2015 FCA Paper 2

Question 1

a) Discuss
a) the pros and cons and
b) possible evidence or controversies regarding outcomes or efficacy of the following analgesic techniques for post-thoracotomy pain relief.
i) Thoracic epidural analgesia (TEA). (13)
ii) Paravertebral block (PVB). (13)
iii) Continuous wound infiltration (CWI). (4)
(The above abbreviations are acceptable in your answer)

Answer 1

In a systematic review by the Procedure Specific Postoperative Pain Management working group (PROSPECT), paravertebral and thoracic epidural continuous infusions of opioid-free local anaestheticwerefoundtobecomparable,butPVAwasassociated with less respiratory complications and hypotension.10 Furthermore, in a Cochrane Review by the authors, PVB was found to be associated with lower rate of major complications including chest infection and acute confusion and minor complications such as low blood pressure, nausea and vomiting, itching and urinary retention when compared to TEA.11 A single bolus of intrathecal opioidbeforeoperationwasalsocomparablewithbothtechniques. However, the duration of analgesia was limited to 24 h.10 Based on the review, PROSPECT recommend that either TEA with local anaesthetics and an opioid or continuous PVA with local anaesthetics combined with parenteral paracetamol and an NSAIDshould beusedasfirst-line analgesia for thoracotomy. Wherethese techniques arenot possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended, which requires the use of supplementary systemic analgesia. The PROSPECT recommendations are summarized in Figure 4. Although VATS is associated with less acute pain than open thoracotomy, it may still be significant if intercostal nerves are compressed by twisting instruments and the need for an incision to extract lobes.Ifthepatienthaspoorrespiratoryreserveortheir disease increases the likelihood of conversion to thoracotomy, TEA is advisable. Otherwise, the combination of PVA with i.v. PCA is a suitable alternative.Whenneuraxial analgesia is not feasible, intercostal nerve block coupled with systemic parenteral analgesia remains an option. The block is simple to perform either percutaneously or under direct vision intraoperatively. However, its limited durationofaction (∼6 h) necessitates repeating the block at multiple levels or starting an infusion. This increases the risk of systemic toxicity from the highly vascular intercostal space. Incomplete analgesia is also aproblemsincethedorsalramisupplyingthebackarenot blocked, which is relevant in posterolateral thoracotomies, and the lateral cutaneous branch may also be missed if the block is performed too anteriorly. Intrapleural analgesia, where local anaesthetics are injected between the layers of the parietal and visceral pleura, is not recommended. Surgery increases the volume of the interpleural space with blood and air which dilutes the spread of local anaesthetics. Systemic absorption of local anaesthetics is also considerable.

Question 2

b) Discuss the factors that impair hypoxic pulmonary vasoconstriction in the non-ventilated lung during one lung ventilation. (20)
[50]

Answer 2

HYPOXIC pulmonary vasoconstriction (HPV) is a reflex contraction of vascular smooth muscle in the pulmonary circulation in response to low regional partial pressure of oxygen (Po2). This vasoconstriction by the pulmonary vasculature represents its fundamental difference from the systemic circulation, which typically vasodilates in response to hypoxia.
1. Position
2. Drugs
• Induction agents
• Volatiles
•
3. Inadequate lung collapse
4. Acid base status pulmonary vasculature vasoconstricts in response to acidosis and dilates during alkalosis
5. Cardiac output Hypoxic pulmonary vasoconstriction will tend to decrease if cardiac output increases and PAPs increase. Also, as cardiac output increases mixed venous oxygen saturation will usually increase and this will also diminish HPV

Question 3

A 1-day-old, 3.3kg neonate, is presented to you, by the paediatric surgeon, for the repair of a
tracheo-oesophageal fistula (TOF). The patient was born at 38 weeks gestation by normal vaginal delivery.
a) What is the typical presentation of a patient with a tracheo-oesophageal fistula? (10)

