seen with parents and spoken to kindly. 2. Highly dependent on parents — development of rapport with them is a high priority. laryngoscopes. including day cases. spare tracheal tubes and i. but the answer is quite simple! Serious omissions likely to cause a fail: Failure to mention fear and pain. warm. good IVI.Page 35 What psychological factors influence your anaesthesia for children aged 2-3 years? Notes for an answer: 1. humidification. ECG. <><><><><><><><><><><><> What facilities are required for transfer of a 2-month old baby to a paediatric unit? Notes for an answer: A trolley which is easily mobile and physically secure. Trained assistants/facilities for. battery powered (need SpO2. Monitoring which is portable. and rapport with. EtCO2. Tolerate pain badly a) need EMLA or similar cream for venepuncture and discussion of management of gaseous induction b) need careful analgesia (but sensitive to opioids and not able to control own PCA) — need discussion of pro's and con's of the main techniques for pain relief. Comment: The question sounds complex. <><><><><><><><><><><><> . cannulas. 3. pulse meter. need discussion of place of premedication.

<><><><><><><><><><><><> Describe the management of acute epiglottitis in a child of three years. then — need for IV infusion. sedation. risk of overventilation. Full stomach (regurgitation risk — need for preoperative nasogastric tube with clear washouts and rapid sequence induction of anaesthesia).Page 36 A 6-week old child has projectile vomiting and is presented for laparotomy. 3. careful O2/halothane or sevoflurane induction. If the patient is a premature baby. extra risk of intracranial haemorrhage. antibiotics (usually cephalosporin for Haemophilus A). Hypokalaemia. difficult intubation (with possible use of steroid cream). throat swab. narrow cricoid ring. humidification. fluid management. risk of fluid overload. 2. Describe the general anaesthetic problems of this case. <><><><><><><><><><><><> . Notes for an answer: Rapport with parents. Alkalosis (needs treatment to lower the serum bicarbonate below 30 mmol/L). Notes for an answer: 1. Small size of patient. Comment: This is a safety question. 6. sensitivity to opioids. more difficult intubation. protocol for eventual extubation. 5. Minimum interference with child prior to careful transfer to theatre with humidified O2. short trachea. Dehydration (needs IVI and full rehydration). blood tests for bacteria and RSV. Hyponatraemia (need IVI with half strength saline). Comment: This condition is rapidly becoming rare. transfer to ITU. IPPV. 4. ENT surgeon standing by. with special paediatric problems — risk of hypothermia. Serious omissions likely to cause a fail: Failure to mention alkalosis and regurgitation risk. Serious omissions likely to cause a fail: Failure to mention careful gas induction and difficult intubation.

e. sedation. and about which patients need greater and which need lower dosage. trimeprazine. effect of Downs syndrome on dosages of sedatives. presenting with cyanosis Notes for an answer: Rapport is established with parents. cyanosis makes this case severe enough to require intubation. humidification. paediatric fluid management. drying secretions. using the format described for answers on ''write short notes on" questions. 2. atropine.g. analgesia. throat swab.. routes of administration. infusion. it would also be acceptable to argue the case against premedicating children! <><><><><><><><><><><><> . hyoscine. <><><><><><><><><><><><> What are the aims of premedication in children? Describe the pharmacology of two such premedicant drugs Notes for an answer: 1. antibiotics (broad spectrum in the first instance). ITU. Needs comment on selection criteria for premedication in children and influence on dosages of premedicants in children with relevant concomitant diseases. induction of anaesthesia (gas or iv). e.g.. protocol for eventual extubation. In answer to the first part of the question. benzodiazepines. 3. Details about two drugs. Humidified O2 therapy. IPPV. Comment: An easy answer for those who premedicate children.v. Needs a comment on sedation. blood cultures for bacteriology and virology.Page 37 Describe the management of acute laryngotracheitis in a child of three years of age. potentially difficult intubation. need for rehydration by i.

Page 39 Chapter 4 Neuroanaesthesia .

clotting in cannula. Noninvasive BP (inaccurate on large arms). brachial plexus and wrist blocks and local infiltration are OK. blocked sample tube. leak in sample tube. CVP (catheter tip peripheral — reading is too high. leak in sample tube. Biers block OK. and regional blockade. Serious omissions likely to cause a fail: Failure to mention intracranial pressure. If head injury is stable and improving. straining. Hypoxia. Pulse (if counting from ECG. height of transducer). zero errors. catheter tip in right ventricle — reading is too high. digit too large or too small for transducer. venous pulsation. and jugular venous obstruction. fuel cell dead). FiO2 (blocked sample tube. delay in alerting hypoxia). interference by N2O. Capnography (sampling site too far from lungs. vomiting. If the head injury is unstable. electrical and mechanical interference). Agent monitoring (interference by N2O). cerebral oedema would be worsened by coughing. Operation may need to be postponed. Pulse oximetry (mechanical and electrical interference. monitor wrongly calibrated). monitor wrongly calibrated. Air embolus doppler (errors due to wrong direction). The intracranial critical volume/pressure compliance point may be reached suddenly. and hypercapnia may critically compress brain. <><><><><><><><><><><><> What monitoring do you consider necessary for a posterior fossa craniotomy? What are the possible sources of error associated with two of the monitors you mention? Notes for an answer: List of monitors (with sources of error in brackets). zero errors. clotting in cannula. a high T wave can apparently double the rate. . damping.Page 40 How does concomitant head injury influence your anaesthetic management of operation for a fracture of the hand? Notes for an answer: Monitoring of head injury required as it may be getting worse — monitoring of GCS. Invasive arterial pressure (damping. abnormal haemoglobins. height of transducer). and hypotension would carry risk of cerebral hypoxia. but care is needed with dosages of local anaesthetics because of side effects. if counting from a digit.

increase in flow and volume of vessels. On pH — reduction On adrenal — secretion of adrenalin. • a rise of venous pressure reduces it. • temperature (cold reduces it). Serious omissions likely to cause a fail Failure to mention effects of drugs. On muscle — increased tone. Drugs • examples are thiopentone. 70 mmHg. Serious omissions likely to cause a fail: Failure to mention cerebral circulation. • neurogenic factors — various effects.Page 41 Describe the physiological effects of high arterial carbon dioxide tension (10 kpa. due to vomiting coughing and straining reduces it. On oxygen dissociation curve — move to the right. CO2 narcosis may supervene. <><><><><><><><><><><><> What factors affect cerebral blood flow? State briefly their importance in relation to anaesthesia within 12 hours of head injury Control Factors • a rise of CO2. • arterial pressure (autoregulation controls it between MAP of 40-140). On cerebral circulation — vasodilation. • PO2 (hypoxia increases it). increases it. . mannitol. Pathological Factors • raised intracranial pressure. propofol. • extracellular pH (acidaemia increases it). raised arteriolar tone. On respiration — stimulation of rate and depth.) Notes for an answer: Effects of high CO2: On general circulation — increased arterial pressure. dilation of skin blood vessels. On heart — arrythmias. Rise of intraocular pressure. Raising of ICP. On coronary flow — increase. increased force of myocardial contraction.

• Other drugs. hyperventilation with low CO2 tension causes cerebral vasoconstriction... • anaesthetic volatile agents (increase it). hypoxia. vomiting. propofol. thiopentone (reduce it). • drugs — induction agents e. hypothermia. hypocapnia. ketamine. for example fentanyl. <><><><><><><><><><><><> . cardiovascular instability.Page 42 How may cerebral bloodflow be affected by general anaesthesia? Notes for an answer: General anaesthesia — disruption of controlling factors by the anaesthetic. Comment: This answer also needs a little discussion of the significance to the anaesthetist of raised intracranial pressure. IPPV. intubation. cardiac failure) hypercapnia.g. raised jugular venous pressure (coughing. fluid loading. e.g.

Page 43 Chapter 5 Obstetric Anaesthesia .

Oxytocic-induced vomiting and the need for antiemetics. The sensitivity of the postpartum uterus to the relaxing effect of halothane. which will accentuate responses to anaesthesia. liver Excretion Side effects. H2 antagonist Clinical effects. 150 mg.m. 4 hrs. reduction of volume and acidity of gastric juice Dose. i. AV block. 4. tablets) Pharmacodynamics: Mode of action. <><><><><><><><><><><><> Write short notes on ranitidine This answer needs most of the following headings: Pharmacy: Type of chemical. 5. 2. nosocomial pneumonia Interactions. Pre-partum narcotic drugs may have been given. and that potential hypovolaemia is as dangerous in regional block as in general anaesthesia. in porphyria and phenylketonuria Plus other features: no effect on cytochrome P450 . storage (glass ampoules.. cardiovascular disturbances. Onset. headache dizziness. bradycardia. Acid gastric juice — with risks of severe pneumonitis from regurgitation and aspiration. The possible presence of an existing epidural for obstetric analgesia.Page 44 How do obstetric factors affect the management of anaesthesia for the removal of a retained placenta? Notes for an answer: 1. which can be used for the anaesthetic. 6. A retained placenta can cause severe blood loss. asystole. i. 3. Serious omissions likely to cause a fail: Failure to mention haemorrhage and shock. oral. and risk of aspiration of gastric acid. CNS disturbances — mental confusion.v. Metabolism. anaphylaxis. therefore good IV access essential. 1 hr. Pharmacokinetics: Routes of administration. Duration.

immediate delivery and even emergency hysterectomy. convulsions and placental failure with risk to baby. Organisation for massive transfusion. oxygen carriage problems). diuretics. Stop haemorrhage — need for oxytocics. . • DIC. with coagulopathy. 6. 4. acute anaemia. • convulsions (exact process not clear) with hypoxia. Serious omissions likely to cause a fail: Failure to mention massive transfusion. Preservation of renal and splanchnic function with dopamine. • low platelets (function may be reduced by aspirin). • albminuria. Anaesthetic for severely shocked patient (hypovolaemia.Page 45 Describe the anaesthetic management of massive intrapartum haemorrhage requiring emergency operation Notes for an answer: 1. 7. renal and other organ function. dopexamine. • intrauterine haemorrhage. fast infusion to replace bloodloss. 2. • HELLP syndrome may occur. Risk of DIC — organisation for fresh frozen plasma. • patients are waterlogged. 5. Serious omissions likely to cause a fail: Failure to mention abnormalities of haemostasis. Give oxygen. yet hypovolaemic. 3. • sodium retention. <><><><><><><><><><><><> Describe the pathophysiological processes of pre-eclamptic toxaemia of pregnancy Notes for an answer: Pre-eclamptic toxaemia arises from changes in the placenta which lead to: • hypertension. Need for large. • placental failure (baby at risk). Later — ARDS or MSOF or ileus may require intensive care. who may have a full stomach with acid gastric juice.

hydrallazine. Monitoring the baby. Clinical monitoring of the mother. platelet levels. Is there temporary or continuous bradycardia? 3. Treatment: there should be a continuous attempt to make all abnormal parameters normal. Is there hyper-reflexia or incipient convulsions? 4.Page 46 You are asked to help with a case of severe pre-eclamptic toxaemia of pregnancy. Assessment: hypertension. urinalysis. weight gain. magnesium sulphate to prevent convulsions. alphamethyldopa). . blood gases. FFP for coagulopathy. coagulation screen. The risks to mother may continue after operation. Arterial pressure control is a high priority (IV colloid. 5. What is your management? Notes for an answer: 1. epidural. Serious omissions likely to cause a fail: Failure to mention magnesium sulphate or to consider the baby. attempt at early delivery. If general anaesthetic is required. CVP. How serious and how acute is it? 2. Monitoring: arterial pressure. proteinuria. upper airway oedema may make intubation difficult.

