Final FRCA VIVA December 2008 - MEDICAL EDUCATION at ...

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaFinal FRCA viva: December 2008Set 1Clinical Long Case:Elderly women for laparotomy perf bowel, with large neckswelling, presumed goitre. Has inspiritory stridor.Discuss ECG (AF), CXR (perf, cardiomegaly, mediastinalmass) and other investigations recommended. Fluidresuscitation, how to do fluid challenge etc. Method ofAFOI,Reason for polycythaemia. Discuss airway management.Critical incident fast AF. Post-op management of airway.Short cases:1. 15yr old with FB in eye, full stomach.2. Epidural trouble-shooting (ie called to ward, post APresection, epidural not working). Discuss sensory/motorblock aspects. Pain scales and pain assessment.3. Can't rememberSciences:1. Anatomy of IJV2. Indications and complications of central venous access3. Adult and children daily fluid and electrolyterequirements, how much Na+ in different fluids4. Paediatric fluids, discuss causes and consequences ofhyponatraemia, SIADH etc5. Oxygen delivery - different facemasks how much %O2,Venturi effect, examples6. Oxygen sampling, draw and explain fuel cell andparamagnetic (old version). Write down actual reactionequations (Pb, Gold, OH-, electrons etc)7. Cholinesterase - what different types are there. Thenacetylcholinesterase inhibitors. Wanted lots of detailabout syptoms and treatment of organophosophoruspoisoning.8. Suxamethonium apnoea - wanted rational behind dibucainenumber (quite detailed). How long the apnoea lasts for thevarious genotypesSet 2LONG CASE ( 8 TH DECEMBER 2008 )76 yr lady admitted 36 hrs ago with abdominal pain,nausea ,vomiting.She has beenresuscitated with i.v.fluids and nasogastric aspiration.31 yrs ago she had a sub-total thyroidectomy but the disease has recurred and she has adiffuse goitre.Thyroid function tests performed 2 yrs ago was normal.She is normally on 0.25mg digoxin and 300mg aspirin.O/EPulse 85/min irregularly irregularBP 130/55 mmHg1

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaSwelling in the neckThe surgeon wants to perform a laparotomy for caecal perforation.INVESTIGATIONSECG : AF rate 75-85CXR : AP view – large mass in the neck, lung fields relatively clear ? minimal pleuraleffusionsHeart looked enlarged( cannot comment as AP view )BIOCHEMISTRY (normal) : Na 139 mmol/l K 3.9 mmol/l Urea 8.0 mmol/l Creatinine108 umol/lFBC : Hb 15.9 g/dlPCV raisedWCC 17.9 X 10^9/ LQUESTIONSSummarise the caseComment on cxr findingsIs she adequately resuscitated ? ( no-raised hb and pcv )Do you want to take her to theatre?How will you pre-optimise her?What other inv do you want? ( ct scan, IDL,nasendoscopy ,thyroid function tests )How would you manage the airway ? (I settled on awake fibreoptic as the safest option )After securing the airway the choice of induction agent,muscle relaxant and maintenanceagent and why?In addition to cvp and art line what else would I like to monitor? ( said cardiac output withDoppler/ lidco)What is lidco and how does it work? ( very briefly-nothing in too much detail )What else to monitor ? ( urine output,peripheral perfusion,core-peripheral temp gradient )Intra-op pt develops AF with rate of 160 and haemodynamic compromise-what would youdo? ( i said ideally DC cardioversion but need to rule out thrombus or anticoagulate-ruledout in this case ...remember pt is only on digoxin without any anticoagulation and is inchronic AF normally—from history )So what would you do? ( amiadarone and dose )What could be the reason for AF ?Causes of AF in general.After the surgery what factors would decide if I would extubate the patient.Pros and cons of extubating v/s period of ventilation post-op.Methods of pain relief ( couldn’t complete – bell rang! )SHORT CASES1) 75 YR OLD WITH AORTIC STENOSIS FOR THR .Signs and symtoms of AS.Examination findings.Investigations to assess severity of AS.Grading of severity on valve area and mean gradient.Cardiologist says doesn’t need valve replacement. Aims of anaesthetic management.How would you anaesthetise him?2) 15 YR OLD WITH PENETRATING EYE INJURY WITH FULL STOMACH.What are the main concerns.Effect of sux on IOP – by how much does it increase it?2

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaHow can you prevent it ?What other option is available - delay surgery till fasted.Surgeon says cant wait- how will you anaesthetise ( I chose modified rapid sequence usingpropofol,rocuronium and alfentanil to prevent pressor response- examiner seemed ok with it.)What are your aims in management ? ( usual stuff like prevent factors increasingiop,maintain normocarbia, adequate analgesia , prophylactic anti-emetics, extubation whenfully awake )How else can you anaesthetise- didn’t understand what the examiner was lookingfor.thankfully moved to next short case.3) PATIENT HAD PROCTOCOLECTOMY EARLIER THIS MORNING.EPIDURAL IN-SITU.LATER IN THE EVENING NURSE ON THE WARD CALLS YOU ( YOU AREON-CALL ) AND SAYS EPIDURAL NOT WORKING AND PT IN PAIN.How will you go about managing this.How do you assess the block?What do you look for in the anaesthetic notes?What do you look for at epidural site? ( catheter slipped out, fluid around site)What are the options available? ( couldn’t complete—bell rang to the rescue)Overall felt both the examiners were friendly and put me at ease . generally lookingfor common sense approach to problems than actual factual details. Helps very muchto have a calm mind and to think before answering. ( easier said than done! )GOOD LUCK TO EVERYBODY .Set 3CLINICAL:63 Year old lady with malignant melanoma on her back. For wide local excision and axillaryclearance in prone position. She had chronic cough and has been treated 3x in the last yearwith antibiotics for recurrent chest infections. She has had a previous R mastectomy forbreast cancer 8 years ago. She also has a recent history of palpitations.Drugs: enalaprilO/E: Wt 54kg Ht 5 ft 5BP 160/105HR 80On examination heart sounds normal. Chest bilaterally wheezy with widespread crackles.CXR: RLL consolidation and (I thought) effusion.ECG: SR but ectopics. LVH. Normal axis. No Q waves.Included:U+E:Na 137K 4.5U 10C 1573

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaPFTs: FEV/FVC ratio 64% Post nebulised salbutamol 67%Reduced FEV1Reduced FVC: Obstructive.Summarise this case briefly.What do you think about her CXR, ECG – went through both.LVH – likely cause.PFTs – reversibility/ causes: COPD, bronchitisRenal impairment and likely causes – ACEI and hypertensive nephropathy.Pre optimisation & other investigations (History, FBC, ABG, Ex Tol, ?CT chest)What about her hypertension – what risk involved – would you proceed?How would you anaesthetise her? What techniques? Monitoring? I said reinforced tube,positioning, eye padding, free abdomen.Problems with prone and what mode of ventilation and what pressures would I set ventilator?Abdominal compartment syndrome.What problems might the surgeons cause you? I said methylene blue and rib resection. Thenproblems with meth blue?Pain relief? I said PCA Morphine as proximity to surgical site/ infection risk with epidural.Mentioned DVT prophylaxis and then asked about guidelines – NICE and theirrecommendations.Post-op she is extubated and goes to recovery; she becomes hypoxic and wheezy – take methrough your management. ABC, ensure no AW obstruction & give oxygen. Listen to chest –give B2 agonists. Etc etcThen differentials: main thing they wanted: post-op atelectasis with V/Q mismatch.How would I manage: I said resp supprt NIV, CPAP, and physio.SHORT cases:1. Dural puncture: what do you do & how do you manage? I put spinal catheter andmentioned explicit risk and precautions needed. Then explain and reassure woman.Late management and differentials.Bld patch & risks and % resolution.2. 60yr old man with severe cardiac history: 2 stents for knee arthroscopy.How would you manage?Assessment, what investigations. Started with history, ECG, CPET. Showed me ECG:Inferior Q waves and lateral deep T inversion. Nomal axis but LVH.Post-MI risk – asked for % risk of peri-op MI – mentioned guidelines ACC.What anaesthetic – I said regional ideal: Lumbar plexus block or femoral/ sciatic.What complications of LA blocks in general.3. 8 yr old boy – found in ditch. Comes to A&E with open fractured tib/fib. What do youdo?ABC – C spine control. APLS. Assessments of conscious level – GCS and AVPU.Signs of HI & indications for CT head – guidelines again AAGBI, NICE.Raised ICP and management – risks and what to avoid – time to draw 1 graph but notime for much detail. CPP.SCIENCE viva:4