Answer 3

seen in 1: 3000 – 4500 live births
involving multiple genes
and complex gene-environment interaction
Respiratory insufficiency, however is the single most
significant risk factor affecting outcome.
Associated anomalies include:
- cardiac (29%) ASD, VSD or Tetralogy of Fallot (presence of major cardiac anomaly reduces an almost
complete survival rate to around 80%)
- duodenal atresia and anorectal (14%)
- genitourinary (14%)
- intestinal malrotation (13%)
- chromosomal abnormalities (trisomy 21, 18, 13q deletion)
- vertebral and skeletal anomalies (10%)
- specific associations (VATER/VACTERL, CHARGE syndrome, Potters syndrome and Schisis association
Suspicion can be raised by antenatal ultrasound which shows an absent or small gastric bubble. A history of
polyhydramnios should prompt the passing of a size 8 – 10 F orogastric tube in the baby soon after delivery. This is
then confirmed by a plain chest and abdominal X-ray. Other anomalies such as vertebral anomalies or ‘double
bubble’ of duodenal atresia can also be detected on preoperative films.
Within a few hours of birth the infant will present frothy, unable to swallow secretions and they may have choking
or cyanotic spells. The development of aspiration pneumonia is a delayed diagnosis. An echocardiogram is highly
recommended prior to surgery and if the child has passed urine a renal US can be delayed until after surgery.

Question 4

1-day-old, 3.3kg neonate, is presented to you, by the paediatric surgeon, for the repair of a
tracheo-oesophageal fistula (TOF). The patient was born at 38 weeks gestation by normal
vaginal delivery.
b) Discuss your pre-operative assessment and perioperative management of this patient.

Answer 4

○ Initial management is to prevent aspiration, so a 8 – 10 F double lumen oro-oesophageal Reploge tube (perforations along the side of the catheter are located only near the tip, which minimises the possibility of suctioning oxygenated air away from the larynx) is inserted into the upper pouch and placed on continous suction or secretions cleared by
regular NGT suction.
○ Maintenance fluid is given, the child nursed at 30˚ head up or on its side.
○ An oesophagoscpy or bronchoscopy is usually performed at the start of surgery to provide absolute confirmation of the position of the defect, then the anticipated surgical approach is extrapleural via a right posterolateral thoracotomy.
○ If a right aortic arch is confirmed on pre-op echo, a left sided approach may be considered.
○ Major concerns about surgery (including
thoracoscopic approach) include accurate identification of anatomical structures and cardiorespiratory instability
due to possible OLV and the distortion of the trachea.

Question 5

A 26-year-old primigravida at 34 weeks gestation is admitted to the labour ward. Her admission
BP is 170/110 mmHg. She complains of headache and epigastric pain
Define severe preeclampsia, and indicate the relevant diagnostic criteria. (5)

Answer 5

Preeclampsia is defined as hypertension occurring after 20-week gestation with SBP >130 DBP >90 mmhg.
Severe preeclampsia is no longer acceptable term it is now referred to preeclampsia with severe features which include
○ Severe hypertension >160/110
○ CNS involvement
○ Pulmonary oedema
○HELLP syndrome
○ Renal impairment

Question 6

What are the organ system effects associated with, and important considerations in the management of severe preeclampsia?

Answer 6

Neuro: neuroprotection, risk of seizure, can. Low Mac and anesthetic, prolonged nmb duration requirements mgso4
Airway : oedema, friable tissues, difficult airway trolley small ett requied
Cardiac : lvd, cardiomyopathy
Respiratory : Low frc, basal atelectasis, v/q mismatch, high airway pressures
Renal : glomerular damage proteinuria,
Hepatic : coagulopathy, Low pseudocholinastarase,

Question 7

Discuss the anaesthetic management of this patient if she presents in pulmonary oedema for caesarean delivery for a non-reassuring fetal heart trace. (30)

Question 8

Question 1
Glutamine supplementation to critically ill patients:
a) What is glutamine, and why should glutamine supplementation been given to critically ill adult and
paediatric patients. What is the rationale for the choice of route of administration? (9)

Question 9

Glutamine supplementation to critically ill patients:
b) What are the potential problems/disadvantages associated with glutamine supplementation?
(3)

Question 10

Tetanus:
a) What is the causative organism of tetanus, and what are the cardiovascular
complications?
(4)

Question 11

Tetanus:
b) Name the drugs used to manage the deranged haemodynamics in patients with tetanus, and state the mechanism of action of each. (8)

Question 12

Question 3
Lactate:
a) Where in the body is lactate produced, and what is the most common mechanism of
hyperlactataemia?

