Question No.

1
How would you determine the causes of arterial hypotension (80/60 mmHg.)
during a prostatectomy, and how would you manage it?

Answer: -
Key points:
1. Blood loss – inspection and analysis of bladder washouts – requires a
discussion of difficulty of assessment.
2. TURP syndrome – clinical signs, use of ethanol marker and breath-analyzer
monitoring.
3. Anaesthetic – too deep, severe hypocapnia, severe bradycardia, spinal block
too extensive, or made more severe by presence of significant cardiac disease.
4. Other medical conditions – myocardial infarction, co-existing aortic stenosis,
cardiac failure – need comment about usefulness of monitoring.

________________

Question No. 2
What causes bradycardia during general anaesthesia and what is the
management of this condition?

Answer: -
Key points:
First of all, this needs a comment about what pulse rates constitute bradycardia.

Causes:
Deep anaesthesia, hypoventilation (e.g., disconnected ventilator), hypoxia,
hypotension (which may also be caused by bradycardia), occulocardiac and other
vagal reflexes, drugs (opioids, neostigmine, B-blockers), cardiac
ischemia/failure/bradyarrhythmias, cerebral compression, high spinal blockade.

Management:
Assess reasons for it and state what limits should provoke action.
Mention use of anticholinergic drugs, e.g., atropine.
Treat cause if possible.

Comment: A common problem.

1
Question No. 3
List the causes and briefly note the management of tachycardia (>100 bpm)
during general anaesthesia in an adult.

Answer: -
Key points:
Causes:
Light anaesthesia, hypercarbia, hypovolaemia, hypotension, tachy-arrhythmia, drugs
(atropine, adrenaline), endocrine problems (thyroid crisis, phaeochromocytoma),
malignant hyperpyrexia, toxaemia.

General management:
a) Assess significance: (e.g., associated with hyper- or hypotension – pulse
rates well above 100 bpm may adversely affect circulation), state need for
experienced help;
b) Treat cause if possible. The target pulse rate is 70-100 bpm.

Tachyarrhythmias:
Mention of DC defibrillation shock if hypotensive.

Specific management:
Sinus tachycardia – carotid sinus massage; Beta-blockers (and contraindications to
these drugs).
Supra Ventricular Tachycardia – carotid sinus massage, adenosine, amiodarone,
verapamil is controversial.
Atrial fibrillation or Flutter – digoxin, amiodarone; DC shock may be needed.
Ventricular tachycardia – amiodarone (lignocaine, flecainide and verapamil are used
much less).

2
Question No. 4
Why do some patients suffer circulatory collapse at the induction of general
anaesthesia and how would you manage it?

Answer: -
Key points:
Causes:
1. Nature of patient’s disease e.g., untreated hypertension, sudden arrhythmia,
cardiac failure (for example in emergency CABG), severe aortic stenosis,
pacemaker failure, pheochromocytoma, and other rare syndromes.
2. Anaphylaxis (hypotension, bronchospasm, flushing, oedema).
a. Stop injecting the anaesthetic agent.
b. O2/ventilation.
c. Adrenaline 50-100 μg.
d. Head down position and 2L colloid volume load.
e. Antihistamines.
f. Steroids.
g. Blood samples.
h. Prevent awareness.
(and then later …
i. Inform patient).
3. Fainting – vasovagal shock. Atropine, and elevation of legs etc.
4. Shock. Prevented by pre-emptive correction of hypovolaemia.
5. Overdose of anaesthetic agent. Prevention is better than cure!
6. Myocardial infarction. ECG will show this.

General management:
Firstly, diagnosis of the cause, based on knowledge of the patient’s preoperative
medical condition, and full monitoring.
In general, anticipation of the problem, with full monitoring; elevation of the legs and
careful use of catecholamines. ACLS plus control of the cause if the collapse
progresses to cardiac arrest.

Comment: There is no simple way of categorizing the answer to this one!

3
Question No. 5a
What physiological changes follows acute hypovolaemia?

Answer: -
Key points:
Definition: imbalance between circulating volume and capacity of circulation.
1. Blood volume falls causing reduced venous return; reduced RA pressure, CO
2. Reduced cardiac output causes systolic and pulse pressure fall
3. Baroreceptors firing reduced, leads to tachycardia, vasoconstriction,
adrenaline secreted in blood and diverted to heart and brain. BP maintained till
loss of 20% volume.
4. Atrial receptors cause ADH secretion (resulting in oliguria and water
retention). Aldosterone secretion (cause Na+ retention), thirst, endorphin
secretion, water transfer from ECF to circulation, resulting in Dilutional
anaemia.
5. Carotid chemoreceptors stimulation causes hyperventilation
6. Cold periphery, pallor, cyanosis, reduced capillary refill.

________________

Question No. 5b
What is the physiological response to rapid loss of 1 litre of blood in the adult?

Answer: -
Key points:
1. General description of the clinical picture in the hypovolaemic patient with
fall of cardiac output, vasoconstriction and hypotension. Some indication of
signs-reduced capillary refill, tachycardia, oliguria, distress, loss of muscle
tone.
2. Compensation:
a. Baroreceptors – arteriolar resistance, venoconstriction, cardiac effects
(tachycardia, raised diastolic) respiratory effects (hyperventilation)
b. Pituitary renal/adrenal axis, renin, angiotensin, ACTH, ADH
c. Fluid shifts from ECF to blood, with time scale.

Comment: This is similar to the previous question, and demonstrates that any subject
may be asked in several different ways.

4
Question No. 6
List the factors which determine the supply of oxygen to the tissues of the body.
How may these factors be altered by septic shock?

Answer: -
Key points:
Factors:
 O2 supply to lungs
 Respiratory drive and adequacy of ventilation
 Pulmonary O2 transfer (shunting and V/Q mismatch)
 Hb level and O2 affinity of haemoglobin, including shifts of the O2
dissociation curve
 Cardiac output and blood distribution
 Capillary function
 Body temperature

Alteration by septic shock:

 Reduction of lung function, cardiac output, arterial pressure
 Unbalanced blood distribution
 Endothelial swelling, capillary closure
 Tissue oedema
 Bypass of capillaries via arteriovenous anastomoses.

________________
Question No. 7
What information can be gained from measuring central venous pressure?

Answer: -
Key points:
a) Normal range: (with variations erect/supine/head down; spont./IPPV; and
effect of tachycardia and bradycardia);
b) Diagnosis and subsequent management of shock;
c) Managing fluid and blood transfusion;
d) Monitoring cardiac performance, esp. right side of heart, and acute left
ventricular failure; note also assessment of venous waves a, c, v.

5
Question No. 8
How would you manage atrial fibrillation which occurs during anaesthesia?
What could be done to prevent it?

Answer: -
Key points:
ECG monitoring is essential for recognition.
1. Management:
a. Use of adenosine, 3mg i.v. – for diagnosis;
b. Use of DC shock (bonus marks for management of this during regional
analgesia);
c. Digoxin 0.5 mg i.v. To control ventricular rate if > 100bpm;
d. Amiodarone 1g infusion to prevent recurrence;
e. Use of beta blockade in thyrotoxicosis;
f. Need for notes about the care of resulting cardiac failure and embolism
problems.

2. Prevention:
a. Recognition of the at-risk patients (thyrotoxicosis/myocardial
ischaemia/mitral stenosis/previous atrial fibrillation/Sick sinus
syndrome/elderly with hypokalaemia). Preoperative ECG is essential
for this;
b. Avoidance of hypotension at induction in the elderly;
c. Preoperative correction of hypokalaemia.

________________

Question No. 9
How does the presence of aortic stenosis affect the management of an
anaesthetic?

Answer: -
Key points:
Fixed cardiac output, with risk of severe hypotension on induction; vasodilation is to
be avoided. Coronary flow reduced, risk of endocarditis (need for antibiotic cover)
and subendocardial ischemia if inotropes are given in large dosage. (Bonus marks for
stating that HOCM is worsened by inotropes).

6
Comment: It is particularly important to mention that coronary flow is dependent on
diastolic pressure, and that tachycardia is to be avoided as it shortens diastolic
interval.

Question No. 10
What are the complications of mitral valve disease during anaesthesia and how
do you prevent them?

Answer: -
Key points:
1. fixed cardiac output, with risk of serious vascular instability (avoidance of
cardiac depression, vasodilation and tachycardia).
2. acute left ventricular failure, with pulmonary oedema, requiring diuresis with
frusemide.
3. bacterial endocarditis, (requiring antibiotic cover).
4. atrial fibrillation (requiring control of rate and treatment of left ventricular
failure). This may cause:
a. arterial thromboembolism, prevented by anticoagulation;
b. cardiac failure, requiring careful use of inotropes.

________________

Question No. 11
A patient’s arterial pressure on admission for moderately urgent
appendicectomy is 170/115 mmHg. Describe your anaesthetic management.

Answer: -
Key points:
The anaesthetist checks it for himself! (it can be due to pain, a full bladder, and the
answer requires a brief discussion of hypertension due to fear.)

Investigation of causative conditions:

a. generalized vascular disease, possible renal and other rare causes of
hypertension (e.g., phaeochromocytoma);
b. is the patient’s abdominal pain due to another, medical, cause? Could it be
angina due to hypertensive crisis?

Management:
Prevention of risks;
 hypotension under anaesthesia;

7
 myocardial infarction;
 cerebral haemorrhage;
 ECG required;
 This diastolic pressure is too high for safety. The operation is postponed for
emergency medical treatment, involving relevant specialists.
Relevant drugs:
 Nifedipine
 Beta blockers
 ACE inhibitors
 Ca channel blockers
 Clonidine, with rapid and carefully monitored intravascular volume
replacement.

Antibiotics are required to cope with a short period of postponement of operation.

Spinal anaesthesia not advisable because of cardiovascular instability.

Comment: The answer to this is longer than many in this book.

________________

Question No. 12
A patient with congestive cardiac failure presents for hip replacement. Describe
your management for the anaesthetic.

Answer: -
Key points:
Problem:
1. the implication is that the patient has serious cardiac and possibly other organ
disease, and requires full investigation, e.g., by ECG, echocardiography and
relevant blood tests.
2. cardiac depression by anaethetics, and
3. uncontrolled vasodilation from cement are the notable risk points, with the
emphasis on prevention.
4. haemorrhage may be considerable with need for accurate volume replacement
with monitoring.

Comment: This is not an uncommon scenario.

8
Question No. 13
A patient presenting for prostatectomy has a pulse rate of 39 beats per minute.
Describe the common causes and management of this.

Answer: -
Key points:
This answer needs a comment on what pulse rates are acceptable and what the target
pulse rate would be.

Causes:
1. heart block (will need anticholinergics and possibly pacing).
2. treatment with beta blockers (reduce the dose and/or use other drugs;
premedicate with anticholinergics).
3. sick sinus syndrome (common in this patient population with risk of atrial
fibrillation, supraventricular tachycardia, ventricular tachycardia and
ventricular fibrillation).
4. failure of implanted pacemaker (needing referral to cardiologist).

This all implies serious cardiovascular disease.

ECG and full drug history is essential (esp. beta blockade). Specialist medical advice
is helpful. Operation will need to be postponed until the pulse rate is normal. Risk of
further bradycardia during and after anaesthetic.

