March 2015

An 80 year-old patient is to undergo 2nd stage revision of a total hip arthroplasty for treated deep joint infection.
  • a)  Which specific pre-operative considerations are relevant to this patient? (5 marks)
  • b)  Describe the important features of the intra-operative anaesthetic management of this case. (7 marks)
  • c)  List the patient risk factors for bone cement implantation syndrome (4 marks) and the steps that can be taken to prevent or minimise its effect? (4 marks)
Hip revision surgery Pass Rate 46.8%, 17.7% of candidates received a poor fail
Examiners felt that this question should have proved relatively easy so the pass and poor fail rates are surprising. Inexperience probably accounts for these results. Strong candidates considered issues such as anticipated blood loss and analgesia. Weak candidates focused on infection control issues and ignored the information that the patient had been treated. This question had a very strong correlation with overall candidate scores.
September 2013

A 74-year-old patient is scheduled for a primary total hip replacement.

a) What are the potential benefits of an enhanced recovery (“fast-track”) programme for this type of surgery? (20%)

b) List the preoperative (30%), intra-operative (35%) and postoperative (15%) factors necessary for a “fast track” programme in this patient.
49.9% pass rate.

A question on enhanced recovery after colorectal surgery featured in the May 2011 paper. Many of the principles of “fast-track” status are now being applied to hip and knee replacement surgery. Some candidates misread the question and focused on anaesthesia for surgery on fractured neck of femur.
To pass the question a very generic answer would have sufficed. Excluding the specific details specific to hip replacement surgery, the following basic principles of enhanced recovery formed part of the model answer.

a) Potential benefits:
Early mobilisation (operative day if possible)
Decreased postoperative complications esp. cardiopulmonary
Decreased length of hospital stay
Cost reduction / theatre efficiency

b) Preoperative factors
Appropriate patient selection
Patient education and motivation delivered by multi-disciplinary team

Preoperative optimisation

Admit on the day of surgery (staggered admissions if possible)
Use of carbohydrate loading (clear complex carbohydrate drinks) NB care with
diabetics Intraoperative factors

Surgical technique: minimise operative time, avoidance of drains
Fluid management: targeted fluid replacement
Tranexamic acid intra-operatively
Prevention of PONV e.g. avoidance of nitrous oxide, use of TIVA, routine anti-
emetics
Use long acting opioids sparingly
Maintenance of normothermia
Use of quick offset anaesthetic agents to allow rapid recovery

Postoperative factors
Use of multimodal analgesia/oral opioids (avoid PCA)
Encourage oral fluids early and early nutrition (energy drinks)
Planned mobilisation and physiotherapy

The board of examiners felt that the pass mark should be high, a designated “easy question”. The question was a strong discriminator.
March 2010

a) List the contraindications (absolute & relative) to the use of a limb tourniquet during surgery. (25%)

b) What are the pathophysiological effects following limb tourniquet inflation (20%) and after deflation? (20%)

c) What are the local complications that may arise with the use of a limb tourniquet? (25%)
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

You are scheduled to anaesthetise a 15 year old girl for correction of her idiopathic scoliosis.
What are the key
(a) preoperative (25%)
(b) intraoperative (40%) and
(c) postoperative (25%) issues
in your anaesthetic management of this patient?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2005

You are scheduled to anaesthetise a 15 year old girl for correction of her idiopathic scoliosis.
What are the key
(a) preoperative (25%)
(b) intraoperative (40%) and
(c) postoperative (25%) issues
in your anaesthetic management of this patient?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2004

What are the indications and contra-indications for the use of an arterial tourniquet?
What complications may arise from the use of such a tourniquet ?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2001

How would you provide optimal pain relief for a 60 year old man undergoing shoulder replacement?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question