Question 13

b) Name other causes of a raised lactate level, and state their mechanism(s). (9)

Question 14

Question 4
Goal-directed fluid therapy (GDFT):
a) Give a definition of “Goal-directed fluid therapy”, and state how fluids are given when applying this
approach. (4)

Question 15

Goal-directed fluid therapy (GDFT):
b) What are dynamic predictors of fluid responsiveness and what do they identify? (10)

Question 16

Question 5
With reference to the use of patient controlled analgesia (PCA) after a laparotomy:
a) What are the potential complications of PCA and how are these avoided? (4)

Question 17

b) Write a prescription for a PCA management plan, exactly as you would in clinical practice. Include
instructions to nursing staff as you feel appropriate. (10)

Question 18

Question 6
With reference to intravenous paracetamol:
a) Describe the contents of a 1g vial of intravenous paracetamol. What side-effects and precautions
relate to the contents other than that of paracetamol? (4)

Question 19

b) What limitations are there on the dosage and administration of intravenous paracetamol for adult
patients in terms of current South African registration? (3

Question 20

c) What is the specific toxic metabolite of paracetamol, and what are the potential side effects
associated with the administration of intravenous paracetamol? (4)

Question 21

Question 7
With respect to the stellate ganglion:
a) What is the stellate ganglion and what are the potential indications for stellate ganglion block? (5)

Question 22

b) What are all the clinical signs that immediately confirm successful stellate ganglion block, and what are the potential complications? (9)

Question 23

Question 8
With regard to complex regional pain syndrome (CRPS):
a) Describe the principal clinical components of CRPS, and give an example of each. (8)

Question 24

b) What is the difference between sympathetically maintained pain and sympathetically independent
pain? (3)

Question 25

Question 9
List the airway implications of long-standing acromegaly, and briefly describe how you would plan your
anaesthetic to provide safe management of these issues. [15]

Question 26

Question 10
Briefly describe the advantages and disadvantages of “tight” glucose control during major surgery and
critical care. [20]

Question 27

Question 11
What are the potential consequences of chronic steroid usage (30 mg prednisone daily), and how would
you manage perioperative steroid administration in such a patient? [15]

Question 28

Question 12
Briefly describe the pathophysiology of trauma-associated coagulopathy. [20]

Question 29

Question 13
What are the clinical applications and evidence for the use of antifibrinolytics in the setting of trauma-
associated coagulopathy? [15]

Question 30

Question 14
Write short notes on the prevention and treatment of fat embolism. [15]

Question 31

You are responding to a rural hospital consult on a patient with severe Acute Respiratory
Distress Syndrome (ARDS) for possible transfer and admission into your unit
a) i) Give a comprehensive definition of Acute Respiratory Distress Syndrome (ARDS) based on the Berlin Definition.
ii) How is the severity of ARDS graded? (6)

Question 32

b) After intubating the patient, what further advice would you give to the referring hospital on ventilatory optimisation before accepting the patient? (14)

Question 33

What are the advanced and non-conventional methods of ventilation available for ARDS and what are the challenges with each of them? (12)

Question 34

c) What are the advanced and non-conventional methods of ventilation available for ARDS and what are the challenges with each of them? (12)

Question 35

i) What are the challenges and controversies of ECMO (extra-corporeal membrane oxygenation) usage in the South African context? (5)

Question 36

ii) What are appropriate guidelines for patient consideration and definite selection for
ECMO? (5)

Question 37

Ms JW is a 25-year-old female with a history of two previous caesarean sections and a
current ultrasound diagnosis of Placenta Praevia for which an elective caesarean section is
scheduled at 38 weeks. During your morning preoperative assessment, an elder from her
church presents you with a signed form stating that, owing to her religious beliefs (Jehovah’s
Witness), Ms JW refuses a blood transfusion during her medical care. Describe your
approach to this situation under the following headings
a) The risk of haemorrhage. (2)

Question 38

i) The validity of the consent form presented to you by the elder, regarding the refusal of blood products.