________________
Question No. 14
In what circumstances may fluid overload occur during operation? How is it
diagnosed and managed?

Answer: -
Key points:
1. Overestimation of the operative losses (e.g., in laparoscopic operations),
with overinfusion.
2. TURP syndrome, with absorption of irrigating fluid.
3. in sever 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:

9
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 emphasized the importance of this.

________________

Question No. 15
Discuss the causes and management of intraoperative hypertension.

Answer: -
Key points:
Preoperative
Assessment, definitions
Causes of hypertension
Action

Intraoperative
Intubation
Physiological response
Treatment
When
With what

Maintenance
Relatively light anaesthesia
Straining on endotracheal tube
Drugs given, e.g., adrenaline
Hypercapnia
Action: first check equipment
Drug

Specific operations
Aortic clamps
Physiology, treatment
Phaeochromocytoma, carcinoid tumour
Elective
10
 Effects, treatment
Emergency

Question No. 16
What are the causes and management of hypoventilation immediately following
anaesthesia?

Answer: -
Key points:
Causes:
1. Obstructed airway.
2. Anaesthetic drugs – especially volatile and opioids.
3. Incomplete reversal of relaxants.
4. Pain
5. Shock.
6. CO2 narcosis (caused by, and a cause of, hypoventilation).
7. Obesity and medical problems of the patient, e.g., myasthenia, pulmonary
disease, raised intracranial pressure.

Management:
Oxygen, ventilation of lungs, reversal of cause.

Comment: This is a question about everyday anaesthetic practice.

________________

Question No. 17
Why do some patients develop ARDS following colectomy? What are the
pathophysiological processes?

Answer: -
Key points:
The sequence of events may be:

Gut wall ischaemia – endotoxaemia – eicosanoid secretion – endothelial damage –

capillary closure – tissue hypoxia and oedema – destruction of type I cell –
proliferation of type II cells – hyaline membrane formation – shunting hypoxia –
deadspace, Hypercapnia – barotraumas (due to IPPV) – lung destruction.
11
12
Question No. 18
Write short notes on the diagnosis and treatment of pneumothorax.

Answer: -
Key points:
1. Diagnosis
The answer needs comments about when this is likely to confront the
anaesthetist, and the difficulty of locating the side.
a. Symptoms: pain dyspnoea, cyanosis, cardiovascular collapse,
especially in tension pneumothorax or bilateral pneumothorax;
b. Signs: abnormal breath sounds, abnormal chest movement, coin
test;
c. Tests: CXR – mediastinal shift, loss of lung marking in periphery.

2. Treatment:
This may be a major life-threatening emergency. IPPV may make the
condition worse! Need for (i.v.) cannula in third ribspace anteriorly, and chest
drain techniques, after which IPPV will be safer.

________________

Question No. 19
What are the adverse effects of intermittent positive pressure ventilation?
How would you minimize them?

Answer: -
Key points:
Possible opening sentences

The important adverse effects of intermittent positive pressure ventilation (IPPV) are
secondary to the increased intra-alveolar and intrathoracic pressures.

There are respiratory, cardiovascular, renal and endocrine effects of intermittent

positive pressure ventilation (IPPV)

IPPV has many effects on the physiology of the ventilated patient.

Respiratory:
Physiological
Ventilation/perfusion mismatch
Increased dead space
13
 Decreased FRC
Progressive atelectasis
Try: large tidal volumes, slow rate, PEEP
Mechanical (barotraumas)
Large airway
Alveolar
Try: avoiding high pressure, sudden pressure changes

Cardiovascular: (assume normocapnia)

Reduced venous return
Effect of age, hypovolaemia
Interaction with lung compliance
Secondary effect on intracranial pressure
Increased pulmonary vascular resistance
Try: maintain intravascular volume, altered I:E ratio

Renal and endocrine

Decreased renal blood flow
Increased antidiuretic hormone
Increased aldosterone
Sodium and water retention

________________
Question No. 20a
What are the adverse effects of oxygen therapy?

Answer: -
Key points:
Opening sentences:
Potentially lifesaving in many situations, oxygen should not be used indiscriminately
because of a number of disadvantages, mostly related to the inspired concentration
and the duration of exposure.

Oxygen has some effects directly due to the oxygen and some due to secondary
physiological changes.

Effects of oxygen itself

Central nervous system toxicity
Mechanism, occurrence
Manifestations, treatment
Pulmonary
Mechanism, occurrence
14
 History
Manifestations, treatment
Effects secondary to physiological changes
Respiratory
With blood carbon dioxide response
(danger exaggerated)
absorption collapse
reduction of lung surfactant
cardiovascular
myocardial depression
vasoconstriction

Others
in neonates
retrolental fibroplasias
(bronchopulmonary dysplasia)
anaemia
drug interactions
physical
fire

________________
Question No. 20b
Discuss the indication for humidification of inspired gases. Evaluate the
methods available.

Answer: -
Key points:
Inspired air is normally warmed and humidified in the upper airway.
Air is normally saturated with water vapour by the time it reaches the trachea.
Anaesthetic gases are dry, but this does not usually cause difficulties unless their use
is prolonged and the upper airway is bypassed.

Physics
Latent heat of evaporation

Clinical
Dry membranes, crusting, atelectasis
Inhibition of cilia

Indications
Tracheostomy

15
 Tracheal intubation

Why it is less important in routine anaesthesia.

Respiratory tract infection (esp. upper)
Children
Adults
Other
Drug delivery
Rewarming in hypothermia

Ideally
Tracheal gas to have satisfactory physical properties
Simple to use and service
With any gases or mode of ventilation
Any ventilatory or system
Safe
Temperature, hydration, electrical

Saline drip
Condensers
Cold water bottle
Warm water bath
Nebulizers

Warm water bath (with detail)

Condenser (for operating theatre)
Other simple devices
Saline drip (to dismiss)
Cold water bottle
More complex devices
Nebulizers

Hot water bath

Mechanism
Disadvantages
Condensation
Variable efficiency
Infection

Condenser
Principle
Advantages
Convenience
Disadvantages
Inefficient
16
 Increased resistance and dead space (children)

Other simple devices

Saline drip (to dismiss)
Cold water bottle: brief description

More complex
Nebulizers
Microdroplets: mechanism
Types
Bernoulli principle
Mechanical
Ultrasonic
Advantages
Constancy
Disadvantages
Cost and complexity
Hazard: supersaturation

________________
Question No. 21
Give a critical account of prophylactic measures designed to reduce the
incidence and consequences of pulmonary aspiration.

Answer: -
Key points:
Prophylaxis against pulmonary aspiration means reducing the volume and acidity of
the gastric contents, reducing the likelihood of vomiting and regurgitation, and
reducing the likelihood of regurgitation becoming aspiration.

Mendelson’s syndrome is the term used to describe the severe asthma-like reaction
from the chemical pneumonitis caused by aspiration of a large volume of gastric
liquid of pH less than 2.5.

Definitions
Types of aspiration
Vomiting and regurgitation
Mendelson’s: definition, incidence, mortality

Increased risk of regurgitation

Anatomical: normal anatomy, hiatus hernia
Obsetetrics
17
 Emergency surgery
Bowel obstruction
Raised intra-abdominal pressure
?nasogastric tube

Neurological
altered conscious level
impaired cough and gag reflexes
recent extubation
seriously ill patients
bulbar palsy
elderly patients

If high-risk:
antacids
magnesium trisilicate, sodium citrate
histamine-2 antogonists
action
cimetidine, ranitidine
others
omeprazole
gastric motility
metoclopramide

If at-risk
mechanical measures
posture: unconscious patient
rapid sequence induction: full description
consider: awake intubation
extubation
conscious level
facilities in recovery room

if, despite all these precautions, aspiration does occur, some believe that steroids,
antibiotics, and bronchial lavage are helpful.

________________
Question No. 22
Discuss the indications and advantages of positive end-expiratory pressure
during mechanical ventilation. What are the harmful effects of this technique
and how may they be minimized?

Uses:

18
Positive end-expiratory pressure (PEEP) is often used for hypoxic patients who
require mechanical ventilation in the intensive care unit.

Positive end-expiratory pressure (PEEP) is used to improve oxygenation in patients

who have adult respiratory distress syndrome.

Positive end-expiratory pressure (PEEP) increases the arterial partial pressure of

oxygen (PaO2) at a given inspired oxygen, but at the cost of reducing cardiac output
by decreasing venous return.

Indication
Prophylactic
To prevent atelectasis: 1 – 5 cm H2O
Therapeutic
To improve oxygenation: 6 – 20 cmH2O
Threshold PaO2 less than 8 kPa on 50 – 60% oxygen
‘best’ PEEP

Mechanism
Increasing functional residual capacity
Preventing water and protein flux into alveoli
Improved surfactant function
Release of prostaglandins from lung tissue

Harmful effects
On lung
Barotraumas
Increased shunt
Cardiovascular
Decreased venous return
Increased pulmonary vascular resistance
Renal
Decreased renal blood flow
Neurological
Increased intracranial pressure

Assessing and controlling PEEP

Watch blood pressure
Measure cardiac output
Monitor mixed venous oxygen saturation
Maintain circulating volume
Dopamine for renal blood flow?
Care with certain patients
Intracranial pressure
Abnormal lungs etc.

19
20
Question No. 23
What are the factors affecting the ability to wean patients from ventilators?
Discuss the criteria and methods used for weaning patients from ventilatory
support.

Answer: -
Key points:
Factors affecting weaning
The initial disease
Infection
Systems
Respiratory
Oxygenation
Ventilation
PaCO2 muscles, effusion, pneumothorax
Cardiac
Renal
Intestinal and feeding
Neurological
Effects of treatment
Drugs
Psychological
Fear and dependence, pain, sleep deprivation

Criteria
Keep factors (as above) in mind
Haemodynamic
Mechanical pulmonary function
Vital capacity more than 10 – 15 ml/kg
Tidal volume more than 5 ml/kg
Peak inspiratory pressure greater than – 20 cmH2O
Resisting minute volume more than 10 L/min
Gas exchange
PaO2 at least 8 kPa on 40% oxygen
D(A-a)O2 less than 40 kPa on 100% oxygen
Dead space ratio less than 0.6

Methods
Sedative drugs, time of day
Techniques
T pieces
Continuous/intermittent
Advantages: simple
Disadvantages: needs attention may be slower
21
 IMV, SIMV, MMV, inspiratory support
Describe
Advantages: probably more pleasant for patient
Easier for attendants
May be quicker
CPAP

Assessment

________________
Question No. 24
Discuss the management of patient admitted to the intensive care unit with acute
severe asthma.

Answer: -
Key points:
Features
Extreme dyspnoea – no speech
Poor air entry – ‘silent chest’
Central cyanosis – V/Q mismatch
Tachycardia: pulse rate > 130/min
Pulsus paradoxus
Hypercapnia
Impaired conscious level

Management
Establish diagnosis
Establish intravenous access, sample
Full blood count
Urea and electrolytes
Sputum sample
Insert arterial line, sample
Chest X-ray
Spirometry if possible

Treatment
Humidified oxygen
Adequate hydration
Drugs
Nebulized salbutamol
Ipratropium bromide
Adrenaline

22
 Aminophylline
Antibiotics
Steroids
Sedation
Physiotherapy

Then
Assess
If worse (hypercapnia, exhaustion, mental state)
Consider ventilation
Large tidal volume, slow rate
No PEEP
Sufficient sedation
Bronchoscopy, lavage
Care: barotraumas, right ventricular failure
Extubation: cover by anaesthesia.