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca1. Anatomy: Phrenic nerve.Where and by what could it be damaged along its course. Take me through each level& mechanism.Course neck and thorax, diaphragm– after explaining course asked specifically wheredoes it lie in the chest.Phrenic nerve damange – how would you tell? What would happen? FRC,paradoxical mov. Why might this be bad and whom particularly at risk.Tests to confirm – end insp CXR. What else? Made up sniffing while visualising withUS!2. Indications for renal replacement. Specifics about uraemia, when and what level RRTindicated.K and what level.Methods of renal replacement and adv/disadv of each. HD, HF, PD. Physicalprinciples.Risks involved: catheter related and procedure related. Specifics of anticoagulation.Mortality benefit and do I know of any trials. Cytokines.3. Very strangely phrased Q: Scenario and end of operation, after using VEC, there is noTOF.Causes of no TOF stimulation- Basically wanted what prolongs blockade, but veryunclear at 1 st ! Drugs, electrolytes, NM disease, neuropathy & equipment factorsAll NM monitoring, types, mechanism – T4:T1 ratio, stimului types, current etc.4. What groups of patients are at risk if you don’t humidify AW gases & why? Groups.Short-term & longterm damage and sequelae. Types of humidification. Passive HME& latent heat vaporisation. Active: Mentioned Bernoulli principle & USS then bellrang.Set 4LONG CASE ( 8 TH DECEMBER 2008 )76 yr lady admitted 36 hrs ago with abdominal pain,nausea ,vomiting.She has beenresuscitated with i.v.fluids and nasogastric aspiration.31 yrs ago she had a sub-total thyroidectomy but the disease has recurred and she has adiffuse goitre.Thyroid function tests performed 2 yrs ago was normal.She is normally on 0.25mg digoxin and 300mg aspirin.O/EPulse 85/min irregularly irregularBP 130/55 mmHgSwelling in the neckThe surgeon wants to perform a laparotomy for caecal perforation.INVESTIGATIONSECG : AF rate 75-85CXR : AP view – large mass in the neck,lung fields relatively clear ? minimal pleuraleffusionsHeart looked enlarged( cannot comment as AP view )BIOCHEMISTRY (normal) : Na 139 mmol/l K 3.9 mmol/l Urea 8.0 mmol/l Creatinine108 umol/lFBC : Hb 15.9 g/dl5

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaPCV raisedWCC 17.9 X 10^9/ LQUESTIONSSummarise the caseComment on cxr findingsIs she adequately resuscitated ? ( no-raised hb and pcv )Do you want to take her to theatre?How will you pre-optimise her?What other inv do you want? ( ct scan, IDL,nasendoscopy ,thyroid function tests )How would you manage the airway ? (I settled on awake fibreoptic as the safest option )After securing the airway the choice of induction agent,muscle relaxant and maintenanceagent and why?In addition to cvp and art line what else would I like to monitor? ( said cardiac output withDoppler/ lidco)What is lidco and how does it work? ( very briefly-nothing in too much detail )What else to monitor ? ( urine output,peripheral perfusion,core-peripheral temp gradient )Intra-op pt develops AF with rate of 160 and haemodynamic compromise-what would youdo? ( i said ideally DC cardioversion but need to rule out thrombus or anticoagulate-ruledout in this case ...remember pt is only on digoxin without any anticoagulation and is inchronic AF normally—from history )So what would you do? ( amiadarone and dose )What could be the reason for AF ?Causes of AF in general.After the surgery what factors would decide if I would extubate the patient.Pros and cons of extubating v/s period of ventilation post-op.Methods of pain relief ( couldn’t complete – bell rang! )SHORT CASES1) 75 YR OLD WITH AORTIC STENOSIS FOR THR .Signs and symtoms of AS.Examination findings.Investigations to assess severity of AS.Grading of severity on valve area and mean gradient.Cardiologist says doesn’t need valve replacement. Aims of anaesthetic management.How would you anaesthetise him?2) 15 YR OLD WITH PENETRATING EYE INJURY WITH FULL STOMACH.What are the main concerns.Effect of sux on IOP – by how much does it increase it?How can you prevent it ?What other option is available - delay surgery till fasted.Surgeon says cant wait- how will you anaesthetise ( I chose modified rapid sequence usingpropofol,rocuronium and alfentanil to prevent pressor response- examiner seemed ok with it.)What are your aims in management ? ( usual stuff like prevent factors increasingiop,maintain normocarbia, adequate analgesia , prophylactic anti-emetics, extubation whenfully awake )How else can you anaesthetise- didn’t understand what the examiner was lookingfor.thankfully moved to next short case.6

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca3) PATIENT HAD PROCTOCOLECTOMY EARLIER THISMORNING.EPIDURAL IN-SITU.LATER IN THE EVENING NURSE ON THEWARD CALLS YOU ( YOU ARE ON-CALL ) AND SAYS EPIDURAL NOTWORKING AND PT IN PAIN.How will you go about managing this.How do you assess the block?What do you look for in the anaesthetic notes?What do you look for at epidural site? ( catheter slipped out, fluid around site)What are the options available? ( couldn’t complete—bell rang to the rescue)Overall felt both the examiners were friendly and put me at ease . generally lookingfor common sense approach to problems than actual factual details. Helps very muchto have a calm mind and to think before answering. ( easier said than done! )GOOD LUCK TO EVERYBODY .BASIC SCIENCE VIVA ( 8 TH DECEMBER 2008 )ANATOMYIndications for central venous cannulation.Anatomy of IJV and SUBCLAVIAN VEIN –in quite some depth.Complications of central venous cannulation.Methods of cannulating.Pros and cons of ultrasound and landmark techniques.PHYSIOLOGYFluid requirements of 6 yr old child.Na and K requirements.What type of fluids and why?What is stress response to surgery ?Why do children need glucose containing fluids ?What are the problems of giving only glucose?Effects of hyponatremia .PHARMACOLOGYWhat is acetylcholinesterase ?Where is it found ? how does it work ?What is pseudocholinesterase? Other name for it ?Where is it found ?What other drugs apart from sux does it metabolise?Natural cause of decreased pseudocholinesterase production ?Genetic variability ,dibucaine no and fluoride no .PHYSICSMethods of o2 delivery to pt .Fixed performance and variable systems.Principle of venturi-mask.A bit about Hudson mask and o2 tents.Measurement of o2 - fuel cell , paramagnetic analyser.Again felt examiners were very friendly. In this viva you need a bit of luck to getasked about what you know well. That builds up the initial confidence and the rest ofthe viva can go well.Other candidates got asked about anatomy of phrenic nerve, renal replacementtherapies, humidity and methods of humidification and muscle relaxants .7

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaTHANK GOD ITS ALL OVER . AS YOU MIGHT HAVE GUESSED I PASSED.Set 5Long Case.30ish old man130 KG Mallampatti 3Poorly controlled epileptic refractory to quad drug therapyKeppraCarbamazepine2 benzodiazepinesInvesigationsCXRVagal nerve stimulatorSleep studiesOSAPolycythaemiaLung function testsPEFR ↓No reversibility givenPresentes with ruptured globe following fall on to radiator, no recollection of events.Discuss management and investigationsShort CasesStridor in childLaproscopic surgeryPhysiological changesComplicationsX-ray caseTB – right upper lobe collapseNeeds urgent surgery for bleeding ectopicHypotensiveResusitive laparotomyHDU post opTB implications side room etc8

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaBasic sciencesPharmacologyMechanisms – (detailed) of excretion by kidneyAffect of renal failure on pharmacokineticsPhysicsTemperatures measurementCauses of hyperthermiaPhysiology of pregenancyManagement of pregnant lady with appendicitisAnatomySympathetic nervous systemSet 6My Questions:Long case: 72 yr Known lung tumor. Comes to A&E with severe pain in the neck. with ASmurmer.Cspice lateral view. C2 mass with A/A subluxation. ECG Lt axis and borderline LVH2Decho AS gradient 35mmhg.discussion went to c-spine fixation and awake fibreoptic and anaesthetic management. andneurological complication and examination.short cases.1 Jehovah's witness.2 preeclamtic. anaesthesia for C/S pros and cons of GA/Spinal and periop management3. Pt who had a tracheostomy 4 days ago starts bleeding from tracheostomy site. how wouldyou manage. causes of bleeding at 4 days. The tracheostomy gets dislodged when taking thepatient to theatre in the corridor how would you manage.basic science viva.Vagus nerve transection at jugular foraman. unilateral and bilateral. they were only interestedin airway problems anatomy, nerve supply etc. discussion also included thyroidectomy. andcomplications.Beta receptors everything and B blockers. Recent publications regarding b blocker uses,,recommendations.plenun system and uses in anaesthetics. other than vaporisers.latex allergy. how long does latex last in the theatre in general exponential decay etcSet 71 A 25 years old lady is brought to A&E unconscious after an overdose of drugs.How will you assess her?How do you assess consciousness?At what level of GCS would you intubate her?She had alcohol and Paracetamol, how will you manage her ( airway & breathing is fine)?When will you give her N acetyl cysteine?What is the route of administration?9

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaIn which solution is it prepared?Which organs are affected by Paracetamol toxicity?What is the pathophysiology of hepatic toxicity?If the INR is high what would you do?2 A 45 year old male patient for a testicular operation wants an epidural for the operation. Hewas very groggy with his last GA and donot want GA.What will you say to him?What risks of Spinal/epidural would you explain to him?Innervation of testies?Risk of pain in regional anaesthetic in teticular surgery?3 A man with Pacemaker for an elective surgery.Routine viva bookcasePacemaker codePreop checkDiathermyElectrical safetyClinical Sciences Viva1 Anatomy of noseIndications of nasal intubation.Risks of nasal intubation.How can you anaesthetise nose?How much lignocaine can be used?How much lignocaine is there in a puff?2 Hyperbaric OxygenMechanism of actionIndicationsCarbon monoxide poisoining ; Criteria for HOTLevels of CO normal/ abnormalPathophysiology of CO poisoningSymptomsContraindications3 SuxamethoniumMechanism of actionMyalgia – reasonHow can you prevent myalgia?Metabolism of SuxPseudocholinesterase deficiency – genetic variabilityOther causes10

