a) List and briefly state the reasons for the cardiovascular (7 marks) and respiratory (4 marks) effects of laparoscopy in the head up position for a Nissen fundoplication (anti-reflux procedure).
b) How may these effects be minimised? (9 marks)
Pass rate 54.5%
This question was judged to be of moderate difficulty. It would appear from their answers that many candidates had not seen a Nissen fundoplication and were unable to go back to first principles and talk about the effects of laparoscopy in the head up position. Also candidates failed to read part (a) of the question and so did not give the cardiovascular and respiratory effects and their causes.
A 26 year-old patient with stage 4B Hodgkin’s disease (spread to lymph nodes and other organs) requires an open splenectomy.
a) List the specific factors that are of importance when planning your anaesthetic management. (10 marks)
b) Outline the options for providing postoperative analgesia for this patient and give a possible disadvantage of each. (6 marks)
c) Which vaccinations should this patient receive and what is the optimal timing of these? (4 marks)
Splenectomy in a patient with Hodgkin’s lymphoma
Pass rate 38.8%
Many examiners marking this question felt that either the candidates had not read the question as carefully as they should have done, or they lacked knowledge of the implications of Hodgkin’s lymphoma and its treatment for anaesthesia. Rather than focusing on specific factors of importance many candidates wrote about general problems when anaesthetising for a splenectomy. This was reflected in the pass rate.
A 45-year-old man is scheduled for a laparoscopic Nissen fundoplication under general anaesthesia. He is graded ASA 1.
a) Describe how laparoscopy can cause adverse effects in this patient. (70%)
b) How may these effects be minimised? (30%)
72.5% pass rate.
This was a modification of a question on the adverse effects of abdominal laparoscopy previously used in the May 2006 paper. The effect of steep head-up position and not Trendelenberg tilt was not appreciated by a number of candidates. A significant number of answers incorrectly referred to the effects of a Trendelenberg position raising intracranial and intraocular pressure. The question was otherwise answered with a good systematic approach to the physiological effects of a pneumoperitoneum and the adverse effects of performing a laparoscopy.
A 57-year-old patient is scheduled for resection of a colonic carcinoma in 3 weeks time. The haemoglobin is 10.1 g/dl at time of referral to the pre-assessment clinic.
a) What intraoperative methods can be used to minimise allogeneic blood transfusion? (35%)
b) What steps constitute the final check required by the National Patient Safety Agency’s “Right Patient, Right Blood” guideline? (25%)
c) What are the additional preoperative preparations that must be made if this patient is a Jehovah’s Witness. (40%)
Question12 JW blood conservation and checking a unit of blood
45.2% pass rate
A routine question on core knowledge not answered well. The knowledge of blood checking procedure was particularly disappointing. Very few candidates failed to mention the need to check with the patient, the ID band and the blood form. Very few stated that the personal responsible for the transfusion should check.