FCA 2017 Paper 1

Question 1

A 40-year-old patient is currently in the 18th week of her third pregnancy. She has experienced recurrent bouts of biliary colic and is scheduled for a semi-urgent laparoscopic cholecystectomy

1. List and briefly discuss the risk factors that this patient has for developing cholelithiasis

Answer 1

○ Biliary stasis and greater secretion of bile with cholesterol increase the risk of gallbladder disease during preg-nancy.
○ Progesterone inhibits the contractility of gastrointestinal smooth muscle, leading to gallbladder hypomotility.
○ The size of the total bile acid pool increases by about 50% during
pregnancy, and the relative proportions of the various bile acids change.
○ The changes in the composition of
bile revert rapidly after delivery, even in patients with gallstones.

Question 2

A 40-year-old patient is currently in the 18th week of her third pregnancy. She has experienced recurrent bouts of biliary colic and is scheduled for a semi-urgent laparoscopic cholecystectomy
During your pre-operative assessment, the mother raises concerns about the risks of anaesthesia to herself and her unborn baby.
2. What are the maternal and foetal risks associated with anaesthesia for non-obstetrical surgery in a pregnant patient? (7)

Answer 2

Maternal
Aspiration risk
Difficult Airway
Pharmacological modifications

Foetal
Risk of pregnancy loss
Teratogenicity
Preterm labor
Intraoperative monitoring

Question 3

A 4A 40-year-old patient is currently in the 18th week of her third pregnancy. She has experienced recurrent bouts of biliary colic and is scheduled for a semi-urgent laparoscopic cholecystectomy
What are the important issues in the pre-operative preparation of this patient?

Answer 3

Multidisciplinary personnel management
Informed consent
Aspiration prophylaxis
Foetal monitoring

Question 4

A 40-year-old patient is currently in the 18th week of her third pregnancy. She has experienced recurrent bouts of biliary colic and is scheduled for a semi-urgent laparoscopic cholecystectomy.

Describe how you would conduct a general anaesthetic for this patient.

Answer 4

Aim: Avoid hypotension, hypoxia, hyperventilation, acidosis
1. Monitoring
• Standard SASA
• Foetal monitoring
3. Induction
• preoxygenation
• RSI
• Cricoid pressure
• ETT vs LMA
• Difficult Airway management plan
4. Maintenance
• Volatile vs tiva
• Analgesia plan
• Ventilation goals
• Haemodynamic goals
5. Emergence and extubation criteria
• Awake vs deep
•
6. Postoperative care
• location
• Analgesia plan
• monitoring fetus
• Monitoring mom

Question 5

A 40-year-old patient is currently in the 18th week of her third pregnancy. She has experienced recurrent bouts of biliary colic and is scheduled for a semi-urgent laparoscopic cholecystectomy
Discuss the offspring’s risks associated with the maternal administration of non-
steroidal anti-inflammatory drugs during the third trimester of pregnancy. (5)

Answer 5

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with an increased risk for some birth defects. The use of NSAIDs and aspirin in the first trimester has increased risk for pregnancy loss (adjusted odds ratio [OR], 1.8 to 8.1).
In the third trimester, NSAIDs and aspirin are usually avoided because of fetal risks, such as renal injury, oligohydramnios, and intrauterine constriction of the ductus arteriosus.
So although chronic use of NSAIDs is common in pain and rheumatology, they are not recommended for use during pregnanc

Question 6

You are called to the emergency room to assist with a trauma victim who has sustained a
gunshot to the right hemi-thorax. The patient is a young male who has a Glasgow Coma
Scale 12/15 and is combative. He has an intercostal chest drain in situ, which has drained
600ml blood since insertion 30 minutes ago. The patient’s vital signs are BP 90/45, pulse
112, SaO2 89 on 60% oxygen mask. He has haemoptysis, which requires repeated suctioning
to clear his oropharynx

What are the pros and cons of resuscitating the patient in the emergency department compared to immediate transfer to the operating theatre for definitive management? Include in your answer the concept of delayed fluid resuscitation and your choice of the appropriate resuscitation fluids.