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaTypes of allelesDibucaine number4 Foetal circulationDraw & explain.Changes at birth.Which drug is used to cause ductus arteriosus closure in babies?Which drug is used to reduce pulmonary hypertension?What is tetralogy of Fallot?What will the anaesthetic considerations in management of TOF?Set 8Long case:80 yr old lady for laparoscopic repair of hiatus hernia with a history of nausea and vomittingfor some time. Anaemic (Hb - 9 normocytic), Albumin - 22, Low magnesium and calcium,significant ischemic changes on her ECG and a large homogenous opacity continuous withher heart shadow and diaphragm in the left lower zone on the Chest x ray. She was ondigoxin and a diuretic and was diagnosed with Atrial fibrillation in the past.QuestionsSummariseDiscussion on investigations and results:what could be the reasons for low calcium and magnesium? would you correct it pre-opwhat could be the reasons for anemia? would you correct itWhat could be the reasons for low albumin in her? would you correct itWhat are the changes in ECG? what is your diagnosis ( Q waves in L2 and AvF, andextensive T wave changes in all leads)What do you think is the cause for the shadow? What are the differentials? How wouldyou confirm.What other investigations do you want and why?How long will you wait before anaesthetising her?What anaesthetic technique?What pain management?What other post operative mangement? HDU/ITUWill she need ITU, if so why?Then we spoke on Nutrition in the ITU, advantages/disadvantages and differences betweenenteral and parenteral nutrition.Short case:Post tonsillectomy bleed..... standard questions relating to assessment of blood loss,resuscitation and management.Atrial flutter and its management.Anatomy:1. Anatomy of trachea and how the anatomy affects an aspirated foreign body in an adult.( extent, relations - both intra and extra thoracic, bronchopulmonary segments. managementof anaesthesia for a foreign body.11

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca2. Cigarrette smoking and its effects: Nicotine, Carbon monoxide, carcinogens, changes tothe cilia, COPD etc etc. What are the effects of stopping smoking? How long would youadvise a chronic smoker to stop smoking before anaesthesia3. Pharmacology: Effects of drugs on ICP: started off from induction agents to all other drugsthat we use in theatre.4. Laser: How is laser produced? and all the standard questions from the basic sciences vivabook..Set 9Clinical long case28 year old primi gravida, 7 hours after an emergency LSCS needs a laparotomy massivePPH. She is tachycardic, BP unrecordable, pale and anxious. Lab results show severeanaemia, coagulopathy, pre renal dysfunction. Blood transfusion is in progressDiscussion was based on resuscitation, blood products, factor 7A, and anaesthesia inhaemodyanmically unstable patient.Few questionsWhat Hb are you happy with?What induction agent, why?Problems with massive transfusion?What are the ways to control PPH? Esp atonic PPHRisk factors for atonic PPHUterine tonics?Surgical ways to control bleeding?Systemic problems with massive transfusion?Post op complications?Showed an xray of ards what could this be if it develops within 12 hours ITU admission?TRALI/overload…discussion on trailPost op renal failure: how to manageClinical short cases1. Showed an ECG of AF with ventricular rate of 90, old inferior wall MI , LAD70 year old male for cystoscopyclinical correlation? How to optimise, wwhen would you anaesthetise? Shock or chemicalcardiovertion? Different scenarios.Causes of AF?Drugs used?Intraoperative fast AF, how to manage2. 80 M k/o COPD with acute exacerbationcauses of deterioration?Any iatrogenic causes? O2 therapy , its mechanism12

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaHow to assess the patient, investigations?TreatmentWhats blue bloater and pink puffers?Who is suitable for NIV? What are the contraindications?When would you think of ventilating?Problems with weaning3. IVDU for Hickman line insertionWhat are the perioperative problems? Vascular access/infections/Issues of pain controlViral diseases he can have?this patient has aids, and you get a needle stick injurywhat is the protocolbasic science viva1. Carotid endarterectomyAnaesthetic options advantages, disaadv.Superficial c plexus block how to perform, why not deep?What are the complications of deep blockWhat are the monitors usedHaws is cerebral function monitored in awake patients2Differences in neonatal resp physiology and their anaesthetic implicationsCongenital diaphragmatic hernias, pathophysiology , how to optimise, ventilatory strategy3. At the end of a long operation in which there was a blood loss of 5 litres the wound edgesare oozy…what the mechanism isDiscussion on cell based coagulation, replacement of factors, what when how much to givewhat are the test used to assess coagulation, bed side tests? TEG in detail4. Arterial blood pressure trace? What info can you gather from the trace?What happens to the position of dicrotic notch in raised svr? I said it would be shiftedproximally on the down slope…he seemed to agreeHow does a line monitor work?What are the sources of error resonance, dampingSet 10Long caseA 23 year old female who has delivered 7 hrs ago LSCS - continuing to pass clots onsyntocinon infusion, large baby weight - 4.5 kgs failure to progress prolonged labour . She isrecieving bloods. Surgeons want to take her up for exploratory laparotomypale anxious HR -140/min BP unrecordableHb - pre LSCS 13.2 g/l post 2.5 9/lPlatelets pre 373 post 7313

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaD Dimer - 6 ( very high)Fibrinogen - NormalCan you summarise the case ?What is going on in your mind as you go to see her ?What is the first thing you do ? ( apparently speed up the infusion)What are the causes for her bleeding ?What is your management ?What are the doses of syntocinon, ergometrine and carboprost ?Where will you take her post op ?Sown X ray - ? ARDS / TRALIWhat is your post op management ?Short cases:1. ECG - AF Causes, coming in for cystoscopy at induction BP crashes what drug would youuse ?2. IV drug abuser - precautions, difficulties , needle stick injury, incidence of HIV positivityafter needle stick, post exposure prophylaxis3. Elderly male COPD called by chest physician how will you asess ? when will you manageconservatively ? Quality of lifeClinical Viva:1. Intra arterial pressure monitoring - indications, damping , resonance, what parameters arederived, draw a trace, complications of arterial puncture,2. GA Versus LA carotid endarterectomy - how do you do deep and superficial cervicalplexus block, complications Local versus GA3. compare and contrast neonatal versus adult physiologyClinical long case28 year old primi gravida, 7 hours after an emergency LSCS needs a laparotomy massivePPH. She is tachycardic, BP unrecordable, pale and anxious. Lab results show severeanaemia, coagulopathy, pre renal dysfunction. Blood transfusion is in progress14

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaDiscussion was based on resuscitation, blood products, factor 7A, and anaesthesia inhaemodyanmically unstable patient.Few questionsWhat Hb are you happy with?What induction agent, why?Problems with massive transfusion?What are the ways to control PPH? Esp atonic PPHRisk factors for atonic PPHUterine tonics?Surgical ways to control bleeding?Systemic problems with massive transfusion?Post op complications?Showed an xray of ards what could this be if it develops within 12 hours ITU admission?TRALI/overload…discussion on trailPost op renal failure: how to manageClinical short cases1. Showed an ECG of AF with ventricular rate of 90, old inferior wall MI , LAD70 year old male for cystoscopyclinical correlation? How to optimise, wwhen would you anaesthetise? Shock or chemicalcardiovertion? Different scenarios.Causes of AF?Drugs used?Intraoperative fast AF, how to manage2. 80 M k/o COPD with acute exacerbationcauses of deterioration?Any iatrogenic causes? O2 therapy , its mechanismHow to assess the patient, investigations?TreatmentWhats blue bloater and pink puffers?Who is suitable for NIV? What are the contraindications?When would you think of ventilating?Problems with weaning3. IVDU for Hickman line insertionWhat are the perioperative problems? Vascular access/infections/Issues of pain controlViral diseases he can have?this patient has aids, and you get a needle stick injurywhat is the protocolbasic science viva15

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca1. Carotid endarterectomyAnaesthetic options advantages, disaadv.Superficial c plexus block how to perform, why not deep?What are the complications of deep blockWhat are the monitors usedHaws is cerebral function monitored in awake patients2Differences in neonatal resp physiology and their anaesthetic implicationsCongenital diaphragmatic hernias, pathophysiology , how to optimise, ventilatory strategy3. At the end of a long operation in which there was a blood loss of 5 litres the wound edgesare oozy…what the mechanism isDiscussion on cell based coagulation, replacement of factors, what when how much to givewhat are the test used to assess coagulation, bed side tests? TEG in detail4. Arterial blood pressure trace? What info can you gather from the trace?What happens to the position of dicrotic notch in raised svr? I said it would be shiftedproximally on the down slope…he seemed to agreeHow does a line monitor work?What are the sources of error resonance, dampingLong Case28 female, primi. Now 7 hours Post LSCS (for failure to progress)She had oxytocin drips for 5 hours before delivary.Delivered 4.8 kg male baby. She looks Unwell, pale,HR -140, BP not recordable, Carotid pulse presentPosted for urgent laprotomyPre LSCSNowHB 136 28PLAT 200 82PT - 18APTT - 76FIBRINOGEN 1.8Rest bloods OkSummary. Asked to go through blood results. What it is?- severe haemorrhagic shock.Causes?Why Atony suggested in this case? Management? ABC, BLOOD, O NEGATIVE,BIMANUAL, INFORM VARIOUS PROFESSIONALS, SENIORS, ITU etc..Other blood products? Monitors? When happy to Induce for laprotomy? What drugs forinduction- I said Ketamine. To ituIn ITU Chest Xray – shows pul odema and ett endobronchial. Why pul odema? How to treatpul odema here? What Other generic measures in ITU? Why DVT and GI prophylaxisneeded in this patient? What are the measures of organ perfusion?When she is extubated, what pain management?16

