Hong Kong College of

Anaesthesiologists Intermediate
Fellowship Examination Jul/Aug 2006

Examiners' Report

General

Eighteen out of 21 candidates passed the examination. Of the 21 candidates, all were
qualified for the oral examination except for one that withdrew just before the written examination.
Same as before, the performance in the viva was generally better than in the written examination.
The passing rates for the individual sections were listed below. Overall the performance of the
candidates were satisfactory.

The comments in the written section below show the basic requirement for each question.
Additional marks will be given to the answers which are relevant to the questions. Irrelevant answers
will not be given marks.

Candidates are examined on a variety of topics during the viva examination. Most of these
questions are structured. Only the introductory viva questions are listed in this report. Improvements
are seen in the use of clear and correctly labeled diagram to help with the answer. Whenever
diagrams are required, they should be drawn to the proportion and clearly labelled.

Written paper

Question 1
Question 2
Question 3

Question 4

Question 5
Question 6
Question 8
Question 9

Question 10
Question 11

Question 12
Viva Topics

Physiology
For the written section, the passing rate was 81% (17 out of 21 passed). All candidates qualified for
the oral examination. The performance in the viva was very good with 20 out of 21 candidates passed
this section. Overall, 95% candidates passed this section.

Written Paper

Q1. Briefly explain how human erythrocytes carry out different types of functions in the body.
76% candidate achieved a pass in this question. This question asked the functions of the RBC not just
the function of Hb. The better candidates acknowledged the necessity of RBC in oxygen transport for
its role in containing Hb rather than having free Hb in the plasma. Candidates tend to answer in a
fixed pattern – e.g. dissolved fraction of O2/ CO2 frequently mentioned in this question. Most
answers appear to be either a description of the O2-Hb dissociation curve or CO2 carriage. Candidates
should expand their answer to beyond the role of Hb to the role of RBC as well. Very few candidates
mentioned the role of RBC in iron transport. Overall this question was reasonably answered as the
main functions (oxygen carriage, CO2 removal, buffering were mentioned)

Q2. Briefly describe the role of buffers in the control of body pH.
90% achieved a pass in this question. Almost all gave a good definition of buffer. The question asked
to describe the role of buffers rather than just to list and describe each buffer. Most had listed HCO3,
higher if they managed to provide a discussion on the relative importance of amount, pKa and open vs
close system, the difference between intracellular and extracellular buffers. Again candidates tended
to confuse RBC and Hb, and frequently mentioned carbonic anhydrase when talking about Hb. Some
candidates considered Hb a plasma protein!

Q3. Discuss the factors affecting the rate of gastric emptying in adults.
81% achieved a pass in this question. Generally well answered. This is an important question in the
practice of anaesthesia therefore examiners are less forgiving with wrong facts. Some forgot the effect
of the types of food, osmolarity, temperature, pH and some confused this question with the factors
which affect gastric acid secretion, which are different. Emphasis should be on the normal physiology
of stomach emptying. Effects from pregnancy, anxiety and pain were often not mentioned – these
patients are often encountered in the preanaesthetic consultation. Drugs that affect stomach emptying
and the presence of pathology were instead frequently mentioned but were of lesser importance to this
question.

Q4. What are primary afferent nociceptors and how do they function? Briefly explain what
happen to their response after a brief period of noxious stimulation.
52% achieved a pass in this question. This is a difficult question, not surprisingly very poorly
answered. This question is on nociceptors not the pain pathway. Wind up, NMDA, AMPA, gate
theory will not score any marks. In this question, “their response” means response of the nociceptors,
not response of the subject/ patient. Many confused peripheral with (central) spinal cord events.
Definition of pain isalso irrelevant, potential tissue damage may cause pain or painful experience but
does NOT activate nociceptors.

Q5. Give an account of cerebrospinal fluid.

71% achieved a pass in this question. It was a simple questions testing the basic knowledge of the
candidates. Better answer should include the amount, composition, functions, formation and
reabsorption rate. Bonus marks were given to correctly labelled graph of formation and reabsorption
of CSF.

Q6. State the reaction catalysed by the enzyme carbonic anhydrase (carbonate dehydratase).
List the physiological processes involving this enzyme in the human body. Briefly describe any
three of these processes.
57% achieved a pass in this question. The question required integration of materials from different
systems of the body. Core answer should include the site of carbonic anhydrase, and the subsequent
effects of such a reaction. Carriage of CO2 in blood, gastric acid secretion, bicarbonate and K/H+
exchange in proximal and distal tubules of kidney were commonly quoted processes.

Q7. What determines cardiac output? Briefly describe 3 methods of measuring cardiac output.
57% achieved a pass in this question - a simple but important question testing the core knowledge of
the candidates. Factors affecting the cardiac output were often adequate but methods of measurement
using Fick’s principle like dye dilution/thermodilution technique, Doppler principle, pulse pressure
contour, thoracic impedance technique were insufficient.

Q8. Describe the factors affecting the vascular motor tone.

67% achieved a pass in this question. The question required the candidates to synthesize from several
physiological processes. Since arterioles are the main site of action, the structure, mechanical
response and innervation of which should be briefly mentioned. Better answer should give a basic
account of autoregulation, systemic humoral and neural control, reactive hyperaemia, and triple
response.

Q9. Discuss the physiological principles involved in the reflex of vomiting.

43% achieved a pass in this question. The vomiting reflex is a complex one involving different parts.
The ability to describe a coordinating reflex is required. A clear diagram with description or
diagrams. The importance of the vomiting centre as a central coordinator was not emphasized in some
candidates. Some candidates spent too much on receptors while some candidates wrote non-scoring
points e.g. complications of vomiting, pathological conditions leading to vomiting.

Q10. List the hormones and briefly outline their roles in the regulation of the blood glucose.
71% achieved a pass in this question. This is a generally well answered question. As insulin and
glucagons play an important role in glucose level regulation, details on these 2 hormones are expected
including when and how their secretion is changed, where they are produced and their effects on
different organs. Almost all candidates were able to list other hormones other than insulin and
glucagons.

Q11. Briefly describe how blood pressure is derived using an oscillometric blood pressure
machine and list the sources of inaccuracies.
67% achieved a pass in this question. This is a simple and fundamental question. We use it everyday
in our daily practice. It requires recall of basic facts. To pass this question, the candidate is expected
to describe components, algorithm and source of inaccuracies of the device.

Q12. What is preoxygenation? Explain the physiological principles of preoxygenating a patient

before the induction of general anaesthesia.
62% achieved a pass in this question. This is a generally well answered question. In this 2-part
question, most candidates were able to give a clear definition of the procedure: 100% oxygen through
a tightly sealed masked for 3 minutes in order to increase oxygen content in the body. To score a pass
in the second part of the question, answers on the effect of breathing 100% oxygen on oxygen content
in the FRC and the subsequent effect on apnoeic time are expected. Most candidates scored bonus by
drawing a table showing different oxygen stores in the body before and after preoxygenation.

Viva Topics

Regional blood flow

Control mechanisms
Coronary vascular resistance
Functions of bile
Composition of bile
Functions of histocytes
Metabolism of bilirubin
Hepatic blood flow
Ceregrospinal fluid
Metabolic acidosis
Control of respiration
Chemoreceptors
Monroe-Kelline Doctrine
Physiological methods to decrease ICP
Definition of pain
Measurement of pain
Kidney blood flow
Renin-angiotensin-aldosterone
Parathyroid hormone and calcitrol
Acidification of urine
Surfactant
Airway resisitance
Homeostasis
Blood group
Thromboxane A2
Platelet activation factor
Importance of endothelium
Stroke volume