March 2016

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)
Transphenoidal hypophysectomy 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.
September 2015

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)
Thyroidectomy 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.
March 2014

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

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.
March 2013

A 45-year-old male with acromegaly presents for an elective trans-sphenoidal hypophysectomy.

a) What is the cause of acromegaly in this patient? (10%)

b) List the clinical features of acromegaly of relevance to the anaesthetist. (45%)

c) How do the surgical requirements for this procedure influence the conduct of the anaesthesia?
57% pass rate.

It was clear that many candidates had not had experience of managing these patients for this type of surgery. Some candidates quoted the prone position for surgical access!

In section c) perhaps it would be easier to organize you thoughts in the form of a table or list.

Surgical requirement
Use of operating microscope
Head-up supine position
Operation on head

Conduct of anaesthesia
“hypotensive” anaesthesia
potential for air embolism
Airway under drapes, armoured tube

This approach makes it so much easier for examiner to spot the scoring answers This question was the second best discriminator of the paper.
September 2012

a) List the causes of primary hyperparathyroidism. (10%)

b) Which biochemical abnormalities are seen in primary hyperparathyroidism? (15%)

c) What are the systemic effects of hyperparathyroidism? (20%)

d) What important factors must the anaesthetist consider before, during and after anaesthesia for parathyroidectomy? (55%)
Question11: Primary hyperparathyroidism/anaesthetic implications.

46.1% pass rate.

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.
March 2012

You are asked to review an 18-year-old male in the Emergency Department who has been found obtunded at home. He is an insulin dependent diabetic with a history of poor control.

Capillary blood glucose is 23.4mmol/L.

a) List the clinical and biochemical findings that confirm severe diabetic ketoacidosis (DKA)? (40%)

b) Outline the management plan for severe DKA within the first hour. (40%)

c) What are the serious complications that can follow the management of DKA? (20%)
Question 7 Critical care/management of DKA

57.2% pass rate
September 2011

A 52-year-old man has been admitted for a tympanoplasty on the morning of surgery. He is a longstanding insulin dependent diabetic who has failed to attend the pre-operative assessment clinic.

a) What specific issues does this patient’s diabetes present? (30%)

b) How should his diabetes be managed whilst in hospital? (35%)

c) What are the anaesthetic considerations for tympanoplasty? (35%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
September 2010

a) List the effects of physiological or excess corticosteroid that are of anaesthetic relevance. (30%)

b) What are the causes of adrenocortical insufficiency? (30%)

c) How may acute corticosteroid insufficiency be diagnosed clinically and biochemically? (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
April 2009

a) Name 4 drugs that may be used to treat thyrotoxicosis and briefly outline their mechanism of action (40%)

b) What are the main anaesthetic priorities in assessing a patient with treated thyrotoxicosis who is presenting for thyroid surgery? (20%)

c) List the procedure-specific complications that may present in the post-operative thyroidectomy patient. (30%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2007

a) List the important causes of hyperkalaemia. (25 %)

b) What are the clinical effects of hyperkalaemia? (15%)

c) Describe your treatment of a patient with critical hyperkalaemia. (50%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question