March 2016

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)
Aortic stenosis 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.
September 2015

  • 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.
March 2015

a) List the factors that may have contributed to an increase in the prevalence of asthma in developed countries in the last 20 years. (5 marks) b) What are the possible causes of acute bronchospasm during general anaesthesia in a patient with mild asthma? (5 marks) c) Outline the immediate management of acute severe bronchospasm in an intubated patient during general anaesthesia. (10 marks)
Asthma Pass Rate 47.0%, 8.5% of candidates received a poor fail
The poor pass rate for this question is of concern as patients with asthma are regularly encountered in daily practice. The treatment of common co-existing medical disorders is specified in the syllabus for the CCT. In general the management of acute bronchospasm was more thoroughly answered than the aetiology and causation sections. This was reflected in a lower poor fail rate compared to other questions which is reassuring for patient safety under general anaesthesia.
March 2015

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.

September 2014

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.
September 2014

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.
September 2014

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.
March 2014

A 27-year-old woman is 13 weeks pregnant. In the antenatal clinic she is found to have an asymptomatic heart murmur. A subsequent echocardiogram shows moderate to severe mitral stenosis.

a) List the causes of mitral stenosis. (15%)

b) How do the cardiovascular changes in pregnancy exacerbate the pathophysiology of mitral stenosis? (45%)

c) Outline the specific management issues when she presents in established labour. (40%)
Pass rate 65.5%

Overall, there was a disappointing lack of knowledge of the pathology of mitral stenosis and some
candidates had no understanding at all. The physiological and clinical aspects were more soundly addressed, and the question proved a very strong discriminator between strong and weak candidates.
March 2014

a) What are the indications for insertion of an implantable cardiac defibrillator (ICD)? (20%)

b) How might surgical diathermy affect the ICD? (20%)

c) A patient with an ICD is listed for elective surgery; what preparations are necessary preoperatively, intra-operatively and
postoperatively? (45%)

d) How does the management differ if this patient requires emergency surgery? (15%)
Pass Rate 67.1%

Generally well answered. Indications for a pacemaker are part of core knowledge incorporating many conditions which have a bearing on the management of anaesthesia. For section (c), some candidates gave generalized answers and failed to focus on the specifics of how the risk of an ICD working inappropriately, or failing to work when necessary, would influences anaesthetic practice. In an emergency situation, deactivation of the ICD would be a reasonable “balance of risks” action.
March 2013

A 56-year-old man is listed for elective surgery. He received an orthotopic heart transplant 12 years before.

a) What key alterations in cardiac physiology and function must be considered when planning general anaesthesia? (50%)

b) What are the implications of the patient’s immunosuppressant therapy for perioperative care? (30%)

c) What long-term health issues may occur in this type of patient? (20%)
27% pass rate.

It is not uncommon to have a patient presenting for surgery that has received a transplanted organ and is on immunosuppressive therapy. A similar question was asked in October 2001. This question proved to be the most difficult question on the paper. A majority of the candidates demonstrated poor understanding of the physiology of a transplanted heart and the side effects of immunosuppressive therapy of relevance to the anaesthetist.
Increased infection risk – may need antibiotic prophylaxis/ strict asepis Common agents cause a degree of chronic kidney disease
Avoid NSAIDs – enhanced side effects
Important to maintain stable plasma levels – ensure drugs taken / given IV steroid cover may be required
Cyclosporine enhances and azothioprine reduces aminosteroid NMB action
March 2013

An 8-year-old child with severe cerebral palsy is scheduled for an elective femoral osteotomy.

a) Define cerebral palsy? (15%)

b) List the clinical effects of cerebral palsy on the central nervous, gastro-intestinal, respiratory and musculoskeletal systems with their associated anaesthetic implications. (50%)

c) What are the specific issues in managing postoperative pain in this patient? (35%)
36.4% pass rate.

This question was poorly answered. Adult and paediatric patients with cerebral palsy presenting for surgery are not uncommon. Many examinees had little or no knowledge of the definition of cerebral palsy and could not put forward a coherent answered regarding the anaesthetic management. Awake-fibreoptic intubation was an inappropriate method of establishing the airway in this patient and the mention of sexual dysfunction was irrelevant.

A snapshot from the model answer below highlights the level of knowledge that was required.
Focusing on the gastrointestinal system involvement:
Clinical effects
Flexion deformities/spasticity
Scoliosis
Immobility
Low muscle bulk
Anaesthetic relevance
Positioning problems; pressure sores;
difficult IVaccess
Restrictive respiratory pattern
Unable to assess cardiopulmonary reserve
Temperature control difficulties

One mark was available for each pair of answers (maximum 2)
September 2012

a) Outline the major changes in the cardiovascular system of elderly patients. (35%)

b) What are the perioperative implications of each change? (65%)
Question 7: Outline the major changes in the cardiovascular system of the elderly and anaesthetic implications.

