Anesthesia Key

B. What factors may contribute to this patient’s fluid deficit? (4 marks)

C. You determine he needs fluid prior to theatre due to his recent losses.

List the 4 categories of fluid replacement to be considered (2 marks)

D. What are the guiding principles of fluids required for resuscitation and maintenance? (4 marks)

E. Calculate the volume of maintenance fluid this patient needs in 24 hours (1 mark)

F. Prescribe maintenance fluid for him for the first 24 hours (1 mark)

G. Define the anion gap (2 marks)

H. How may infusing 0.9% saline affect the anion gap? (1 mark)

I. How may infusing Hartmann’s solution affect the anion gap? (1 mark)

Total 20 marks

Question 2

You are called to the emergency department for a stand-by call for a collapsed 13-month-old child.

A. Complete this table, including detail specific to this patient, to show how you would prepare for their arrival using the advanced paediatric life support (APLS) guideline WETFLAG (7 marks)

W(1 mark)
E(1 mark)
T(1 mark)
F(1 mark)
L(1 mark)
A(1 mark)
G(1 mark)

B. What other preparations would you make? (5 marks)

C. Fill in the following table with normal ranges for a 1–2-year-old child (3 marks)

Heart rate (1 mark)
Systolic blood pressure (1 mark)
Respiratory rate (1 mark)

D. Define the term neonate (1 mark)

E. What are the 4 commonest causes of neonatal collapse? (4 marks)

B. Complete the table showing the pathophysiology of nociceptive versus neuropathic pain (1 mark for each correct answer to a maximum of 6 marks)

Total 20 marks

Question 3

A. Define pain (2 marks)

	Nociceptive	Neuropathic
Origin
Triggered by
Indicative of
Duration

C. Give 4 different questionnaires that can be used to assess chronic pain (4 marks)

D. Give 4 methods of assessing acute pain (4 marks)

E. Give 4 problems with these assessment tools? (4 marks)

B. What is the specific role of von Willebrand’s Factor? (1 mark)

Total 20 marks

Question 4

A 21-year-old man is listed for dental extractions (UR8, LR8, UL8, LL8) as a day case. His only medical history is von Willebrand’s disease (vWD) type 1, associated with easy bruising.

A. Define vWD? (2 marks)

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C. Indicate the likely findings on blood testing. In the boxes, enter raised [↑], decreased [↓], or normal [↔] for each parameter (1 mark awarded for each correct pair of answers to a maximum of 3 marks)

	Platelet count	Bleeding time	APTT	PT	Fibrinogen	Factor VIII level
Von Willebrand’s disease

D. The patient attends the preoperative assessment clinic. What logistics, investigations, and specific therapies should be considered prior to presenting for surgery?

Specific Therapies

(2 marks)

E. The patient presents on the day of surgery. Describe the advantages and disadvantages of endotracheal intubation via the nasal route in this patient (3 marks)

	Advantage (1 mark)	Disadvantages (2 marks)
Nasal intubation	1.	1.——————— 2.———————

F. How can intra- and postoperative bleeding be minimized during this case? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

Total 20 marks

Question 5

A. What factors must you take into account for consent to be considered ‘informed’? (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

B. Name 2 acts of parliament which legislate for capacity to consent in the UK (2 marks)

C. What change to the consent process evolved from the Montgomery versus Lanarkshire Health Board judgement handed down March 2015? (3 marks)

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D. What difficulties are there in explaining risks to a patient? (4 marks)

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E. What is a Caldicott Guardian? (2 marks)

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F. What are the 4 principles of ethical decision-making that must be considered in clinical practice? (4 marks)

A. List 3 risk factors for the development of phantom limb pain postoperatively (3 marks)

Total 20 marks

Question 6

A 73-year-old man presents with a gangrenous left foot and requires an urgent below-knee amputation. He is known to have peripheral vascular disease, previous CVA, COPD, and stable angina. His current medication includes clopidogrel, ramipril, simvastatin, isosorbide mononitrate. He also takes zomorph 30mg b.d. with sevredol 5mg for breakthrough pain and regular paracetamol for ischaemic limb pain.

B. Outline your management of this patient to treat acute pain and attenuate the likelihood of developing chronic pain following amputation using the subheadings to follow

Preoperative (3 marks)

Intraoperative (3 marks)

Postoperative (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

C. Outline the correct process during ‘Stop Before You Block’ (2 marks)

D. Give the 2 main branches of the sciatic nerve. Describe the motor response elicited by stimulation of each nerve (4 marks)

Nerve (2 marks)	Motor response (2 marks)

Total 20 marks

Question 7

A 68-year-old man is known to have aortic stenosis.

