Hong Kong College of Anaesthesiologists

Final Fellowship Examination July/August 2003

Examiners Report

Written examination 25th July 2003

Viva examination 29th & 30th August 2003
OSCE 31st August 2003

External Examiners:
Professor Peter Booker, Royal College of Anaesthesia (UK)
Dr David Scott, ANZCA (Australia)
The external examiners took an active role in each section of the examination.
Internal Examiners:
Written: Amy Cho, SL Tsui, Mike Irwin, Anne Kwan, A O’Regan, MC Kung, Anandaciva, CK
Chan
Vivas: TW Lee, Anne Kwan, Cindy Aun, A O’Regan
OSCE: Cindy Lai, Serena Fung Theresa Hui, Victor Yeo, Simon Chan, A O’Regan, TW Lee, CT
Hung, Edward Ho, BH Yong, CK Koo, YF Chow, Anthony Ho, Kevin Mui, CK Chan, PW Cheung,
Steven Wong, MTV Chan

General Comments
As in previous examinations candidates did not perform as well in the written section as in the viva
section. Better organisational and presentation skills (in particular, legible hand-writing) would
improve many candidates marks. To address these deficiencies candidates are advised to spend
more time in their examination preparation practising written questions.

PAPER 2- SHORT ANSWER QUESTIONS

1. A healthy 26 year old man develops intra-operative bradycardia and hypotension whilst
having an inguinal hernia repair performed under subarachnoid anaesthesia. List the possible
causes and briefly outline your management. (10/26 passed)
Most candidates managed to get the main categories of possible causes such as high block,
hypovolaemia, Bezold-Jarisch reflex, vasovagal shock, and vagal stimulus. In some cases,
inappropriate emphasis was placed on causes such as local anaesthetic toxicity and anaphylaxis. Very
few mentioned causes such as drug error and sedation. The better candidates prioritized the possible
causes, and illustrated decisiveness in the management of quite a well known crisis situation under
spinal anaesthesia, including a low threshold of using adrenaline should the patient not respond
promptly to fluid, iv atropine or vasoconstrictor therapy.

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2. You are asked to anaesthetise a healthy 15 year old boy who has sustained a penetrating
injury to an eye. He had a full meal 1 hour before the injury. Outline your anaesthetic
technique and justify your choice. (22/26 passed)
On the whole, this question was adequately answered with most candidates identifying and
addressing the following problems: the need for urgent surgery to salvage the eye and reduce
infection, full stomach, the need for avoiding factors which could increase risk of further extrusion
of eye contents such as meticulous smooth induction, attenuating the sympathetic response to
laryngoscopy and intubation. However some failed to justify their choice of anaesthesia.

3. A 58 year old woman presents for an abdominal hysterectomy. At your pre-operative visit
you note a prolonged QT interval on her ECG. Discuss the possible causes and implications of
this finding and how it would affect your anaesthetic management. (11/26 passed)
There was a lack of knowledge of the drugs that can result in prolonged QT amongst the candidates.
A surprisingly large number of candidates did not know of the risk of VT (Torsade de Points) in this
condition, and the emergency management of this serious arrhythmia. It is disturbing to note that
some candidates would have just taken this patient on for the hysterectomy without knowing the
implication of the condition.

4. Discuss the important issues in the management of the anaesthetic for a 35 year old man
having debridement of extensive (30%) neck, chest and leg burns 3 days after the injury. The
patient has been managed unintubated in intensive care. (21/26 passed)
This questions was generally well answered with most candidates addressing the question under the
following management headings: airway, temperature, blood and fluid balance, monitoring, nutrition,
pain relief and duration of procedure.

5. Outline, with reasons, the possible consequences of an adult patient arriving in the recovery
room after a laparotomy with a core temperature of 34 °C. (18/26 passed)
The management and prevention of hypothermia is a problem central to the provision of good
anaesthetic care. However, although the majority of candidates passed this question, few achieved
good marks. Most candidates identified discomfort, shivering, vasoconstriction, prolongation of
spontaneous recovery, increased postoperative bleeding and increased incidence of wound infection
but many failed to appreciate the potential for increased incidence of vital organ dysfunction,
prolonged hospitalization and increased hospital mortality rate.