Answer 6

Assessment: NCEPOD code 1 (immediate) therefore requires immediate lifesaving operation, resuscitation simultaneously with surgical treatment.
1. Haemorrhagic shock
• ongoing bleeding with high drain outputs
• neurological fallout 2nd to hypoperfusion
• threatened airway & ventilation, low GCS, poorly oxygenation based on sats+ haemoptysis

Damage control resusc: o ABC
o Permissive hypotension
o Limitation of crystalloids
o Favour early blood product use -PROPPR Trial** plasma, RCC & platelets 1:1:1 ratio
o Early use of TXA

Phases of DC

1. Part zero- from scene to OT
2. Part one- theater
3. Part two- ICU & resuscitative phase
4. Part tree - back to OT

Permissive hypotension SBP 80-90mmHg/ Mean 50-60mmHg
Restrict volume replacement to target above MAP/SBP until bleeding controlled
Vasopressors in addition to fluids
* aggressive volume administration increases risk of ACS, DC lap,coagulopathy, MOF, nasocomial infection, increases volume of blood transfusion, prolong ICU stay + hospital stay

Question 7

You are called to the emergency room to assist with a trauma victim who has sustained a
gunshot to the right hemi-thorax. The patient is a young male who has a Glasgow Coma
Scale 12/15 and is combative. He has an intercostal chest drain in situ, which has drained
600ml blood since insertion 30 minutes ago. The patient’s vital signs are BP 90/45, pulse
112, SaO2 89 on 60% oxygen mask. He has haemoptysis, which requires repeated suctioning
to clear his oropharynx

Describe how you would secure the airway. Include in your answer the manoeuvres to
ensure proper placement of a double lumen endobronchial tube and the actions that
you would take to manage hypoxaemia that develops during one lung ventilation. (25)

Question 8

Children with active and recent (within 4 weeks) upper respiratory tract infections (URTI’s)
are at an increased risk of peri-operative respiratory adverse events (PRAE)
Outline the principles of the anaesthetic management of a young child with an URTI for urgent surgery. (20)

Question 9

Children with active and recent (within 4 weeks) upper respiratory tract infections (URTI’s)
are at an increased risk of peri-operative respiratory adverse events (PRAE)
During pre-operative evaluation, what factors would influence your decision to proceed
or postpone elective surgery in a 4-year-old child with an URTI? (15)

Question 10

Children with active and recent (within 4 weeks) upper respiratory tract infections (URTI’s)
are at an increased risk of peri-operative respiratory adverse events (PRAE)

Give a short overview of
i) The pathophysiology of viral-induced airway hyper-reactivity.
ii) The risk factors for peri-operative adverse respiratory events (PRAE). (15)

Question 11

What can be done to minimise post-operative pulmonary complications? Divide your answer
into the following

List risk factors for post-operative pulmonary complications. Where appropriate,
indicate pre-operative strategies to minimise complications. (20)

Question 12

What can be done to minimise post-operative pulmonary complications? Divide your answer
into the following
Describe peri-operative changes in functional residual capacity, mechanisms involved
in these changes and strategies to mitigate them. (20)

Question 13

What can be done to minimise post-operative pulmonary complications? Divide your answer
into the following

Describe further strategies during the peri-operative phase that may improve
respiratory outcome. (10)

Question 14

a) What are the therapeutic options and their mechanisms of action for acute haemorrhage due to coagulopathy in a patient with chronic kidney disease? (5)

Question 15

b) List the anticoagulation modalities that can be used for haemodialysis (intermittent or continuous). (5)

Question 16

Describe the different clinical syndromes that may result from incomplete acute spinal cord injury, indicating the anatomic site of injury

Question 17

A patient with an incomplete injury at cervical level C3 requires surgery 2 weeks following the injury. List the anticipated cardiovascular changes in this patient. (3)

Question 18

What drugs would you use to treat hypotension in this patient? (3)

Question 19

An opioid-dependent patient has an elective total knee replacement under general anaesthesia. a) What are the considerations when prescribing opioids for post-operative analgesia in this patient? (4)

Question 20

The patient develops opioid hyperalgesia after IV morphine patient-controlled analgesia is started i) List 4 intra-operative techniques that could decrease the risk of opioid hyperalgesia. (2)