________________
Question No. 25
How do the intraoperative surgical complications of excision of thyroid goiter
affect the management of the anaesthetic?

Answer: -
Key points:
1. stimulation of carotid baroreceptors by surgical manipulations may destabilize
arterial pressure. Surgery may cause haemorrhage, pneumothorax; splitting of
sternum would require IPPV; recurrent laryngeal palsy and external laryngeal
palsy may cause postoperative airway obstruction; concomitant.
Parathyroidectomy may cause early postoperative tetany.
2. damage to the trachea (including tracheomalacia) may occur with
postoperative airway obstruction.
3. finally – the surgical elbow in the patient’s eye!

23
Question No. 26
What are the anaesthetic problems posed by surgical removal of a
phaeochromocytoma?

Answer: -
Key points:
1. Preoperative unstable arterial pressure requiring alpha and (later) beta
blockade with restoration of circulating blood volume.
2. Avoid histamine releasers in premed and anaesthetic – they may cause a
crises.
3. Vasodilators may be needed for pre-operative hypertension.
4. Vasoconstrictors (adrenaline, noradrenaline, angiotensin) needed for post-
removal hypotension.
5. Requires full-scale monitoring (details needed).
6. Secondary phaeochromocytomas may be missed at operation, with
postoperative ongoing symptoms.

________________

Question No. 27
What are the anaesthetic problems posed by surgical removal of a parathyroid
odenoma and how do you cope with them?

Answer: -
Key points:
1. excessively high Ca++ would pose a risk of serious arrhythmias (may need
emergency lowering of Ca++, anti-arrhythmic drugs and K+ infusion).
2. pneumothorax (prevention by IPPV, treatment by chest drain).
3. air embolus (prevention by avoiding too steep head-up tilt, treatment by
turning patient on side and evacuation by central line).
4. haemorrhage (treated by infusion and transfusion).
5. recurrent nerve damage (with postoperative obstruction, requiring
reintubation).
6. postoperative tetany requiring Calcium injection (needs details of preparations
and doses).

Comment: This is an easy question.

24
Question No. 28
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?

Answer: -
Key points:
You need to state that this diabetes will be out of control.
Issues to mention include:
a. History of patient’s 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.

________________
Question No. 29
What are the functions of the thyroid gland and how are they controlled? What
are the effects of thyroid dysfunction on anaesthesia?

Answer: -
Key points:
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.
25
Effects of dysfunction:
a. myxoedema – sensitivity to anaesthetics and cold, instability of circulation;
b. thyrotoxicosis – atrial fibrillation, thyroid crisis,
Question No. 30
Discuss the perioperative complications of subtotal thyroidectomy.

Answer: -
Key points:
Patients for subtotal thyroidectomy must have their thyroid function assessed
preoperatively so that they can be given the appropriate medical treatment to make
them euthyroid before surgery.

The two main concerns of the anaesthetist before subtotal thyroidectomy are thyroid
function and possible respiratory obstruction.

Assessment of thyroid function

Clinical
Drugs
Investigation
?further treatment

Assessment of airway
history
radiographs
formal vocal cord study

General assessment

Operative phase
difficult airway
premedication
equipment: tracheal tubes
eyes
IV access
Maintenance
Spontaneous breathing or ventilate?
Problems
Haemostasis
Venous pressure
Arrhythmias
Thyroid crisis
Hypotension

26
Extubation and recovery
Coughing
Look at cords
Airway
Bleeding: ?tracheal compression
Recurrent laryngeal nerve injury
Laryngeal oedema (later)

Later complications
Thyroid crisis
(hypothyroidism)

________________

Question No. 31
How does concomitant head injury influence your anaesthetic management of
operation for a fracture of the hand?

Answer: -
Key points:

Monitoring of head injury required as it may be getting worse-monitoring of GCS.

The intracranial critical volume/pressure compliance point may be reached suddenly.

If the head injury is unstable, cerebral oedema would be worsened by coughing,

straining, vomiting, and jugular venous obstruction. Hypoxia, and Hypercapnia may
critically compress brain, and hypotension would carry risk of cerebral hypoxia.
Operation may need to be postponed.

If head injury is stable and improving, brachial plexus and wrist blocks and local
infiltration are OK, Biers block OK, but care is needed with dosages of local
anaesthetics because of side effects.

27
Question No. 32
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?

Answer: -
Key points:
List of monitors (with sources of error in brackets).
Noninvasive BP (inaccurate on large arms).
Invasive arterial pressure (damping, clotting in cannula, zero errors, height of
transducer).
Pulse oximetry (mechanical and electrical interference; digit too large or too small
for transducer; abnormal haemoglobins; venous pulsation; delay in alerting hypoxia).
Capnography (sampling site too far from lungs, blocked sample tube, interference by
N2O, leak in sample tube, monitor wrongly calibrated).
Agent monitoring (interference by N2O).
FiO2 (blocked sample tube, leak in sample tube, monitor wrongly calibrated, fuel cell
dead).
Pulse (if counting from ECG, a high T wave can apparently double the rate, if
counting from a digit, electrical and mechanical interference).
Air embolus Doppler (errors due to wrong direction).
CVP (catheter tip peripheral-reading is too high, catheter tip in right ventricle-reading
is too high; damping, clotting in cannula, zero errors, height of transducer).

________________
Question No. 33a
What factors affect cerebral blood flow? State briefly their importance in
relation to anaesthesia within an hour of head injury.

Answer: -
Key points:
Control factors
 A rise of CO2, increases it;
 A rise of venous pressure reduces it;
 Arterial pressure (autoregulation controls it between MAP of 60-160);
 Extracellular pH (acidaemia increases it);
 PO2 (hypoxia increase it);
 Neurogenic factors-various effects.
Pathological factors
 Raised intracranial pressure, due to vomiting coughing and straining reduces
it;
28
Drugs
 Examples are thiopentone, propofol, mannitol.

________________

Question No. 33b

How may cerebral blood flow be affected by general anaesthesia?

Answer: -
Key points:
General anaesthesia-disruption of controlling factors by the anaesthetic;e.g.,
Cardiovascular instability, raised jugular venous pressure (coughing, vomiting, fluid
loading, hypoxia, intubation, IPPV, cardiac failure) Hypercapnia, hypocapnia,
Hypothermia; hyperventilation with low CO2 tension causes cerebral
vasoconstriction;

 Drugs-induction agents e.g., propofol, thiopentone (reduce it);

 Anaesthetic volatile agents (increase it);
 Other drugs, for example fentanyl, ketamine.

________________
Question No. 34
What arrangements are required for an adult head-injured patient, during
transfer to a neurosurgical unit?

Answer: -
Key points:
1. Identification tag for patient.
2. clear notes of injuries, with investigations (eg., X-rays), and ongoing Glasgow
Coma Score chart.
3. hard collar if cervical spine injury is suspected.
4. intravenous infusion (or central line).
5. intubation and ventilation of patients who are comatosed, depressed conscious
level, or who have had fits; with added oxygen.
6. monitoring, pulse oximetry, capnography, arterial pressure.
7. administration of analgesic and relaxant.
8. administration of mannitol or frusemide, if not already given.
9. smooth slow journey, head-up position, trained escort.
29
Question No. 35
How does the physiology of children aged 1 year differ from that of adults?

Answer: -
Key points:
Infants have:
1. More increased heart and respiratory rates in response to demands than adults.
The ribs are more horizontal, and the respiration is more diaphragmatic.
2. Higher metabolic rate – more rapid onset of cyanosis.
3. Reduced renal concentration function – need more water.
4. Greater risk of hypothermia due to relatively larger surface area.
5. Greater sensitivity to opioids, partly due to nervous system immaturity, partly
to hepatic clearance.
6. Larger volume of distribution for water-soluble drugs.

Comment: The question sounds complex, but the answer is quite simple!

________________
Question No. 36
What psychological factors influence your anaesthesia for children aged 2-3
years?

Answer: -
Key points:
1. Very easily frightened – need to be seen with parents and spoken to kindly;
need discussion of place of premedication, including day cases.
2. Highly dependent on parents – development of rapport with them is a high
priority.
3. 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, but the answer is quite simple!

30
Question No. 37
A 6-year old child has projectile vomiting and is presented for Laparotomy.
Describe the general anaesthetic problems of this case.

Answer: -
Key points:
1. Alkalosis (needs treatment to lower the serum bicarbonate below 30 mmol/L.).
2. Dehydration (needs IVI and full rehydration).
3. Hyponatraemia (needs IVI with half strength saline).
4. Hypokalaemia
5. Full stomach (regurgitation risk – need for preoperative nasogastric tube with
clear washouts and rapid sequence induction of anaesthesia).
6. Small size of patient, with special paediatric problems – risk of hypothermia,
risk of overventilation, risk of fluid overload, sensitivity to opioids, narrow
cricoid rings, short trachea, more difficult intubation. If the patient is
premature baby, extra risk of intracranial haemorrhage.

Comment: This is a safety question.

________________
Question No. 38
A child of 12 years has been admitted following a road accident. At emergency
Laparotomy the surgeon announces that the liver is ruptured. Describe your
management of the case up to the end of the operation.

Answer: -
Key points:
This is severe road trauma and needs a comment about search for, and possible
presence of, other injuries, especially head injury.
 Organize massive blood cross-match, and supplies of fresh frozen plasma
 Circulatory support (drugs and colloids and crystalloids in severe
haemorrhage), citrate problems
 Diagnosis of blood clotting abnormalities, with intraoperative coagulation
screening
 Keeping the patient warm
 Blood glucose support
 Organization of ITU
 Keeping parents informed of progress
 Perhaps consider secondary transfer to liver unit.

31
Question No. 39
Describe the anaesthetic management for a 5-year-old patient who requires
reoperation for haemorrhage an hour after tonsillectomy.

Answer: -
Key points:
1. assessment and resuscitation: intravenous infusion of colloids and blood
until the patient is clinically not shocked (details needed). Oxygen is
required.
2. premedications: not usually required for tonsillar haemorrhage in the first
six hours after operation.
3. induction of anaesthesia; rapid sequence induction with cricoid pressure
and intubation.
4. maintenance of anaesthesia: light anaesthetic, a nasogastric tube is passed
and the stomach emptied.
5. postoperative care: further assessment of shock, anaemia, and analgesia.
Oxygen is required.

________________

Question No. 40
Discuss the perioperative management of a 29-week premature neonate with a
congenital diaphragmatic hernia.