6. Discuss the advantages and disadvantages of the three long-acting local anaesthetics:
bupivacaine, levobupivacaine and ropivacaine, when used for axillary brachial plexus block.
(13/26passed)
A detailed applied knowledge of the drugs used in anaesthesia practice is essential for all practicing

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anaesthetists. This question was poorly answered suggesting that many candidates failed to
appreciate the necessity of maintaining their pharmacology knowledge past the intermediate
examination. Many of the candidates who failed this question had no knowledge of levobupivicaine
and those who passed struggled to provide satisfactory discussion of the advantages and
disadvantages of each drug in the setting of axillary brachial plexus block. Most failed to arrive at the
conclusion that bupivicaine should not used. Some of the general heading which candidates were
expected to address when answering this question were: the speed of onset, duration of action,
potencies, potential for toxicity, the affect of adrenaline as an additive,

7. A one year old child is suspected of having aspirated a peanut and is booked for an
emergency bronchoscopy. Describe your anaesthetic management. (20/26 passed)
This question was not well answered with most candidates barely passing. Candidates are expected
to describe the preoperative assessment, intra-operative anaesthetic care and postoperative care of a
one- year-old infant with upper airway obstruction. Most candidates elaborated well on preoperative
assessment although some missed the fasting time / full stomach. Not all foreign body inhalations are
so urgent as to require immediate surgery and a period of fasting may be possible. Many candidates
didn’t mention or elaborate on the subsequent management after the foreign body was removed. A
few candidates mentioned the use of nitrous oxide which is not suitable in this circumstance. Many
chose propofol but without elaboration on how to use it safely on a child of this age.

8. A 28 year old primigravida with pre-eclampsia is in labour. Her obstetrician has advised her
to consider epidural analgesia. She has concerns about the possible effect of the epidural on
labour and on the need for instrumental delivery. Outline how you would address these
concerns. (20/26passed)
Most candidates passed this question but only a few scored higher marks. In this question, it is
important to deliver the message of relative risk-benefit ratio of epidural analgesia to this parturient,
who is a primigravida with pre-eclampsia. It is not difficult for a final FHKCA candidate to list the
advantages and risks of epidural in a parturient. Most candidates did give comprehensive
description on these facts. However, the discussion should mention the special advantages with
respect to the parturient in this question. Few of the candidates discussed and emphasized the
relative risk-benefit ratio of epidural analgesia. The candidates are expected to highlight the
beneficial effects of epidural out-weight its risks. The controversy on possible increase in
instrumental delivery rate related to epidural shall also be discussed. The patient is specifically
concerned about the risk of instrumental delivery but this was not well addressed by some
candidates.

9. Outline the main characteristics of the myasthenic syndrome. How and why do they differ
from those seen in myasthenia gravis? (8/26 passed)

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This question is only fairly answered, some candidate scored higher marks but others failed due to
poor knowledge on the patho-physiology of myasthenic syndrome and myasthenia gravis. Many
candidates didn’t mention the effect of de-polarizing and non-depolarizing muscle relaxants in the
two different conditions.

PAPER 1- SCENARIO QUESTIONS

Scenario A
You are asked to see a 14 year old patient with Down’s Syndrome scheduled for extraction of
four molar teeth. His old notes have been mislaid, but his carers inform you that he has been in
hospital before.

1. Outline, with reasons, your preoperative assessment of this patient. (19/26 passed)
Most candidates gave answers that concentrated on patients with cardiac problems without specific
emphasis on patients with Downs Syndrome. In addition to a routine anaesthetic screening history,
emphasis should have been directed at obtaining a history, examination and investigations pertaining
to excluding the majority of the following associations:
Neurological: learning difficulties, hypotonia
Cardiovascular: Endocardial cushion defects, ventricular septal defects, ductus arteriosus,
Tetralogy of Fallot
Orthopaedic: atlanto-axial subluxation , cervical spondylosis
Respiratroy: susceptibility to sub-glottic stenosis, respiratory tract infections and obstructive sleep
apnoea
Others: possible hypothyroidism and gastro-oesophageal reflux, drug sensitivities, difficulties
obtaining venous access, difficulties ensuring fasting observance.