46.9% pass rate.

This question was set to explore the knowledge of both the physiological and pathological changes that occur as a result of ageing. Many of the answers were insufficiently detailed and not systematic. It is acceptable to structure your answers in tabulated form if the sections of a question are linked. In this case the answers to a) and b) were associated.

For example:

a) Cardiovascular change
Increased systemic vascular resistance Hypertension
Left ventricular hypertrophy
Beta receptor down-regulation
b) Anaesthetic implication
Reduced responsiveness to catecholamines and sympathomimetic agents
Cardiovascular instability
May need to obtund pressor responses Antihypertensive medication

Other cardiovascular changes include reduced autonomic responsiveness, reduced cardiac output secondary to reduced stroke volume, degeneration of SA/AV nodes and conducting system, increased incidence of valvular heart disease and ischaemic heart disease. Similar questions in future might feature changes of the respiratory or central nervous systems of the elderly.
March 2012

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.
March 2012

A 54-year-old inpatient collapses in the toilet.

a) What symptoms (15%) and signs (15%) might suggest acute pulmonary thrombo-embolism (PTE) as the cause of this acute event?

b) List investigations and their characteristic findings that might be of further assistance in establishing the diagnosis of PTE. (40%).

c) What are the principles of management of a shocked patient resulting from massive acute PTE?(30%)
Question 8 Critical care/medicine/ diagnosis and management of PE

77.5% pass rate
September 2011

a) What characteristic neurological changes occur immediately and in the first three months following transection of the spinal cord at the fourth thoracic vertebra? (25%)

b) What other clinical problems may develop following this type of injury? (40%)

c) List the advantages of a regional anaesthetic technique for a cystoscopy in this patient. (20%)

d) Why and when may suxamethonium be contraindicated in a patient with spinal injury? (15%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
September 2011

a) List the commonest causes of chronic liver disease in adults. (15%)

b) Outline the effects of chronic liver disease on organ systems. (60%)

c) What elements constitute the Child-Pugh scoring system? (25%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
March 2011

a) List the harmful chemicals in tobacco smoke. (15%)

b) What are the pathophysiological effects of tobacco smoking on the cardiovascular (20%), respiratory
(25%) and other body systems? (20%)

c) What advice would you give to a smoker attending a preoperative assessment clinic six weeks before a
scheduled procedure under general anaesthesia? (20%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
September 2010

a) How may a patient with sickle cell disease present in an acute crisis? (20%)

b) Outline the important preoperative (25%), intraoperative (30%) and postoperative (15%) considerations
when anaesthetising a patient with sickle cell disease for an elective procedure.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
September 2009

a) List the effects of chronic alcohol misuse on the nervous, cardiovascular and gastrointestinal (including hepatobiliary) systems. (40%)

b) What are the clinical features of the acute alcohol withdrawal syndrome? (25%)

c) How would you manage a patient with established acute alcohol withdrawal syndrome? (25%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
September 2009

a) What features in the clinical history and examination would increase your suspicion that an adult patient has obstructive sleep apnoea (OSA)? (20%)

b) List the preoperative investigations that may be useful in the assessment of the OSA patient. For each investigation, indicate the abnormality you would expect to find. (30%)

c) An adult patient with known OSA is listed for an open cholecystectomy. How will the presence of OSA influence your perioperative management of this patient? (40%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2009

a) Describe how atrial fibrillation may present. (10%)

b) List 5 causes of atrial fibrillation. (25%)

c) What principles underlie the management of atrial fibrillation? (25%)

d) What are the main anaesthetic considerations when performing elective Direct Current Cardioversion? (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2008

A parturient, (Gravida 2 Para 1), arrives at a DGH in labour with signs of fetal distress at 38 weeks gestation. She has had her antenatal care elsewhere. She refuses a regional technique and a decision is made to proceed with an emergency caesarean section under general anaesthetic. She is known to have a medium- size secundum atrial septal defect (ASD), is currently asymptomatic and has turned down cardiac surgery. She is followed up regularly by her cardiologist and has had a recent echocardiogram confirming the diagnosis.

a) Describe your understanding of the cardiac pathophysiology of ASD. (20%)

b) What are your considerations specific to the cardiac condition in this patient?
i) Preoperatively (20%)
ii) General anaesthetic principles focused on the cardiac condition (30%)