Answer: -
Key points:
Problems of neonatal physiology
Respiratory
Low pulmonary compliance (pneumothorax)
Increased pulmonary vascular resistance
Apnoeic episodes
Temperature control
Haemostasis
Glucose metabolism

Problems of neonatal anaesthesia

Weight: 1 –2 kg
Venous access
Intubation
Oxygenation

32
 Hypoxia and hyperoxia (retrolental fibroplasia)
Fluids

Preoperatively
Nursed semi-upright
NG tube
Humidified oxygen
Ventilate if necessary
Fluids
Check biochemistry
Transport to theatre

In operating theatre
Check lines
Induction
Avoid nitrous oxide & mask ventilation
Monitoring

Maintenance
Drugs
Technique
Heat loss
Monitoring
Especially
Oximetry
Airway pressure (pneumothorax)
Blood loss

Postoperatively
Gastric suction and IV fluids
Indication for extubation
Indications for continued ventilation
Perhaps pulmonary vasodilator
Extracorporeal membrane oxygenation

33
Question No. 41
How do obstetric factors affect the management of anaesthesia for the removal
of a retained placenta?

Answer: -
Key points:
1. A retained placenta can cause severe blood loss, therefore good IV access
essential, and that potential hypovolaemia is as dangerous in regional block as
in general anaesthesia.
2. Acid gastric juice-with risks of severe pneumonitis from regurgitation and
aspiration.
3. Pre-partum narcotic drugs may have been given, which will accentuate
responses to anaesthesia.
4. The possible presence of an existing epidural for obstetric analgesia, which
can be used for the anaesthetic.
5. The sensitivity of the postpartum uterus to the relaxing effect of halothane.
6. Oxytocin-induced vomiting and the need for anti-emetics.

________________

Question No. 42
Describe the anaesthetic management of massive intra-partum haemorrhage
requiring emergency operations.

Answer: -
Key points:
1. Give oxygen
2. Stop haemorrhage – need for oxytocin; immediate delivery and even
emergency hysterectomy. Need for large, fast infusion to replace blood-loss.
3. Anaesthetic for severely shocked patient (hypovolaemia, acute anaemia,
oxygen carriage problems), who may have a full stomach with acid gastric
juice.
4. Organization for massive transfusion
5. Risk of DIC – organization for fresh frozen plasma
6. Preservation of renal and splanchnic function with dopamine, dopexamine,
diuretics.
7. Later – ARDS or MOF or ileus may require intensive care.

34
Question No. 43a
Describe the pathophysiological processes of pre-eclamptic toxaemia of
pregnancy.

Answer: -
Key points:
Pre-eclampsia toxaemia arises from changes in the placenta which lead to:
 Hypertension
 Albuminuria
 DIC, with coagulopathy
 Low platelets (function may be reduced by aspirin)
 Intrauterine haemorrhage
 Convulsions (exact process not clear) with hypoxia
 Placental failure (baby at risk)
 Sodium retention
 Patients are waterlogged, yet hypovolaemic
 HELLP syndrome may occur.

________________
Question No. 43b
You are asked to help with a case of severe pre-eclamptic toxaemia of
pregnancy. What is your management?

Answer: -
Key points:
1. Assessment: hypertension, proteinuria, weight gain. How serious and how
acute is it?
2. Monitoring the baby. Is there temporary or continuous bradycardia?
3. Clinical monitoring of the mother. Is there hyper-reflexia or incipient
convulsions?
4. Monitoring: arterial pressure, blood gases, platelet levels, coagulation screen,
CVP, urinalysis.
5. Treatment: there should be a continuous attempt to make all abnormal
parameters normal. Arterial pressure control is a high priority (IV colloid,
epidural, hydralazine, alpha-methyldopa), magnesium sulphate to prevent
convulsions.

FFP for coagulopathy, attempt at early delivery. If general anaesthetics is required,

upper airway oedema may make intubation difficult.

35
The risks to mother may continue after operation.
Question No. 44
What factors influence the choice of anaesthetic for insertion of arteriovenous
shunt for haemodialysis?

Answer: -
Key points:
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 area relevant:

 Anaemia
 Hyperkalaemia (suxamethonium, cardiac arrythmias – not a problem if patient
has been dialysed very recently);
 Many nondepolarizing 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.

________¤________

Question No. 45a

Write short notes on ondansetron.

Answer: -
Key points:
This answer needs most of the following headings:
Pharmacy:
Type of chemical, storage (plastic ampoules) preparation, concentration

Pharmacodynamics:
Mode of action, 5HT3 serotonin antagonism
Clinical effects: antiemetic
Dose, 4 – 8 mg
Onset, minutes
Duration, 8 hrs.

Pharmacokinetics:
Routes of administration, IV<IM<oral
Metabolism, liver
36
Side effects, constipation, headache, flushing, transient visual disturbances
Plus other features: especially useful in chemotherapy.
Question No. 45b
Write short notes on ranitidine.

Answer: -
Key points:
This answer needs most of the following headings:

Pharmacy:
Type of chemical, storage (glass ampoules, tablets)
Pharmacodynamics:
Mode of action, H2antagonist
Clinical effects, reduction of volume and acidity of gastric juice
Dose, 150 mg.
Onset, 1 hr.
Duration, 4 hrs.
Pharmacokinetics:
Routes of administration, oral, i.m., i.v.
Metabolism, liver
Excretion
Side effects, cardiovascular disturbances, bradycardia,AV block, asystole; CNS
disturbances-mental confusion, headache dizziness; anaphylaxis, nosocomial
pneumonia
Interactions, in porphyria and phenylketonuria
Plus other features: no effect on cytochrome P450.

________¤________

Question No. 46a

Write short notes on rocuronium.

Answer: -
Key points:
This answer needs most of the following headings:
Pharmacy:
Type of chemical, storage (solution in glass ampoules,) preparation, concentration.

Pharmacodynamics:
Mode of action, nondepolarizing neuromuscular blockade
Clinical effects, relaxation
37
Dose, 0.5 mg/kg
Onset, 60 secs.
Duration, 45 – 60 mins.

Pharmacokinetics:
Routes of administration, i.v.
Metabolism, liver
Interactions, volatile and local anaesthetics, aminoglycoside antibiotics
Plus other features: rapid onset due to low receptor occupancy, with high biophase
concentrations.

________¤________
Question No. 46b
Write short notes on mivacurium.

Answer: -
Key points:
This answer needs most of the following headings:

Pharmacy:
Type of chemical (benzylisoquinoline), strong, (aqueous, in glass ampoules)
preparation, concentration 10mg/ml.

Pharmacodynamics:
Mode of action, nondepolarizing neuromuscular drug.
Clinical effects, relaxant
Dose, 0.1 – 0.2 mg/kg.
Onset, 3 mins.
Duration, 10 mins.

Pharmacokinetics:
Routes of administration, i.v.
Metabolism, serum cholinerterase
Side effects, histamine release
Interactions, volatile and local anaesthetics, aminoglycoside antibiotics, other
relaxants.

38
Question No. 47a
Write short notes on desflurane

Answer: -
Key points:
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 effect, coughing, laryngospasm, excitement on inhalation including
Plus other features (low solubility, blood/gas partition coefficient 0.4, oil/gas 18.7;
high SVP (88@200 C; MAC50 6%; Boiling point 22.80; vaporizer designed to run
above boiling point).

________¤________
Question No. 47b
Write short notes on minimum alveolar concentration.

Answer: -
Key points:
Definition: a measure of the potency of volatile anaesthetics. MAC 50 is the minumum
alveolar concentration required to prevent physical reaction to skin incision in 50%
of subjects.
Isoflurane 1.15%; enflurane 1.7%; desflurane 6%; sevoflurane 2%; halothane 0.75%.
It varies with age, greatest at one month; lowest in premature babies and old age.
Increased by: adrenaline, severe surgical stimulus.
Decreased by: sedation, analgesia, pregnancy.
MAC95 is the minimum alveolar concentration required to prevent reaction to skin
incision in 95% of sunjects.
Other features: in mixtures of anaesthetic gases, the various MAC’s are additive.
39
Question No. 48a
What are the medical effects of opioids drugs?

Answer: -
Key points:
1. analgesia
2. addiction
3. respiratory depression
4. nausea and vomiting
5. bradycardia
6. miosis
7. sedation
8. hallucintations
9. bronchospasm
10. biliary spasm
11. renal colic
12. slowing of premature labour
13. itching
14. histamine release
15. muscle rigidity

________¤________
Question No. 48b
Write short notes on naloxone.

Answer: -
Key points:
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, 7μg/kg.
Onset, rapid
Duration, 30 mins – 6hrs (i.m.)

40
Pharmacokinetics:
Routes of administration, i.m., i.v.
Metabolism, liver
Side effects, reverses nitrous oxide anaesthesia

________________
Question No. 49
Write short notes on Sucralfate.

Answer: -
Key points:
This answer needs most of the following headings.

Pharmacy:
Type of chemical, storage (liquid), preparation, concentration

Pharmacodynamics:
Mode of action, physical protection of gastric mucosa
Clinical effects, at pH < 4 polymerises and adheres to ulcer craters, preventing peptic
ulceration
Dose, 2 g. twice daily
Onset, immediate
Duration, hours

Pharmacokinetics:
Routes of administration, oral
Excretion, via GI tract
Side effects, no effect on gastric pH
Plus other features: the name means sucrose (aluminium) suophate – it increases
gastric production of mucus, and does not cause nosocomial pneumonia.

41
Question No. 50a
Write short notes on midazolam.

Answer: -
Key points:
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.

________¤________
Question No. 50b
Write short notes on ropivacaine.

Answer: -
Key points:
This answer needs most of the following headings:
Pharmacy:
Type of chemical (amide), storage (aqueous solution in glass ampoules),
concentration (0.5 – 1 %).

Pharmacodynamics:
Mode of action, inhibition of nerves conduction
Clinical effects, local analgesia
Dose, 0.5 – 1 %
Onset, 20 mins.
Duration, 8 – 9 hrs.

42
Pharmacokinetics:
Routes of administration, infiltration, epidural
Metabolism, liver
Side effects, less toxic than bupivacaine
Plus other features: better motor block than bupivacaine.

________________
Question No. 51a
How do antihypertensive drugs affect the management of anaesthesia?

Answer: -
Key points:
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 nondepolarizing
relaxants.
8. withdrawal of some antihypertensives cause excessive rebound of arterial
pressure.

Comment: This is common clinical scenario.

43
Question No. 51b
Write short notes on verapamil hydrochloride.

Answer: -
Key points:
This answer needs most of the following headings:
Pharmacy:
Type of chemical, storage (tablet, aqueous solution), preparation, concentration

Pharmacodynamics:
Mode of action, Ca++ channel blocker, mainly slow channel cardiac effects
Clinical effects, class 4 anti-arrhythmic; increases refractory period, reduces
excitability and dilates arterioles
Dose, oral – 100-500 mg/day, adult; 2.5 mg i.v.
Onset, minutes.
Duration, hours.

Pharmacokinetics:
Routes of administration, oral
Side effects, constipation
Interactions, digoxin, volatile anaesthetics, beta blocking drugs.

________________

Question No. 52
What is the mode of action of the following in lowering arterial pressure?

Answer: -
Key points:
 Isoflurane – vasodilation
 Halothane – negative ionotropy 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 blood volume and after load

44
 Septic shock syndrome – negative inotropy, pulmonary vasoconstriction,
opening of A-V anastomoses
 Ventricular fibrillation – no cardiac out put
 Spinal anaesthesia – vasodilation
 Anaphylactic shock – vasodilation

________¤________
Question No. 53a
Write short notes on amiodarone.

Answer: -
Key points:
This answer needs most of the following headings:
Pharmacy
Pharmacodynamics:
Mode of action, a K+ channel blocker which uncouples beta receptors from the
regulatory unit of the adenylate cyclase complex.
Clinical effects, class 3 anti-arrhythmic, control of ventricular and supraventricular
arrythmias
Dose, 100 – 250 mg.
Onset, rapid
Duration, months

Pharmacokinetics:
Routes of administration, oral, i.v.
Metabolism, liver (half life 26-107 days)
Side effects, mild negative inotrope; microdeposits of drug in cornea; pulmonary
interstitial infilatration.
Interactions, prolongs life digoxin; potentiate other anti-arrhythmics;
Plus other features: affects thyroid function; avoid in porphyria, contains iodine.