2. You think he may be slightly cyanosed and a little breathless at rest. On auscultation, you
hear a soft systolic heart murmur. The rest of your cardiovascular system examination is
essentially normal. What is your differential diagnosis? Describe, with reasons, what
additional information you require before you would be happy to administer an anaesthetic to
this patient. (10/26 passed)
Most answers were poorly organized. After excluding respiratory tract infection candidates were
expected to identify a severe cardiac condition as the probable cause of the symptoms. The most
likely diagnosis is ventricular septal defect with some degree of pulmonary hypertension. (cyanosis
suggests the possibility of Eisenmenger’s syndrome with its risk of sudden death.) The other
differential diagnoses are atrial septal defect, patent dutus arteriosus and mitral regurgitation. It is
important to assess his cardiac condition carefully and optimize his condition before proceeding to
the elective procedure under antibiotic cover therefore candidates were expected to defer surgery
until a firm diagnosis has been established and risk/benefit ratio of anaesthesia/surgery better

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assessed (i.e cardiology assessment, echocardiogram, review of all pertinent previous medical notes,
medications and previous cardiac surgery).

3. Outline, with reasons, the disadvantages and advantages in listing this patient for daycare
surgery. (8/26 passed)
It is important to balance the risks /benefits before offering this patient day care surgery. This
question was poorly organized by most candidates with many failing to identify the possible benefits
of day care surgery for this patient after he has undergone thorough pre-operative assessment as listed
in Question 2. If there is no significant pulmonary hypertension from his cardiac condition and if he
is not suffering from other major health problems, he is suitable for daycare surgery. The advantages
in this patient with learning difficulties include: return to familiar surroundings as soon as possible,
decreased risk of hospital acquired infections, as well as the resources and cost benefits. However
daycare would not be suitable if the patient has significant pulmonary hypertension, because of
increased risk of post-operative complications such as hypoxia, arrhythmias and death requiring
close post-operative monitoring and management. Good candidates also highlighted the problems of
ensuring proper fasting in a day care setting, post-operative pain control and the possible increased
chance of requiring in patient admission with arrangements for this if needed.

Scenario B
A 47 year old male who is otherwise well presents with a right upper lobe lung abscess 7 cm in
diameter. He is scheduled for a right upper lobectomy.

4. What problems could the presence of this abscess cause during induction and maintenance,
and how would you overcome these problems. (17/26 passed)
All candidates highlighted the potential for contamination of the left lung with pus from possible
rupture of the abscess during induction or abscess communication with the bronchial tree but many
failed to highlight the important role of positioning at induction to minimize this problem i.e.
keeping the abscess lowermost – induce with the patient lying on the right side. Better candidates
identified this as potentially making intubation difficult but readily overcome by turning the head to
the left, or using a right handed laryngoscope. All candidates emphasized the importance of isolating
the lung with an appropriate sized left double lumen tube with position checked using a fibreoptic
scope. Surprisingly many candidates failed to emphasize the central role of identifying and
controlling systemic infection before embarking on surgery and only a few candidates identified the
possibility that the abscess could be tuberculous necessitating important infection control measures.

5. The patient develops hypoxia (saturation 75%) at the beginning of the resection. Describe
what steps you would take to restore adequate oxygenation. (22/26 passed)
Overall most candidates followed a logical approach to this common problem associated with one

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lung ventilation. However some candidates omitted to mention that they would give the patient
100% oxygen and others failed to highlight the early role of re-checking tube and cuff positioning
with the fibre-optic scope then proceeding to PEEP to left lung followed by gentle inflation and
CPAP to the right lung with ongoing communication with the surgeons. Temporary bronchial and
pulmonary artery occlusion were mentioned by better candidates as methods to try should the
problem persist.