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaWhen can she breast feed?Short Case- Clinical1. 70 MALE for day case TURBT. HTN, plays golfECG- read through it? Whats callibration? It was AF. Features on ECGCauses? He wanted IHD/HTN/VALVULAR DISEASE AND THYROTOXICOSIS]What to do? Patient has no symptoms? Post pone? Yes?- speak to cardiologistAfter few days, AF sorted. Introp- sudden HYPOTENSION? Causes?Not in AF. Whats inotrope of choice?2. Young male/IVDU/AIDS/for Hickmans lineIssues?? why infection in IVDU?Problems- Needle stick injury- Whats risk of AIDS infection? Factors governing the rate?How compared to HbsAg? FIRST AID HOW? Then-occ health. Post exposure prophylaxiswhatdrugs?Clinical Science Viva1. carotid enarterectomy -LA describe how? What dermatomes blocked? Complicationsof block? Adv and disadv of LA. If needs GA , what major issues? How monitor CBFunder GA? WHAT problem post op? Incidence of stroke? It seems carotid stenosiscauses 20% of all the Stroke in any population. I guessed it to perfection2. Respiratory Physiology of neonate? How diff than adults? Chest wall, ribs, capacities,diaphragm, alveoli, etc. How control different? Said about chemorecptor lesssensetive???airway differences? Wanted obligate nose-breathers.Cong Diaghpramatic hernia, what is it? Whats problem? Incidence? Presentation? Principlesof Management of anaesthesia?3. Prolonged operation, post op oozing from canula site- Causes. Wanted DIC,hypothermia, Liver damage, hypocalcemia, sepsis, drugs like nsaid, heparinInvestigations? Briefly each and which part of coagulation pathway tested?Asked about TEG. How the test is done. Draw a normal and one abnormal trace?What blood products can be given to correct coag problems? What drugs, and how theywork?Transfusion triggers for plat, cryo, rbc, factor 8 concentrates?4. IABP- indications? Complications.? Draw a pulse trace? What all information?Wanted a lot of stuff here..for stroke volume, clearly indicate which part of area under the curve( upto diacrotic notch).What is transducer? Problems with them?Long case63 year old female is posted for elective procedure of excision of malignant melanoma andgrafting.She is a hypertensive on treatment with enalapril 10 mg odShe has been a smoker for 30 years and in the last year has been treated for chest infectionswith antibiotics 4 to 5 times.On examination pulse 70 per minute regular. Blood pressure 170/105She has wide spread wheeze and crackles at the bases on auscultation17

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaInvestigationsBiochemistrySodium 135Potassium 4.5Urea 10Creatinine 130No other blood investigations like FBC were providedA set of spirometry results which showed a FEV 1/ FRC of 62% and 67% postbronchodilator therapyAn ECG which showed a few ventricular premature complexes and a LVH by voltage criteriaA chest x-ray which showed a loss of air shadowing in the rt base + right costophreinc angleobliteration. It showed a cardiomegalyQuestionsTell me about your caseTell me about the blood tests. Are the results standard or are they adjusted to the patient’scharacteristics (age sex etc)?Tell me about the ECGTell me about the x rayWhat about the spirometry results? Are these results adjusted to patient characteristics? Is theimprovement after bronchodilator therapy significant?I had mentioned investigations and optimisation in my summary. He then said lets say yourpatient is optimised and now ready for surgery .What is your anaesthetic plan.I mentioned preop visit and premedicationWhy premed? Is it your normal practice? Why particularly in this patient then?I went on to checking machine drawing drugs etc..Etc… He said it is all done talk thro youranaestheticAfter I mentioned arterial line –Why arterial line? And induction and intubation withreinforced endotracheal tube, we moved on to prone positioningHow will you physically do the positioning? Number of people, how will you turn, how willyou position head, protect eyes and nervesPostoperatively the patient develops wheezing and hypoxia in PACU. How will youmanage?Would you send this patient to HDU / ITU?Bell….Short casesYou have done a dural puncture with a 16 gauge needle in obstetrics. How will you proceed?I mentioned our hospital protocol of subarachnoid catheter. What drug will you give? Howlong will it act for? What will you tell the midwives?Is there anything else you can do? Try another space. What are the advantages anddisadvantages of catheter and trying another space?What will you do during follow up?If she has head ache how will you diagnose a post dural puncture headache from othercauses?How will you treat- conservative and then blood patchHow will you do a blood patch?What filter will you use to inject the blood? I said I have seen 2 of my consultants performingblood patch and we did not use a filter.18

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca2. 54 year old weighing 107 kilogrammes , hypertensive is coming in for a knee arthroscopyECG given showed t wave inversion in lead1 , aVL and V3, V4, V5, V6. There were Qwaves in Lead 2 and aVFThe questions which followed were a bit vagueTell me about ECGWhat do your findings indicate? I said IHD.Would you do any further investigations? What else you can ask? I said exercise tolerance inhistory.Would you do this as a day case? I said you mentioned only the weight I need to find out theBMI. If obese I would not do this as day case because of the co morbidities.3. 8 year old boy RTA with fracture tibia and fibula. Found in a pool of mud. Unconscious.In A & E. Orthopaedicians want to fix the fracture. How will you proceed?I said the ATLS approach. It has all been done by the A&E staff.I said if airway is not secured I need to make sure the child is safe from that point. He saidGCS is 6. I intubated the child with manual in line stabilisationWhat will you do next? Breathing and Circulation…It has all been done.Anything else apart from GCS. I mentioned look for signs of significant head injury- skullfractures, bleeding from nose, ears and papillary signs. This child has unequal pupils..Whatdo unequal pupils signify?Unconscious, So I will do CT head.While taking back to ITU blood pressure increases and pulse rate drops.. What will you do?What is this sign called?I said sign of worsening increased ICP? What measure will you take?After mentioning everything I said neurosurgical opinion.Basic SciencesAnatomy.Tell me about the phrenic nerve. I started with nerve roots an then the course till thediaphragm. Which sided phrenic nerve is longer and why. Where does it lie in the thoracicinlet?Tell me about the causes for phrenic nerve palsy and paralysis. Which anaesthetic proceduresin particular.How will the patient present clinically. How will you diagnose. What will you see in dynamicfluoroscopy?How will you treat this condition? I said symptomatic and phrenic nerve pacingPhysiology.Renal replacement therapyWhat are the indications for renal replacement therapy?How will you do these in the ITU?Talk through the principles of CVVHF and CVVHDFDraw a diagram and show me from the patient end to machine endWhat factors will act in the micro fibres--- molecular size and negative chargesWhat are the complications?PharmacologyYou have given a 32 year old patient 8 mgs of vecuronium during induction. Its 1 hour sincethen and the operation is done. But there are no twitches on TOF. How will you proceed?19

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaI said I will look for causes—technical factors ----fault in neuromuscular monitor. Whatfaults can occur- electrode not applied properly- what nerves will you use to test, where willyou place electrodesBattery- how will you know if the battery is lowPatient factors- liver failure, renal failureHypothermiaElectrolyte abnormalities—she asked me list all of them which I didDrugs- What drugsHow does Vecuronium get metabolised and excreted?What else can you test apart from TOF in these situations? Mentioned Post tetanic count—Explain? . How many twitches will signify reversal?In TOF what figure you look for to extubate?How are the various muscle group susceptible to muscle relaxants- vocal cords, smallmuscles of the hand and diaphragmatic. What is the significance during reversal?PhysicsHumidificationWhy do we humidify inspired gases?How will you humidify inspired gases? Advantages, disadvantages and risks of eachWhat is relative humidity and absolute humidity?What is the humidity in upper airway?How does HME work? What is its efficiency?Hazards of humidifying inspired gasesI had mentioned about venturi in nebulisation technique. Tell me how that works. Draw adiagram to explainBell…From the Wednesday-Long case- PPH (management of), how would you anaesthetise the patient for laparotomy(which induction agent, RSI etc), patient then moved to ICU post-op: shown CXR of ARDS(what are the causes of ALI/ARDS, what ventilation strategies do you know..?)Clinical short cases- 1) AF 2) COPD 3) NeedlestickClinical sciences: Anatomy was femoral nerve (3 in 1, lumbar plexus), Diabetes and Insulin(did I know about inhaled insulin? Turned out neither had the examiner!, pathophysiologyand management of DKA), Diathermy and the complications of it.FINAL FRCA EXAM QUESTIONS (8 th Dec 2008)Long case:Euthyroid big goitre for emergency laparotomy. XRC with retrosternal extension. ECG withAF, on antithyroid drugs, digoxin & aspirin, BP 150/90, septic on inv• Summarise the case• Go through the investigations• More about Hb, hematocrit• What more investigations you want• What would to look for in fibreoptic nasoendoscopy• What would the CT neck and thorax tell you• What does the ECG suggest20