45
Question No. 53b
Write short notes on adenosine.

Answer: -
Key points:
This answer needs most of the following headings:
Pharmacy
Type of chemical (endogenous nucleoside)

Pharmacodynamics:
Mode of action, stimulation of A1 receptors
Clinical effects, negative chronotropy on sinus node, negative dromotropy on
atrioventricular node; termination of supraventricular tachycardias
Dose, 3 mg.
Onset, one circulation time
Duration, 1 minute

Pharmacokinetics:
Routes of administration, i.v.
Interactions, alteration of potency of anaesthetics
Plus other features: avoid in sick sinus syndrome, heart block and asthma.

________________
Question No. 54
Discuss the desirable properties and the unwanted side-effects of nitrous
oxide.

Answer: -
Key points:

Desirable properties
Low blood/gas solubility (0.47 at 370C)
Rapid uptake and recovery
Concentration and second gas effect
Analgesic
As carrier gas of general anaesthesia
Decreases requirement for other anaesthetics
Entonox
Non-irritant to the airway
Non-flammable
46
Little ventilatory

Unwanted side-effects
Hypoxia: high inspired nitrous oxide, diffusion hypoxia
Increased pressure in body spaces
Awareness
Some circulatory depression
Theoretical support of combustion
Interference with vitamin B12 metabolism

________________
Question No. 55
Discuss the methods available for the relief of pain following abdominal
hysterectomy.

Answer: -
Key points:
Advantages:
 NSAID’s (reasonably powerful, no respiratory depression or vomiting).
 Other oral analgesics: very safe but most are not so powerful.
 IM opiates (powerful and safe).
 PCA (powerful, swift reaction to pain, patients can customize dosage to
their own needs).
 Epidural catheters (superb, powerful analgesia).

This answer needs a note about customizing treatment for the individual patient and
discussion patient preferences!

Complications:
 NSAID’s (haemorrhage, ulcers, renal failure and bleeding).
 IM opiates (nausea, vomiting and delay in action).
 PCA (needs common sense, reasonably strong fingers and may cause
vomiting and hallucinations. Serious overdose has occurred.).
 Epidural catheters (weak, numb legs and risk of unrecognized apnoea from
opiates; and hypotension).

47
Question No. 56
What are the advantages and disadvantages of the local anaesthetic and
epidural anaesthetic techniques for the repair of an inguinal hernia?

Answer: -
Key points:
Ilioinguinal
Advantages:
 Simple
 No hypotension
 No resp. depression in patients with respiratory failure
 Control of own airway
 Conscious
 No IPPV
 Avoids use of opioids.

Disadvantages:
 Does not always work, especially on the hernia sac
 Ilioinguinal nerve may be damaged
 Moderate failure rate.

Epidural
Advantages:
 Control own airway
 Conscious, avoids IPPV in patients with respiratory failure
 Catheter for longer analgesia
 Avoids systemic opioids.

Disadvantages:
 More complex technique
 Hypotension
 Hypovolaemia
 Backache
 Infection
 Drug toxicity
 Total spinal
 Haematoma
 Foreign body may be left in spinal canal.

48
Question No. 57
What factors would influence your decision to choose a regional technique in
preference to a general anaesthetic for transurethral resection of the prostate?

Answer: -
Key points:
Indications for regional analgesia (RA):
Patient preference in favour of RA, COAD, good postoperative analgesia; reduction
of haemorrhage due to parasympathetic blockade.

Contraindications of RA:
Patient preference against RA, uncooperative patient, untreated hypertension,
ischaemic heart disease, fixed cardiac output, physical abnormalities (spinal
deformity), local sepsis, disorders of haemostasis, e.g., anticoagulants.

The following are also relevant to this answer:

The advantages (reasons for not choosing) of regional analgesia:
 Avoidance of respiratory depression in the obese and in respiratory failure;
easier recognition of TURP syndrome, less bleeding, easier recovery as patient
is fully awake.

Disadvantages (reasons for not choosing) of regional analgesia:

 Immediate: inappropriate dosage causing total spinal; hypotension, respiratory
depression, apnoea, bradycardia, intravascular injection of local anaesthetic,
headache itching, incontinence, retention of urine, paralysis of legs preventing
ambulation.
 Later complications: arachnoiditis, meningitis, backache, epidural haematoma
and abscess; neurological damage from inadvertent injection of toxins; spinal
artery syndrome; foreign body left in dural space.

Comment: It is helpful in an answer like this to categorize your points.

49
Question No. 58a
What are the dangers and complications of intradural spinal analgesia?

Answer: -
Key points:
Immediate: inappropriate dosage causing total spinal; hypotension, respiratory
depression, apnoea; bradycardia; intravascular injection of local anaesthetic;
headache, itching, incontinence, retention of urine, paralysis of legs preventing
ambulation.

Later complications: arachnoiditis, meningitis, backache, epidural haematoma and

abscess; neurological damage from inadvertent injection of toxins; spinal artery
syndrome; foreign body left in dural space.
Comment: There is still a widespread misconception that spinals are always safe!

________¤________
Question No. 58b
What are the dangers and complications of extradural analgesia?

Answer: -
Key points:
The hazards of epidural anaesthesia:
 Inadvertent spinal or total spinal. Subdural injection, with effects similar to
total spinal.
 Systemic toxicity from local anaesthetic absorption,
a. Cardiovascular; low arterial pressure; low output; low systemic
vascular resistance; bradycardia
b. Convulsions followed by depression.
 Cardiovascular – hypotension, bradycardia
 Respiratory – respiratory depression, apnoea; impaired cough and tidal
volume.
 Other systems – urinary retention or incontinence.
 Increased gut tone and relaxation of sphincters.
 Nausea, vomiting, headache, restlessness.
 Backache.
 Abducens palsy
 Neurological damage, spinal artery syndrome, arachnoiditis, radiculitis, sepsis
(meningitis or abscess).
 Broken needle or catheter.
 Epidural or spinal haematoma, spinal abscess.
 Inadequate block (failed, unilateral, missed segment, patchy).
50
Comment: it is difficult to know to stop with this list! These are only the main
complications.

Question No. 59
What is the place of local analgesic nerve blocks in the anaesthetic technique for
cholecystectomy (excluding “spinal” and extradural technique)? State briefly
how they are performed. What are their shortcomings? What are their risks?

Answer: -
Key points:
Place: very helpful for supplementary and postoperative analgesia, using long-acting
agents.

Shortcomings: Note that these blocks by themselves are inadequate for surgery,
because the gall bladder is often innervated by vagus and/or phrenic nerves.

Performance: Clean skin first, have i.v. access and available resuscitation equipment.

Subcostal block: infiltrate subcostal area of abdominal wall in both subcutaneous and
muscle layers, with local analgesic.

Risk: peritoneal, pleural or pericardial puncture.

Intrapleural block: insert i.v. or special cannula into pleural space at angle of rib,
taking care to avoid pneumothorax and intercostal artery puncture.

Risk: pneumothorax, and volumes of local analgesic required are close to toxic
doses.
Intercostal block: short bevel needle inserted just below rib, posterior to angle, into
subcostal groove.

Risk: haematoma and pneumothorax. The problem of overlap of innervation from

adjacent intercostal nerves is solved by blocking multiple spaces.

Comment: There is a great risk of over-running your allotted time. Keep this answer
in note form.

51
Question No. 60
Discuss the mechanism of action and use of spinal opioids.

Answer: -
Key points:
Receptors
mu1: analgesia spinal & supraspinal
delta: analgesia spinal & supraspinal
kappa: spinal
(mu2, sigma: not analgesia or not spinal)

Inhibitory spinal pathways

Large afferent A-beta fibres (close gate)
Descending inhibitory fibres (peri-aqueductal grey)

Intrathecal
Uptake:
diffusion into spinal cord
lipophilic drugs: rapid onset, longer duration, greater incidence of respiratory
depression, e.g. morphine
Removal
diffuses back into blood supply of the cord, CSF, extradural space

Extradural
Uptake:
dural transfer, then as intrathecal
systemic absorption
(extra dural fat)
Removal
epidural veins
from sites of action: as intrathecal
Indications
postoperative pain
fractured ribs
obstetrics
terminal
The plan must then include the side-effects.
Side-effects
Ventilatory depression
Age, dose, route, water or lipid solubility; concurrent systemic opioid
Nausea and vomiting
Urinary retention
Itch
Neurological risk
52
 (arachnoiditis – safety of new drugs?)
Question No. 61
Write short notes on: -
a) Complication of neurolytic block
b) Neurolytic agents
c) Transcutaneous nerve stimulation (TENS)
d) Cryo-analgesia

Answer: -
Key points:
Complication of neurolytic block
Failure of block
Intravascular injection
Spread to other structures, e.g., spinal cord
Sphincter disturbance
Complications of denervation
Sloughing, neuritis, anaesthesia dolorosa
Corneal damage
How to avoid (brief)
Neurolytic agents
Phenol, alcohol, chlorocresol
Compare for: concentration, baricity, pain on injection,
Onset, spread, local analgesia effects, differential block,
Toxicity, propensity for chemical neuritis, uses
TENS
Description
Portable electrical stimulator
Patient adjust
Endogenous opoids, substantia gelatinosa
Placebo?
Uses
Localized mild to moderate pain
Postherpetic, phantom limb, causalgia, low back pain
Advantages: no serious disadvantages, non-invasive
Disadvantages: skin reactions, non-responders
Cryo-analgesia
Description
Of the machinery
Of the neural effect
Uses
Atypical facial pain
Intercostals neuralgia
Post-thoracotomy
Adverse effects
53
 Neuritis
Soreness at site of insertion of probe

Question No. 62
What factors show that intubation of the larynx will be difficult enough to
indicate fiberoptic intubation?

Answer: -
Key points:
1. Examination of point
a. History of rheumatoid arthritis; known history of difficult intubation –
Cormack & Lehane scores from previous laryngoscopies;
b. Poor mouth opening (< 3fb);
c. Low Malampatti score;
d. Thyromental distance
2. Trismus.
3. congenital abnormalities of the face or neck.
4. Known or suspected laryngeal obstruction (need to mention soft tissue X-ray
of neck).
5. Previous suxamethonium masseter spasm (if rapid sequence induction is
needed).

This answer needs a note on whether any of these factors are absolute indications,
and how many of the predictive factors need to be present to indicate fibreoptic
intubation.

________________
Question No. 63
How do you manage the physiological consequences of surgical manoeuvres
during abdominal laparoscopy?