Page 47 Chapter 6 Cardiothoracic Anaesthesia .

blood supply from thyroid arteries. inserted into central tendon. vein. which moves mucus.g. thyroid. aorta. and inferior vena cava. laterally subclavian arteries. kidneys. In this case it is simply the airway! <><><><><><><><><><><><> Describe the anatomy of the diaphragm. inferior vena cava. T4). including its relations Notes for an answer: Origin (cricoid. below – stomach. including its relations Notes for an answer: A sheet of muscle. arcuate ligaments and crura. recurrent nerves and pleura on right side. . fascia and muscle. liver. spine. extra marks can often be gained by noting the function of the structure in question. Comment: In an anatomy question. lined by ciliated epithelium. spleen. aorta. Chest – anteriorly innominate artery. internal mammary artery. blood supply from surrounding vessels.. draining to inferior thyroid plexus. the xiphisternum. Relations: Above – pleura. posteriorly – oesophagus. heart. strap muscles.Page 48 Describe the anatomy of the trachea. arising from the lower 6 costal cartilages. platysma. pericardium. Function: Rhythmic respiration and abdominal straining. lungs. Innervated by recurrent laryngeal nerves and vagi. Carina is related to pulmonary artery bifurcation. laterally – carotid sheath. posteriorly oesophagus. (Also perforated by thoracic duct and hemiazygos vein). recurrent nerves and vagi. Relations: Neck – pretracheal fascia. Innervated by phrenic nerve (C345). C6). arcuate ligament. oesophagus (passing through hiatus) aorta. ribs. tubular midline structure of horseshoe-shaped cartilages (keep airway open). e. There are three main openings – for oesophagus. termination (carina.

to posterior atrioventricular groove. septum and bundle branches. to anastomose with left coronary. . with obtuse. L coronary (dominant in 20%) from left (posterior) sinus between left auricle and pulmonary trunk. R coronary (dominant in 50%) from right coronary sinus. It continues as circumflex in atrioventricular groove. 2. Bundle of His. 2. posterior vein of left ventricle. with posterior interventricular and posterolateral branches. 3. Anterior cardiac veins open into right atrium. goes down right atrioventricular groove (marginal branch down right ventricle). pulmonary conus. and oblique vein of left atrium). <><><><><><><><><><><><> Describe the venous drainage of the myocardium Notes for an answer: 1. Supplies SA node. Thebesian veins (venae cordis minimae) drain into the cavities of the heart. between aorta and right auricle. middle and small cardiac veins. marginal and left lateral branches. It lies in the atrioventricular groove. gives left anterior descending (anterior interventricular) branch which supplies anterior left ventricle. The coronary sinus drains 90% of left ventricular blood supply from five tributaries (great. and drains into the right atrium to the left of the opening of the inferior vena cava.Page 49 Describe the arterial blood supply of the myocardium Notes for an answer: 1. AV node.

right bundle goes under base of anterior papillary muscle of tricuspid valve (as the moderator band) and ramifies in the muscle of the right ventricle. There are 3 internodal pathways (anterior. Bundle of His is inferoposterior to membranous portion of septum. AV node on right side of central fibrous body (has labyrinthine structure which delays conduction and limits number of impulses coming through). <><><><><><><><><><><><> How may abnormalities of cardiac conduction be revealed by the electrocardiogram? Notes for an answer: • Atrial fibrillation. Function: It contains P cells which generate impulses.Page 50 Describe the conducting system of the heart Notes for an answer: This system is specialised myocardial tissue and has pacemaker activity and conduction functions. • Sick Sinus Syndrome. Comment: Each one needs a small description of what the abnormality looks like. has atrionodal. left bundle (below posterior cusp of aortic valve) has 2 branches which ramify in the muscle of left ventricle and interventricular septum. nodal and nodal-His regions. Mention of oesophageal and intracardiac leads. • Heart block. near the top of the crista terminalis and the right auricle. • Re-entry arrythmias. James fibres go to Bundle of His. posterior). middle. SA node on right side of SVC root. Serious omissions likely to cause a fail: Sinuatrial and atrioventricular nodes. . Other (pathophysiological) pathways: Bundle of Kent bypasses AV node. and their significance (usually ischaemic). • Bundle branch block.

Page 51 Describe the anatomy of the bronchial tree Notes for an answer: 1. 4. <><><><><><><><><><><><> Describe the nerve supply of the larynx Notes for an answer: Branches of vagus nerve: Superior laryngeal nerves — external — motor to cricothyroid. curve round the aorta and subclavian artery. beneath the lower part of the pyriform recess. 6. Nerve supply from the pulmonary plexus — vagus is constrictor. 2. They enter the larynx behind the cricothyroid joints. The bronchial tree extends from the carina to the bronchioles. Comment: This is an easy question! . lower — AMALP. Lower bronchi down to 16th division end as terminal bronchioles. 3. R main 15mm x 2cm from carina to intermediate bronchus. Branches — upper — APA. noncholinergic (NANC) system is bronchodilator and mucus secreting. stiffened by small rings and plates of cartilage. Bronchial artery supply from aorta (and third right posterior intercostal artery). L main 13mm x 5cm. lower-APAL. middle — LM. and return to the neck alongside trachea and oesophagus. Lined by pseudostratified columnar ciliated epithelial cells with goblet and serous cells. They arise in the chest. nonadrenergic. internal — sensory from mucosa above cords. (Each letter represents the name of a branch) 5. Recurrent laryngeal nerves — sensory below cords and motor to the other small muscles. adrenergic is dilator. Branches: left upper APA (lingular SI). It is a branching tubular structure. to pulmonary and azygos veins.

the subclavian artery and vein cross the medial end of the first rib and join the brachial plexus. • inferiorly — first intercostal space. • laterally — posterior triangle of neck. • medially — pleura. with intercostal muscles vessels and nerves. artery behind). Relations: • lower surface — pleura. including its relations Notes for an answer: First rib has upper and lower surfaces (lower surface featureless). thoracic duct. head articulates with body of T1. • neck of rib — root of T1. • superiorly — clavicle. costae and serratus anterior inserted into lateral border. . the brachial plexus crosses from superomedial to inferolateral. muscle insertions: scalenus anterior inserted into scalene tubercle (vein in front. phrenic nerves and sympathetic chain. and tubercle with transverse process.Page 52 Describe the anatomy of the first rib. curves downwards and forwards. subclavius. lev. Function: formation of rib cage and respiration. vagus. sickle shaped.

Page 53 Chapter 7 Trauma and Emergency Anaesthesia .

skin necrosis. Describe your management of the case up to the end of the operation Notes for an answer: This is severe road trauma and needs a comment about search for. hypothermia. with intraoperative coagulation screening. • circulatory support (drugs and colloids and crystalloids in severe haemorrhage). • keeping the patient warm. Cardiac. convulsions. retention of urine. often overdosed with other drugs and alcohol. citrate problems. Autonomic. 4. • perhaps consider secondary transfer to liver unit. other injuries. sympathetic stimulation and anticholinergic effects. regurgitation risk. Serious omissions likely to cause a fail: Failure to mention managing massive transfusion. cardiac failure (most inotropes make tachyarrythmias worse). • keeping parents informed of progress. • organisation of ITU. sedation. and possible presence of. and supplies of fresh frozen plasma. Drug overdose effects in general. Comment: It helps to categorise these effects. At emergency laparotomy the surgeon announces that the liver is ruptured. 2. Serious omissions likely to cause a fail: Failure to mention convulsions and tachyarrythmias <><><><><><><><><><><><> A child of 12 years has been admitted following a road accident. • blood glucose support. 3. loss of airway control.Page 54 What are the effects of an overdose of a tricyclic antidepressant drug? Notes for an answer: 1. Brain. • diagnosis of blood clotting abnormalities. tachyarrythmias. especially head injury. coma. <><><><><><><><><><><><> . • organise massive blood crossmatch.

including correct labelling is as important as the technical side). K+ 5. kidney interactions. d) Autotransfusion. hypocalcaemia. hypomagnesaemia. embolism.v. N/A Pharmacokinetics: routes of administration. ARDS. crossinfection. circulatory overload. Cl111. hypothermia. coagulopathy. water and electrolyte replacement clinical effects. mmol/l. Lactate 29. How may they be reduced? Notes for an answer: 1. immediate duration. Pharmacodynamics: mode of action.. Ca++ 2. rehydration dose. 2. lactate load is unsuitable for diabetic patients Plus other features: same electrolyte concentrations as plasma <><><><><><><><><><><><> Describe the adverse affects of blood transfusion. excretion. hyperkalaemia. cell savers and predonation solve many of these problems. Acute and delayed haemolytic reaction. Serious omissions likely to cause a fail: Most of the complications. Reduction of adverse effects: a) Set up a good transfusion service! (the administrative side. 500ml/4-6 hrs onset.g. e) Monitor the patient for overload and transfusion reactions. i. <><><><><><><><><><><><> . concentration (isotonic) Na+ 131. appropriate to clinical situation — e.Page 55 Write short notes on Hartmann's solution This answer needs most of the following headings: Pharmacy: type of chemical (intravenous electrolyte solution) storage (glass or plastic) preparation. b) Warm the blood during transfusion. Platelet transfusion may be needed. c) Ca++ and fresh frozen plasma are given to correct coagulopathy. immunosuppression. citrate intoxication.

CPD adenine or SAGM.Page 56 Describe the alternatives to donor blood transfusion Notes for an answer: 1. hetastarch. Autologous transfusion — predonation/perioperative haemodilution cell savers/salvage with reinfusion. Crystalloids: normal saline. Comment: The above items should be described in detail. <><><><><><><><><><><><> . albumin. haemaccel. <><><><><><><><><><><><> What are the contents of a unit of transfusion blood? Describe briefly the alternatives which can be used in an emergency haemorrhage situation until transfusion blood becomes available Notes for an answer: Contents: 350 ml. with lower clotting factors and low platelets. blood. Alternatives: Colloids: dextran 70. Haemoglobin infusion with 2. 4.0. 5% dextrose. It becomes progressively more hyperkalaemic and acidotic during storage. 3. 2. Fluorocarbons—fluosol emulsion 5ml/dl. hespan. Hartmann's solution.3 DPG analogue (nephrotoxicity of red cell stroma). 150 ml. gelofusine. (Most is plasma-reduced and therefore low in albumin and globulins). Colloid infusion (which will be limited by progressive anaemia). O2 carriage @ FiO2 1.

needle valves on flowmeters to restrict flow. resuscitation from shock and haemorrhage Dose. immediate Duration. not the patient). Reducing valve and flow restrictor for cylinders. heidbrink valve (the pressure relief valve protects the machine. Metabolism.Daltons) storage (glass or plastic). 2. <><><><><><><><><><><><> Describe the features of the Boyle's anaesthetic machine and Bain system which protect the patient from pulmonary barotrauma Notes for an answer: The following items need to be addressed: 1. risk of overinfusion Comment: This answer will also need details of the various types of product.v. i. expansion of the plasma compartment Clinical effects. via kidneys Side effects.Page 57 Write short notes on Gelatin-based plasma substitutes This answer needs most of the following headings: Pharmacy: Type of chemical (high molecular weight colloids 30-70 K. concentration (frequently slightly hypertonic) Pharmacodynamics: Mode of action. preparation. appropriate to clinical situation Onset. which limits pressure rises. allergy. Airway pressure limiter (and its limitations). hours Pharmacokinetics: Routes of administration. <><><><><><><><><><><><> . very little Excretion. thin-walled bag.