Question 21

ii) List 4 treatment options for opioid hyperalgesia. (4)

Question 22

a) List the MRI access and safety zones. (4)

Question 23

How does the environment of the MRI suite affect anaesthetic equipment and devices? (6)

Question 24

Describe the technique of an Intraconal Block for ophthalmic surgery. (5)

Question 25

What are the common contra-indications for this block? (5)

Question 26

How do the following environmental factors affect the vigilance of staff in the operating room? a) Temperature. (5)

Question 27

b) The environmental toxicity of anaesthetic agents. (5)

Question 28

A new-born with a congenital diaphragmatic hernia will require surgical intervention. a) What are the selection criteria for pre-operative extracorporeal membrane oxygenation in these patients? (5)

Question 29

What are the contra-indications to the use of extracorporeal membrane oxygenation in these patients? (5) [10]

Question 30

A patient with Antiphospholipid Antibody Syndrome requires emergency laparotomy for a ruptured extra-uterine pregnancy. a) What is the pathophysiology of this condition? (5)

Question 31

b) What are the post-operative considerations in this patient? (5)

Question 32

Question 10 What is meant by a “PICOT” statement and how is this approach useful when applying new research to your practice? [10]

Question 33

With regards to Dual Anti-Platelet Therapy (DAPT) following a Percutaneous Intervention (PCI), how long should DAPT be administered for? (2)

Question 34

Explain how you would determine which patients can deviate from the above stipulated duration of therapy and the Grade/level of evidence supporting this decision. (8

Question 35

What are the 3 requirements for informed consent for research subjects? (3)

Question 36

What factors may change the validity of a minor’s consent or their ability to give consent? (2)

Question 37

What methods, principles and adjuncts will assist you in obtaining “informed consent” from a minor? (5) [10]

Question 38

Describe (or draw) the chemical structure of Ketamine. (4)

Question 39

With special reference to the Pharmacokinetics and Pharmacodynamics, tabulate the advantages and disadvantages of Ketamine use in Procedural Sedation in the paediatric population. (6)

Question 40

List the important features of the Pathophysiology/Secondary pathology of Preeclampsia. (7)

Question 41

What are the important findings regarding Low Dose Aspirin Therapy in Preeclampsia? (3) [10]

Question 42

List the factors that increase the risk of an airway fire during Laryngeal surgery/procedures. (5)

Question 43

List the measures you would institute to minimise the risk. (5)

Question 44

A 2-month-old ex-premature infant, currently at 42 weeks post conceptual age and weighing 3kg underwent a general anaesthetic with an uncomplicated caudal for an inguinal hernia repair. Provide a complete post-operative list of instructions as well as a list of drugs and doses that you would prescribe for this child.

Question 45

During an anaesthetic for a laparotomy you discover that you made a substitution drug error. The patient received 7.5mg of morphine through the epidural catheter shortly before the end of the procedure. At the end of surgery, the patient is extubated, is awake, pain free and has a respiratory rate of 14 per minute. List the important points in managing this incident. [10]

Question 46

During a neurosurgical case the surgeon discovers that a vital instrument is not available. He becomes angry and starts shouting at the scrub sister that the surgical tray is ALWAYS missing instruments and that he cannot operate like this. The sister becomes passive and withdrawn. What are the main points that need to be considered and dealt with in this conflict resolution scenario? [10]

Question 47

A 55-year-old man with bullous lung disease underwent an elective thoracotomy for a lobectomy. Four hours post-operatively he develops fast atrial fibrillation with hypotension. a) List 3 possible causes for the atrial fibrillation in this scenario. (3)

Question 48

b) Briefly provide a description of appropriate management strategies in treating atrial fibrillation and then suggest the most appropriate strategy for this patient. (7)

Answer 48

1. Stable
2. Unstable
3. Anticoagulated
4. Not Anticoagulated
5. Chronic vs acute

Question 49

Question 20 You are required to transport a ventilated intensive care unit (ICU) patient with abdominal compartment syndrome and pulmonary oedema to theatre for a laparotomy. List the main points related to this scenario that need to be considered to facilitate a safe transfer from ICU to the operating theatre. [10]