Hong Kong College of Anaesthesiologists

Intermediate Fellowship Examination

July/August 2004

Examiners' Report

Written Paper:

Q1.

Q2.

Q3.

Q4.

Q5.

Q6.

Q7.

1
Q8.

Q10.
Q11.

Q12.

Topics of the Oral Examination

Statistics
Anticholinesterase: classification and toxicity
Colloids
Serotonin
Thiopentone
Etomidate
Bioavailability
Chi-square
Dexmedetomidine
Isoflurane and cvs preconditioning
Compare sevoflurane and desflurane
Morphine and its metabolites
Dose-response curve
Drug development
Compare propofol with thiopentone
First and zero order kinetics
Heparin

Physiology Section

Nine candidates (50%) achieved a pass mark in the written section and 3 failed
to attain the minimum standard required for the oral examination. The viva was
successfully passed by 13 (87%) out of the 15 candidates. After all, 12 candidates
(67%) passed the physiology section.

Written Paper

Q1. Briefly describe how the kidney excretes an acid urine.

50% of candidates passed this question. The roles of bicarbonate reabsorption and
urinary buffers were mentioned by most of the candidates. However, no one had
clearly pointed out the generation of an acid urine is an energy consuming process.
In the proximal tubules, hydrogen ion is excreted as a result of secondary active
transport while it is excreted by active H:K ATPase pump in the distal tubules.
Therefore the contribution by the proximal tubules is relatively small compared to the
distal tubules and collecting ducts. The fact that H ion pump is increased in metabolic
acidosis was only attempted by one candidate. Ammonia production can also be
increased to 700 mmol/day in the presence of metabolic acidosis. Consideration of
electroneutrality will
also help candidates to understand the mechanism of hydrogen secretion in relation to
sodium, potassium and bicarbonates changes better. Therefore, the main points
-
expected included the importance of resorption of HCO3 in the proximal tubule (with
+
no net acid loss) followed by active secretion of H in the distal tubule which is
- +
buffered by HPO4 and NH4 . Additional marks were awarded for details of the above,
mentioning the normal acid load, the maximum pH gradient, and the role of
glutamine. Extra marks were also awarded to candidates who explained that all
- -
HCO3 reabsorbed is ‘new’ HCO3 . A common error was to focus too much on the
proximal tubule, where no net excretion of acid occurs.

Q2. Briefly describe the factors that influence the mixed venous partial pressure
of oxygen.

33% of candidates passed this question. Candidates overlooked the importance to

define what is mixed venous blood. Though different approaches were used by the
candidate, the use of Fick’s principle to describe the relationship among mixed venous
oxygen content and cardiac output, arterial oxygen content and oxygen consumption
by tissue was easier to understand. Better candidates then related the venous
oxygen content to that of the partial pressure by means of oxygen dissociation curve.
Respiratory and cardiovascular factors leading to a change in arterial oxygen content
were often incomplete. The main points expected included a definition of PmvO2,
including its site of measurement, as well as the relationship between PmvO2 and
mvO2 content via the HbO2 dissociation curve. Also required was a description of
how PaO2, cardiac output, Hb concentration, and peripheral O2 extraction affect
PmvO2. Additional marks were awarded for an explanation of the concepts involved,
including equations where appropriate. Credit was given to candidates who explained
how shifts in the HbO2 dissociation curve affect PmvO2, and to those who mentioned
the effects of CO and CN poisoning. Common omissions were neglecting to explain
how PmvO2 is linked to mvO2 content, and ignoring the effects of Hb
concentration and cardiac output.

Q3. Describe and compare the cardiac performance of infants to that of adults.
33% of candidates passed this question. Good answers were few. It was expected that
candidates would briefly describe the factors influencing ‘cardiac’ performance in both
infants and adults (ie. heart rate, preload, contractility, and afterload). The difference in
resting heart rates should have been mentioned as well as the greater connective tissue
(and therefore reduced compliance) in infant myocardium. Indicating that the cardiac
output in the infants is more heart rate dependent than in adults was also expected.
Additional marks were awarded for explaining that infants have less cardiac reserve
due to resting cardiac performance being closer to maximal than in the adult, and that
infants have less response to volume loading. Many candidates wasted time
describing the neonatal circulation, which was not required. For the cardiac output
which is higher in terms of ml/kg/min in neonates, but the cardiac index is the same
as that of adult except in the first few weeks of life.

+ + + +
Q4. Briefly describe how the Na -K pump (Na -K ATPase) works and its
importance to cellular function.
61% of candidates passed this question. It was expected that candidates would
+ +
describe how the Na -K pump is a form of primary active transport across cell
+ +
membranes in most cells, that it utilizes ATP, and exchanges 3Na for 2K . Some
mention of its importance in (a) maintenance of intracellular Na and K
concentrations, (b) its contribution to the resting membrane potential (allowing,
among other functions, the transmission of action potentials), and (c) the setting up of
+
Na gradients for secondary active transport, was also expected. Additional marks
+ +
were awarded for details of the structure of Na -K ATPase, and description of its
role in maintaining cell volume. A common error was to focus too much on the
resting membrane potential without mentioning other functions. A discussion of the
Gibbs-Donnan equilibrium was not required. Only one candidate mentioned the
importance of high intracellular potassium level which is vital to the functioning of
many intracellular enzymes.