Baroreceptors firing reduced. Carotid chemoreceptors stimulation causes hyperventilation. b) pituitary renal/adrenal axis. 4. raised diastolic) respiratory effects (hyperventilation). shift of water into circulation. 3. distress. Some indication of signs—reduced capillary refill. muscle and viscera to heart and brain. vasoconstriction and hypotension. adrenaline secretion. 6. 1. loss of muscle tone. endorphin secretion. Blood volume falls causing reduced venous return. angiotensin. General description of the clinical picture in the hypovolaemic patient with fall of cardiac output. thirst. BP maintained till loss of 20% volume.Page 58 What physiological changes follow acute hypovolaemia? Notes for an answer: Definition: imbalance between circulating volume and capacity of circulation. ADH. Cold periphery. ACTH. venoconstriction. redistribution of CO from skin. oliguria. resulting in dilutional anaemia. ADH. Cortisone secretion. and demonstrates that any subject may be asked in several different ways. Atrial receptors cause ADH secretion (resulting in oliguria and water retention). 2. 5. Serious omissions likely to cause a fail: Baroreceptors. Comment: This is similar to the previous question. tachycardia. <><><><><><><><><><><><> What is the physiological response to the rapid loss of 1 litre of blood in the adult? Notes for an answer: 1. Compensation: a) baroreceptors—arteriolar resistance. leads to tachycardia. <><><><><><><><><><><><> . cardiac effects (tachycardia. Reduced cardiac output causes systolic and pulse pressure fall. pallor. reduced capillary refill. water transfer from ECF to circulation. c) fluid shifts from ECF to blood. with timescale. reduced RA pressure. CO. cyanosis. 2. renin. vasoconstriction. Aldosterone secretion (causes Na+ retention).

cold inspired gases.Page 59 Outline the factors responsible for the maintenance of cardiac output Notes for an answer: 1. and cooling of the blood. myocardial contractility (Starling's Law of the heart). Diastolic coronary blood flow and PaO2. <><><><><><><><><><><><> What are the causes and effects of hypothermia? Notes for an answer: Causes: Conduction. 3. Effects: Dysrythmias at < 31° C. Prolonged action of general anaesthetics and relaxants. as when a limb is packed in snow. drowning. shivering and hypoxia on recovery. increased Hb oxygen affinity. supplying the substrates for muscle action. radiation. peripheral vasoconstriction. convection. Serious omissions likely to cause a fail: Failure to mention Starling's law. cooling of the blood: cold IV infusions.e. convection: evaporation of skin prep or water vapour from exposed serous cavities during operation. <><><><><><><><><><><><> . Sympathetic and parasympathetic activity. 4. absent shivering response (due to anaesthesia or alcohol intoxication). PaCO2 levels.. or a donor organ transported in melting ice. loss of hypothalamic control. coagulation problems. Venous return.g. and heart rate (especially in children)—Bowditch effect. deliberate hypothermia during cardiopulmonary bypass. fall in CBF. 2. conduction of heat to cold surroundings. radiation to cold surroundings (note the importance of ambient temp). dry. especially when there is vasodilation. reduced O2 consumption. Inotropic hormones. slow metabolism of drugs and citrate. inotropic hormones and nerve control of heart. acidosis.

X ray: chest. Investigations: FBC. urine output and CVP. IV access is established. note of the appropriate anaesthetic drugs. skull. Blood sample for drug levels if history indicates this. oxygen. arterial pressure. Exposure (other injuries). Resuscitation. GCS monitoring is commenced). Serious omissions likely to cause a fail: Cervical collar. capillary refill. pupils. and the main elements of ATLS. Circulation—pulse. and IPPV. capnography. <><><><><><><><><><><><> . pelvis.Page 60 Describe the immediate rescusitation (in the first hour) of an unconscious patient admitted to the A & E department after falling off a ladder Notes for an answer: Primary survey—the main elements of ATLS. Cervical support collar is placed until cervical spine is known to be stable. the vomiting risk. pulse oximetry. O2. Breathing. Secondary survey: more detailed examination and repeated further assessments. Items A and B. C: volume replacement as necessary with monitoring of arterial pressure. neck. capillary refill (hypotension is likely to be due to extracranial bleeding or spinal injury). O2 is given. ABG's. Cross-match. BP. Airway. Monitoring: ECG. Disability of cerebrum (level of consciousness. intubation (with care of cervical spine). CVP. cricoid pressure (because of the vomiting risk).

Page 61 Chapter 8 Acute and Nonacute Pain Management .

oral.Page 62 What are the medical effects of opioid drugs? 1. Pharmacokinetics: Routes of administration. Bronchospasm 10.v. nausea and vomiting. 1 mg/kg. liver Side effects. Addiction 3. Miosis 7. Sedation 8. Slowing of premature labour 13. Histamine release 15. Bradycardia 6. (phenylpiperidine) storage (aqueous in glass ampoules). preparation (synthetic) concentration Pharmacodynamics: Mode of action opioid agonist Clinical effects. <><><><><><><><><><><><> Write short notes on pethidine This answer needs most of the following headings: Pharmacy: Type of chemical. im. Biliary spasm 11.. Nausea and vomiting 5. Respiratory depression 4. Analgesia 2. addiction. analgesia. addiction. epidural Metabolism. sedation. Hallucinations 9.. Muscle rigidity Serious omissions likely to cause a fail: Failure to mention respiratory depression and addiction. respiratory depression. relaxation of smooth muscle Dose. Renal colic 12. Itching 14. nausea and vomiting. histamine release. Onset. respiratory depression. . minutes Duration. 2-4 hrs. i.

synthesised in 1939. MAOI's—collapse and coma Plus other features: related to atropine.Interactions. .

This answer needs a note about customising treatment for the individual patient and discussing patient preferences! Complications: • NSAID's (haemorrhage. • IM opiates (powerful and safe). Serious overdose has occurred. and hypotension). patients can customise dosage to their own needs). renal failure and bleeding). powerful analgesia). reasonably strong fingers and may cause vomiting and hallucinations. numb legs and risk of unrecognised apnoea from opiates. • Other oral analgesics: very safe but most are not so powerful.). • PCA (powerful. no respiratory depression or vomiting). and the dangers of epidural opiates. • IM opiates (nausea. • Epidural catheters (weak. <><><><><><><><><><><><> . ulcers. • PCA (needs common sense. • Epidural catheters (superb. vomiting and delay in action). Serious omissions likely to cause a fail: Failure to mention PCA. swift reaction to pain.Page 63 Discuss the methods available for the relief of pain following abdominal hysterectomy Notes for an answer: Advantages: • NSAID's (reasonably powerful.

Pharmacokinetics: Routes of administration. preparation. other NSAIDs <><><><><><><><><><><><> Describe the principles involved in prevention and treatment of postherpertic neuralgia in the upper limb Notes for an answer: Place of preventive analgesia of herpes zoster. gastric irritation. minutes Duration. oral. may be helped by tricyclic drugs and other coanalgesics. analgesics and constipators. The examiner also needs to see the usual pharmacological details e. storage (powder or tablet). platelet inhibition. using the answer format for questions which start ''Write short notes on.Page 64 Write short notes on tenoxicam This answer needs most of the following headings: Pharmacy: Type of chemical (nonsteroidal anti-inflammatory drug).v. Onset. 10-12 hrs.". local analgesics. <><><><><><><><><><><><> . analgesia Dose. .g. acyclovir cream.. IV guanethidine block. This is neuropathic pain and is self-limiting. Serious omissions likely to cause a fail: Respiratory depression.m. local prostaglandin inhibition Clinical effects. concentration Pharmacodynamics: Mode of action.. 20-40 mg. i. capsaicin cream. . tendency to renal failure Interactions. i. but codeine doesn't sedate and has less respiratory depression by IM route. <><><><><><><><><><><><> Compare and contrast pethidine and codeine Notes for an answer: Both Controlled Drugs. liver Side effects. Metabolism.

storage (powder or tablet) Pharmacodynamics: Mode of action. <><><><><><><><><><><><> Describe the pharmacological eeffects of pparacetamol Notes for an answer: This answer needs most of the following headings: Pharmacy: Type of chemical (simple analgesic drug).Page 65 Describe the adverse reactions which may follow the use of non-steroidal anti-inflammatory drugs Notes for an answer: PGE1 synthase inhibition causing (reversible) gastric irritation. Pharmacokinetics: Routes of administration. analgesia Dose. exacerbation of asthma. hepatic damage. overdose causes serious hepatic damage Interactions. 10-15 mg/kg. liver Side effects. Serious omissions likely to cause a fail: Renal failure. potentiates other analgesics <><><><><><><><><><><><> . central prostaglandin inhibition Clinical effects. Thromboxane A inhibition causes irreversible loss of the adhesiveness of existing platelets. aseptic meningitis in patients with SLE. renal failure. water retention. 4-6 hrs. rashes. Onset. minutes Duration. oral Metabolism. angioedema.

simple analgesia Clinical effects. Onset. analgesia Dose. minutes Duration. liver Side effects. potentiates other analgesics <><><><><><><><><><><><> . 30-65 mg.Page 66 Describe the P0armacological effects of dextropropoxyphene Notes for an answer: This answer needs most of the following headings: Pharmacy: preparation (tablet). 6-8 hrs. oral Metabolism. it is an opiod Pharmacodynamics: Mode of action. respiratory depression and acute heart failure. Pharmacokinetics: Routes of administration. overdose convulsions Interactions.

Page 67 Chapter 9 Intensive Therapy .

Antibiotics may be needed. 4. 6. Plasmapheresis may be needed. Prevention of bedsores and use of physiotherapy. How do you cope with the medical problems of this situation? Notes for an answer: 1. Intubation and IPPV for respiratory failure. Respiratory failure (and how it is diagnosed) would indicate intubation and IPPV. nasogastric tube and enteral nutrition will be required. Identification of what caused relapse and treatment of infections if appropriate.Page 68 A patient is admitted to the intensive care unit with a relapse of myasthenia gravis. with risk of chest infections. and the answer should address this. Will this be a short. Comment: The mention of ITU indicates that this relapse is severe. Steroid cover may be required. Problems of inability to swallow and excessive secretion of saliva due to anticholinesterases. 7. How do you cope with the medical problems of this situation? Notes for an answer: 1. <><><><><><><><><><><><> A patient is admitted to the intensive care unit with Guillain Barre Syndrome. 6. Problems of inability to move and the unhappiness this causes. 3. 2. Identification of the degree of disability. Steroid cover may be required. 5. Serious omissions likely to cause a fail: Failure to mention anticholineserases and respiratory failure. 3. Antibiotics may be needed for this. 4. Protection of the eyes because of inability to blink. with risk of infections.or long-term case? How will nutrition be provided? <><><><><><><><><><><><> . 5. 2. Prevention of bedsores and use of physiotherapy.