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca• What are the causes of AF• How does Digoxin work• Where, why and how will you optimise• Where will you put central line? (I said femoral…what are the disadvantages)• Other monitoring• What are the adv and disadvantages of oesophageal Doppler• Will you put epidural in this one?• How will you anaesthetise• Tell me how will you do awake fibreoptic intubation (wanted topic anesthesia indetail)• Develops tachycardia postop…differential diagnosis?The long case was pretty straight forward. I just thought the examiner was dragging me to theanswers he wanted to tick on his paper. Good for me, but it distracted me initially. When Iwas describing something in a systematic way or classifying (e.g causes of AF) he would stopme in the middle and ask direct question regarding a particular DD. I got scared initially andthought that I am not answering fluently. I think it was not true. He just wanted to get to thebottom of the list ASAP. I then decided to answer ‘his’ way! Trying to guess what’s on hismind! It worked!!Short Cases:Aortic stenosis for elective hip replacement• What are causes of aortic stenosis• 3 classical symptoms of AS (I said angina, syncope and dint remember the 3 rd one(breathlessness, I think)! So I said palpitations!• He went through pathophysiology of each• Desperately wanted the equation: Coronary perfusion pressure = Mean aortic pr –LVEDP!! I realised a bit late!• More investigations• I said 2D Echo: He asked how will it help. I said to know the severity of AS. When Iwent to describe the grades and the numbers, he stopped me and said ‘it’s ok!’ Heseemed very happy with the answer.• How would knowing the severity help you. He wanted mild, moderate severe and thedecision (I said I will discuss the necessity of the op. wheather he needs to have it atall. Since it is an elective op, mild- go ahead, severe- repair/ replace the valve first,Moderate- weigh the risk benefit!) He seemed satisfied.15 yr old, full stomach with penetrating eye injury• What are the issues• What is paediatric age group• How will you go about this case• What precautions would you take (wanted antacids, antiemetics, anticholinergics?,minimise pressor response)• I said Rocuronium 1 mg/kg. He asked me if I personally think it works as good as thesux. Since I had said Roc, I stood by my decision and said ‘yes’!! He was reluctant toaccept and wanted a ‘no’! But I said it is an evidence based decision! He again askedme ‘my personal opinion’!! I again said, I think it works just as good!21

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaPoorly working epidural following AP resection on the ward• How will you go about it (I said, going thro’ notes, anaesthetic charts, examination ofthe patient, assessment of block, check the epidural pump, catheter etc)• What else? (didn’t know what to say…but eventually found out he specificallywanted me to say that I will ask for the nature, site and duration of the pain)• When I said that, he said patient suffers from chronic backache!• He also specifically wanted me to say that I will find out if the insertion of theepidural catheter was difficult and wheather it gave analgesia in the recovery!I felt a bit inadequate disorganised after answering this viva even though I knew it all. Theexaminer asked me again the same things in detail, I thought I had already answered!Basic Sciences• Tell me about cholinestarases (I had 10 seconds of ‘black out’ period!) Then I tried towork out….anticholinesterases, anticholinergics….oh! I said, cholinesterases areENZYMES!• She smiled and agreed! She asked me if I know any types. I said Acetyl andPseudocholinesterase (Drew a diagram of NM junction to show Achesterase inpresent in the synaptic clefts! Didn’t want blank gaps in my viva. I thought drawingsomething would help! May be she ll ask me something related to NMJ!!...Shedidn’t!)• Other names for pseudo…I said Atypical / Plasma / Butyryl• She was particularly happy with ‘butyryl’ and asked me if I think its just one enzymeor group of enzymes…I said group (of course)!!• Do you know subtypes? ………No!!• Tell me the drugs metabolised by Pseudo. Are they all metabolised by the sameenzyme?• Tell me the causes of low serum cholinestarases• What is Dibucaine number• What is normal• What does the number 80 mean?• Concentration of Dibucaine used in this test?• What is fluride number?• Various abnormal genotypes possible? (I wrote down homogenous and heterogenousnormal, atypical, silent and fluride…but also wanted the combinations amongstthemselves which I forgot to mention! Such as hetero fluoride and atypical - Ef:Ea)• Where does Acetylcholine attach on the acetyl cholinesterase enzyme (I drew abeautiful diagram!! She was happy)• Types of anticholinesterases (3 types- competitive, non-competitive, irreversible)• Example of each• Duration of action of Neostigmine• Treatment of OPC poisoning (Wanted protection of health care workers since poisoncan traverse the skin and mucous membranes)• Mechanism of action of Pralidoxime• How do you measure oxygen (bell went off just after I answered!)Clinical sciences22

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca• Indications of central venous canulation• Anatomy of internal jugular vein• Anatomy of subclavian vein (wanted scalene anterior muscle in particular! I drew itbut didn’t label it…so he pointed at it and asked ‘what structure is this!’)• Complications of central venous canulation• 6 yrs old child- calculate maintenance fluid requirements• Why is it important to calculate• What fluid would you give• What are you worried about (Wanted me to say hypoNa)• WhyThe examiners were pleasant except for the short cases examiner! He was really aggressive!But it was a great experience overall. Honestly, I had not thought of many questions and theiranswers before despite them being pretty obvious and I think you have to think and applyyour knowledge when you are actually answering. The questions may appear more or lessfamiliar and basic now, but they appear ‘new’ there! I suppose it is because of the way theyare asked. I would suggest people to keep your mind as stable and open as you can and beassured that if you have done decent reading and hard work for this exam, it will get throughto the examiners12 th December 2008Joy SandersClinical VivaLong Case80yr old frail lady presenting for elective laparoscopic hiatus hernia repairRecent admission 3 months ago with chest pain, not relieved with GTN spray. Fast AF foundECG – treated with digoxin.PMHxDiverticulitisHypertensionDHxACEIPPIDigoxinExamination?reduced air entry left baseRR 16. Temp 36.9, HR 90, BP 160/80IxHb 9, normocyticRaised WCC and CRPAlbumin 22, other LFTs normal. Low Mg2+, Ca2+23

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaU+E normalECG: AF, rate 90. global T wave inversion, LAD, poor R wave progressionCXR: (poor film!) but air space shadowing left lower/middle zone ?hiatus herniaQuestionsBloods – likely causes or raised CRP/WCC, Hb (not much discussion about this), lowalbumin – causes, effectsDiscuss ECG - ?causes of T wave changes ?ischaemia ?digoxin effectsCauses of AFDifferentiating cardiac from oesophageal chest painCXR - ?large hiatus hernia seen ?collapse/consolidationOptimisation and further investigationsPremedicationAnaesthetic management plan and post op plansEffects of laparoscopic surgery – CVS/Resp/Renal/GI etcPatient drops sats and hypotensive in recovery – possible causes, management…..management of suspected tension pneumothoraxShort Cases1. Obesity – gave height and weight of female patient (morbidly obese) discussion onBMI, systemic effects of obesity and complications2. Bleeding tonsil in 5 yr old – calculation of blood loss, vital signs, problems,management of induction, drug doses, tube sizes etc3. Shown ECG of 4:1 atrial flutter (rate controlled) – what drugs may patient be on?This patient has end stage renal failure awaiting renal transplant - ?worrying, ?managmentClinical Sciences VivaAnatomyClinical presentation of foreign body aspiration. If patient stable, how would youanaesthetise? Lead onto anatomy of trachea – length, position, diameter, number of rings,relations, tracheobronchial treePhysicsLasers – acronym, types and clinical uses, mechanism of action, characteristics of light,protection of patient and staff in theatre and potential hazards, laser tubes, low FiO2 and why.Alternatives to intubation. Risks of jet ventilation.PhysiologySmoking – physiological effects – CVS/Resp/CNS/carbon monoxide/immune function(which components affected). Time frames for cessation. Implications for anaesthesiaPharmacology24

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaRaised ICP – Monro Kelly doctrine/ graphs/ how to control raised ICP in theatre. Effects onICP (+mechanisms) of inhalational agents (which is worst?), nitrous oxide, induction agents(thiopentone, ketamine), muscle relaxants, mannitolClinicalDeatails provided for the candidateLong Case:75 yr oldPMH: Diabetes, Hiatus hernia, HypertensionMedications: Diuretics, ACE inhibitors, omeprazoleBooked for a thoracotomy for isolated neoplasm in Lung few weeks laterAdmitted in A& E yesterday with severe pain in neckExamination:BP, Pulse normalRhonchi in both lung fieldsEjection systolic murmur over left sternal edgeRespiratory rate : 25/minuteInvestigations:ECG: Left axis DeviationRight Bundle branch blockQ waves ?ABG: on 21% oxygenPO2 – 9, PCO2 - 4, Ph 7.45, HCO3- 24PFTsPEFR – reducedFEV/FVC – 70%EchocardiographyEjection fraction 70%Thickened aortic valve, gradient across valve 38 mmHGOther findings normalX-ray C SpineInadequate film ( C7/T1 not visible)C1/C2 subluxationQuestions on:25

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaAll investigations, how do you diagnose Left axis deviation, grading of Aortic stenosis,grading of FEV/FVCWhat other investigations will you do?How to assess severity of aortic stenosisCauses of neck pain in this patientHow can lung tumours presentTechnique of GA – awake fibreoptic intubationHow do you anaesthetise airway for awake fibreoptic intubationWhat monitoring ? – Spinal cord monitoringWhat methods of pain reliefCriteria for extubation – Phrenic nerve injury ?Where manage post op?Short Cases1. Jehovah witnessQuestions asked:Why as an anaesthetist you would worryQuestions on preop optimisation, consent issues, Gillick competenceClasses & Mechanisms of action of anti platelet drugs2. Preeclampsia : 36 week primigravida BP 160/90, Pulse, 124/minQuestions asked:What problems the above patient posesHow do you diagnose preeclampsia?How is different from pregnancy induced hypertensionHow can you control her blood pressure better?What investigations will you do?Mechanism of action of magnesium and dosesWhat monitoring will you do and how would you anaesthetise her?Risks of GA in this patient3. Patient had tracheostomy 5 days ago, you are called to ward to see him, and he isbleeding profusely from the tracheostomy siteQuestions asked:How will you proceed?When will you take him to theatre?What anaesthetic technique?Final FRCA Viva questions:ClinicalDeatails provided for the candidateLong Case:75 yr old26