Q5. Briefly describe the ABO and Rhesus blood group systems indicating which
antigens and antibodies are found in each group.
72% of candidates passed this question. The topic is relevant to routine clinical
practice. Most candidates were aware of the ABO system, whereas only the good
candidates comprehended the Rh system, particularly the CDE antigens. Better
candidates tabulated the genotypes and phenotypes, without wasting time on
repetitive descriptive sentences. Many candidates confused the nature of the ABO
antibodies (IgM) and Rh antibodies (IgG), and hence the clinical implications,
including intravascular and extravascular haemolysis, and placental transfer. Most
candidates were not aware of the ethnic differences in the prevalence of ABO and Rh
blood groups amongst Chinese and Caucasians. It was expected that candidates would
list the 4 main ABO blood groups and describe the antigens and antibodies found
with each. Similar information was expected for the 2 main Rh groups. Candidates
should also have mentioned that the ABO antibodies are naturally occurring,
whereas the Rh system requires previous exposure for antibodies to develop.
Additional marks were awarded for more detail on
the antigens and antibodies and in particular for describing that ABO antibodies are
IgM, and therefore do not cross the placenta (in contrast to Rh antibodies, which are
IgG). Credit was given to candidates who indicated that ABO antigens are found on
most cells of the body, whereas Rh antigens are found only on red blood cells. A
common omission was failure to indicate which antibodies were associated with each
group. A common error was to confuse IgM and IgG antibodies between ABO and Rh
groups.

Q6. Briefly describe how insulin reduces blood glucose levels.

67% of candidates passed this question. Most candidates were able to describe the
effects of insulin on liver carbohydrate metabolism and peripheral uptake of glucose.
Better candidates were able to also to describe the effects of insulin on adipose tissues.
In general, candidates were deficient in the knowledge of cellular physiology,
including the characteristics and mechanisms of actions of membrane insulin
receptors and glucose transporter proteins. A few candidates were not aware that
glucose entered muscle and fat cells by facilitated diffusion. It was expected that
candidates would provide a brief description of insulin, its site of production, and
its mode of action through a cell membrane receptor with secondary messengers.
Some detail of the effect of insulin on glucose transport through cell membranes was
required. A brief summary of the effects of insulin on intermediary metabolism that
result in a reduction in blood glucose was also required. Additional marks were
awarded for detail of the insulin receptor and the effect of insulin on key enzymes.
Credit was given also for commenting on the different effects of insulin on different
tissues. A common error was to describe factors influencing insulin release, which
was not required. A common omission was failure to mention that insulin acts
through a receptor.

Q7. Describe how coughing effort is modified in an awake person breathing

through an endotracheal tube.
Only 11% of candidates passed this question. Most candidates were only able to
outline the normal cough reflex. However, most were unable to describe the
normal act of coughing, such as glottic closure, positive intrapleural pressure,
dynamic airway compression and turbulent flow. A few candidates were unable to
appreciate that glottic closure would be impossible following tracheal intubation.
Most candidates were unable to describe the effect of tracheal intubation on
expiratory gas flow and intrapleural pressure during coughing. It was expected that
candidates would describe the normal steps involved in a cough, and indicate that
this is suboptimal in the presence of an endotracheal tube (ETT) due the inability
to close the glottis (and
therefore the inability to generate a high intrathoracic pressure). In this way the cough
becomes much like a forced expiratory manoeuvre. The reduced pressure gradient,
and subsequent lower flow rate and gas velocity make the clearance of secretions and
other particles less effective. Additional marks were awarded for normal values of
pressure and flow, and an indication of how these are modified in the presence of an
ETT. Many candidates spent too much time describing the cough reflex, which was
not required, or discussed turbulent flow in detail. Some candidates commented on
the effects of anaesthesia on coughing, which also was not required. A common
error was to indicate that the cough was less effective due to the increased resistance
of the ETT.

Q8. Describe the physiological changes in a patient who has a biliary fistula that
leads to complete loss of bile.
72% of candidates passed this question. Better candidates began the answer with a
brief description of bile volume and content. Most candidates were able to outline
physiologic changes in acid-base, fluid and electrolytes. A number of candidates
confused metabolic acidosis with alkalosis, and some over-stated the effect of daily
fluid loss of 1 L on body fluid homeostasis. Most candidates omitted the renal and
respiratory compensatory changes. The very poor candidates only mentioned the
effects of loss of bile salts, and omitted the more important effects of loss of fluid and
electrolytes. It was expected that candidates would describe the normal volume and
composition of bile, and list the effects of the loss of each. These include a relatively
minor loss of volume, but a major loss of bicarbonate leading to a metabolic acidosis.
The loss of bile acids will also reduce the absorption of fat and fat soluble vitamins.
The reduced absorption of vitamin K will eventually lead to impaired coagulation.
Some mention of the compensatory responses for loss of bicarbonate (ie. buffering,
increased ventilation, and renal responses) and to a lesser extent loss of volume, was
also expected. Additional marks were awarded for correct values of bile constituents,
and for indicating that the acidosis would be associated with a normal anion gap.
Credit was also given for describing the responses to sodium loss, including the
increased aldosterone and its effects on the kidney. Common omissions were to
ignore the compensatory responses and the effects of reduced fat absorption. A
common error was to describe a metabolic alkalosis resulting from a loss of
bicarbonate.