Page 69 Why do some patients develop ARDS following colectomy? What are the pathophysiological processses? Notes for an answer: The sequence of events may be: gut wall ischaemia — endotoxinaemia — eicosanoid secretion — endothelial damage — capillary closure — tissue hypoxia and oedema — destruction of type I cell — proliferation of type II cells — hyaline membrane formation — shunting. • oesophageal intubation by mistake. <><><><><><><><><><><><> Describe the complications of endotracheal intubation. Longer Term: • candida/haemorrhage/crusting/dilation of trachea/stenosis of trachea. • bronchospasm. • subglottic oedema and stenosis in children. causing obstruction. Serious omissions likely to cause a fail: Failure to mention endotoxin and generalised endothelial damage. • herniation of cuff. hypercapnia—barotrauma (due to IPPV)—lung destruction. • endobronchial intubation resulting in one-lung ventilation. hypoxia — deadspace. • kinking of tube with respiratory obstruction. • throat packs left in. • sore throat. Notes for an answer: Short Term: • cardiovascular—reflexes due to intubation. Serious omissions likely to cause a fail: Failure to mention obstruction and nosocomial infection in the longer term. • laryngospasm on extubation. • obstruction of tip against tracheal wall. <><><><><><><><><><><><> .

Arches up across rib. 5-10 Hz. Rates: 1-1. • reduction of pulmonary leak during IPPV in cases of bronchopleural fistula. postero-laterally lies subclavian artery and pleura. and cupola of pleura. subclavian artery. transverse processes. (high frequency oscillation). then medial. from lower border of first rib. <><><><><><><><><><><><> . vagus. traverses the neck from jugular bulb to subclavian vein. and join internal jugular vein behind sternoclavicular joint.Page 70 What is the venturi principle? Describe the clinical uses of high frequency jet ventilation Notes for an answer: Principle: High speed gas jet causes suction on surrounding areas with entrainment of surrounding gas. <><><><><><><><><><><><> Describe the anatomy of the internal jugular vein Notes for an answer: Jugular—large thin-walled vein. The lower part is behind sternomastoid. across scalenus anterior insertion to enter thorax. Anterior is clavicle. It lies in front of prevertebral fascia. Uses: • rigid bronchoscopy and intratracheal surgery. then lateral. • to allow reduced requirement for sedation during IPPV. posteriorly is vagus and phrenic nerves.5-5 Hz. From above lies posterior. in carotid sheath with artery and vagus. then anterior to artery. vertebral muscles. • reduction of pulmonary barotrauma in ARDS.5 Hz. downwards and forwards. and lower down. <><><><><><><><><><><><> Describe the anatomy of the subclavian vein Notes for an answer: The subclavian is the continuation of the axillary vein. • for the development of intrinsic PEEP in the intensive care case. phrenic. 1.

c) landmarks. pneumothorax. (midpoint between mastoid and manubrium. Avoidance: a) position of patient. g) chest X-ray for position of cannula tip. thoracic duct injury on left. c) landmarks. e) avoidance of unwanted damage to other structures e.g. and how do you avoid them? Notes for an answer: Complications: Air embolism. e) avoidance of unwanted damage to other structures in neck by good knowledge of anatomy and inserting needle in upper half of neck to avoid pleura. pneumothorax. and how do you avoid them? Notes for an answer: Complications: Air embolism. b) careful preparation of skin. surgical emphysema. haematoma. head down. sepsis. haematoma. <><><><><><><><><><><><> What are the possible complications of subclavian vein cannulation. f) aspiration test for position of cannula tip. <><><><><><><><><><><><> . b) careful preparation of skin. d) use of seldinger wire system and careful direction of insertion. surgical emphysema. f) aspiration test for position of cannula tip. pleura by not allowing needle to go between ribs. sepsis. 1 cm below midpoint of clavicle..Page 71 What are the possible complications of internal jugular vein cannulation. artery puncture. lateral to carotid artery). sympathetic trunk damage. Serious omissions likely to cause a fail: Failure to mention pneumothorax. g) chest X-ray for position of cannula tip. carotid or vertebral artery puncture with cerebral damage. d) use of seldinger system and careful direction of insertion towards suprasternal notch. Avoidance of Complications: a) position of patient — head down. Serious omissions likely to cause a fail: Failure to mention pneumothorax and carotid artery puncture.

Compare the properties of dopamine with this ideal Notes for an answer: Effective in normal and abnormal hearts. severe anticoagulation with heparin). • Hb level and O2 affinity of haemoglobin. no arrythmias. preventing endotoxinaemia. side effects — pulmonary and systemic vasodilation. half life 3 min.. no alpha effects. bradycardia. doesn't raise myocardial VO2. raises renal and splanchnic perfusion. a description of nitric oxide is also appropriate <><><><><><><><><><><><> List the properties of an ideal inotrope. • tissue oedema. sweating. • body temperature. arterial pressure. headaches hypotension. How may these factors be altered by septic shock? Factors: • O2 supply to lungs. • unbalanced blood distribution. Dopamine comes out quite well! <><><><><><><><><><><><> List the factors which determine the supply of oxygen to the tissues of the body. no side effects. infusion 2-5 µg/kg/min. • endothelial swelling. including shifts of the O2 dissociation curve.Page 72 Describe the pharmacology of a drug used to relieve severe pulmonary vasoconstriction Notes for an answer: An example would be: prostacyclin (inhibits platelet aggregation. • respiratory drive and adequacy of ventilation. • bypass of capillaries via arteriovenous anastomoses. • pulmonary O2 transfer (shunting and V/Q mismatch). Alteration by Septic Shock: • reduction of lung function. cardiac output. thrombocytopenia. flushing. • capillary function. • cardiac output and blood distribution. <><><><><><><><><><><><> . capillary closure. pallor.

g. storage (liquid). sepsis and hypotension). hours Pharmacokinetics: Routes of administration. preparation. right ventricle. At the same time. via GI tract Side effects.. serum bicarbonate is measured. concentration Pharmacodynamics: Mode of action. via internal jugular line. and pulmonary artery. and pHi derived from the Henderson-Hasselbalch equation) and in which situations it is deranged (pHi is reduced in shock. infection. <><><><><><><><><><><><> . arrythmias. CO2 from gastric mucosa diffuses into this. at pH < 4 polymerises and adheres to ulcer craters. 2 g. <><><><><><><><><><><><> Write short notes on pulmonary capillary wedge pressure Notes for an answer: Need comment on: • method of inserting the flotation catheter. oral Excretion. twice daily Onset. no effect on gastric pH Plus other features: the name means sucrose (aluminium) sulphate — it increases gastric production of mucus. immediate Duration. completely filled with saline. and a sample is withdrawn and measured. physical protection of gastric mucosa Clinical effects. • pressures during insertion.g. e. preventing peptic ulceration Dose. • interpretation of readings.. and does not cause nosocomial pneumonia. <><><><><><><><><><><><> Write short notes on Sucralfate This answer needs most of the following headings: Pharmacy: Type of chemical. in the superior vena cava. • complications of technique (e. damage to pulmonary vessels).Page 73 Write short notes on gastric tonometry Need a description of how pHi is derived and measured (catheter with a balloon. right atrium.

renal vasodilator Dose. 2. Onset.v. i. vasoconstriction in high dosage <><><><><><><><><><><><> Discuss the occurrence of metabolic acidosis in patients in the intensive care unit Notes for an answer: 1. shunting problem due to hyaline membrane. preparation. concentration Pharmacodynamics: Mode of action. <><><><><><><><><><><><> . 1-10 µg/kg/min.Page 74 Write short notes on dopamine This answer needs most of the following headings: Pharmacy: Type of chemical (catecholamine). diffusion problem due to oedema. renal failure. Causes — tissue hypoxia. crusting. immediate Duration. 3. Treatment — need discussion of the problems of bicarbonate. deadspace problem due to capillary blockage. barotrauma due to hyperventilating normal lung in juxtaposition to areas of stiff diseased lung. storage (aqueous solution in coloured glass ampoules). and their considerable limitations. Secondary nosocomial infection. insulin antagonism (with the various acids involved). stimulation of adrenergic and dopamine receptors Clinical effects. inotrope. Metabolism. Prevention — The methods of preventing the above. <><><><><><><><><><><><> Give a brief account of the pulmonary problems that occur during intermittent positive pressure ventilation of the lungs in ARDS Notes for an answer should include the following aspects: misplacement of tracheal tube. liver Side effects. very transient unless infused Pharmacokinetics: Routes of administration.

storage (aqueous solution in glass ampoules) Pharmacodynamics: Mode of action. bradycardia.Page 75 Write short notes on prostacyclin This answer needs most of the following headings: Pharmacy: Type of chemical (natural hormone). inhibits platelet aggregation Clinical effects. pulmonary and systemic vasodilation. used in haemofiltration Dose. pulmonary and systemic vasodilation. sweating Interactions. Pharmacokinetics: Routes of administration. Onset.v. severe anticoagulation with heparin Plus other features: used in haemofiltration <><><><><><><><><><><><> . infusion 2-5 µg/kg/min. immediate Duration. flushing. i. pallor. liver Side effects. half-life 3 min. headaches hypotension. Metabolism.

Page 77 Chapter 10 Clinical Measurement .

) Comparison of absorption at different wavelengths (not necessarily the isobestic point) gives relative concentrations of HbO and Hb. The pulsing (AC) component is amplified and displayed digitally or graphically. Light absorbed depends on their concentrations and the thickness of the medium. Analyser sites may be direct (instream) or indirect via withdrawn sample. <><><><><><><><><><><><> . zero = air. the SpO2. The steady (DC) component is rejected. CO2 absorbs the infrared and emergent beams are compared by photoelectric cells.Page 78 Describe the physical principles of the pulse oximeter Notes for an answer: Hb and HbO have different absorption spectra. there is some doubt about the relevance of this. cylinder or reference cell Serious omissions likely to cause a fail: Failure to mention zeroing the calibration. infrared beam splits and passes through a reference and sample gas chambers. span — using accurately known CO2 sample from machine. How may it be calibrated? Notes for an answer: Principle of the infrared device: two different atoms in a molecule cause infrared absorption. Calibration of each model (at the top end of the SpO2 scale) is done using volunteers. (Beer-Lambert Law. Infrared light from diode emitter passes through or is reflected from skin to a photodetector. <><><><><><><><><><><><> Describe the physical principles of a capnograph. Calibration: electronic/physical.

movement artefacts). • disconnection of anaesthetic system (sudden fall of CO2 to zero). • oesophageal intubation (no CO2 in gas). Serious omissions likely to cause a fail: Failure to mention oesophageal intubation. emphysema. Sources of error: interference. so SpO2 falsely low. • shock (low CO2 production). 6. • MH (fast rising CO2). nail polish and dirt. • PE. mechanical (fingers too large for probe. COHb counted as HbO. Warning of central hypoxia may be delayed. • fall of cardiac output (falling CO2). 2. air embolism (sudden fall of CO2 excretion). Fails during poor tissue perfusion (a useful sign of poor perfusion). so SpO2 falsely high. 3. 5. airtrapping (sloping plateau). electrical. • rebreathing (graph does not return to zero on inspiration). 4.Page 79 What information can a capnograph give about an anaesthetic? Notes for an answer: End-tidal carbon dioxide monitoring may indicate: • adequacy of ventilation. Comment: In spite of these sources of error. pulse oximetry is an excellent monitor! <><><><><><><><><><><><> . methaemoglobin and bilirubin counted as Hb. • wearing off of relaxants (notching of capnograph plateau). Methylene blue. <><><><><><><><><><><><> What are the sources of error of the pulse oximeter? Notes for an answer: 1. Inaccurate in presence of venous congestion (venous pulsation) or low SpO2 (not calibrated in this range). • death (cessation of CO2 production). Inaccurate during cardiopulmonary bypass. light. • sodalime exhaustion (rising CO2).