Immediately following delivery by caesarean section under general anaesthesia, the SpO2 falls to 70%. You confirm that ventilation is not an issue.

c) What are the possible causes? What are your immediate actions in theatre? (20%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2008

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

76.6% pass rate

In the main was a well-answered question
October 2007

a) What are the clinical features of acquired myasthenia gravis? (25%)

b) What tests are available to confirm the diagnosis? (15%)

c) What are the important aspects of the management of a patient with generalised myasthenia gravis presenting for laparoscopic cholecystectomy? (50%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2007

a) What are the important considerations in the preoperative assessment of a hypertensive patient presenting for elective surgery? (50%)

b) Outline the perioperative risks associated with hypertension and their management. (40%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2007

A 23 year old female presents with acute urinary retention caused by a central L5/S1 intervertebral disc prolapse. You are asked to provide general anaesthesia for lumbar microdiscectomy. She weighs 160kg and has a Body Mass Index of 53.

a) What arrangements with the operating theatre staff will you make that are specific to this case? (30%)

b) Outline your approach to airway management throughout the case. (40%)

c) Indicate the principles of management of postoperative analgesia in this patient. (20%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2006

A 90 year old woman with a fractured neck of femur is scheduled for a dynamic hip screw. She weighs 45 kg. She is in atrial fibrillation and takes digoxin 125 micrograms, warfarin 5 mg and furosemide 20 mg daily. Her blood pressure is 150/90 mmHg and heart rate 80 beats per minute.

(a) What underlying medical conditions may have caused her fall? (30%)

(b) What are the advantages and disadvantages of general versus regional anaesthesia in this patient? (30%)

(c) What would you do about her anticoagulation?(15%)

(d) How could her current medication affect her anaesthetic management? (15%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2006

A 70 year old retired airline pilot is scheduled for a total knee replacement. Apart from his knees he says he has been “fit for as long as I can remember”. Relevant findings on examination are a regular pulse, palpable at the wrist but slow rising and of low volume. On auscultation he has a harsh ejection systolic murmur best heard at the 2nd intercostal space on the right sternal edge. The murmur radiates into his neck. His apex beat is displaced 2cm laterally and is easily palpable. PA Chest Xray shows a cardiothoracic ratio of 0.5. Examination of the ECG shows the S wave in lead V1 and R wave in lead V5 summate to 45 mm. His blood pressure is 135/90 and he is on no antihypertensive medication.

a) What is the SINGLE most likely cause of the murmur in this patient? (10%)

b) What is the most likely aetiology? (10%)

c) What symptoms are classically associated with this lesion? (30%)

d) What investigations are available to assess the severity of this lesion? (20%)

e) What are the expected findings of the investigations in the presence of a lesion classified as severe? (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2005

What are the endocrine causes of secondary hypertension? (25%)

What is the pharmacological management of each of these endocrine conditions? (35%)

State the mechanism of action of each drug. (40%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2005

What are the important organisational (40%) and clinical (60%) factors which govern the anaesthetic management of patients over 80 years of age?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2004

What are the presenting clinical features of infective endocarditis? (40%)

What are the principles that guide the use of antibiotics as prophylaxis against this condition during surgery? (60%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2004

List the causes of perioperative atrial fibrillation.
What are the dangers of acute onset atrial fibrillation.?

How would you manage acute atrial fibrillation in the postoperative period?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2004

What problems are associated with anaesthesia for elective surgery in a patient with dialysis- dependent renal failure ?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2003

Outline the pathology of acute coronary syndromes. What pharmacological treatments are available for patients with an acute coronary syndrome?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2003

Discuss the principles of the management of a 25 year old patient with Down’s syndrome, who requires multiple dental extractions.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2003

A patient with aortic stenosis presents for non-cardiac surgery. What are the clinical features of aortic stenosis and how would pre-operative investigations influence your peri-operative management?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2002

A 78 year old male heavy smoker is admitted for laparotomy for his rectal cancer. He is treated
with bendrofluazide and atenolol for hypertension (160/90mm Hg on admission). What specific actions would you take to improve the chances of a successful outcome.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2001

A 70 year old man presents for a total hip replacement. He has no significant past medical history. At the anaesthetic assessment clinic he is noted to have a grade III ejection systolic murmur at the right sternal edge, radiating to his neck.

Describe, with reasons, what investigations should be undertaken on this patient and explain how the results would affect your anaesthetic management.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2001

What are the anaesthetic considerations in a patient with autonomic neuropathy?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2001

A patient who has undergone a heart transplant requires non-cardiac surgery. What problems may this present for the anaesthetist?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question