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaPMH: Diabetes, Hiatus hernia, HypertensionMedications: Diuretics, ACE inhibitors, omeprazoleBooked for a thoracotomy for isolated neoplasm in Lung few weeks laterAdmitted in A& E yesterday with severe pain in neckExamination:BP, Pulse normalRhonchi in both lung fieldsEjection systolic murmur over left sternal edgeRespiratory rate : 25/minuteInvestigations:ECG: Left axis DeviationRight Bundle branch blockQ waves ?ABG: on 21% oxygenPO2 – 9, PCO2 - 4, Ph 7.45, HCO3- 24PFTsPEFR – reducedFEV/FVC – 70%EchocardiographyEjection fraction 70%Thickened aortic valve, gradient across valve 38 mmHGOther findings normalX-ray C SpineInadequate film ( C7/T1 not visible)C1/C2 subluxationQuestions on:All investigations, how do you diagnose Left axis deviation, grading of Aortic stenosis,grading of FEV/FVCWhat other investigations will you do?How to assess severity of aortic stenosisCauses of neck pain in this patientHow can lung tumours presentTechnique of GA – awake fibreoptic intubationHow do you anaesthetise airway for awake fibreoptic intubationWhat monitoring ? – Spinal cord monitoringWhat methods of pain relief27

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaCriteria for extubation – Phrenic nerve injury ?Where manage post op?Short Cases1. Jehovah witnessQuestions asked:Why as an anaesthetist you would worryQuestions on preop optimisation, consent issues, Gillick competenceClasses & Mechanisms of action of anti platelet drugs2. Preeclampsia : 36 week primigravida BP 160/90, Pulse, 124/minQuestions asked:What problems the above patient posesHow do you diagnose preeclampsia?How is different from pregnancy induced hypertensionHow can you control her blood pressure better?What investigations will you do?Mechanism of action of magnesium and dosesWhat monitoring will you do and how would you anaesthetise her?Risks of GA in this patient3. Patient had tracheostomy 5 days ago, you are called to ward to see him, and he isbleeding profusely from the tracheostomy siteQuestions asked:How will you proceed?When will you take him to theatre?What anaesthetic technique?Clinical ScienceAnatomy: Nerve supply of larynxMuscles of larynxNerve injuries and effects on vocal cordsCauses of stridor post thyroidectomyPhysiology: Non invasive ventilationCPAP & BiPAP – physiology behind their useComplications of non invasive ventilationIndications & contraindications for non invasive ventilationAlveolar gas equation, how does CO2 effect oxygenationPharmacology: Pros & Cons of beta blockersMechanisms of actionClassification of beta blockersIndications, contraindications & complications28

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaPhysics: What do you understand by plenum principle?Applications of plenum principle in anaesthesiaDiagram of vaporiserHow does Bair Hugger work?Theatre ventilation systemsIn a patient with latex allergy how do you decide how many hours youshould leave theatre closed before using to make sure it is free from latex? (Something todo with time constants!)Long case67F, rheumatic fever as child, cardiac surgery 24 years ago; MIs, CVA, ET 100m with frame.Fallen over, #NOF – needs Austin Moore. Ht 5 foot, Wt 96kgDrugs – spironolactone, lisinopril, bumetanide, DF118, warfarinECG – LBBBCXR – two metallic valves, small effusions, big heartU+E – Urea 16, Creat 140FBC – normocytic, normochromic anaemia, WCC 3, INR 3.6Discussions – list problems. Talk through all investigations and possible cause. How to‘optimise’. What anaesthetic.Short cases1. Causes of weakness in long stay ICU patients!2. 16F with Down’s syndrome for dental work. Issues with Down’s. How to anaesthetise.3. 23F for urgent C-section. Categories of section. History / exam / what anaesthetic for cat 2section.Science…Anatomy“Draw the efferent cardiac sympathetics” – [I didn’t do anything for a few seconds as Ithought she hadn’t asked me the whole question]. Eventually got onto the denervated heartafter I’d repeatedly drawn a medulla and the vagus nerve – problems with the denervatedheart.PhysiologySickle cell anaemia. Talked about it. Problems. Molecular stuff; HbA/HbS. Tourniquets.Exchange transfusions…Pharmacology“Tell me about post-hepatic neuralgia” – [Felt there wasn’t much point carrying on at thisstage]. Symptoms, treatment. Got onto action of amitriptyline, carbamazepine. “I’ve thinkwe’ve had enough of this topic, lets move onto to something else shall we?” – [was that a hintI was that bad?]Clinical measurementCardiac output monitoring. Some time talking about Lidco (couldn’t for the life of meremember what role lithium had in this pulse contour analysis), TODs (waveform and various29

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendoncabits it measures and calculates), Picco – luckily the bell went as the little knowledge I’ve everhad about Picco had vanished.Long Case58 yr old man presents with a 1 day history of lower abdo pain and vomiting. Previous heavyalcohol intake and ? still consuming alcohol.Also smoker 20/day.Surgeons would like to take him for an emergency laparotomy as soon as possible.O/E – Painful lump in the right groin. HR – 150bpm BP – 132/80 ApyrexialMeds – NilAllergies – NilBloods:Hb 14.7Plt 330WCC 12.7Na 128K 5.1Ur 10Cr 84LFT’s - NormalClotting – NormalCXR – AP erect. Hyperexpanded. Normal heart size. Shadowing left upper zone ? Oldscarring from TB ? Pleural plaque. Bullae both upper lobes.ECG – Fast AF ~150bpm. Inverted T waves inferior leads and Q waves anterior leads.Questions:Summarise the caseWhat could be the causes of the lump in the groin?Comment on the blood results. What are causes of hyponatraemia?What about the LFT’s and clotting being normal? What do you usually see in patients withexcess alcohol intake?Comment on the CXR. What could be causes for shadowing in the left upper zone?Comment on the ECG.What are your pre-op considerations? How would you fluid resuscitate? What are your endpoints?What other investigations would you like?How would you manage the AF?How are you going to anaesthetise him?Pro’s and cons of epidural.Intra-op Sudden low BP to 60 systolic. What are the differentials?If it was a tension pneumothorax how would you manage it?Post op oliguria – causes and management.30

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaClinical Short Cases1. 19 year old afro Caribbean male for emergency appendicectomy. Sickledex test positive.What does this result mean? What’s the difference between sickle trait and disease?What levels of PO2 they sickle. Why don’t the RBC’s sickle in the venous circulation if PO2there is 5.3Kpa?What about Thalassaemia? Difference between alpha and beta, homozygous andheterozygous. Complications seen in patients with Thalassaemia.2. 19 year old male asked to review in A&E for after RTA. GCS 13 and linear fracture onSkull x-ray. Compound fracture to right lower leg which surgeons would like to take totheatre.Indications for CT head? Image anything else also? Clearing the C-Spine?Transferring patient to CT – reasons to intubate first (how would you do this?), monitoring?Management of head injury.Surgeons want to take him to theatre for his leg how would you manage this (GCS still 13 butCT brain is normal).3. 25 year old lady asked to review about having awareness post GA for c-section.How would you manage this?What would you look for on the anaesthetic chart? (Monitoring, drugs, timing, blood lossetc..) Reasons for awareness in obstetrics? Incidence?Is awareness always a problem?Other high risk areas for awareness.Preventing awareness (use of BIS).Basic sciences1. Anatomy – Blood supply to the brain. Draw the Circle of Willis. What part does eachartery supply? Commonest sites for Aneurysms? Causes of aneurysms? Typicalpresenting symptoms of SAH. Management of cerebral vasospasm.2. Glucocorticoids - Where are they made? How released much/day? Effects of Cortisolin the body. HPA axis. Cortisol and stress response to surgery. Typical signs of apatient on long term steroids. Replacement therapy of patients on steroids coming forsurgery. How do you perform a short synacthen test?3. Magnesium – Where is it found in the body? Effects? Levels? Uses (wanted lots ofuses)? Effects of toxicity.4. Defibrillator – Difference between synchronized and unsynchronized DC shock.Difference between mono and biphasic defibrillators. How does a defibrillator work?Draw a diagram.LONG CASE28 yr old primi with prolonged labour and 8 hrs of synto infusion – normal vaginal delivery.7 hours after this, obstetricians want to take to theatre for laparatomy.O/EPale, anxious lady31

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaHR- 145/minBP unrecordableCarotid pulses palpableSao2 not recordableOne unit of blood transfusion ongoingHb- 2.8Coag profile: DIC pictureU&E s : pre renal pictureQuestions:1. Summarise2. Comment on blood investigations3. Plan and immediate action4. How much of blood to organise5. Anaesthetic technique and management6. Post op care7. Causes of obst hemorrhage8. Details of blood products and what each contains9. Medical management of obst bleeding10. DIC pathogenesisSHORT CASES1. AFECG shown and asked to describe the findingsManagement of acute AF – algorithmCauses of AFAnaesthetic implications- Fast AF intra op and management2. COPD pathogenesisEmphysema and chronic bronchitis – differenceCalled to assess a patient in the ward with resp failure – causes and management3. IV drug addict and known HIV + for Hickman line insertionAnaesthetic implicationsNurse sustains needle stick injury – how would you manageBASIC SCIENCE1. Carotid endarterectomy: GA vs LA ; anatomy of cervical plexus; how to performblocks and complications2. Neonatal physiology and management of cong diaphragmatic hernia3. Tests of clotting : oozing from wound edges after a surgery involving 5 l of blood loss( I later realised that all questions in this section from royal college book)4. IABP – indications; complications; damping and resonanaceThursday 11th Dec.32