A. List 3 cardinal symptoms of worsening aortic stenosis? (3 marks)

B. What are the 3 most common causes of aortic stenosis? (3 marks)

C. Describe the pathophysiology of worsening aortic stenosis (3 marks)

D. He attends preoperative assessment during workup for consideration of a valve intervention. What are the expected abnormal findings in aortic stenosis? (4 marks)

Clinical examination signs

E. An updated echocardiogram is requested as part of the preoperative assessment. Describe 3 specific measurements on echocardiography indicating severe aortic stenosis? (3 marks)

F. List 3 potential valve interventions for severe symptomatic aortic stenosis? (1 mark)

G. You plan to anaesthetise the patient for valve intervention. What are the cardiovascular goals specific to aortic stenosis for this patient? (3 marks)

A. Complete the STOP-BANG scoring tool for OSA (8 marks)

Total 20 marks

Question 8

A 59-year-old man is scheduled for an elective lumbar discectomy. At the preassessment clinic the nurse is concerned he may have obstructive sleep apnoea (OSA)

S(1 mark)
T(1 mark)
O(1 mark)
P(1 mark)
B(1 mark)
A(1 mark)
N(1 mark)
G(1 mark)

B. What are the endocrine (3 marks) and cardiovascular (3 marks) consequences of OSA?

Endocrine (3 marks)

Cardiovascular (3 marks)

C. This patient is investigated and diagnosed with OSA. You intend to use high-flow nasal oxygen therapy for preoxygenation and postoperatively. What are the specifics of high-flow nasal oxygen therapy which confer physiological advantage? (6 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

Total 20 marks

Question 9

A 90-year-old woman with a fractured neck of femur is scheduled for operative fixation with a dynamic hip screw. She weighs 45kg. She has atrial fibrillation (AF) and takes digoxin 125µg, warfarin 5mg, and furosemide 20mg daily. Her blood pressure is 150/90mmHg and heart rate is 80 beats per minute.

A. Define frailty syndrome (1 mark)

B. From the information in the question, what underlying comorbidities may have caused her fall? Complete the table with at least one cause in each category (5 marks–1 per column)

CVS	CNS	Metabolic	Global changes with age	Infection

C. Complete the table to show the advantages of general versus advantages of regional anaesthesia in this patient? (6 marks)

	Advantages
General anaesthesia (3 marks)	1.
	2.
	3.
Regional anaesthesia (3 marks)	1.
	2.
	3.

D. How would you manage her anticoagulation perioperatively? (3 marks)

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E. What formal scoring systems could you use to estimate her risk of morbidity and mortality? (1 mark)

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F. List 4 of the variables which increase the risk of mortality at 30 days in the frail population (4 marks)

A. Describe the main perioperative pain management issue in this patient (1 mark)

Total 20 marks

Question 10

In the preassessment clinic, a 62-year-old patient requires hysterectomy for endometrial cancer. She has hypertension, depression, back pain, and fibromyalgia. Her body mass index (BMI) is 45.

She takes lisinopril, sertraline, co-codamol (30/500) 8 tablets per day, oxycodone 40mg b.d., and shortec 10mg for breakthrough pain, which she usually requires twice per day. The gynaecologists do not wish to postpone her operation.

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B. How much oral morphine equivalent (OME) does she take in 24 hours? (2 marks)

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C. What specific measures would you take to reduce the impact this has perioperatively? (4 marks)

D. Outline your plan for perioperative analgesia (6 marks)

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E. You are called to review her in recovery as she reports severe pain. She is using a standard patient controlled analgesia (PCA) regime of 1mg morphine bolus with a 5-minute lockout. Give 2 ways you can increase the efficacy of this PCA? (2 marks)

F. What other analgesics might you consider at this stage? (1 mark)

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G. What are your instructions on discharge from recovery? (2 marks)

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H. What other classes of drugs might you prescribe for the postoperative period? (2 marks)

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Total 20 marks

Question 11

You have been called to the emergency department to review a 24-year-old man with a significant traumatic brain injury, following an assault. He has no other injuries.

A. What would be the indications to intubate and ventilate this patient? (8 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

7.———————

8.———————

B. You intubate and ventilate the patient successfully with cervical spine stabilization and prepare for transfer. Outline your management to prevent secondary brain injury (6 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

7.———————

8.———————

C. What are the 2 recommended values to target to prevent secondary brain injury? (2 marks)

Intracranial pressure (1 mark)
Cerebral perfusion pressure (1 mark)

D. The patient is transferred safely to the tertiary neurosurgical centre where they find his intracranial pressure is raised, despite your management.

What further options are there to reduce intracranial pressure? (4 marks)

Total 20 marks

Question 12

You are asked to see a 24-year-old woman on the postnatal ward who is 36 hours following a spontaneous vaginal delivery. She had an epidural in labour. She is now complaining of severe headache. You suspect a postdural puncture headache (PDPH).

A. List 6 other possible causes of a headache in this patient (6 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

6.———————

B. Describe the pathophysiology of headache in PDPH (3 marks)

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C. List 5 classical symptoms of PDPH (5 marks)

1.———————

2.———————

3.———————

4.———————

5.———————

D. The patient is also complaining of double vision. Describe a likely cause and specific findings on neurological examination (2 marks)

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E. List 3 options for management of postdural puncture headache symptoms (3 marks)