Answer: -
Key points:
Physiological upsets (with management in brackets):
1. Vascular reflexes; bradycardia (atropine 0.2 – 0.5 mg will correct this).
2. Gas in peritoneium causes diaphragmatic splinting (IPPV is required).
3. Gas in blood vessels causes air embolism (requiring “air embolism drill”).
4. Excess absorption of CO2 (moderate hyperventilation).
5. Haemorrhage (you need to state that this can be massive, requiring urgent
group-specific transfusion).

54
6. 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).
7. Surgical emphysema – can cause severe pain.

55
Question No. 64
What are the “anaesthetic” problems caused by morbid obesity?

Answer: -
Key points:
1. Definition of morbid obesity in terms of body mass index is required (greater
than 40 kg/M2.

Problems:
Respiratory system – increased work of breathing, diaphragmatic splinting, difficult
intubation, underventilation, reduced lung volumes, pulmonary “shunting”,
Hypercapnia, hypoxia (operative and postoperative), slow equilibration with inhaled
anaesthetics.
Cardiovascular system – blood volume increased, increased cardiac work,
hypertension and coronary disease, risk of DVT, less water per unit of body weight;
Miscellaneous – hiatus hernia, regurgitation.
Technical – difficult to move, lift and nurse – spontaneous respiration restricted,
difficult to intubate, especially when front dental crowns are present, difficult
venepuncture, estimation of drug dosage is difficult, inaccuracy of noninvasive
arterial pressure monitoring, regional and local blocks are technically difficult,
surgery is often more prolonged.

Comment: This is large answer to complete in 10-15 minutes, unless you have
thought it out beforehand.

________________
Question No. 65a
How do you prevent unplanned awareness during general anaesthesia?

Answer: -
Key points:
1. History from patient (previous unplanned awareness; physiological resistance
to anaesthesia; alcoholism, etc.)
2. Preoperative checks of machine, vaporizers (or syringe drivers if using total
intravenous anaesthesia). Vaporizers are refilled before they become empty.
3. Monitoring of breathing system – including agent, especially when using the
closed circle system. 1 MAC of volatile anaesthetic is normally sufficient.
4. Adequate premedication, especially benzodiazepines.
5. Use of ear muffs or plugs on patient during surgery.
6. Monitoring of patient (this needs a very brief discussion of the value of
“clinical” signs, and a few details about the available awareness monitors).
56
7. Not placing reliance on opioids to prevent awareness.
Question No. 65b
How would you detect unplanned awareness during general anaesthesia?

Answer: -
Key points:
1. Monitoring of breathing system – (including anaesthetic agent), and/or syringe
driver system.
2. Monitoring of patient
a) Clinical;
b) Cerebral function monitoring;
c) Spectral Edge Frequency analysis;
d) Bisectral Index;
e) Frontiles EMG etc;
f) Evoked potentials and response;
g) Respiratory Sinus Arrhythmia analysis;
h) Oesophageal contraction rate.

A brief comment on the usefulness and inadequacies of these monitors is required.

________________

Question No. 66a

What signs would lead you to suspect that a patient under general anaesthesia
was developing malignant hyperpyrexia? Describe your immediate
management.

Answer: -
Key points:
Signs:
 High tachycardia; Hypercapnia; cyanosis/hypoxia; hyperthermia; muscle
rigidity; metabolic and respiratory acidosis; initial hypertension; followed by
cardiovascular failure; mottled rash.

Management:
 Hyperventilate with oxygen; stop trigger agents; repeatedly measure blood
gases; electrolytes and temperature;
 Inject dantrolene, 1 mg/kg, i.v., repeated (to inhibit sarcoplasmic Ca++ release);
 i.v. sodium bicarbonate, 0.3 mmol/kg;
 insulin/dextrose to control hyperkalaemia;
57
 diuresis to prevent renal failure;
 ITU admission.
Question No. 66b
What is the pathophysiology of malignant hyperpyrexia? How would you
investigate it?

Answer: -
Key points:
1. Abnormal Ca++ from sarcoplasmic reticulum on exposure to triggers gives rise
in Ca++ pump activity; binding of troponin C causes massive muscle
contraction and uncoupling of oxidation from phosphorylation.
2. The role of the ryanodine receptor is central to this process.
3. The condition is inherited as an autosomal dominant.
4. Masseter spasm in children may be associated with it.
5. Triggers: suxamethonium, halothane, physiological stress and many other
agents.

Investigation:
 During the crisis: CPK levels > 20,000.
 After the crisis: muscle biopsy (MHSusceptible, MHEquivocal,
MHNonsusceptible). MHEcould be exposed to ryanodine.
 Investigate the family.

________________
Question No. 67a
Describe the circle system for anaesthesia. What are its advantages and
limitations?

Answer: -
Key points:
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
58
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

________________
Question No. 67b
What are the safety features of the anaesthetic machine?

Answer: -
Key points:
Pipelines
Non-compressible
Non-interchangeable

Cylinders
Colour
Pin index
Reducing valve
Flow resister

Flowmeters
Identification
Hypoxic mixture protection
Bobbin, static
Top spring

Vaporizers
Selection
Filling

Back-bar
Pressure-relief valve

59
 Oxygen failure

Fresh gas outlet

Emergency oxygen
Other
Anti-static
Pipes and electric cables
Modern machines

________________
Question No. 68a
How do you estimate bloodloss during various types of surgery?

Answer: -
Key points:
1. Clinical condition of patient e.g., capillary refill, warm periphery, quality and
volume of pulses in various parts of body.
2. Monitoring CVP; arterial pressure – invasive and noninvasive (with comment
on pressure needed for production of urine) (MAP 70 mmHg).
3. Visual assessment of swabs, drapes and sucker bottle, allowing for volume of
saline washouts.
4. Other weigh swabs.
5. Hb estimation of TURP irrigation fluid and calculation of bloodloss.

________________
Question No. 68b
Describe the adverse effects of blood transfusion. How may they be reduced?

Answer: -
Key points:
1. Acute and delayed haemolytic reaction, circulatory overload, hypothermia,
embolism, hyperkalaemia, citrate intoxication, cross-infection, ARDS,
immunosuppression, hypomagnesaemia, hypocalcaemia, coagulopathy.
2. Reduction of adverse effects:
a. Set up a good transfusion service! (the administrative side, including
correct labeling is as important as the technical side)
b. Warm the blood during transfusion

60
c. Ca++ and fresh frozen plasma are given to correct coagulopathy. Platelet
transfusion may be needed
d. Auto-transfusion, cell savers and pre-donation solve many of these
problems
e. Monitor the patient for overload and transfusion reactions

61
Question No. 69
Describe the physiological effects of high arterial carbon dioxide tension (10
kpa, 70 mmHg.)

Answer: -
Key points:
Effects of high CO2:
On general circulation-increased arterial pressure; raised arteriolar tone, dilation of
skin blood vessels.
On cerebral circulation-vasodilation, increase in flow and volume of vessels. Raising
of I CP.
On respiration –stimulation of rate and depth.
On oxygen dissociation curve-move to the right.
On coronary flow-increase.
On heart – arrhythmias; increased force of myocardial contraction,
On muscle-increased tone.
On pH-reduction.
On adrenal-secretion of adrenaline.
Rise of intraocular pressure.
CO2 narcosis may supervene.

________________

Question No. 70a

Write short notes on Hartmann’s solution.

Answer: -
Key points:
This answer needs most of the following headings.

Pharmacy:
Type of chemical (intravenous electrolyte solution) storage (glass or plastic)
preparation, concentration (isotonic) Na+ 131; K+ 5; Cl- 111; Ca++ 2; Lactate 29;
mmol/l.

Pharmacodynamics:
Mode of action, water and electrolyte replacement
Clinical effects, rehydration
Dose, appropriate to clinical situation – e.g., 500ml/4-6 hrs.
Onset, immediate
62
Duration, N/A

63
Pharmacokinetics:
Routes of administration, i.v.
Excretion, kidney
Interactions, lactate load is unsuitable for diabetic patients
Plus other features: same electrolyte concentrations as plasma.

________________
Question No. 70b
Write short notes on Gelatin-based plasma substitutes.

Answer: -
Key points:
This answer needs most of the following headings: -
Pharmacy:
Types of chemical (high melecualr weight colloids 30-70 K. Daltons) storage (glass
or plastic), preparation, concentration (frequency slightly hypertonic).

Pharmacodynamics:
Mode of action, expansion of the plasma compartment
Clinical effects, resuscitation from shock and haemorrhage
Dose, appropriate to clinical situation
Onset, immediate
Duration, hours

Pharmacokinetics:
Routes of administration, i.v.
Metabolism, very little
Excretion, via kidneys
Side effects, allergy, risk of overinfusion

Comment: This answer will also need details of the various types of product.

64
Question No. 71
Describe the alternative to donor blood transfusion.

Answer: -
Key points:
1. Colloid infusion (which will be limited by progressive anaemia).
2. Autologous transfusion – predonation/perioperative haemodilution cell
savers/salvage with reinfusion
3. Fluorocarbons – fluosol emulsion 5ml/dl. O2 carriage @ FiO2 1.0.
4. Haemoglobin infusion with 2,3 DPG analogue (nephrotoxicity of red cell
stroma).

Comment: The above items should be describe in detail.

________________
Question No. 72
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.

Answer: -
Key points:
Contents:
350 ml, blood, 150 ml. CPD adenine or SAGM. (Most is plasma-reduced and
therefore low in albumin and globulins). It becomes progressively more
hyperkalaemic and acidotic during storage, with lower clotting factors and low
platelets.

Alternative:
Colloids: dextran 70, gelofusine, hespan, haemaccel, hetastarch, albumin.
Crystalloids: normal saline, Hartmann’s solution, 5% dextrose.

65
Question No. 73a
What are the causes and effects of hypothermia?

Answer: -
Key points:
Causes:
Conduction, convection, radiation, and cooling of the blood.
Radiation to cold surroundings (note the importance of ambient temp), e.g., drowning

Convection: evaporation of skin or water vapour from exposed serous cavities during
operation, especially when there is vasodilation, loss of hypothalamic control, absent
shivering response (due to anaesthesia or alcohol intoxication); dry, cold inspired
gases;

Conduction of heat to cold surroundings, as when a limb is packed in snow, or a

donor organ transported in melting ice;

Cooling of the blood: cold IV infusions, deliberate hypothermia during

cardiopulmonary bypass.

Effects:
Dysrhythmias at < 310 C. Prolonged action of general anaesthetics and relaxants,
slow metabolism of drugs and citrate, increased Hb oxygen affinity, fall in CBF,
reduced O2 consumption, peripheral vasoconstriction, acidosis, coagulation problems,
shivering and hypoxia on recovery.

________________
Question No. 73b
Discuss the causes, effects and management of unplanned hypothermia during
anaesthesia.

Answer: -
Key points:
Causes
Radiation, (convection, conduction)
Evaporation
Intravenous fluids

Patients and operations

Neonates, elderly

66
Effects
Cardiovascular
Bradycardia
Decreased cardiac output
Vasoconstriction
ECG changes
Arrhythmias
Respiratory
Oxyhaemoglobin curve shifts to left
Gas solubilities increase

Effects (cont)
Central nervous system
Decreased cerebral blood flow
Liver
Drugs, citrate
Biochemistry
Endocrine
Stress
Blood clotting
Neuromuscular
Postoperative
Shivering

Prevention
Monitoring
Theatre temperature
Warming blankets
Cover patient and exposed viscera
(use warm fluids: irrigation, infusion)

Management
Slow rewarming
High inspired oxygen
Chlorpromazine to prevent shivering
Consider elective postoperative ventilation

67
Question No. 74
A patient is admitted to the intensive care unit with a relapse of myasthenia
gravis. How do you cope with the medical problems of this situation?

