A 54 year-old patient with base of tongue cancer presents for a hemiglossectomy and radial forearm free flap reconstruction
a) Which specific factors must the anaesthetist consider when assessing this patient prior to surgery? (10 marks)
b) List the benefits of a free flap reconstruction. (2 marks)
c) What are the causes of flap failure and how may they be prevented in the peri-operative period? (8 marks)
Pass Rate 31.5% Inexperience probably accounts for the poor pass rate for this question. Weak candidates suggested assessment of a potentially difficult airway as the important pre-operative feature, but ignored the co- morbidities associated with causative factors such as smoking and alcohol consumption. The impacts of major physiological changes that are caused by such prolonged and invasive surgery were ignored. The role of the anaesthetist in influencing free-flap survival was particularly poorly answered.
A 71-year-old patient requires a rigid bronchoscopy for biopsy and possible laser resection of an endobronchial tumour.
a) Outline the options available to maintain anaesthesia (20%) and manage gas exchange. (30%)
b) How will use of the laser change the management of anaesthesia? (15%)
c) What are the possible complications of rigid bronchoscopy? (35%)
Pass Rate 60.8%
This question proved discriminatory between candidates who gave a mature and thoughtful answer and those that did not understand the implications of “tubeless” ENT / thoracic surgery. Weaker candidates proposed the use of laser-proof endotracheal tubes, and even double lumen endobronchial tubes and cardiac bypass to facilitate gas exchange. Part (a) tended to score scored badly whilst parts (b) and (c) were better known. Focus in part (c) was dominated by traumatic complications with candidates forgetting “anaesthetic” issues such as; laryngospasm and bronchospasm, pneumothorax / barotrauma / volutrauma from jet ventilation, cardiovascular disturbances, pulmonary infection, hypoxaemia, hypercarbia and awareness.
A 20 year old male was assaulted and sustained a bilateral fractured mandible which requires surgical fixation. Following the assault he was unconscious for 5 minutes. You are asked to see him the next day. He has no other injuries.
a) Outline your preoperative assessment of this patient. (55%)
b) What are anaesthetic options for surgery? (45%)
Question11 Critical care/management of airway problem/tracheostomy