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaLong Case:74yr old West African Woman presenting for Cervical Laminectomy. Cervical Spine changesbelow C3. PMH of Hypertension and Diabetes.Drugs: Insulin, Atenolol, Ca ch blocker, ACE, Prazocin, Aspirin, Dypridamole.Examination:BP 150/80Systolic murmur radiating to carotidsMotor changes: Legs 0/5, Arms 3/5.Investigations:Hb 11 - no indices given, plts and WCC normalNA and K normal, Cr about 190, Ur about 20ECG 1st degree HB. no other abnormailtyCXR Enlarged heartQuestions:SummaryWhat do you think about her BP control - I explained multipharmacy implied resistanthypertensionConsequences of HypertensionInterpretation of murmur - AS. Symptoms and signs of AS.How would I further pre-assess this patientAssessment of diabetes - systems approachRun through each investigation in turn:Classification of Anaemias - MCV/MCHInvestigation of Sickle Cell disease/traitCauses of Renal FailureECG interpretation - causes of Heart block - related to Beat blocker/Ca ch blocker?Physiology of sinus arrhythmiaWould I be happy to proceed with this ECG - yesHow further get this patient ready for theatre - he was looking for: get in night before, slidingscale, 1st on listHow would I anaesthetise / intra-op with temp, cell saver, ?neuro-phys monitoringEffect of CVS disturbance / arrhythmia on ASPost op Care - HDUPost op analgesia - no PCA given arm weaknessShort Cases:1. Pacemakers: Indications, classification, what is the commonest type (DDD). Why nolonger VVI. Benefit of DDD (AV pacing better than V pacing alone - more physiological)pre-assessment, intra-op management, any anaesthetic drugs affect pacemaker function (sux,volatiles). Why is the pacemaker positioned where it is.2. Pt had Anaesthetic 25 yrs ago and now presents for hydrocele repair wanting epidural -discuss. Fairly basic. I said spinal, what level, what risks for spinal. ?could GA be better nowthan 25 years ago. What risks do I warn people about GA. So, was I going to do this as a GAor spinal. I said yes. Was I going to let the patient make up his own mind - I said yes. Couldhe have spinal as daycase - I said yes.33

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca3. Woman found at home drowsy after suspected overdose - 80g paracetamol.Management - ABC / AVPUReasons she could be drowsy - other substancesOther investigations incl Head CTHow would I intubate. Management of head injured patient.ABG findings. Reasons for Met Acidosis - related to Anion gap.Treatment of paracetamol overdose - would I treat before 4 hour level if good history forparacetamol overdose - I said yesWhy N- acetyl cysteine. Pathophysiology of paracetamol poisoningBasic Science:1. ANATOMY Anatomy of the nose - I may aswell have got up and walked out for theduration of this question. Apparently there is no nasal artery!Did eventually get onto the functions of the nose, reasons for nasal airway / intubation, howto anaesthetise, LA toxicity2. PHYSIOLOGY. Changes to the foetal circulation at birth.Wasn't interested in me just explaining the anatomy of the foetal circulationDA changes, PVR changes, DV changes, changes due to clamping of Umbilical cord onSVR,What is Tetralogy of fallot?How would I anaesthetise a 18 month old with tetralogy of fallot (SVR and PVR changes).Factors affecting PVR.3. PHARMACOLOGY. Suxamethonium - draw it, what is it, where does it work on NMJ.Does it work pre-synaptically - I said no which is why you don't get fade on TOF....theyseemed to like that.Side effects of sux. Containdications.Who gets muscle pains. How to reduce incidence of muscle pains - I said benzo, precurarisation.....theywanted another one but I didn't know.Sux apnoea - congenital and acquired. no questioning on Dibucaine but others in the samegroup had in depth questioning on that.Options to anaesthetise 11 yr old for Appx with sux apnoea - AFOI / Mod RSI with Roc.Problem with roc - long block - quick few q's on structure of sugammadex - does it work foratracurium!4. Hyperbaric oxygenIndications for use (I said infection - clostr. perfringens and cerebral abscess, COHbpoisoning, Deompression sickness, Low O2 carrying capacity eg. jehovas witness who hasbled)Oxygen content equationHow does it affect Carboxyhaemoglobin....why does it help. Indications for use in Carbonmonoxide poisoning.Where is nearest Hyperbaric chamber to you?Problems with Hyperbaric Oxygen - oxygen toxicity (pulmonary, CNS - Bert effect)Problems with Anaesthetising someone in a hyperbaric chamber. What is it like in ahyperbaric chamber?34

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaI passed despite knowing absolutely nothing about the anatomy of the nose......guess it goesto show they don't fail you for not knowing something like that if you know the importantstuff!Thanks for the help on the courses. Invaluable.Regards,Final FRCA Viva December 2008Imran MohammadLong casePost-partum haemorrhage28yr old primip presents for emergency laparotomy 7 hours after emergency caesareansection for failure to progress. She had been on a syntocinon infusion for 7 hours, 4.38kgfoetus delivered, large post-partum haemorrhage. Uterine clots evacuated since delivery.At presentation – pale, very anxiousHR 140bpm, unrecordable BP, pulse oximetry not picking up trace. Carotid pulse palpable.Bloods before LSCS (normal ranges given)Hb 13Platelets 235Other bloods unremarkableBloods after LSCSHb 2.8Platelets 84PT 19APTR 1.8Fibrinogen 1.7K 5No other investigations produced at this point although CXR showing bilateral infiltratesconsistent with ARDS provided during the vivaQuestions on:How would you resuscitate this patient?Definitions of massive post-partum haemorrhage.Classification of hypovolaemic shockPeri-operative management.Would you place an arterial line if you could not feel a radial artery pulse?Drugs affecting uterine tone.Post-operative management on ITUShown CXR – expected to comment on adequacy, positions of lines, tube, patchy airspaceopacificationDiscussion about ARDS – definition, clinical presentation, causes, ITU management.35

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaShort casesAtrial fibrillationAsked to interpret ECG showing atrial fibrillation with fast ventricular response.Asked about signs of compromise, peri-operative management, would you anaesthetise apatient with fast AF, what would you do if it occurred intra-operatively in association withprofound hypotension. How would you anaesthetise for an elective cardioversion.COPDReferred a COPD patient on the medical ward by the medical registrar for respiratory failure.Describe how you would assess this patient.Indications for intubation and ventilation.Medical management for respiratory failure.Interim measures before intensive care.Indications and contra-indications of non-invasive ventilationHIV/AIDSHow would you anaesthetise a patient with known AIDS for Hickman line placement.Discussed assessment, viral load, CD4 count and implications, possible treatments they maybe taking.Indications for Hickman line placement.Universal precautions.Needlestick injury protocol. Risks of transmission of HIV.Screening for other blood-borne viruses.What is post-exposure prophylaxis?Science VivaFemoral nerveDescribe anatomy – wanted detail of course from lumbar plexus, anterior/posterior divisionsto terminal branches, motor and sensory supplyFemoral nerve block – technique, indications, contra-indications, local anaesthetic choice anddose.3-in-1 block – nerves blocked (or not blocked!)Management of local anaesthetic toxicity.Head injurySecondary brain insult – causes.Cerebral blood flow graph – CO2, O2, MAP.ICP – definition, normal range, monitors, causes of raised ICP, management of raised ICP.Management of head injury on the intensive care unit.NIR spectroscopy – how does it workTranscranial Doppler – basic information on how it works wanted, which artery used?Diabetic ketoacidosisPathophysiologyKetone body synthesis, acetone, acetoacetic acid, beta-hydroxybutyric acidUtilisation of ketone bodies by brain, heart and tissuesClinical presentations and management of DKASynthesis and actions of insulin, particularly with respect to ion shifts36

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaWhat happens if hypernatraemia corrected rapidly - interested in fluid shifts, cerebraloedema.Surgical diathermyWhat is it, how does it work?Interested in current density, frequency, current, risk of electrocutionBipolar/unipolar comparisonEffect on pacemakers/ICDsDiathermy plates, what happens if they are loosely appliedIsolating capacitorThe examiners were friendly and helpful. They did not seem to mind too much if the precisedetail of basic science was not there, I felt they were much more interested in clinicalcompetence. I found it difficult to distinguish between my basic and clinical science viva.Whilst the preparation for the Final - in particular for the SAQs - is more stressful, I have nodoubt that the actual exam is easier than the Primary.Long case:A 28 year old lady who delivered 7 hours ago needs emergency laparotomy. Her current Hbis 28. BP 60/40. Peripheral pulse not felt. Carotid pulse felt. She is currently being transfused.Her investigation results:HbBefore laparotomy2813Before deliveryWCC1414Fibrinogenlow normalhigh normalPlatelets80150PT18normalAPTTNaKUreaCreatinineD-dimer601405high normalhigh normalelevatednormalnormalnormalnormalnormalQuestions:1. Summarise the case37

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendonca2. What are the abnormalities in the investigations3. Why Urea and creatinine high normal4. What is the abnormality in the coagulation profile5. What would you do6. Whom will you inform7. What would you ask in the blood bank8. Would you transfuse platelets (with the platelet of 80)9. What do you need in the theatre10. How will you induce11. What induction agents12. What muscle relaxants13. Why pancuroneum14. What are the medical management15. What are the surgical options16. Whats the finding in xray (bilateral diffuse infiltration )17. What are the causes18. How will you manage in the ITU (cardiac output monitoring)19. Other routine managementShort cases:1. ECG: irregular but I was able to see p waves.Questions about AFAF: causes and managementWarfarin- when will you stopDC cardiversion – when will u do2. COPDCauses for acute exacerbation of COPDFindings in emphysema and chronic bronchitisMedical managementITU management3. HIV-drug addictWhat are the problems?What are the precautions?How will you avoid needle stick injury?What will you do if it happens?What drugs for prophylaxisFollow-upBasic science1. Femoral NerveDetailed anatomyMotor and sensory supplyHow will u do the block?3 in 1 block38