Answer: -
Key points:
1. Identification of what caused relapse and treatment of
infections if appropriate.
2. Problems of inability to swallow and excessive secretion of
saliva due to anticholinesterases; nasogastric tube and enteral nutrition will be
required.
3. Respiratory failure (and how it is diagnosed) would indicate
intubation and IPPV, with risk of chest infections. Antibiotics may be needed
for this.
4. Protection of the eyes because of inability to blink
5. Prevention of bedsores and use of physiotherapy
6. Plasmapheresis may be needed
7. Steroid cover may be required.

Comment: The mention of ITU indicates that this relapse is severe, and the answer
should address this.

________________

Question No. 75
A patient is admitted to the intensive care unit with Guillain Barre Syndrome.
How do you cope with the medical problems of this situation?

Answer: -
Key points:
1. Identification of the degree of disability
2. Problems of inability to move and the unhappiness this causes
3. Intubation and IPPV for respiratory failure, with risk of infections. Antibiotics
may be needed.
4. Prevention of bedsores and use of physiotherapy
5. Steroid cover may be required
6. Will this be a short-or long-term case? How will nutrition be provided?

68
Question No. 76
What is the venturi principle? Describe the clinical uses of high frequency jet
ventilation.

Answer: -
Key points:
Principle:
High speed gas jet causes suction on surrounding areas with entrainment of
surrounding gas.
Rates: 1 – 1.5 Hz. 1.5 – 5 Hz. 5 – 10 Hz. (high frequency oscillation).

Uses:
 Rigid bronchoscopy and intratracheal surgery
 For the development of intrinsic PEEP in the intensive
care case
 Reduction of pulmonary barotraumas in ARDS
 To allow reduced requirement for sedation during IPPV
 Reduction of pulmonary leak during IPPV in cases of
bronchopleural fistula.

________________
Question No. 77a
Write short notes on gastric tonometry.

Answer: -
Key points:
Need a description of how pH is derived and measured with a balloon, completely
filled with saline. CO2 from gastric mucosa diffuses into this, and a sample is
withdrawn and measured. At the same time, serum bicarbonate is measured, and pH
derived from the Henderson-Hasselbalch equation) and in which situations it is
deranged (pH is reduced in shock, sepsis and hypotension).

69
Question No. 77b
Write short notes on pulmonary capillary wedge pressure?

Answer: -
Key points:
 Method of inserting the floatation catheter, e.g., via internal jugular line
 Pressure during insertion, in the superior vena cava, right atrium, right
ventricle, and pulmonary artery
 Interpretation of readings
 Complications of technique (e.g., infection, arrhythmias, damage to
pulmonary vessels).

________________

Question No. 78
Discuss the occurrence of metabolic acidosis in patients in the intensive care unit

Answer: -
Key points:
1. Causes – tissue hypoxia, renal failure, insulin
antagonism (with the carious acids involved).
2. Prevention – The methods of preventing the above,
and their considerable limitations.
3. Treatment – need discussion of the problems of
bicarbonate.

70
Question No. 79a
Describe the physical principles of a capnograph. How may it be calibrated?

Answer: -
Key points:
Principle of the infrared device: two different atoms in a molecule cause infrared
absorption; infrared beam splits and passes through a reference and sample gas
chambers. CO2 absorbs the infrared and emergent beams are compared by
photoelectric cells. Analyzer sites may be direct (instream) or indirect via withdrawn
sample.

Calibration: electronic/physical; zero = air; span – using accurately known CO 2

sample from machine, cylinder or reference cell.

________________
Question No. 79b
What information can capnograph give about an anaesthetic?

Answer: -
Key points:
End-tidal carbon dioxide monitoring may indicate:
 Adequacy of ventilation
 Oesophageal intubation (no CO2 in gas)
 Rebreathing (graph does not return to zero
on inspiration)
 Sodalime exhaustion (rising CO2)
 Fall of cardiac output (falling CO2)
 PE; air embolism (sudden fall of CO2
excretion)
 MH (fast rising CO2)
 Shock (low CO2 production)
 Disconnection of anaesthetic system
(sudden fall of CO2 to zero), emphysema, air-trapping (sloping plateau)
 Wearing off of relaxants (notching of
capnograph plateau)
 Death (cessation of CO2 production).

71
Question No. 80
What precautions should you take when anaesthetizing a patient known to have
suffered from viral hepatitis?

Answer: -
Key points:
1. protect staff and other patients – assessment of infectivity of
patient (HBsAg, Hepatitis A, Hepatitis C and other infective diseases),
information to all staff, use of disposable equipment and safe disposal. Use of
gloves etc., practice of correct “sharps drill”. Check Hepatitis B immunization
status of all staff.
2. Protect patient – liver function tests to assess hepatic reserve,
and appropriate care with dosages of drugs.

Comment: It would be difficult to know how much detail to give in this answer. This
would have to be dictated by the time available.

________________

Question No. 81
What problems does hiatus hernia pose for the anaesthetized patient and how
do you cope with them?

Answer: -
Key points:
1. Regurgitation and aspiration of highly acidic juice causes pulmonary airways
burn; if this occurs, it is managed by tracheal washout, IPPV, possibly steroids
and antibiotics.
2. Haemorrhage from peptic ulcer, if present; oesophagitis; resultant anaemia.
3. The giant hiatus hernia may interfere with lung function.
4. Managed by premedication with H2 antagonist and metoclopramide. Cricoid
pressure is needed during induction, with tracheal intubation to protect lungs.

Needs discussion of difficulty of insertion of nasogastric tube and pH estimation.

72
Question No. 82
What is the relevance to anaesthetic management of ankylosing spondylitis?
What strategies would you employ to overcome them?

Answer: -
Key points:
Problems:
Stiff neck and jaw - intubation difficulty; reduced pulmonary function needs
assessment, esp. if kyphotic.

Strategies:
1. Use of regional blocks; spinal blocks are desirable but difficult! – spinal X-ray
is needed.
2. Elective fibreoptic intubation or tracheostomy may be needed if general
anaesthesia is unavoidable, especially if there is:
a. known history of difficult intubation – Cormack & Lehane scores from
previous laryngoscopies;
b. poor mouth opening (< 3fb)
c. low Malampatti score;
d. short thyromental distance (< 6cm)
e. small mandible size and inability to protrude jaw;
f. neck stiffness (you would need to mention neck X-rays here). This is
perhaps the most critical of these feature.

________________

Question No. 83
What would happen if a full dose of thiopentone was given to a patient with
acute intermittent porphyria and why?

Answer: -
Key points:
The patient would become anaesthetized, but:
Thiopentone stimulates hepatic delta ALA synthetase, giving excess porphyrins,
causing:
a. Neuropathy, epilepsy, psychiatric symptoms;
b. Abdominal pain and vomiting
c. Tachycardia, hypertension, acute LVF;
d. Red urine

This is a dose-related effect.

73
Neuropathy may last for weeks, needing IPPV, and intensive care.

74
Question No. 84a
What is the management of an acute sickle cell crisis?

Answer: -
Key points:
1. Remove precipitating factors, e.g., cannabis, hypoxia, cold, acidosis.
2. Give oxygen and rehydrate the patient.
3. Prevent cold, hypoxia and acidosis occurring during treatment.
4. Control very severe pain with large doses of opiates.
5. Prevent joint and organ damage which can be fatal.
6. Exchange transfusion has been used with success.

________________
Question No. 84b
How do you judge the significance and plan the management of preoperative
anaemia?

Answer: -
Key points:
Significance:
What has caused it? How severe is it? (when the Hb is below 10g/dl. It will cause
reduced oxygen carriage). Is it acute or chronic (with compensation by raised 2.3
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, drug history)/chronic bloodloss from gut,
bladder or uterus (microcytosis)/aspirin or NSAID usage? There will be reduced O 2
flux and possibly high output cardiac failure if severe.

Investigations:
The medical history will have indicated which lines should be further investigated.

Management:
The relevant issues are:
a. how severe
b. how acute the anaemia is and whether it is “renal” (accept Hb of 7-8g/dl);
and how urgent surgery is (emergency indicates transfusion, and possibly
urgent need to stop cause of bleeding if possible).

The non-urgent situation calls for discussion of Fe++ therapy, erythropoeitin, and
correction of haemostasis factor levels.
75
Comment: This is a common problem but not an easy question to answer.
Question No. 85
In what ways does Down’s syndrome affect the management of an anaesthetic?

Answer: -
Key points:
1. resistance to sedative
2. large size and difficult veins
3. excess salivation and large tongue
4. associated ASD and VSD, with risk of intracardiac shunting and endocarditis
(need for antibiotics).
5. immune deficiency with risk of infection and cross infection.
6. communication problems resulting in fear and failure to comply with
instructions (rapport with parents essential).

Comment: Anaesthetists should be professionally competent in these situations.

________________

Question No. 86
What precautions should be taken when anaesthetizing a patient with myotonia
dystrophica?

Answer: -
Key points:
1. Prevention of aspiration of stomach contents.
2. Prevention of prolonged apnoea by avoiding thiopentone.
3. Prevention of cardiovascular depression and dysrhythmias by being sparing
with volatile agents.
4. Prevention of severe myotonia by avoiding suxamethonium.
5. Awareness that nondepolarizing relaxants do not stop myotonia.
6. Awareness that anticholinesterases may worsen myotonia.
7. Dantrolene may reduce myotonia and should be available.
8. Central neural blockade is useful (if appropriate).
9. Postoperative IPPV may be required.
10. Preparedness for these patients to be very heavy for their age.

Comment: This is rare but important.

76
Question No. 87
How would you judge the significance of preoperative jaundice?

Answer: -
Key points:
Causes:
Is there infective hepatitis? – need to test for HBsAg, Hepatitis A, Hepatitis C, and
enquire about malaria, glandular fever. Would there be a cross infection risk for
staff?

It is due to; drug (paracetamol, halothane), with risk of fulminating hepatic failure
(what is the drug history?); gallstone; Gilbert’s syndrom; haemolysis; cirrhosis; Ca
pancreas; pancreatitis (Serum amylase and blood glucose levels are required)?

Effects:
Has it affected blood coagulation, and therefore jeopardize haemostasis? Is there
hepatic failure (function tests needed)? Is there concomitant renal failure (electrolyte
tests)?
Are there cerebral effects, e.g., in the neonate?

________________

Question No. 88
What complications of operations on the bony structures of the lower half of the
face may affect the anaesthetic management, and how do you deal with them?

Answer: -
Key points:
1. “Oculocardiac” reflex – bradycardia – atropine needed
2. Interference with tracheal tube, the nasal route may be preferable, and
armoured tube may be required.
3. Massive haemorrhage, requiring massive crosmatch and massive
transfusion, with CVP monitoring.
4. Postoperative airway problems, due to swelling and pre-existing
abnormalities.

77
 5. Postoperative vomiting problems when the jaws have been wired together,
requiring antiemetics, awake extubation and strategy for emergency
unwiring.