5. <><><><><><><><><><><><> . c. head-up position. and acute left ventricular failure. 2. Administration of analgesic and relaxant. Intravenous infusion (or central line). spont. note also assessment of venous waves a. v. Serious omissions likely to cause a fail: Failure to mention treatment of shock. and effect of tachycardia and bradycardia). Identification tag for patient. Smooth slow journey. 8. esp. capnography. right side of heart. 7. X-rays). trained escort./IPPV. Hard collar if cervical spine injury is suspected.Page 80 What arrangements are required for an adult head-injured patient. 9. Administration of mannitol or frusemide. pulse oximetry. if not already given. during transfer to a neurosurgical unit? Notes for an answer: 1..g. or who have fitted. c) Managing fluid and blood transfusion. Clear notes of injuries. d) Monitoring cardiac performance. b) Diagnosis and subsequent management of shock. Intubation and ventilation of patients who are comatose. with investigations (e. 4. 6. <><><><><><><><><><><><> What information can be gained from measuring central venous pressure? a) Normal range: (with variations erect/supine/head down. 3. depressed conscious level. and ongoing Glasgow Coma Score chart. arterial pressure. Monitoring. with added oxygen.

Page 81 Chapter 11 Regional and Local Analgesia .

other catecholamines potentiated Plus other features: a very safe and effective drug <><><><><><><><><><><><> . rise of arterial pressure. <><><><><><><><><><><><> Write short notes on ephedrine This answer needs most of the following headings: Pharmacy: Type of chemical (catecholamine). i. iv.. Comment: There is still a widespread misconception that spinals are always safe! Serious omissions likely to cause a fail: Failure to mention apnoea and hypotension. alpha and beta agonist Clinical effects. concentration (30mg/ml. itching. incontinence.). foreign body left in dural space.Page 82 What are the dangers and complications of intradural spinal analgesia? Notes for an answer: Immediate: inappropriate dosage causing total spinal. liver Side effects. topical Metabolism. Pharmacodynamics: Mode of action. bronchodilation. backache. headache. apnoea. retention of urine. epidural haematoma and abscess. increases awareness during light anaesthesia Interactions. respiratory depression.. bradycardia. intravascular injection of local anaesthetic. meningitis. Later complications: arachnoiditiis.m. paralysis of legs preventing ambulation. neurological damage from inadvertent injection of toxins. Onset. relief of nasal congestion Dose. seconds Duration. storage (aqueous solution in glass ampoules). 3-30 mg. hypotension. spinal artery syndrome. 3-30 mins. Pharmacokinetics: Routes of administration.

low systemic vascular resistance. • Inadequate block (failed. • Abducens palsy. • Epidural or spinal haematoma. • Neurological damage. Comment: It is difficult to know where to stop with this list! These are only the main complications. apnoea. restlessness. Subdural injection. spinal artery syndrome. spinal abscess. headache. <><><><><><><><><><><><> . • Increased gut tone and relaxation of sphincters. unilateral. bradycardia. bradycardia b) convulsions followed by depression. patchy). • Nausea. Serious omissions likely to cause a fail: Failure to mention total spinal. • Systemic toxicity from local anaesthetic absorption. systemic toxicity. • Broken needle or catheter. sepsis (meningitis or abscess).Page 83 What are the dangers and complications of extradural analgesia? Notes for an answer: The hazards of epidural anaesthesia: • Inadvertent spinal or total spinal. vomiting. radiculitis. arachnoiditis. • Backache. impaired cough and tidal volume. low cardiac output. low arterial pressure. missed segment. with effects similar to total spinal. • Respiratory — respiratory depression. hypotension. • Other systems — Urinary retention or incontinence. a) cardiovascular. • Cardiovascular — hypotension.

• moderate failure rate. • ilioinguinal nerve may be damaged. • no resp. depression in patients with respiratory failure. Disadvantages: • does not always work. • control of own airway. • no IPPV. • catheter for longer analgesia. • haematoma. • conscious. • backache. . • hypotension. • no hypotension. • foreign body may be left in spinal canal. especially on the hernia sac. avoids IPPV in patients with respiratory failure. • drug toxicity. Disadvantages: • more complex technique. • infection. • total spinal.Page 84 What are the advantages and disadvantages of the local anaesthetic and epidural anaesthetic techniques for the repair of an inguinal hernia? Notes for an answer: Ilioinguinal Advantages: • simple. failure to list the disadvantages of epidural analgesia. • conscious. • hypovolaemia. Epidural Advantages: • control own airway. • avoids use of opioids. • avoids systemic opioids. Serious omissions likely to cause a fail: Failure to mention value in patients with respiratory failure.

kidney Side effects. Pharmacodynamics: Mode of action.Page 85 Write short notes on prilocaine This answer needs most of the following headings: Pharmacy: Type of chemical (amide). epidural. intravenous regional block Metabolism. up to 8 mg/kg. to orthotoluidine (causes methaemoglobinaemia) Excretion. blockade of nerves Clinical effects. local analgesia Dose. storage (aqueous solution in glass ampoules). <><><><><><><><><><><><> . methaemoglobinaemia Plus other features: one of the safest local analgesics. liver. minutes Duration. of 0. 1-2 hours Pharmacokinetics: Routes of administration.5-2% solution Onset. infiltration.

<><><><><><><><><><><><> . anticoagulants. less bleeding. backache. The following are also relevant to this answer: Advantages (Reasons for Choosing) of Regional Analgesia: • Avoidance of respiratory depression in the obese and in respiratory failure. Serious omissions likely to cause a fail: Failure to mention advantage of regional analgesia in respiratory failure and morbid obesity.g. meningitis. bradycardia. apnoea. easier recovery as patient is fully awake. uncooperative patient. fixed cardiac output. retention of urine. spinal artery syndrome. Disadvantages (Reasons for not Choosing) of Regional Analgesia: • Immediate: inappropriate dosage causing total spinal. untreated hypertension.. local sepsis. physical abnormalities (spinal deformity).Page 86 What factors would influence your decision to choose a regional technique in preference to a general anaesthetic for transurethral resection of the prostate? Notes for an answer: Indications for Regional Analgesia (RA): Patient preference in favour of RA. reduction of haemorrhage due to parasympathetic blockade. epidural haematoma and abscess. hypotension. easier recognition of TURP syndrome. COAD. neurological damage from inadvertent injection of toxins. Comment: It is very helpful in an answer like this to categorise your points. Contraindications of RA: Patient preference against RA. good postoperative analgesia. • Later complications: arachnoiditis. respiratory depression. intravascular injection of local anaesthetic. ischaemic heart disease. disorders of haemostasis. paralysis of legs preventing ambulation. headache itching. foreign body left in dural space. e. incontinence.

Page 87

Write short notes on midazolam This answer needs most of the following headings: Pharmacy: Pharmacodynamics: Mode of action, benzodiazepine receptor agonist Clinical effects, sedation, amnesia Dose, 1-10 mg. Onset, minutes Duration, 1-2 hours Pharmacokinetics: Routes of administration, i.m., i.v., oral Metabolism, liver Excretion, kidney Side effects, overdose causes unconsciousness, with loss of airway control, and hypoxia Interactions, reversed by flumazenil

<><><><><><><><><><><><>

What factors influence the choice of anaesthetic for insertion of arteriovenous shunt for haemodialysis? Notes for an answer: The effect of general anaesthetics on renal function (risks of hypoxia and hypotension; the effect of NSAIDS on renal function). Effect of renal failure on general anaesthetics — the following are relevant: • anaemia; • hyperkalaemia (suxamethonium, cardiac arrythmias — not a problem if patient has been dialysed very recently); • many nondepolarising relaxants greatly prolonged. Thus regional blocks are ideal, for example plexus block may dilate blood vessels and make the operation easier; and they avoid the problems of general anaesthetics, but some patients may prefer general anaesthesia in addition. Furthermore, brachial plexus block would be contraindicated if the patient were anticoagulated. Comment: There is no right or wrong technique here, there are merely advantages and disadvantages.
Serious omissions likely to cause a fail: Failure to mention anaemia and hyperkalaemia

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Page 88

Write short notes on naloxone This answer needs most of the following headings: Pharmacy: Type of chemical, (oxymorphone derivative), storage (aqueous solution in glass ampoules), preparation, concentration Pharmacodynamics: Mode of action, opiate antagonist with receptor affinity but no receptor stimulation Clinical effects, reversal of respiratory depression caused by natural and synthetic opioids Dose, 7 µg/kg. Onset, rapid Duration, 30 mins-6hrs (i.m.) Pharmacokinetics: Routes of administration, i.m, i.v. Metabolism, liver Side effects, reverses nitrous oxide anaesthesia

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Describe the effects and treatment of bupivacaine overdosage Notes for an answer: Effects: 1. Vascular — hypotension, cyanosis. 2. Cardiac — arrythmias, negative inotropy, arrest. 3. Cerebral — convulsions, hypoxia. Treatment: Oxygen, IPPV, ACLS for cardiac arrest; diazepam, anticonvulsants. Careful volume loading, needs mention of dangers of inotropes in worsening of arrythmias, and dangers of some anticonvulsants, e.g., thiopentone in worsening of cardiac failure. Comment: This is a question of safety and omissions would be marked severely.
Serious omissions likely to cause a fail: Failure to mention cardiac arrest and convulsions. Failure to mention the need for oxygen in treatment.

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Page 89

What are the advantages and disadvantages of the supraclavicular and axillary approaches to the brachial plexus block Notes for an answer: Supraclavicular: Advantages: wider area of block. Disadvantages: pneumothorax risk, vessel damage (inc. thoracic duct); risk of intravascular injection; location of plexus may be difficult. Axillary: Advantages: much less risk of pneumothorax; location of plexus is usually easier. Disadvantages: inadequate block above elbow unless large volumes of analgesic are used; vessel damage; axillary skin may be infected; risk of intravascular injection. Comment: An easy question for those who have performed these blocks!
Serious omissions likely to cause a fail: Failure to mention pneumothorax.

<><><><><><><><><><><><>

Write short notes on adrenaline This answer needs most of the following headings: Pharmacy: Type of chemical (amine), storage (aqueous solution in glass ampoules or syringes). Pharmacodynamics: Mode of action, stimulates sympathetic receptors, alpha 1 and 2; beta 1 and 2 Clinical effects, rise of pulse rate and atrerial pressure, redistribution of circulation, dilate bronchus and pupil raise central excitatory state, quieten gut Dose, 0.1 mg for anaphylaxis; 1mg for CPR; 1/200,000 vasoconstrictor for local anaesthetics Onset, rapid Duration, 10 mins Pharmacokinetics: Routes of administration, i.v. and infiltration Metabolism, catechol-o-methyl transferase and monoamine oxidase Side effects, feelings of panic! Interactions, monoamine oxidase inhibitors, cocaine

<><><><><><><><><><><><>

v. with local analgesic. What are their shortcomings? What are their risks? Notes for an answer: Place: very helpful for supplementary and postoperative analgesia. Shortcomings: Note that these blocks by themselves are inadequate for surgery. Intercostal block: short bevel needle inserted just below rib. because the gall bladder is often innervated by vagus and/or phrenic nerves.Page 90 What is the place of local analgesic nerve blocks in the anaesthetic technique for cholecystectomy (excluding ''spinal" and extradural techniques)? State briefly how they are performed. access and available resuscitation equipment. or special cannula into pleural space at angle of rib. Subcostal block: infiltrate subcostal area of abdominal wall in both subcutaneous and muscle layers. Comment: There is a great risk of over-running your allotted time. into subcostal groove. Risk: peritoneal. posterior to angle. have i.v. Keep this answer in note form. The problem of overlap of innervation from adjacent intercostal nerves is solved by blocking multiple spaces. <><><><><><><><><><><><> . pleural or pericardial puncture. using long-acting agents. Performance: Clean skin first. Risk: pneumothorax. and volumes of local analgesic required are close to toxic doses. Intrapleural block: insert i. Serious omissions likely to cause a fail: Failure to mention at least two of these blocks. taking care to avoid pneumothorax and intercostal artery puncture. Risk: haematoma and pneumothorax.