Q9. Briefly describe how cardiac output is measured using a thermodilution

technique.
56% of candidates passed this question. Measurement of cardiac output is important in
clinical anaesthesia and hence candidates are expected to have reasonable knowledge
of this core topic. Very few candidates gave a definition of cardiac output. A
description of the Fick principle is expected and how it is used in the
thermodilution technique. Some candidates managed to get the site of fluid injection
0
(right atrium, not ventricle) wrong. Also, most candidates mentioned 0 C normal
saline or 5% dextrose; in clinical practice, room temperature fluids are
commonly used. Very few stressed the
importance of rate of injection. Only 2 candidates mentioned that. The relationship of
area under curve to concentration change was also expected. Credit was given for
source of inaccuracies and strategies to improve it. It is the overall impression of the
examiners that the candidates lack clinical experience and probably had never seen
this form of cardiac output measurement performed before.

Q10. Briefly describe the factors that influence hepatic blood flow.
61% passed this question. This is a factual and rather straightforward question. Most
answers were disorganized. Few candidates mention the effects of mechanical
ventilation, pH, pO2, PCO2 on hepatic blood flow. It was expected the candidates
would state the hepatic blood flow as percentage of cardiac output, the relative
contribution from the hepatic artery and portal venous circulation, and the factors
affecting each of the circulation in terms of pressure gradients and resistance.
Additional marks would be given for mentioning the low-pressure system in hepatic
sinusoids and the effects of various factors on the hepatic vascular resistance. Extra
marks would also be given for the effects of anaesthetic agents and other drugs on the
hepatic blood flow.

Q11. Outline the physiological changes that predispose pregnant patients with
mitral stenosis to the development of pulmonary oedema after delivery.
39% of candidates passed this question. Candidates were expected to understand the
physiological changes that occur at term pregnancy and after delivery and to overlay
the effects of mitral stenosis. It was expected that candidates would mention about the
effects of increase blood volume, decrease vascular resistance and autotransfusion
during delivery on the preload status of pregnant mothers. Candidates should also
describe the deleterious effects of tachycardia and fixed cardiac output on the
development of pulmonary oedema in mitral stenosis patients. Extra marks would be
given for mentioning the stress associated with labour pain, decrease in oncotic
pressure and higher resting heart rate in pregnancy. Credits would be given for the
effects of fluid loading during regional anaesthesia and the myocardial depressant
effects of anaesthetic agents used for general anaesthesia. Candidates who did not pass
were those who did not cover the physiological changes adequately.
Q12. A healthy lowlander climbed to an altitude of 10,000 ft (3,300 m), where the
barometric pressure is 547 mm Hg (73 kPa). Briefly show how the climber’s
arterial oxygen tension breathing air is calculated. Describe the physiological
responses.
28% of candidates passed this question. This question was divided into 2 parts. The
correct calculation of arterial oxygen tension at altitude using the alveolar gas
equation was expected. However, many candidates were unfamiliar with the alveolar
gas equation and arrived at the wrong answer. The barometric pressure was
deliberately set at 547 mm Hg to facilitate easy calculation of moisturized inspired
partial pressure of oxygen ie. (547-47 mmHg) x 0.2. 47 mmHg being the partial
pressure of water vapour at body temperature. Many candidates either did not make
the correction or erroneously subtracted 47 mmHg after obtaining the partial pressure
of inspired oxygen ie. (547 x 0.2) – 47 mmHg. The second part of the question on the
physiological responses due to altitude was reasonably answered.

Topics of the Oral Examination

Alveolar gas equation

Laminar and turbulent flow
Haemoglobin molecules
Electrocardiogram: normal intervals
Pressure curve for right ventricle and pulmonary artery
Factors affecting cardiac output
Vascular function curve
Loss of 1 litre of blood
Glucose metabolism
Thermometer
Cerebral compliance
Papillary reflex
Body fluid compartments
Starling’s forces across capillaries
Renal blood flow
Arterial blood gases of acute respiratory acidosis
Causes of increased arterial carbon dioxide tension
Dead space
Pulmonary vascular resistance
Functional residual capacities
Oscillometry in blood pressure measurement
Pressure waveform in aortic arch
Coronary blood flow
LV pressure volume loop
Effects of increased afterload
Oxygen debt
Humidity and its measurement
Cerebral blood flow
Blood brain barrier
Osmolality
Glomerular filtration rate
Urine formation
Thirst
Buffer system