6. Describe and justify your method of postoperative pain control. (23/26 passed)
The first part of the question was generally well answered. Most candidates identified a thoracotomy
wound as a cause of considerable postoperative pain requiring well a planned analgesia technique
with either Patient Controlled Analgesia, an opioid infusion or an epidural infusion as the central
method of pain relief. The better candidates also identified the need for an adequate rescue analgesia
plan to be in place. Good answers highlighted the role of a multi-modal analgesic regime-
intercostals nerve blocks performed under direct vision by the surgeon, PCA or epidural, and
paracetamol suppositories etc.
Although there is a theoretical objection to epidural based on potential infection from blood borne
bacteria from the abscess. there is no evidence in the literature to support this concern in a patient
who does not have evidence of systemic infection.
Many candidates failed to score high marks because they could not justify their choice of analgesia.

Scenario C
A 70 year old lady is admitted for an elective gastrectomy for treatment of her carcinoma of
stomach. Preoperative assessment showed apathy, sluggish response to verbal command and a
mean heart rate of 55/min.
7. List the anaesthetic implications of hypothyroidism. (17/26 passed)
Most candidates had no problem with mainly descriptive question. Anaesthetic drug requirements,
recovery profile,
CVS instability, potential airway problems, temperature control, associated adrenal
insufficiency and, the high mortality of myxoedema coma were well elucidated by the majority
of candidates.

8. Describe your pre-operative preparation of this patient. (15/26 passed)

Half of the candidates failed to recognize the relationship between IHD and the hypothyroid state
with even more failing to address potential co-morbidities with other endocrine systems, the possible
need for rapid thyroid replacement under ECG monitoring with attendant risks of precipitating an
acute myocardial infarction. This is one of the special disease entities which needs the input of an
endocrinologist as part of the anaesthetic preparation. The risk / benefit of delaying surgery to allow
thyroid replacement was ignored by some candidates.

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9. Before thyroid replacement therapy could be commenced, she has a severe hematemesis
(confirmed at endoscopy as active arterial bleeding from the malignant gastric ulcer) and is
booked for emergency laparotomy under general anaesthesia. Describe your anaesthetic
management. (8/26 passed)
Most of the candidate fared poorly partly as a result of poor organization. This question lends itself
to being divided into the following sections: 1) the general theme of any emergency operation of a
relatively hypovolemic patient with possibility of full stomach, and 2) the other theme pertaining to
her state of hypothyroidism and related problems, such as anticipated airway problem, hypothyroid
state, possible co-morbidity such as adrenal insufficiency, temperature regulation, delayed
emergence, and preoperative ventilator and circulatory supportive care as required. Candidates
were expected to state that the surgery could not be delayed and that verbal consultation with the
endocrinologist is required regarding advisability of giving this patient enteral T3 or IV T4
(contraindicated in the presence of ischemic heart disease).

VIVA QUESTIONS
Scenario based questions:
Patient with history of suspected latex allergy for elective surgery
Morbid obesity with obstructive sleep apnoea for laparoscopic cholecystectomy
Obstetrics -patient with asthma
Obstetrics- prolapsed cord, substance abuse
Patient with pacemaker for sick sinus syndrome
Laparoscopic resection of adrenal tumour
Anaesthesia for cerebellar pontine angle tumour
Patient with hypertension develops intra op myocardial ischemia and infarction during total knee
replacement
Patient with acute forearm injury requiring tendon and nerve repair- brachial plexus block
Patient with head injury and difficult airway
Anaesthesia for clipping of cerebral aneurysm
Venous air embolism
Patient with acute blood loss of 2.5litres
Jehovah Witness for Left hepatectomy for hepato-cellular carcinoma
Chronic smoker with intra operative bronchospasm

Stand alone question:

Diabetes mellitus
Dental injury
Intra-arterial thiopentone

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Patient with old CVA, carotid stenosis and mild aortic stenosis for elective nonvascular surgery
Pregnant patient for cholecystectomy
Laryngeal mask airway
Role of NSAIDS in patients undergoing hysterectomy
Anaesthetic considerations in a patient donating bone marrow
“blood transfusion trigger”- considerations
acid aspiration prophylaxis
Anaesthetic considerations in patient with Parkinson’s disease requiring upper gastrointestinal
surgery
Post-operative confusion in the elderly- predisposing factors
Complications of blood transfusion
Gas supplies
Intercostals blocks
Ex-premie requiring inguinal herniotomy
Modern vapourizer designs- desflurane requirements
Post operative bleeding in child with tonsillectomy done
Establishment of anaesthetic service for MRI
Previous awareness- management
Statistics- P, power, How to choose between using a Mann-Whitney U test,.student T-test or Fishers
Exact test when performing a 2 group test
Rheumatoid arthritis- anaesthetic implications
Alpha 2 agonists role in post operative epidural analgesia
Ankle block
PDPH
Indication for PAC for AAA surgery
Intraoperative tachycardia
SVT causes- management
Caudal in children
URTI and anaesthesia
Negative pressure pulmonary oedema
Low flow anesthesia- advantages and disadvantages
Clinical trials- morphine versus a new analgesic
Anatomy and physiology of cerebral blood flow
Factors influencing cerebral blood flow

OSCE
Station 1. Communication (6/26 passed)
Candidates were asked to interview the wife of a young patient who coughed during elective clipping

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of cerebral aneurysm, resulting in aneurysm rupture. Surgeon had to ligate the internal carotid artery.
The overall performance of the candidates was below average. Most candidates demonstrated proper
attitude and showed empathy for the tragedy during the interview. However, only one candidate
mentioned that the aneurysm might rupture spontaneously or as a result of surgical manipulation.
Many candidates had unclear concept regarding medical negligence and compensation.

Station 2. Physical Examination (22/26 passed)

Candidates were asked to examine the respiratory system and the cardiovascular system of two
manikins which had signs inspiratory stridor and mitral stenosis respectively.

Station 3 Physical Examination (20/26 passed)

Candidates were asked to perform an airway assessment of a patient who had rheumatoid arthritis
and previous thyroid surgery.

Station 4 ACLS/ATLS (23/26 passed)

Candidates were asked about the resuscitation and subsequent management of a road traffic accident
victim with head and thoraco-abdominal injuries.

Station 5. X-rays (20/26 passed)

Candidates were asked to interpret seven CXR and one neck X-ray. Overall performance was fair.
Candidates were required to describe all the abnormal features and relevant “normal” features in the
films, for example, CXR with pneumothorax without fracture ribs or central line seen to account for
the lesion. Surprisingly, quite a number of candidates could not detect tension pneumothorax during
the examination. It is worrying because the patient may have adverse outcome if this potentially
lethal condition cannot be diagnosed in time. The films should also be interpreted with the clinical
history given. Good candidates approached the X-ray films systematically and not missed important
features.

Station 6. Practical Procedures (24/26 passed)

Candidates were asked to discuss the use of pulmonary artery catheters. A few candidates stated that
the balloon should be inflated in the right ventricle. While some may practice this, it is not the correct
answer for an exam (and not the standard practice!). Many had no idea of the usual pressures
obtained.

Station 7. Anatomy and Regional Anaesthesia (19/26 passed)

Candidates were examined on the sensory supplies and regional anaesthesia techniques of the upper
airway. Most candidates performed satisfactorily. Poorly performed candidates gave only a vague
picture of the innervation of the nose, oropharynx and the larynx. Neural blockade of the nose by

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using antomical landmarks was expected. Better candidates could describe the different approaches
to superior laryngeal nerve blockade.

Station 8. Equipment (13/26 passed)

In this non-interactive station, candidates had to write answers on the marking sheets questions on the
circle system and the Bain circuit.

Station 9. Investigations (15/26 passed)

Candidates were asked to interpret one each of renal function test, renal and liver function test, and
haemodynamic indices, and three ECG.

Station 10. Crisis Management (20/26 passed)

This station tested the skills of handling “malignant” hypotension after induction of anesthesia. The
station used the human patient simulator to reproduce the scenario. Therefore, the test condition was
identical for all candidates. Majority of the candidates passed the station. The best candidate
followed the COVER ABCD algorithm and managed the crisis well. It is however, surprising that
many candidates were vague in the dosage of commonly used drugs for resuscitation (including
adrenaline).

END

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