5-1%). less toxic than bupivacaine Plus other features: better motor block than bupivacaine <><><><><><><><><><><><> . <><><><><><><><><><><><> Write short notes on ropivacaine This answer needs most of the following headings: Pharmacy: Type of chemical (amide). local analgesia Dose. and proceed to midline. Pharmacodynamics: Mode of action. Comment: A diagram would be helpful here. liver Side effects. each one has sensory input to dorsal horn. concentration (0.5-1% Onset. and traverse intervertebral foramina. Lumbar nerve of L1 supplies inguinal region.Page 91 Give a brief description of the sensory nerve supply of the thoracic cage and abdominal wall Notes for an answer: Supraclavicular nerves in pectoral region. 20 mins. intramuscular branch continues. other anterior divisions travel in subcostal grooves. Pharmacokinetics: Routes of administration. The thoracic intercostal nerves T1-T12. epidural Metabolism. Serious omissions likely to cause a fail: Failure to mention the cutaneous branch. infiltration. 8-9 hrs.and extradural spaces. T1 goes via brachial plexus. inhibition of nerve conduction Clinical effects. where intramuscular branch surfaces. these nerves cross intra. Cutaneous branch given off in midaxillary line. both cross the costal cartilages. T4 to sternum. 0. Duration. storage (aqueous solution in glass ampoules). T10 to umbilicus. scrotum and labia. and enter abdominal wall (in subcutaneous and intramuscular layers respectively).

Comment: Extra marks for identifying major and minor complications and their frequency. 6. In the posterior triangle of the neck. hypoxia. collapse. 2. Comment: It is a great help to have thought this answer out before meeting it in an examination! Serious omissions likely to cause a fail: Failure to mention the neck. it lies on the upper surface of the first rib. the first rib and the axilla. haematoma and ensuing thrombosis). convulsions. with immediate toxic effects. <><><><><><><><><><><><> . and lies on the second rib and first intercostal space.Page 92 Briefly describe the anatomical relations of the brachial plexus Notes for an answer: Relations: Transverse processes of C5-T1. 3. arrythmias. cyanosis. swelling. pain. 4. redness. loss of function). <><><><><><><><><><><><> What are the complications of the supraclavicular and axillary brachial plexus blocks and how do you recognise them? Notes for an answer: Complications (with signs for recognition in brackets): 1. failure to recover function after block wears off). 5. scalenus anterior and medius. Serious omissions likely to cause a fail: Failure to mention pleural damage or pneumothorax. which separate it from the pleura. whose fascia helps to form its sheath. seen on chest X-ray). Infection (heat. Nerve damage (pain on injection. Toxic effects of local analgesic (hypotension. Vessel damage (intravascular injection. hypoxia). Under the clavicle and subclavius it joins the subclavian vessels. The shoulder joint and humerus lie laterally as it traverses the axilla. involuntary movement of arm. later. Thoracic duct damage (development of chyloma). Pleural damage with pneumothorax (cough.

posteriorly by neural arch (laminae). bounded posteriorly by fused laminae. lymphatics and minor arteries. laterally by pedicles and sacral intervertebral foraminae. This is traversed by cauda equina with pia mater (cord ends at L2).Page 93 Describe the anatomy of the sacral canal and its contents Notes for an answer: Extends from the lower border of L5 to sacral hiatus. It is lined with periosteum. <><><><><><><><><><><><> . Comment: This is essential anatomical knowledge for anaesthetists. Contents—fat. Comment: This is essential anatomical knowledge for anaesthetists. Serious omissions likely to cause a fail: Failure to mention cauda equina and dura. and filum terminale. cauda equina with pia mater. Serious omissions likely to cause a fail: Failure to mention cauda equina and dura. Traversed by dural sac—dura and arachnoid maters. Lined by periosteum with posterior longitudinal ligament anteriorly. subarachnoid space and CSF. veins. dura (to lower border of S1 or upper border of S2 (S3 in small children). filum terminale. S4-5. Contents: epidural space—fat veins lymphatics. anteriorly by fused vertebral bodies. laterally by pedicles with neural foraminae. <><><><><><><><><><><><> Describe the anatomy of the epidural space at the level of the fourth lumbar vertebra A canal formed anteriorly by body of vertebra and discs. nerves with dural cuff. ligamentum flavum posteriorly.

Page 95 Chapter 12 Medicine and Surgery Related to Anaesthesia .

concentration Pharmacodynamics: Mode of action.Page 96 What precautions should you take when anaesthetising a patient known to have suffered from viral hepatitis? Notes for an answer: 1. use of disposable equipment and safe disposal. Onset. Hepatitis C and other infective diseases). practice of correct "sharps drill". increases refractory period. Comment: It would be difficult to know how much detail to give in this answer. beta blocking drugs <><><><><><><><><><><><> . constipation Interactions. hours Pharmacokinetics: Routes of administration. 2.. minutes Duration. information to all staff. mainly slow channel cardiac effects Clinical effects. reduces excitability and dilates arterioles Dose.5 mg i. This would have to be dictated by the time available. 2. class 4 antiarrythmic.v. aqueous solution). digoxin. storage (tablets. Serious omissions likely to cause a fail: Failure to mention protection of staff. Protect staff and other patients—assessment of infectivity of patient (HBAge. volatile anaesthetics. Protect patient—liver function tests to assess hepatic reserve. Hepatitis A. oral—100-500 mg/day. Ca++ channel blocker. Check Hepatitis B immunisation status of all staff. oral Side effects. and appropriate care with dosages of drugs. Use of gloves etc. <><><><><><><><><><><><> Write short notes on verapamil hydrochloride This answer needs most of the following headings: Pharmacy: Type of chemical. adult. preparation.

f) need for notes about the care of resulting cardiac failure and embolism problems. d) amiodarone 1g infusion to prevent recurrence. abnormal chest movement. c) digoxin 0. b) Use of DC shock (bonus marks for management of this during regional analgesia).v. e) use of beta blockade in thyrotoxicosis. a) symptoms: pain. especially in tension pneumothorax or bilateral pneumothorax. dyspnoea. Prevention: a) recognition of the at-risk patients (thyrotoxicosis/myocardial ischaemia/ mitral stenosis/previous atrial fibrillation/Sick sinus syndrome/elderly with hypokalaemia). 2. loss of lung markings in periphery. Treatment: This may be a major life-threatening emergency.5mg i. <><><><><><><><><><><><> . c) tests: CXR—mediastinal shift. cardiovascular collapse. Diagnosis: The answer needs comments about when this is likely to confront the anaesthetist.v.) cannula in third ribspace anteriorly. Preoperative ECG is essential for this. after which IPPV will be safer. b) signs: abnormal breath sounds. to control ventricular rate if > 100bpm. Management: a) Use of adenosine. and the difficulty of locating the side. b) Avoidance of hypotension at induction in the elderly. 3mg i.v.Page 97 How would you manage atrial fibrillation which occurs during anaesthesia? What could be done to prevent it? Notes for an answer: ECG monitoring is essential for recognition. 1. coin test. 2.—for diagnosis. cyanosis. c) Preoperative correction of hypokalaemia. IPPV may make the condition worse! Need for (i. and chest drain techniques. Serious omissions likely to cause a fail: Failure to mention the ECG and the resulting cardiac failure <><><><><><><><><><><><> Write short notes on the diagnosis and treatment of pneumothorax Notes for an answer: 1.

100-250 mg. Pharmacokinetics: Routes of administration. dizziness. doxapram Plus other features: regular monitoring of theophylline levels required <><><><><><><><><><><><> .. CNS stimulation. aminophylline (agitation) <><><><><><><><><><><><> Write short notes on aminophylline This answer needs most of the following headings: Pharmacy: Storage (aqueous solution in glass ampoules) Pharmacodynamics: Mode of action. gastric irritation. phenytoin. bronchodilator and stabiliser of cardiac rhythm Dose. peripheral chemoreceptor stimulant Clinical effects. Interactions. muscle fasiculations. Onset.v. 1 hour Pharmacokinetics: Routes of administration. Ephedrine (in children). rapid Duration.Page 98 Write short notes on doxapram This answer needs most of the following headings: Pharmacy: Type of chemical. preparation. cyclic AMP inhibition Clinical effects. carbamazepine. oral. i. better given as infusion Onset. minutes Duration. liver Side effects. storage (aqueous solution in glass ampoules and plastic bags). MAOI's. 1 mg/kg. barbiturates.) Pharmacodynamics: Mode of action. tachycardia. Side effects.v. i. 4-6 hrs. nonspecific respiratory stimulant Dose. sweating. hypokalaemia Interactions. concentration (2 mg or 20 mg/ml. Metabolism.

2. <><><><><><><><><><><><> What is the relevance to anaesthetic management of ankylosing spondylitis? What strategies would you employ to overcome them? Notes for an answer: Problems: Stiff neck and jaw—intubation difficulty. d) short thyromental distance (< 6cm). Haemorrhage from peptic ulcer. reduced pulmonary function needs assessment. Needs discussion of difficulty of insertion of nasogastric tube and pHi estimation. Managed by premedication with H2 antagonist and metoclopramide. Serious omissions likely to cause a fail: Failure to mention difficult intubation and reduced lung function. The giant hiatus hernia may interfere with lung function. Elective fibreoptic intubation or tracheostomy may be needed if general anaesthesia is unavoidable. and H2 antagonists. <><><><><><><><><><><><> . esp. especially if there is: a) known history of difficult intubation—Cormack & Lehane scores from previous laryngoscopies. with tracheal intubation to protect lungs.Page 99 What problems does hiatus hernia pose for the anaesthetised patient and how do you cope with them? Notes for an answer: 1. if present. it is managed by tracheal washout. e) small mandible size and inability to protrude jaw. oesophagitis. possibly steroids and antibiotics. IPPV. c) low Malampatti score. 2. if this occurs. Use of regional blocks. Strategies: 1. This is perhaps the most critical of these features. resultant anaemia. b) poor mouth opening (< 3fb). spinal blocks are desirable but difficult!—spinal X -ray is needed. 4. Regurgitation and aspiration of highly acidic juice causes pulmonary airways burn. f) neck stiffness (you would need to mention neck X-rays here). Serious omissions likely to cause a fail: Failure to mention cricoid pressure. if kyphotic. Cricoid pressure is needed during induction. 3.