Comment: This is another example of demonstrating your skills in an important

clinical scenario.

78
Question No. 89
A patient requires an anaesthetic for removal of an infected molar tooth which
is causing severe trismus. Describe the problems and outline the anaesthetic
methods.

Answer: -
Key points:
1. problems – woody swelling in pharynx, unable to open mouth, severe local
infection and toxaemia, pus in pharynx. Local anaesthesia is unhelpful.
Relaxants will not usually relieve trismus, because the spasm arises in the
muscles of mastication themselves.
2. the airway should be secured, and needs a brief discussion of four
methods: General anaesthesia; awake fiberoptic intubation; blind nasal (not
easy because of swollen tissues); tracheostomy (different if the neck is also
swollen); induction of general anaesthesia: the safest is inhalation
induction, using high O2, spontaneous breathing, e.g., with halothane or
sevoflurane; not IV induction.
3. trismus relaxes under general anaesthesia and cords may be visualized in
the usual way. There is still the problem that pus may be in the pharynx.
4. awake extubation is safest for the airway.

Comment: This question is about a safety issue.

________________
Question No. 90
Describe the anaesthetic management for a patient with perforating eye injury
who had a large meal in the last hour.

Answer: -
Key points:
1. postpone the operation if possible; if not possible:
premedication with metoclopramide and H2 antagonist.
2. the use of suxamethonium is controversial as it raises intraocular pressure.
3. the use of intubation is controversial as it also raises intraocular pressure.
Opiates are important here.
4. if intubation is essential, cricoid pressure, and a very careful laryngeal
spray with lignocaine.
5. laryngeal mask has been used successfully, after a period of saturation.
6. postoperatively, prevention of coughing and vomiting is important.

79
Question No. 91
What are the mechanisms involved in anaphylactic and anaphylactoid
reactions? How would you manage a patient showing signs of such a
reaction?

Answer: -
Key points:
Anaphylactic reactions
Antibody and antigen  histamine release
Needs prior exposure/cross-sensitivity
Type I: lgE and mast cells, atopy, family history
Classical complement-mediated reaction
Circulating lgG
Second exposure activates all complement

Anaphylactoid reactions
Histamine without antibody and antigen
Prior exposure not necessary
Alternative pathway for complement

For anaesthetics, the most likely and dangerous time for these reactions is at
induction of anaesthesia, though they can occur at any time to any drug.

Some drugs:
Thiopentone, suxamethonium, alcuronium, plasma substitutes, antibiotics

Recognition:
Histamine (and other vasoactive substances)  cardiovascular collapse,
bronchospasm, skin and mucous membrane signs, clotting abnormalities.

Differentiate from:
Simple overdose, syncopal episode, asthma, aspiration

Management:
Immediate: call for help. 100% oxygen, CPR if necessary, fluid (colloid best),
adrenaline, nebulized salbutamol, steroids. Abandon elective surgery.
Then: contact laboratory, take blood
Later: fill in yellow card, skin and blood testing, counselling

80
Question No. 92
Give an account of the advantages and disadvantages of closed circuit
anaesthesia with carbon dioxide absorption.

Answer: -
Key points:
Equipment
To-and-fro, circle (simple diagram)
Soda-lime

Advantages
Economy
Less pollution
Conservation of humidity and heat

Disadvantages
Absorption not 100% efficient
Inhalation of soda-lime dust
Resistance
Needs knowledge and/or monitoring
Oxygen/denitrogenation
Agent
VOC (VIC)
Mechanically complex
Malfunction, misassemble
Cleaning

________________
Question No. 93
Describe the physical principal of pulse oximetry and indicate its uses and
limitations.

Answer: -
Key points:
Probe
Position
Light-emitting diodes (LEDs), detector

Physics
Absorption
Pulse LEDs and ambient light
81
 Low wavelength
Pulsatile absorption (relation to other absorption)

Output:
Pulse, saturation
Types of display, alarms

Saturation
Human eye and cyanosis
Examples of value

Circulation
Simple pulse monitor
In vascular and microvascular surgery
Circulatory adequacy in controlled limb
With cuff (for blood pressure)
Pulse wave form
Arrhythmias
Amplitude

In treatment
Adjusting PEEP
Deliberate hypoxia in premature neonate
Effectiveness of cardiopulmonary resuscitation (CPR)

General limitations
Specific limitations
Inherent
Not arterial oxygen tension
Response time
Low output, vasoconstriction, venous congestion
Abnormalities
Of haemoglobin
Pigments
On skin
In blood
Pulses
External interference
Diathermy
Ambient light
Motion artefact
Dangers
Trauma from probe

82
Question No. 94
Describe the methods which can be used to monitor the depth of anaesthesia
during surgery.

Answer: -
Key points:
Clinical signs:
(Guedel) breathing, laryngospasm, swallowing, heart rate and blood pressure,
pupils and lacrimation, sweating, movement

isolated forearm:
some circumstances

signals derived from electroencephalogram

raw ECG: brief physiology: basic waves, basic changes; too complex cerebral
function monitor; single bipolar lead, simple signal of amplitude and frequency;
crude
computer analysis: spectral arrays and methods of representing changes in
power and frequency.
Main problems: requires expertise, depends on particular drugs and agents,
expensive, operating theatre is electronically noisy

Evoked potentials:
Brief physiology: auditory, somatosensory, visual even more experimental,
problems as above

Oesophageal motility:
Spontaneous and provoked contractions. Poor specificity
Frontile muscle electromyogram: experimental

83
Question No. 95
What factors should lead you to anticipate difficulty with tracheal intubation?
Describe the management of anticipated and unanticipated difficult intubation.

Answer: -
Key points:
Appearance
Short muscular neck with full set of teeth
Protruding upper incisors and/or maxilla
Receding mandible
Poor mouth opening
Long high arched palate
Fauces and uvula not visible
High larynx

Radiological signs
Increased alveolar – mental distance
Increased posterior depth of the mandible
Decreased atlanto-occipital distance

Acquired conditions
Restricted mouth opening
Restricted neck movement
Soft tissue swelling
Laryngeal
Tracheal

Management (anticipated difficulty)

Intubated before?
Change since last time?
Consider:
Surgery with local anaesthesia
Need for intubation
No relaxant
Equipment: blades, tubes, bougies, laryngeal mask
Awake intubation
Inhalational induction
Blind nasal
Retrograde catheter
Circothyroidotomy/tracheostomy
Fibreoptic: awake/anaesthetized

Management (unanticipated difficulty)

Can you ventilate with mask and airway?
84
 Yes: as above (cricoid pressure if emergency)
Re-establish spontaneous breathing
No: get help
Cricothyroidectomy
Consider postponing operation
?elective tracheostomy
write clear notes, tell patient

________________

Question No. 96
What are the causes of unexpected delay in the return of consciousness after
general anaesthesia? Describe your management.

Answer: -
Key points:
The most common cause of unexpected delay in the return of consciousness is an
absolute or relative overdose of drug.

Prolonged action of anaesthetic drug

Volatiles, adjuncts
Absolute overdose
Increased sensitivity, e.g., age
Delayed elimination
Long-acting drugs

Altered physiology
Hypo- or hypercapnia
Hypoglycaemia
Hyperosmolar non-ketosis
TURP syndrome
Hypothermia

Pathophysiology
Liver disease
Porphyria
Endocrine
Hypothyroidism
Cerebral events

Primary management:
85
 Is the patient breathing?
Review the anaesthetic
Drugs and fluids
Ventilation
Circulation
Surgical events
Investigations and treatment as indicated
The patient
?diabetic
drugs, disease
investigations and treatment as indicated

Secondary management
simple neurological assessment
observe in recovery or ITU?
(contact neurologist)

________________

Question No. 97
In what way are the consequences of renal failure of importance to the
anaesthetist?

Answer: -
Key points:
Physiology
Fluids
Distribution, plasma protein
Electrolytes
Esp. potassium and acid-base
Treatment for hyperkalaemia
Cardiovascular system
Hypertension
Drugs
Heart failure
Pericardial effusions
Respiratory system
Susceptible to infection
Nervous system
Uraemic encephalopathy
Autonomic neuropathy
Haematology

86
 Anaemia
Platelet dysfunction
Heparin for dialysis
Bones
Calcium
Immunology
Prone to infection
(immunosuppression for transplant)
hep B and HIV

pharmacology
premedicants
induction agents
relaxants
suxamethonium and potassium
non-depolarizers
volatile agents
fluoride ion

practical
veins
using dialysis lines
fistulae
protection
postoperative analgesia

________________

Question No. 98
Describe the perioperative management of a 13-year-old girl with acute
appendicitis who is an unstable diabetic.

Answer: -
Key points:
The management of this girl depends on the degree of instability of the diabetic state.

This girl is likely to be dehydrated and hyperglycaemic and more generally ill than a
non-diabetic with appendicitis.

Although acute appendicitis is an emergency, the operation must be delayed until the
diabetes has been brought under control.

87
The first priorities with this girl are biochemical assessment, intravenous fluids, and
the setting-up of an insulin infusion but, because of the risk of perforation, an
operation for acute appendicitis cannot wait until diabetic control is perfect.

Assessment
General
Biochemical
History: normal treatment
Investigations

Treatment
Hyperglycaemia
Ketoacidosis
Dangers of too rapid correction
?intensive care
timing of operation
premedication

Operative phase
anaesthetic drugs
because of appendicitis
rapid-sequence induction
antibiotic prophylaxis
because of diabetes
containing control: no Hartmann’s
biochemical monitoring
caution with PECO2
?nasogastric tube
reversal and extubation

Postoperatively:
analgesia
continue control
for how long?

88
Question No. 99
Discuss the possible complications of general anaesthesia for adults in the dental
chair.

Answer: -
Key points:
Assessment – suitable?

Equipment
For emergency: tubes, resuscitation
Especially chair to go flat
Monitoring

Induction

Maintenance
Agent
Nasal mask
Pack

Initial problems with the airway

Obstruction
Cause
Pack
Blocked nose
Loss of tone
Laryngospasm
Apnoea
(bronchospasm)

Complicated problems with the airway

vomiting
regurgitation

Cardiovascular complications
the ‘single operator’
should all be flat?
Hypotension
With normal heart rate
With bradycardia
Arrhythmias

89
Problems in recovery
Staffing and equipment
Question No. 100
Outline the principles of control of cross-infection in the intensive care unit.

Answer: -
Key points:
Cross-infection in the intensive care unit can delay recovery of the patients or even
threaten their lives.

Cross-infection in the intensive care unit (ICU) is a complication of 30 – 40 % of

admissions.

Hospital-acquired infections can complicate any admission and they are even more
likely in the intensive care unit (ICU) where the patients are debilitated, there is
frequent close contact between patients and staff, and invasive procedures are a
normal part of treatment.

Routes and organisms

Other patients (direct/indirect), staff
Air-borne, contact, ingestion
Increased likelihood of infection

General control
Within patient, of contact

Personal hygiene

Invasive procedures
Aseptic technique
Life of intravenous, intra-arterial, central venous lines care, choice of site

Equipment
Ventilators
Filters, maintenance
Humidifiers
Disposables

Antibiotics
Involve microbiologist
Take samples
?prophylaxis
?selective decontamination

90
Organization
Adequate separation of beds
Isolation

91