Question 39

ii) Under what circumstances can or can’t you administer blood despite this document?
(3)

Question 40

List blood conservation strategies and alternatives to blood transfusion and indicate their acceptability to Jehovah’s Witness patients. (15)

Question 41

Ms JW is a 25-year-old female with a history of two previous caesarean sections and a
current ultrasound diagnosis of Placenta Praevia for which an elective caesarean section is
scheduled at 38 weeks. During your morning preoperative assessment, an elder from her
church presents you with a signed form stating that, owing to her religious beliefs (Jehovah’s
Witness), Ms JW refuses a blood transfusion during her medical care. Describe your approach to this situation under the following headings
How would you obtain informed consent from the patient?

Question 42

Ms JW is a 25-year-old female with a history of two previous caesarean sections and a
current ultrasound diagnosis of Placenta Praevia for which an elective caesarean section is
scheduled at 38 weeks. During your morning preoperative assessment, an elder from her
church presents you with a signed form stating that, owing to her religious beliefs (Jehovah’s
Witness), Ms JW refuses a blood transfusion during her medical care. Describe your
approach to this situation under the following headings
The rights of other parties in this scenario
i) The fetus. (4)
ii) The father. (2)
iii) The church elder. (1)

Question 43

Based on the fact that a severely injured trauma patient is likely to develop an early
coagulopathy, known as acute coagulopathy of trauma, please discuss the following
a) A definition and proposed mechanism for this phenomenon. (5)

Question 44

Based on the fact that a severely injured trauma patient is likely to develop an early
coagulopathy, known as acute coagulopathy of trauma, please discuss the following
The most appropriate early assessment for this phenomenon and a rationale for such
testing. (10)

Question 45

The concept of haemostatic resuscitation and the management of acute coagulopathy of trauma. (30)

Question 46

Briefly state your opinion on whether leuco-depleted packed red blood cells should be used during trauma resuscitation in a South African context. (5)

Question 47

A 70-year-old patient with an un-ruptured descending thoracic aortic aneurysm (TAA)
presents for endovascular stenting. He is a smoker and a well-controlled hypertensive and
claims to have a good functional capacity
a) Briefly discuss the advantages and disadvantages and outcomes of stenting in the
management of TAA with reference to the types of patient for which this procedure is
most suited. (10)
b) Discuss the pre-operative assessment of his cardiovascular risk. (20)

Question 48

Discuss the pre-operative assessment of his cardiovascular risk. (20)

Question 49

Tabulate the major intra-operative complications of this (TAA) procedure and what the anaesthetist can do to prevent them. (20)

Question 50

Question 1
List the peri-operative concerns of uncorrected mitral stenosis in a patient for elective caesarean
section. [10]

Question 51

Question 2
With respect to central sensitisation
a) Define this entity (4)

Question 52

With respect to central sensitisation
b) Discuss the pathophysiology (6

Question 53

Question 3
Write short notes on labour epidural associated fever under the following headings
a) Definition and differential diagnosis. (6)

Question 54

Question 3
Write short notes on labour epidural associated fever under the following headings
b) Mechanisms. (4)

Question 55

Question 4
a) Discuss the use of intra-thecal opioids in caesarean section delivery. (5)

Question 56

b) Discuss the pharmacokinetics of intra-thecal morphine. (5)

Question 57

Question 5
Regarding the peri-operative blood pressure management of the severe pre-eclamptic and
eclamptic patient
a) Briefly discuss the underlying physiological principles. (5)

Question 58

b) List the goals of management. (5)

Question 59

Question 6
A patient is scheduled for bilateral exploration of the parathyroid glands because of multiple
parathyroid adenomas
a) What is the primary metabolic disturbance associated with this condition? (1)

Question 60

b) What electrocardiographic changes would you expect to find with this syndrome? (1)

Question 61

c) What symptoms would one expect to elicit during the pre-operative interview of the patient
with this condition? (4)

Question 62

d) What complications could you anticipate after surgical resection of the parathyroid glands?(4)

Question 63

Question 7
A three-month-old baby presents for retinal laser treatment of Retinopathy of Prematurity. She was
born at 28 weeks of gestational age, was treated with surfactant therapy and required two weeks
of ventilatory support after birth
a) Discuss some of the associated systemic morbidities you would ask for on taking a history
from the mother of this baby. (6)