Onset.Page 100 Write short notes on nifedipine This answer needs most of the following headings: Pharmacy: Storage (liquid in capsules) Pharmacodynamics: Mode of action. calcium channel antagonist Clinical effects. minutes Duration. vasodilation is to be avoided. with risk of severe hypotension on induction. Dose. (Bonus marks for stating that HOCM is worsened by inotropes). potentiated by cimetidine Plus other features: fast onset. 4-8 hrs. Comment: It is particularly important to mention that coronary flow is dependent on diastolic pressure. no rise of intraocular pressure <><><><><><><><><><><><> How does the presence of aortic stenosis affect the management of an anaesthetic? Notes for an answer: Fixed cardiac output. percentage lowering of arterial pressure in hypertension. Serious omissions likely to cause a fail: Failure to mention fixed cardiac output. and that tachycardia is to be avoided as it shortens diastolic interval. 10 mg. <><><><><><><><><><><><> . coronary vasodilation. headaches dizziness and flushing Interactions. oral. Coronary flow reduced. sublingual Side effects. Pharmacokinetics: Routes of administration. with risk of severe hypotension on induction. risk of endocarditis (need for antibiotic cover) and subendocardial ischaemia if inotropes are given in large dosage.

cannabis. Serious omissions likely to cause a fail: Failure to mention pain and need for oxygen. and neuropathy. Prevent cold. Exchange transfusion has been used with success. hypertension. epilepsy. psychiatric symptoms. Prevent joint and organ damage which can be fatal. Give oxygen and rehydrate the patient. e. needing IPPV. Control very severe pain with large doses of opiates. 6. hypoxia. Serious omissions likely to cause a fail: Failure to mention delta ALA synthase. giving excess porphyrins. c) tachycardia. and intensive care. 3. but: Thiopentone stimulates hepatic delta ALA synthase. b) abdominal pain and vomiting. Neuropathy may last for weeks. This is a dose-related effect. acidosis.. hypoxia and acidosis occurring during treatment.g. acute LVF. <><><><><><><><><><><><> . 2. d) red urine. cold. <><><><><><><><><><><><> What is the management of an acute sickle cell crisis? Notes for an answer: 1. Remove precipitating factor. 5. 4. causing: a) neuropathy.Page 101 What would happen if a full dose of thiopentone was given to a patient with acute intermittent porphyria and why? Notes for an answer: The patient would become anaesthetised.

Comment: Anaesthetists should be professionally competent in these situations. 2. Serious omissions likely to cause a fail: Failure to mention the risks of thiopentone and suxamethonium. Immune deficiency with risk of infection and cross infection. Associated ASD and VSD.Page 102 In what ways does Down's Syndrome affect the management of an anaesthetic? Notes for an answer: 1. Awareness that anticholinesterases may worsen myotonia. Serious omissions likely to cause a fail: Failure to mention the cardiac complications. Communication problems resulting in fear and failure to comply with instructions (rapport with parents essential). 5. Prevention of aspiration of stomach contents. Prevention of severe myotonia by avoiding suxamethonium. 8. 6. 2. 3. 7. Central neural blockade is useful (if appropriate). with risk of intracardiac shunting and endocarditis (need for antibiotics). 3. Prevention of prolonged apnoea by avoiding thiopentone. Excess salivation and large tongue. Awareness that nondepolarising relaxants do not stop myotonia. Preparedness for these patients to be very heavy for their age. 6. <><><><><><><><><><><><> What precautions should be taken when anaesthetising a patient with dystrophia myotonica? Notes for an answer: 1. 9. Large size and difficult veins. Postoperative IPPV may be required. Dantrolene may reduce myotonia and should be available. 4. 5. 10. Comment: This is rare but important. Prevention of cardiovascular depression and dysrhythmias by being sparing with volatile agents. <><><><><><><><><><><><> . Resistance to sedatives. 4.

recurrent laryngeal palsy and external laryngeal palsy may cause postoperative airway obstruction. Requires full-scale monitoring (details needed).Page 103 How do the intraoperative surgical complications of excision of thyroid goitre affect the management of the anaesthetic? Notes for an answer: 1. with postoperative ongoing symptoms. 3. Preoperative unstable arterial pressure requiring alpha and (later) beta blockade with restoration of circulating blood volume. concomitant parathyroidectomy may cause early postoperative tetany. Damage to the trachea (including tracheomalacia) may occur with postoperative airway obstruction. Surgery may cause haemorrhage. 6. splitting of sternum would require IPPV. Stimulation of carotid baroreceptors by surgical manipulations may destabilise arterial pressure. 4. 2. postoperative airway obstruction. Vasodilators may be needed for operative hypertension. <><><><><><><><><><><><> . 5. pneumothorax. 3. angiotensin) needed for post-removal hypotension. Avoid histamine releasers in premed and anaesthetic—they may cause a crisis. noradrenaline. <><><><><><><><><><><><> What are the anaesthetic problems posed by surgical removal of a phaeochromocytoma? Notes for an answer: 1. Serious omissions likely to cause a fail: Failure to mention unstable arterial pressure. Secondary phaeochromocytomas may be missed at operation. 2. histamine releasers and need for full-scale monitoring. Vasoconstrictors (adrenaline. Finally—the surgical elbow in the patient's eye! Serious omissions likely to cause a fail: Failure to mention need for IPPV.

Comment: This is an easy question. vasodilation and tachycardia).Page 104 What are the anaesthetic problems posed by surgical removal of a parathyroid adenoma and how do you cope with them? Notes for an answer: 1. b) cardiac failure. This may cause: a) arterial thromboembolism. Serious omissions likely to cause a fail: Failure to mention atrial fibrillation and bacterial endocarditis. 4. Pneumothorax (prevention by IPPV. antiarrythmic drugs and K+ infusion). requiring diuresis with frusemide. with pulmonary oedema. 3. <><><><><><><><><><><><> What are the complications of mitral valve disease during anaesthesia and how do you prevent them? Notes for an answer: 1. 3. (requiring antibiotic cover). Serious omissions likely to cause a fail: Failure to mention postoperative tetany requiring Calcium. Bacterial endocarditis. 6. requiring reintubation). prevented by anticoagulation. 5. Atrial fibrillation (requiring control of rate and treatment of left ventricular failure). 2. <><><><><><><><><><><><> . Excessively high Ca++ would pose a risk of serious arrythmias (may need emergency lowering of Ca++. 4. Fixed cardiac output. Recurrent nerve damage (with postoperative obstruction. Acute left ventricular failure. with risk of serious vascular instability (avoidance of cardiac depression. treatment by chest drain). Air embolus (prevention by avoiding too steep head-up tilt. treatment by turning patient on side and evacuation by central line). Haemorrhage (treated by infusion and transfusion). 2. Postoperative tetany requiring Calcium injection (needs details of preparations and doses). requiring careful use of inotropes.

• clonidine. <><><><><><><><><><><><> . • cerebral haemorrhage. and the answer requires a brief discussion of hypertension due to fear. a full bladder. Relevant Drugs: • nifedipine. Comment: The answer to this is longer than many in this book. Serious omissions likely to cause a fail: Failure to mention emergency medical investigation and treatment of hypertension. possible renal and other rare causes of hypertension (e. The operation is postponed for emergency medical treatment. b) is the patient's abdominal pain due to another. involving relevant specialists. Spinal anaesthesia not advisable because of cardiovascular instability. • ACE inhibitors. • myocardial infarction. cause? Could it be angina due to hypertensive crisis? Management: Prevention of risks. and risk of severe hypotension under anaesthesia.) Investigation of Causative Conditions: a) generalised vascular disease. • ECG required. phaeochromocytoma).. Describe your anaesthetic management Notes for an answer: The anaesthetist checks it for himself! (It can be due to pain. with rapid and carefully monitored intravascular volume replacement. medical. • beta blockers.Page 105 A patient's arterial pressure on admission for moderately urgent appendicectomy is 170/115 mmHg. • this diastolic pressure is too high for safety. Antibiotics are required to cope with a short period of postponement of operation.g. • Ca channel blockers. • hypotension under anaesthesia.

3. Describe your management for the anaesthetic Notes for an answer: Postpone the operation and control the cardiac failure. premedicate with anticholinergics). ventricular tachycardia and ventricular fibrillation). Cardiac depression by anaesthetics. Specialist medical advice is helpful. beta blockade). 2. echocardiography and relevant blood tests. Comment: This is not an uncommon scenario. Risk of further bradycardia during and after anaesthetic. uncontrolled vasodilation from cement are the notable risk points. with the emphasis on prevention. <><><><><><><><><><><><> . ECG and full drug history is essential (esp. e. Sick sinus syndrome (common in this patient population with risk of atrial fibrillation. Haemorrhage may be considerable with need for accurate volume replacement with monitoring. Heart block (will need anticholinergics and possibly pacing). Treatment with beta blockers (reduce the dose and/or use other drugs. Serious omissions likely to cause a fail: Failure to mention postponement of operation. Failure of implanted pacemaker (needing referral to cardiologist). 2. Describe the common causes and management of this Notes for an answer: This answer needs a comment on what pulse rates are acceptable and what the target pulse rate would be.. Serious omissions likely to cause a fail: Failure to mention that this sign usually indicates serious cardiovascular disease. Causes: 1. by ECG. The implication is that the patient has serious cardiac and possibly other organ disease.g. supraventricular tachycardia.Page 106 A patient with congestive cardiac failure presents for hip replacement. and 3. 4. Problems: 1. This all implies serious cardiovascular disease. and requires full investigation. Operation will need to be postponed until the pulse rate is normal. <><><><><><><><><><><><> A patient presenting for prostatectomy has a pulse rate of 39 beats per minute. 4.

emboli (requiring anticoagulation). and blocked nose due to adenoid hypertrophy—the presence of pyrexia is a useful sign. Serious omissions likely to cause a fail: Failure to mention cardiac failure. <><><><><><><><><><><><> Write short notes on atrial fibrillation Notes for an answer: Causes: ischaemia. and cannon waves. This answer requires a brief discussion about difficulty in diagnosis because of fast onset of colds in children. Diagnosis: irregularly irregular pulse (including deficit). digoxin. triggers: hypotension and hypokalaemia. amiodarone.Page 107 How does the common cold influence fitness for anaesthesia? Notes for an answer: 1. Serious omissions likely to cause a fail: Failure to mention the risk of laryngospasm and cardiac arrest in children. <><><><><><><><><><><><> . Treatment: need to mention adenosine. which depends on severity of cold and need for intubation. and the indications for anticoagulation. 3. Risk of cardiac arrest in children—up to 4-6 weeks after infection. 2. Risk of laryngeal spasm/bronchospasm/cyanosis during operation. A genuine cold presents a risk of postoperative chest infection. rheumatic heart disease. The ECG makes the diagnosis. thyrotoxicosis. and differentiation from teething. Tonsillectomy during a cold may cause marked haemorrhage and local infection. DC shock. left ventricular failure. Complications: poor cardiac output. The answer needs a comment on the significance of uncontrolled rate.

and possibly urgent need to stop cause of bleeding if possible). <><><><><><><><><><><><> .Page 108 How do you judge the significance and plan the management of preoperative anaemia? Notes for an answer: Significance: What has caused it? How severe is it? (When the Hb is below 10g/dl. Management: The relevant issues are: a) how severe. it will cause reduced oxygen carriage). b) how acute the anaemia is and whether it is ''renal" (accept Hb of 7-8g/dl). and correction of haemostasis factor levels.3 DPG)? Does the patient have chronic renal failure (high blood urea and creatinine)/ carcinomatosis (skeletal X-ray survey)/leukaemia (blood film)/malnutrition (red cell volume)/coagulopathy (coagulation profile. erythropoeitin. and how urgent surgery is (emergency indicates transfusion. Comment: This is a common problem but not an easy question to answer. Is it acute or chronic (with compensation by raised 2. bladder or uterus (microcytosis)/aspirin or NSAID usage? There will be reduced O2 flux and possibly high output cardiac failure if severe. Serious omissions likely to cause a fail: Failure to mention oxygen carriage. Investigations: The medical history will have indicated which lines should be further investigated. drug history)/chronic bloodloss from gut. The non-urgent situation calls for discussion of Fe++ therapy.