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaLateral cutaneous nerve of thigh anatomy and blockLA toxicity- managementIntralipid doses2. Head injury with elevated ICPITU managementWhat parameters u will aim for?How CBF controlled - graphsWhat is jugular venous oxygen saturation?What are the implications?Pharmacological managementOther monitors?3. DiathermyDraw diathermy circuitAll in detail about monopolar and bipolar diathermyWhat are the problems?How will you preventPacemaker – how it interferesHow will u manage a patient with pacemaker?What is the problem with defib and pacemaker4. Insulin and DKAWhat is Insulin?Half-lifeWhat is DKAhow ketone bodies produced?What are the problems?How will you correct hyperglycaemia?Hypokalaemia managementAcidosis managementLong case:28 yo primip with PPH requiring an emergency laparotomy.7 hours post Em LSCS for failure to progress (despite syntocinin infusion).She had been back for an ERCP(evacuated large clots)and was on a syntocinin infusion.o/e: Pale, anxiousNIBP unrecordable, HR 140, 02 sats not picking upCarotid pulse palpableBloods: Hb 2,8g/dl, Plts 95, APTT 78, TT extended, Fibrinogen 1.8What would you do?Massive Haemorrhage protocol (cons obs, cons ananethist, haematology, porters, oda)100% 02 ABC2 large bore IV cannulaeWhat fluid would you give her? Blood - if her blood not avail immediately? would give 0negative bloodwhen would you be happy to take her to theatre? what parameters? (BP recordable, radial39

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendoncapulse)Other monitoring - urinary catheter, arterial line (not CVP now as coagulopathic)How would you anaesthetise?Preop - Ranitidine IV, Blood in theatre level I warmer,etcNaCitrate pre 02 RSI with criciodWhat drugs? titrated dose of thiopentone (small) and SuxWhay thiopentone? because that is what I am used to - they were happyYou have blood pouring in and suddenly you get another drop in BP - what would you doCheck screen - HR rhythm ....what would you give ? phenylepherine How much ? 50-100mcg Why? alpha agonist usein obstetrics (better than ephedrine mixed alpha beta) they were happyWhat drugs can you give to contract the uterus?synntocinin - how much - 5 units then an infusion of 40units/4 hrssyntometrine - What is that? syntocinin 5units and ergometrine 500mcg what are the SEs?HTN 100% N+Vcarbaprost PGF2alpha SE's n+v and what else ? oh bronchospasmok patient survived and in ituShown an CXR (6 hours post admission)- what are the major abnormalities? Rendobronchial intubation, bilateral fluffy shadowing .. GoodDDx: ARDS (yes too early)pulmonary odema (from fluid overload)TRALI .... good When is onset of TRALI? within 6 hours of blood transfusion. GoodShort Cases:1. Elderly man for cystoscopy for haematuriaECG - AF with Q waves in inferior leads - what would be cause of them - old infarctWhat are causes of AF - IHD, AMI, Cardiomyopathy, HTN, Thyrotoxicosis, AlcoholHow about if a patient is really unwell ... oh sepsisWhat drugs would he be on: bblocker (post AMI and rate controll), digoxinWhat are the problems with AF? Atrial thrombus - emboli to cause CVA, distalischaemiaSo what other drugs may he be on? aspirin if low risk, warfarin if high riskWould you proceed with case if these were new findings on ECG? No, an elective caseWhat further Ix ? ECHO what would you be looking for ? EF what else? atrialthrombus what else? what is a common cause of AF that you failed to mention earlier?mitral valve disease - i would look at size of valves normal 4-6cm2 and gradient, dopplerflow for MRIf it was old findings and he was on warfarin with an INR 2 would you stop hiscoagulation preop?I said I would liase with the surgeon - if they were happy for a quick cystoscopy I washappy to proceed with stopping - they said good better not to go messinfg around withanticoagulation.2. Asked to review a patient on the ward with COPD with acute exacerbationWhat could be the cause of acute exacerbation:I said pneumonia, pleural effusion (infection or other cause), certain drugs (histaminereleasing .. etcThey said what else ,...what do emphysematous patients get .. bulla .. ahh a40

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendoncapneumothorax ,, goodWhat is the difference between Chronic bronchitis and emphysema ?How do you assess a patient with COPD exacerbation on the ward?How do you treat ?? I forgot to say oxygen!!! but when asked said I would limit theamount intially with a venturi mask and increment upwards as BTS guidelines onemergency oxygen therapy. they seemed happy.3. You are asked to anaesthetise a young man IVDU and HIV for Hickman line insertion.What are the problems:Problems to do with HIV and problems to do with IVDUMainly concentrated on problems to do with IVDU (some candidates it was the otherway round)Talked about difficulty with IV access - may need to do a gas induction, problems withcompliance, risk of infection for staff - What can be done to minimise risk of infection?Last on list, disposable equipement, notify staff, universal precautions, double scrub,mask and eyewear.You sustain a needlestick injury - what would you do according to hospital protocol .....BASIC SCIENCES:1. Have you ever seen a carotid endarectomy under LA ?What are the advantages and disadvantages?How do you perform a block - superficial and deep cervical plexus block explianed.Said there is a recent editorial in the BJA which states there is no difference in outcomebetween the two and that as the deep cervical block is associted with lots morecomplications - superficial block better. Also mentioned the GALA study which is goingto show no difference in outcome between CAE under LA or GA.2. Asked to tell the difference between adult and neonatal respiratory system.Broke it down into anatomical differences and physiological differences.Fairly basic question.Asked about FRC is it smaller ? well it is 30mls/kg so yes And why is that important -because it is Oxygen reservoir - therefore there is less O2 stores and as babies have ahigher resting 02 consumption they desaturate more quickly. Good3. I think it may be in the college book.Something like - you are in OT at the end of a major operation with large blood loss andmassive transfusion and the surgeon tells you the patient is quite oozy. What is possiblecauses:# dilutional: blood transfusion without clotting factors# DIC: complication of massive transfusion or sepsis# I also said ABO incompatibility - they said yes but it was obvious it was not whatthey were afterOther complications of massive blood transfusion ....What tests would you do - send fbc (does that assess clotting function ? it does assessplatelet number), ok what else - INR, APPT (what is normal APTT ?) What do both thosetests assess : extrinsic and intrinsic pathway etcReally wanted very little detail41

University Hospitals Coventry & Warwickshire NHS Trust: Dr C MendoncaWhat other tests ?? TEG - Do you know anything about it ? YEs - starting describing itand they start they didnt want that much detail.Asked what clotting products would give - much much and at what triggers.I said FFP 15ml/kg if INR >1.5, Platelets if < 50, Cryoprecipitate if Fibrinogen < 1.0g/dlThen asked what drugs you could give if still bleeding:Antifibrinolytics: tranexamic acid and aproptinin (but now unlicensed)What elseNOVO 7 - well if your haematologist lets you4. Draw an arterial line traceWhat information does it tell you: SBP, DBP, MAP, contractility, SV (area under graphup to diacrotic notch), SVR,changes depending on where it is in body. Also show arrhythmiasAsked about components of IABP kit - very brief descriptionsTalk about catheter, fluid column, transducer (strain gauge) and wheatstone bridge(didnt want me to draw it)Asked indications for using art line ?Asked complications1. Long case: 60 yrs old lady for fracture neck of femur. Previous history of aortic and mitralvalve replacement 20 yrs ago on warfarin, poor exercise tolerance 25 yards, on diuretics,digoxin and lisinopril (s/o heart failure on examination), ECG : junctional rhythm.They asked about preoptimization. what investigation ?( they told me on Echo ejectionfraction of 25% )She had Hb of 10. Would you transfuse her? Na was 130. Is it normal? what was the cause oflow Na?HDU for preoptimization? Cardiac output monitoring? How would to anaesthetise? I said GAwith femoral nerve block.Short cases1 Down's syndrome2.Critical care polyneuropathy3.Category A LSCS (spinal vs GA)Basic Sciences1. Sympathetic supply of heart starting from brain. Differences between normal anddenervated heart. How would u manage a patient with heart transplant coming for noncardiac surgery.2. sickle cell disease3. post herpetic neuralgia. treatment and meachanism of action of all drugs.4. cardiac output monitoring: LiDCO, Oesophageal dopplerlong case:76 female,acute surgical abdo,for laparotomyon fast AF,BMI 3042

University Hospitals Coventry & Warwickshire NHS Trust: Dr C Mendoncainspiratory stridorhigh wccpmhx: thyroidectomy,hypertensioncxr:thyroid with retrosternal extension,tracheal deviation,SVCsyndromeshort cases:1.failed epiduarl in the ward for a pancolectemy2.severe AS for TKR3.full stomach + penetrating eye injurybasic sciences:fluid repalcement and daily electrolyte req in paed , new NPSA issue,which fluids anddetailsoxygen delivery devices, variable and fixed orifice devicesanatomy of the internal jugular and subclavianveins + air embolismshort cases:1. jehovahs witness2. pre eclampsia3. bleeding trachy site and management thereafterlong case75 y/o man with lung ca awaiting lobectomy. presents with acute neck pain.pmh - htn, hiatus herniadh - candesartan, ranitidine, bdzecg - nadpft - nadc spine - subluxation of c1-2echo - assummarydiagnosis of neck painecho findings - management of asmanagement of neck - immobilisation, theatre, awake fibreoptic intubation, proning,extubation, analgesia, hdu43