Question 64

b) Define apnoea of prematurity. (4)

Question 65

Question 8
A patient requires a commando procedure with a latissimus dorsi free flap repair for carcinoma of
the floor of the mouth. Briefly outline how the anaesthetist can influence and enhance the survival
of the free flap. [10]

Question 66

Question 9
a) Describe the anatomy of the infant lumbar spine. (5)

Question 67

b) Discuss how the alterations in the pharmacokinetics of local anaesthetics influence the effect
of caudal anaesthesia in infants. (5)

Question 68

Question 10
A 26-year-old patient with Down’s Syndrome and glaucoma is booked for a trabeculectomy. The
patient is taking acetazolamide, echothiopate and timolol eye drops for her condition
a) Describe the class of drug and at least one of the common systemic side effects of these
drugs. (3)

Question 69

A 26-year-old patient with Down’s Syndrome and glaucoma is booked for a trabeculectomy. The
patient is taking acetazolamide, echothiopate and timolol eye drops for her condition
b) Name two intra-operative complications that can occur with this procedure and how you
would manage them. (7)

Question 70

Question 11
Classify and outline the possible complications associated with Cardiopulmonary Bypass (CPB) in
an adult patient.

Question 71

Question 12
a) What physiological changes occur in a spontaneously breathing patient in the lateral
position?

Question 72

b) What physiological changes occur during one-lung ventilation? (3)

Question 73

c) What will you do when a patient de-saturates during one-lung ventilation? (4)

Question 74

Question 13
a) What are the indications and contra-indications for the insertion of an intra-aortic balloon
pump (IABP)? (4)

Question 75

b) Describe the mechanism of action and physiological effects of an IABP. (4)

Question 76

c) What are the potential complications of IABP insertion? (2)

Question 77

Question 14
With respect to anaesthesia for an oesophagectomy
a) Describe the clinical features of carcinoma of the oesophagus that are relevant to
anaesthesia.

Question 78

b) Outline what evidence-based intra-operative and post-operative strategies can be used
during an oesophagectomy to reduce post-operative pulmonary complications. (7)

Question 79

Question 15
A young adult patient requires a general anaesthetic for an elective cardiological intervention in
the catheter laboratory/suite.
a) What challenges and potential problems may be encountered anaesthetising a patient in the
catheter suite? (5)

Question 80

b) What are the key principles of anaesthesia in this specific location? (5)

Question 81

Question 16
With reference to the statistical analysis of quantitative data
a) Draw, annotate and explain a normal distribution curve. (5)

Question 82

b) Define Type I error and Type II error. (3)

Question 83

c) Using examples, explain the difference between sensitivity and specificity of a test. (2)

Question 84

Question 17
An intellectually gifted (IQ 135) 14-year-old patient with severe spasticity from cerebral palsy is
scheduled for contracture release in the upper limbs. She has reported to ward staff that should
she suffer a cardiac arrest under anaesthesia, she wishes not to be resuscitated. Briefly discuss
the reasons why a Do Not Attempt Resuscitation (DNAR) order may or may not be implemented in
this patient, including the consent process. [10]

Question 85

Question 18
Regarding the use of therapeutic hypothermia in patients with traumatic brain injury
a) Classify therapeutic hypothermia (TH). (2)

Question 86

b) Briefly discuss the proposed mechanisms of benefit. (8)

Question 87

Question 19
a) Normally a new drug will undergo four phases of clinical trials in humans. Briefly outline the
purpose of each of these phases. (4)

Question 88

b) Some restricted medications may only be procured for use in patients by submitting a section
21 application to the Medicines Control Council (MCC)
i) What would be the motivation for such an application? (2)
ii) What obligations attach to the applicant in this scenario? (4)

Question 89

Question 20
a) Regarding the options for monitoring cerebral perfusion during carotid clamping in a patient
undergoing carotid endarterectomy (CEA) under general anaesthesia (GA), how would you
monitor this patient effectively to prevent stroke based on the likely pathophysiology?

Question 90

Discuss in the context of the following monitors: Carotid stump pressure, transcranial Doppler
ultrasound and near intra-red spectroscopy.