a) What are the theoretical advantages of “off pump” coronary artery bypass grafting (OPCAB) compared to an “on bypass” technique? (7 marks) b) What are the potential causes of haemodynamic instability during OPCAB? (5 marks) c) Which strategies help to minimise this haemodynamic instability? (8 marks)
Pass rate 60.4% It is encouraging that the pass rate for this question was high. Hopefully this reflects the fact that candidates are ensuring they get exposure to the subspecialty of cardiac anaesthesia prior to sitting the exam. Some candidates did not give enough detail in parts b and c, concerning the causes and mitigation of haemodynamic instability during off-pump cardiac surgery, so failed to score well. This question correlated well with overall performance i.e. those candidates who scored well in this question did well in the exam overall.
A 70-year-old woman with aortic stenosis presents for an open aortic valve replacement (AVR).
a) What is the pathophysiology of worsening aortic stenosis? (8 marks)
b) Which specific cardiac investigations may be used in assessing the severity of this woman’s disease? (3 marks)
c) Give values for the peak aortic flow velocity, mean pressure gradient and valve area that would indicate that this woman has severe aortic stenosis. (3 marks)
d) What would be your haemodynamic goals for the perioperative management of this patient? (6 marks)
Pass rate 41.8%
The pass rate for this question was the second lowest overall. Aortic stenosis is a common condition and its pathophysiology and management should be known to candidates sitting this exam. In part (a) many candidates simply gave the symptoms of aortic stenosis rather than describing the pathophysiology. This could have been due to not reading the question carefully enough but may also reflect lack of knowledge. As mentioned in previous reports, candidiates should endeavour to arrange taster sessions in modules such as cardiac anaesthesia if they have not done them prior to sitting the SAQ paper.
a) What are the central and peripheral neurological complications of coronary artery bypass surgery? (7 marks)
b) What are the risk factors for central neurological complications? (6 marks)
c) How can the incidence of central neurological complications be reduced? (7 marks)
Neurological complications of coronary artery bypass grafting
Pass rate 54.6%
Candidates who did well in this question tended to do well overall. There was quite a spread of scores with some candidates having a very clear idea of the answers and others seemingly not very much idea at all. Whether this reflects the fact that some candidates sitting the exam have no experience of cardiac anaesthesia is not clear. However, as stated in previous reports, candidates who have no exposure to the mandatory units of training should endeavour to spend a few sessions gaining first hand experience prior to sitting the SAQ paper.
A 67 year-old patient is to undergo coronary artery surgery on cardiopulmonary bypass (CPB).
a) What dose of heparin is used to achieve full anticoagulation for CPB and how is it given? (2 marks)
b) Which laboratory and “point-of-care” tests determine the effectiveness of heparin anticoagulation in CPB patients? Give the advantages and/or disadvantages of each test. (10 marks)
c) What are the causes of inadequate anticoagulation in a patient whom it is believed has already received heparin? (5 marks)
d) Describe the possible adverse reactions to protamine. (3 marks)
Heparin for bypass surgery
Pass Rate 61.5%, 17.2% of candidates received a poor fail This question proved straightforward to candidates who had rotated through a cardiac unit or had read a textbook on cardiothoracic anaesthesia. Many weak candidates neither had knowledge of the intraoperative dosing of heparin for bypass surgery nor aspects of appropriate monitoring. Again, inexperience was the predominating factor in success or failure in this item.
a) What are the purposes (3 marks), typical composition (4 marks) and physiological actions of cardioplegia solutions? (5 marks)
b) By which routes can solutions of cardioplegia be administered? (2 marks)
c) What are the possible complications of cardioplegia solution administration? (6 marks)
Pass Rate 16.5% Cardioplegia is an important basic tool in cardiothoracic anaesthesia although not used invariably in current surgical procedures. It was evident from the answers which candidates had undertaken an attachment in this area of practice, or had read an appropriate text book. The importance of considering the mandatory units of training in preparation for the Final FRCA examination has been emphasised above.
You are asked to review a 65-year-old man on the Cardiac Intensive Care Unit who underwent coronary artery bypass surgery earlier in the day.
a) Which clinical signs suggest the development of acute cardiac tamponade? (40%)
b) List the investigations and their associated derangements that could confirm the diagnosis of acute cardiac tamponade. (15%)
c) What is the management of acute cardiac tamponade in this patient? (45%)
57.6% pass rate.
This question was designated an “easy” question by the exam board and was a good discriminator. The investigations and associated derangements were linked and one mark was awarded for both correct answers. The management of acute pericardial tamponade was generally answered in a generic way (ABC, call for help etc.) but a number of candidates wasted time and effort on managing an anaesthetic in this situation.
Many failed to monitor the clotting and administer blood products or reversing agents if indicated.
a) What are the theoretical advantages of “off pump” coronary artery bypass grafting (OPCAB) compared to “on bypass” technique? (35%)
b) What causes haemodynamic instability during OPCAB? (20%)
c) Which strategies help to minimise this haemodynamic instability? (25%)
d) Outline the measures that help to minimise perioperative hypothermia during OPCAB. (20%)
Question 9: Off-pump cardiopulmonary bypass.
37.3% pass rate.
Cardiothoracic anaesthesia is currently a mandatory unit of training and as such a question will feature in each SAQ paper. The Royal College recognizes that candidates taking the exam at ST3 level may not have yet had significant experience of this sub-speciality and for this reason this question was designated as difficult. Nevertheless it was felt that this question would be able to be answered by candidates using some basic principles, (similar to question 4). Again, this question was poorly answered. Many candidates answered b) and c) with on-pump rather than off-pump issues.
A pass would have been achieved by writing these ten key points:
a) Theoretical advantages of OPCPB Reduced platelet dysfunction Reduced neurological injury
b) Causes of haemodynamic instability Mechanical displacement of heart Arrhythmias
e) Minimising perioperative hypothermia (as with any anaesthetic) Increase ambient theatre temperature Warm IV fluids Use hot-air warmers
The only answers that were specific to OPCPB surgery were in a), the other answers were generic. There were 24 key facts in the model answer. Factors contributing to poor performance were lack of knowledge, inexperience and failure to read the question. This question was the best discriminator in the paper.
A patient on the ICU, who had cardiac surgery completed 3 hours ago, is still intubated. What clinical features might suggest the development of acute cardiac tamponade? (55%) How might you confirm the diagnosis? (5%) Outline your management of acute cardiac tamponade? (40%)
Question11 Critical care/management of airway problem/tracheostomy