A 54-year-old male with acromegaly presents for a trans-sphenoidal hypophysectomy.
a) What is acromegaly? (2 marks)
b) List the clinical features of acromegaly which are of relevance to the anaesthetist. (8 marks)
c) What other clinical presentations of a pituitary adenoma may be encountered? (2 marks)
d) What specific considerations, including surgical factors, may influence the conduct of anaesthesia in this patient? (8 marks)
Pass rate 58.8%
The examiners felt that this question was answered well despite it having been adjudged to be hard. However, few candidates either knew that acromegaly was a multisystem disease or could list the other possible clinical presentations of a pituitary adenoma e.g. mass effects. Candidates who performed poorly in part (d) failed to describe the specific issues when anaesthetising a patient for this procedure and focused more on general neuroanaesthetic principles. This is a common mistake that has occurred in many questions across many exams. This question also correlated well with overall performance.
a) Which investigations are specifically indicated in the preoperative assessment of a patient presenting for thyroidectomy for treated thyrotoxicosis? (5 marks)
b) What particular issues must the anaesthetist consider during the induction, maintenance and extubation phases of anaesthesia for a euthyroid patient having a total thyroidectomy? (11 marks) c) Describe the specific post-operative problems that may be associated with this operation. (4 marks)
Pass rate 31.9%
The first and last parts of this question on pre-operative tests and postoperative considerations were well answered. The majority of the marks were lost in the middle section on issues to be aware of during anaesthesia for elective thyroidectomy. Many of candidates concentrated on management of thyroid storm or difficult airway, both of which are relatively rare during such surgery. It is likely that some candidates failed to read the question correctly because it was clearly stated that the patient was euthyroid making thyroid storm very unlikely.
A 45-year-old patient is reviewed in the preoperative assessment clinic prior to surgery for excision of a phaeochromocytoma.
a) What are the characteristic symptoms (15%) and signs (30%) of a phaeochromocytoma? b) Which specific biochemical (10%) and radiological (5%) investigations might confirm the diagnosis of a phaeochromcytoma?
c) What therapeutic options are available to optimise the cardiovascular system prior to surgery?(40%)
Pass Rate 44.7%
Most candidates knew the radiological / diagnostic tests for this condition. Some candidates confused the signs and symptoms of phaeochromocytoma with carcinoid syndrome and thereby lost marks. Most candidates knew that alpha blockade had to be started before beta blockade but did not mention optimizing circulating volume, nor drugs such as calcium channel blockers and magnesium.
Knowledge of the causes and clinical features of primary hyperparathyroidism was generally adequate. However candidates appeared to have little idea of the anaesthetic issues and often wrote generic answers with little or no focus on the specifics of parathyroid surgery. It was a common misconception that parathyroid adenomas are large and will obstruct the airway. Hardly any candidates mentioned gland localization techniques (methylene blue) and a significant number did not include hypocalcaemia as an important postoperative problem. Many failed to mention optimal patient positioning and the fact that the surgeon may wish to use a peripheral nerve stimulator.