a) List the effects of cigarette smoking on the cardiovascular system and on oxygen delivery, outlining the pathophysiological mechanisms involved. (12 marks)
b) List the effects of cigarette smoking on the respiratory system, other than those you have outlined above, that are relevant to the conduct of general anaesthesia. (4 marks)
c) What advice would you give a smoker 24 hours before a scheduled procedure under general anaesthesia and why? (4 marks)
Smoking and anaesthesia
Pass rate 55.5%
The relevance of this question to everyday practice makes the fact that it was well answered all the more pleasing. Candidates who lost marks generally did so because they did not know the pathophysiological mechanisms involved in the difficulties caused by smoking. Remember that applied physiology is also part of the syllabus.
A patient with end-stage chronic liver disease is listed for elective surgery under general anaesthesia.
a) List the common causes of chronic liver disease. (3 marks)
b) Explain which systemic effects of chronic liver disease are of importance to the anaesthetist and why. (9 marks)
c) Outline the Child-Pugh scoring system and explain how this may be used to stratify mortality risk for this patient. (8 marks)
Chronic liver disease
Pass Rate 54.0%, 35.8% of candidates received a poor fail This question proved the most discriminatory question of the paper. Many candidates showed poor general knowledge of liver disease. Weak candidates were unable to associate the effects of chronic liver disease with the consequences for anaesthesia which raises concerns for safe practice. Few understood how the Child-Pugh score allowed stratification of risk.
A patient is to receive a cadaveric renal transplant.
a) Detail the aspects of your pre-operative assessment specific to chronic kidney disease (CKD). (11 marks)
b) How can the function of the transplanted kidney be optimised intraoperatively? (3 marks)
c) How may this patient’s postoperative pain be optimally managed? (3 marks)
d) Explain why some common post-operative analgesic drugs should be avoided. (3 marks)
Pass Rate 59.1% Overall this question was answered well and was a very strong discriminator between candidates. Weaker candidates tended to ignore the anaesthetic implications of; 1) diseases which lead to chronic renal failure, 2) the importance of preserving dialysis catheters / fistulae sites, 3) the implications of a prior failed renal transplantation and any associated immunosuppressive therapy, and most surprisingly 4) the need for pre- operative investigations. Inexperience is the most likely cause of these omissions.
A 72 year-old patient with longstanding severe rheumatoid arthritis (RhA) presents for total knee replacement.
a) Which joints may be affected in RhA and indicate why this involvement is ofrelevance to anaesthesia. (4 marks)
b) Which systemic features of RhA may be elicited during preoperative assessment? (10 marks)
c) Outline the preoperative investigations that are specifically indicated in this patient and the derangements that each may show. (6 marks)
Pass Rate 59.1% This question was one of the easiest on the paper. The overall pass rate for this question seems very low given that patients with Rheumatoid Arthritis are regularly encountered in daily practice, particularly for arthroplasty procedures. The answers given by most candidates reveal a poor understanding of important factors in the pre-operative assessment of these patients. Many scripts demonstrated a “medical student” level of appreciation of the topic, e.g. writing “the neck” in response to the first question on joints affected by the disease. A “scattergun approach” was taken by weaker candidates who wrote down all the pre- operative investigations they could recall despite the question asking for specific examples.
A 35 year-old man presents for a laparoscopic cholecystectomy. He was diagnosed with myotonic dystrophy 10 years ago.
a) What is myotonic dystrophy and how is it inherited? (2 marks)
b) What are the problems of myotonic dystrophy relevant to anaesthesia? (10 marks)
c) Outline the important aspects of preoperative assessment and intraoperative management that are specific to myotonic dystrophy. (8 marks)
Pass Rate 6.5% The prevalence of Myotonic Dystrophy is comparatively high, and anesthetists are much more likely to encounter a patient with this condition than one with Malignant Hyperthermia risk. Poorly applied general anaesthesia causes significant morbidity and mortality in myotonic patients and the disease is rightly considered an “old chestnut” which all clinicians should be able to manage appropriately. Most candidates had very poor knowledge of this subject confusing myotonia with forms of muscular dystrophy whose prevalence is rarer. However strong candidates scored significantly in excess of the pass mark which suggests their preparation for the Final FRCA examination was better. Most weak individuals thought incorrectly that suxamethonium was contraindicated due to a risk of hyperkalaemia, and failed to mention the importance of pre-operative echocardiography in detecting any associated cardiomyopathy. This question was a poor discriminator as so many candidates scored very poorly, and remedial reading on the topic is recommended for the majority of this cohort.
A 52-year-old woman is to undergo laparotomy for ovarian malignancy having completed 3 cycles of primary chemotherapy. She has a BMI of 23 but massive ascites.
What specific features of this case will affect the anaesthetist’s approach to the; a) pre-operative (50%), b) intra-operative (25%) and c) post-operative management (25%) of this patient?
Question 2: Major gynaecological surgery /oncology
46.4% pass rate
This question was generally not answered well. Again, many candidates wrote a generic answer and therefore missed out on valuable marks. The specific features of the case related to the effects of malignancy, chemotherapy, ascites and how the extent of surgery would affect anaesthesia.
A 72 year-old female with longstanding severe rheumatoid arthritis presents for total knee replacement.
a) Describe the clinical features of this disease relevant to anaesthesia. (50%)
b) List the preoperative investigations you might consider. For each investigation state the indications in this patient (e.g. routine or in response to certain findings) and briefly outline the derangements that may be associated with rheumatoid arthritis. (40%)
Question11 Critical care/management of airway problem/tracheostomy
Concerning the cardiovascular risk evaluation for elective non-cardiac surgery; a) Identify “high risk” cardiovascular patient-specific factors that MUST be evaluated and treated before elective surgery. (50%) b) Identify “intermediate and low risk” cardiovascular and non cardiovascular patient-specific factors that may need further investigation and treatment before elective surgery. (40%)
Question11 Critical care/management of airway problem/tracheostomy