Page 109

A patient with non-insulin-dependent diabetes is to undergo amputation of an infected gangrenous leg. What is the correct peri-operative management of the diabetes? Notes for an answer: You need to state that this diabetes will be out of control. Issues to mention include: a) History of patients previous diabetic status. b) Involvement of diabetologist. c) Assessment of current biochemical status plus awareness of possible loss of control due to gangrene—danger of hyper- and hypoglycaemia—requiring assessment of blood glucose, electrolytes, hydration status (Hartmann's solution is avoided because of lactate load). d) Preoperative management—antibiotics, rehydration urine output, hourly blood glucose and electrolyte monitoring, insulin prescription (sliding scale/Alberti regime: K+, insulin, glucose infusion). e) Operative management—maintain diabetic regime, monitor blood sugar (intervals of 1 hour on average). f) Postoperative management—Awareness of rapid improvement in diabetes, use of sliding scale, timing of return to preoperative regime. Comment: This is quite a common clinical situation.
Serious omissions likely to cause a fail: Failure to mention diabetes will be out of control, with need for insulin.

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Page 110

How would you judge the significance of preoperative jaundice? Notes for an answer: Causes: Is there infective hepatitis?—need to test for HBAge, Hepatitis A, Hepatitis C, and enquire about malaria, glandular fever. Would there be a crossinfection risk for staff? Is it due to; drugs (paracetamol, halothane), with risk of fulminating hepatic failure (what is the drug history?); gallstones; Gilbert's syndrome; haemolysis; cirrhosis; Ca pancreas; pancreatitis (Serum amylase and blood glucose levels are required)? Effects: Has it affected blood coagulation, and therefore jeopardise haemostasis? Is there hepatic failure (function tests needed)? Is there concomitant renal failure (electrolyte tests)? Are there cerebral effects, e.g., in the neonate?
Serious omissions likely to cause a fail: Failure to mention the appropriate tests.

<><><><><><><><><><><><>

How do antihypertensive drugs affect the management of anaesthesia? Notes for an answer: 1. They reduce raised arterial pressure (this needs a little discussion of the limits, and target pressures at different ages). 2. They commonly vasodilate the patient, which requires care in the use of vasodilating anaesthetics. 3. They commonly increase circulating volume, which is a safety factor, and the indication for continuing medication through the perioperative period. 4. Beta blockers may limit changes of cardiac rate and output and cause severe bradycardia. 5. Some cause renal failure in certain situations, with problems of anaemia, hyperkalaemia, acidosis and prolongation of relaxants. 6. Clonidine will potentiate anaesthetics and analgesics. 7. Thiazides lower the serum K+, prolonging and potentiating nondepolarising relaxants. 8. Withdrawal of some antihypertensives cause excessive rebound of arterial pressure. Comment: This is common clinical scenario.
Serious omissions likely to cause a fail: Failure to mention lowered arterial pressure.

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Page 111

What are the functions of the thyroid gland and how are they controlled? What are the effects of thyroid dysfunction on anaesthesia? Notes for an answer: Functions: production of thyroxine and T3 to control metabolic rate, growth, cerebral activity. They interact with other hormones. Control: TSH from anterior pituitary; negative feedback control. Effect of Dysfunction: a) myxoedema—sensitivity to anaesthetics and cold, instability of circulation; b) thyrotoxicosis—atrial fibrillation, thyroid crisis.
Serious omissions likely to cause a fail: Failure to mention myxoedema and atrial fibrillation.

<><><><><><><><><><><><>

In what circumstances may fluid overload occur during operation? How is it diagnosed and managed? Notes for an answer: 1. Overestimation of the operative losses (e.g., in laparoscopic operations), with overinfusion. 2. TURP syndrome, with absorption of irrigant. 3. In severe toxaemia with capillary hyperpermeability, causing pulmonary oedema. 4. Where the patient has inappropriate ADH secretion, renal failure, acute left ventricular failure. 5. During and after cardiopulmonary bypass. Diagnosis: onset of hypoxia, rise of ventilation pressures, auscultation of crepitations in the lungs, froth in tracheal tube. Management: diuretics, treatment of acute heart failure, oxygenation, fluid restriction, triple strength albumin if appropriate. Comment: CEPOD have emphasised the importance of this.
Serious omissions likely to cause a fail: Failure to mention TURP syndrome and overinfusion.

<><><><><><><><><><><><>

4. Hb < 10g/dl). obstruction of peripheral vasculature). Histotoxic—tissues are unable to utilise delivered O2 (CO poisoning. 3. opening of A-V anastomoses • Ventricular fibrillation — no cardiac output • Spinal anaesthesia — vasodilation • Anaphylactic shock — vasodilation <><><><><><><><><><><><> . Stagnant—bloodflow is slow (poor cardiac output. <><><><><><><><><><><><> What is the mode of action of the following in lowering arterial pressure? • Isoflurane — vasodilation • Halothane — negative inotropy and vasodilation • Propofol — vasodilation • Lignocaine — negative inotropy • Enflurane — negative inotropy and vasodilation • Desflurane — vasodilation • Thiopentone — negative inotropy and vasodilation • GTN — vasodilation • Pulmonary embolism — physical obstruction of circulation • Ruptured aortic aneurysm — reduction of bloodvolume and afterload • Septic shock syndrome — negative inotropy. Hypoxic—PaO2 is low (inadequate respiration. Comment: This is basic physiology upon which anaesthetic practice is based. Where are they seen clinically? Notes for an answer: 1. 2. Serious omissions likely to cause a fail: Failure to mention all four types. pulmonary vasoconstriction. cyanide poisoning). Anaemic—Hb and O2 carriage is low (anaemia. low FiO2).Page 112 Name and define the different types of hypoxia.

" questions).g.Page 113 Describe all the clinical actions of one anaesthetic agent and two other drugs you might use to lower arterial pressure during anaesthesia Notes for an answer: Many drugs can do this. Onset. <><><><><><><><><><><><> . enflurane. contains iodine. direct vasodilators (SNP and nitrates). <><><><><><><><><><><><> Write short notes on amiodarone This answer needs most of the following headings: Pharmacy Pharmacodynamics: Mode of action. 100-250 mg. class 3 antiarrythmic. liver (halflife 26-107 days) Side effects. months Pharmacokinetics: Routes of administration. Comment: Space forbids a full treatment of all the possibilities for this answer. . isoflurane. microdeposits of drug in cornea. prolongs life of digoxin. The pharmacodynamics and side-effects should all be mentioned as in the answers to the "Write short notes on.v. Metabolism. control of ventricular and supraventricular arrythmias Dose. desflurane. rapid Duration. halothane. i. . hydrallazine clonidine. Interactions. mild negative inotrope. e. ganglion blockers. oral. potentiates other antiarrythmics. a K+ channel blocker which uncouples beta receptors from the regulatory unit of the adenylate cyclase complex Clinical effects. avoid in porphyria. alpha and beta blockers. Plus other features: affects thyroid function. pulmonary interstitial infilatration..

v. 1 minute Pharmacokinetics: Routes of administration. termination of supraventricular tachycardias Dose.Page 114 Write short notes on adenosine This answer needs most of the following headings: Pharmacy: Type of chemical (endogenous nucleoside) Pharmacodynamics: Mode of action. Onset. stimulation of A1 receptors Clinical effects. heart block. negative chronotropy on sinus node. Interactions. alteration of potency of anaesthetics Plus other features: avoid in sick sinus syndrome. one circulation time Duration. and asthma <><><><><><><><><><><><> . negative dromotropy on atrioventricular node. i. 3 mg.

Page 115 Chapter 13 Faciomaxillary. Ophthalmic and ENT .

2. spontaneous breathing. "Oculocardiac" reflex — bradycardia — atropine needed. Local anaesthesia is unhelpful. massive haemorrhage and airway problems. tracheostomy (difficult if the neck is also swollen). pus in pharynx. 5. requiring antiemetics. and armoured tube may be required. and three of the above approaches to intubation. awake extubation and strategy for emergency unwiring. awake fibreoptic intubation. Problems — woody swelling in pharynx. because the spasm arises in the muscles of mastication themselves.g. blind nasal (not easy because of swollen tissues). <><><><><><><><><><><><> A patient requires an anaesthetic for removal of an infected molar tooth which is causing severe trismus. induction of general anaesthesia: the safest is inhalation induction. Awake extubation is safest for the airway. Postoperative airway problems. The airway should be secured. 4.. and how do you deal with them? Notes for an answer: 1. Serious omissions likely to cause a fail: Failure to mention bradycardia.Page 116 What complications of operations on the bony structures of the lower half of the face may affect the anaesthetic management. There is still the problem that pus may be in the pharynx. Interference with tracheal tube. using high O2. Comment: This question is about a safety issue. 3. Massive haemorrhage. Comment: This is another example of demonstrating your skills in an important clinical scenario. severe local infection and toxaemia. with halothane or sevoflurane. Relaxants will not usually relax trismus. e. with CVP monitoring. Serious omissions likely to cause a fail: Failure to mention trismus not releasing with relaxants. and needs a brief discussion of four methods: General anaesthesia. unable to open mouth. due to swelling and pre-existing abnormalities. 4. Trismus relaxes under general anaesthesia and cords may be visualised in the usual way. with problems. the nasal route may be preferable. <><><><><><><><><><><><> . requiring massive crossmatch and massive transfusion. 2. 3. not IV induction. Postoperative vomiting problems when the jaws have been wired together. Describe the problems and outline the anaesthetic methods Notes for an answer: 1.

Induction of anaesthesia: rapid sequence induction with cricoid pressure and intubation. if not possible: Premedication with metoclopramide and H2 antagonist. 2. <><><><><><><><><><><><> . Maintenance of anaesthesia: light anaesthetic. 6. and analgesia. Postpone the operation if possible. and a very careful laryngeal spray with lignocaine. 2. Premedication: not usually required for tonsillar haemorrhage in the first six hours after operation. a nasogastric tube is passed and the stomach emptied. <><><><><><><><><><><><> Describe the anaesthetic management for a 5-year-old patient who requires reoperation for haemorrhage an hour after tonsillectomy Notes for an answer: 1. 3. If intubation is essential. The use of suxamethonium is controversial as it raises intraocular pressure. 3. Oxygen is required. anaemia. cricoid pressure is required. 4. 5. Oxygen is required. prevention of coughing and vomiting is important. The use of intubation is controversial as it also raises intraocular pressure. Opiates are important here. Assessment and resuscitation: intravenous infusion of colloids and blood until the patient is clinically not shocked (details needed). 4. Laryngeal mask has been used successfully. Postoperatively.Page 117 Describe the anaesthetic management for a patient with a perforating eye injury who had a large meal in the last hour Notes for an answer: 1. 5. Postoperative care: further assessment of shock. after a period of saturation.

Page 118 How would you perform a block of the maxillary nerve? Notes for an answer: 1. including anticoagulation). 2. clean skin. b) blood is aspirated — move needle slightly to exit bloodvessel. i.v. Operative: availability of resuscitation equipment. above mandible. Short-bevel needle is inserted below mid point of zygoma. gain consent. Full monitoring is applied. c) air is aspirated — withdraw needle 0. It is then angled upwards and forwards and advanced 1 cm. and advanced towards contralateral eyeball until it meets pterygoid plate. Aspiration is performed: a) nothing aspirated — inject 2 mls of local analgesic. Preoperative: assess patient (details required. access. 3. close to the maxillary nerve. to enter the pterygomaxillary fissure.5-1cm — the tip is in the nasal cavity! <><><><><><><><><><><><> .

Page 119 NOTES .

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