FCA 2022

Question 1

A 65-year-old patient, without chronic disease requires a laparoscopically assisted
abdomino-perineal resection for a low rectal adenocarcinoma, staged as Duke’s A. Describe
your anaesthesia management under the following headings with particular attention to
nutrition, fluids, and analgesia
a) Pre-operative preparation. (10)
b) Intra-operative management. (30)
c) Post-operative care. (10)
[50

Question 2

A 50-year-old man with sepsis following a ruptured appendix is presented for an emergency
laparotomy. Discuss the following aspects in the anaesthetic management of this patient
a) Patient factors in this scenario that influence drug selection for induction and
maintenance of anaesthesia. (15)
b) Your approach to intra-operative haemodynamic and metabolic optimisation. (10)
c) The organ-protective measures you would institute to prevent the complication of multi-
organ dysfunction syndrome. (25)
[50]

Question 3

3 You are the anaesthetist covering labour ward when you are called to assist with the
management of a 35-year-old term primigravida in labour, who has developed a suspected
amniotic fluid embolism (AFE)
a) Discuss the proposed pathogenesis of AFE. (10)
b) Describe the clinical presentation c) Discuss your management of a patient with AFE. (15)
d) List 5 ways in which cardio-pulmonary resuscitation should be modified when performed
in a pregnant patient.

Question 4

of AFE and list a differential diagnosis. (20)

Question 5

c) Discuss your management of a patient with AFE.

Question 6

List 5 ways in which cardio-pulmonary resuscitation should be modified when performed
in a pregnant patient.

Question 7

You are consulted about a 65-year-old male patient presenting for a femoro-popliteal (fem-
pop) bypass, secondary to significant claudication. He has a history of a previous myocardial
infarct and subsequently had uneventful coronary artery bypass graft surgery 5 years ago.
He is diabetic, hypertensive, and has a 40 pack year smoking history with renal insufficiency.
His blood pressure is 140/93 mmHg with a resting pulse rate of 70 per minute. His medication
includes aspirin, enalapril, atenolol and insulin
a) Describe your pre-operative concerns and optimisation strategies for this patient. (20)

Question 8

You are consulted about a 65-year-old male patient presenting for a femoro-popliteal (fem-
pop) bypass, secondary to significant claudication. He has a history of a previous myocardial
infarct and subsequently had uneventful coronary artery bypass graft surgery 5 years ago.
He is diabetic, hypertensive, and has a 40 pack year smoking history with renal insufficiency.
His blood pressure is 140/93 mmHg with a resting pulse rate of 70 per minute. His medication
includes aspirin, enalapril, atenolol and insulinb) Discuss the positive and negative aspects of regional versus general anaesthesia in this
patient.

Question 9

You are consulted about a 65-year-old male patient presenting for a femoro-popliteal (fem-
pop) bypass, secondary to significant claudication. He has a history of a previous myocardial
infarct and subsequently had uneventful coronary artery bypass graft surgery 5 years ago.
He is diabetic, hypertensive, and has a 40 pack year smoking history with renal insufficiency.
His blood pressure is 140/93 mmHg with a resting pulse rate of 70 per minute. His medication
includes aspirin, enalapril, atenolol and insulin Explain your approach in this patient to the use of contrast media peri-operatively.

Question 10

You are consulted about a 65-year-old male patient presenting for a femoro-popliteal (fem-
pop) bypass, secondary to significant claudication. He has a history of a previous myocardial
infarct and subsequently had uneventful coronary artery bypass graft surgery 5 years ago.
He is diabetic, hypertensive, and has a 40 pack year smoking history with renal insufficiency.
His blood pressure is 140/93 mmHg with a resting pulse rate of 70 per minute. His medication
includes aspirin, enalapril, atenolol and insulin
d) Post-operatively, the patient develops hypotension in the high care unit. How will you
approach this problem?

Question 11

Question 1
Intracranial pressure monitoring
a) How is cerebral perfusion pressure (CPP) calculated using intracranial pressure (ICP)
values? (1)
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b) Give two other monitors that are used for multimodal brain monitoring, to assist decision
making when treating patients with acute brain injury in a neurointensive care unit. (2)
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c) Why are these monitors used in addition to monitoring ICP and CPP? (1)
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d) Should hyperventilation be used to reduce ICP after severe traumatic brain injury? Explain
your answer. (3)
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e) Give the indications for using ICP monitoring after severe traumatic brain injury. (3)

Question 12

Question 2
A patient with Cushing disease from a pituitary tumour presents for a transsphenoidal
hypophysectomy
a) What hormonal abnormality causes Cushing disease? (1)
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b) List 6 systemic abnormalities that occur as a result of the hormonal abnormalities in Cushing
disease. (3)
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c) Post-operatively, the patient complains of extreme thirst and is passing large amounts of
dilute urine. The blood glucose is normal. What is the most likely diagnosis, and why has it
occurred? (2)
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d) What abnormalities of serum and urine osmolarity occur as a result of the condition diagnosed
in c) above? (2)
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e) When should this patient be treated for the condition diagnosed in c) above, and how? (2)
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[10]

Question 13

Question 3
This question should be answered in accordance with the 2015 American Heart Association
Guidelines for Cardiopulmonary Resuscitation or the 2015 Resuscitation Council of South Africa
Guidelines.
a) In the event of an adult cardiac arrest due to ventricular fibrillation
i) How often should the patient be defibrillated? How many Joule should be used
(monophasic and biphasic)? (2)
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ii) Give 2 drugs that may be considered for administration, and provide the initial dose
for each drug. (3)
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b) In the event of an adult developing a narrow complex tachycardia with no haemodynamic
instability
i) Give 2 contra-indications to the use of vagal stimulation using carotid sinus massage.
(1)
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ii) Give 2 alternative physical methods of vagal stimulation that may be used instead. (1)
iii) Give 2 drugs that may be used to treat this tachycardia and give the initial doses of
each drug.

Question 14

Question 4
A woman known to have hypertrophic obstructive cardiomyopathy (HOCM) is booked for an elective
caesarean section at 38 weeks gestation
a) What are the cardiac structural abnormalities associated with HOCM? (2)
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b) What are the haemodynamic goals when administering anaesthesia for the caesarean
section in this patient? (5)
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c) What are the problems associated with giving oxytocin at delivery to this patient and how can
it be avoided? (3)
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________________

Question 15

Question 5
Regarding pacemakers
a) A patient has a pacemaker programmed for AAI
i) Describe how this mode of pacing works. (1)
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ii) In which type of cardiac conduction abnormality is this type of pacing used? (1)
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b) A patient has a pacemaker programmed as DDDR
i) What does the “R” stand for? (1)
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ii) What is the benefit to this patient of having the “R” programmed into the pacemaker?
(1)
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c) A patient has an implantable cardioverter-defibrillator (ICD)
i) Give 3 intra-operative problems that can occur with this device and explain how they
can be avoided. (6)

Question 16

Question 6
A 20-year-old male presents for anaesthesia for surgical repair and stabilisation of his facial
fractures sustained in a motor vehicle accident 8 hours previously
a) Describe your evaluation of his airway prior to induction. (5)
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b) Having found no problems indicating difficulty with his airway, describe your anaesthetic
induction technique with emphasis on the intubation of this patient for repair of his fractured
mandible and broken nose. (5)

Question 17

Question 7
A 15-year-old boy has laryngo-tracheobronchial papillomatosis requiring frequent laser and surgical
removal under general anaesthesia
a) What are the pre-operative concerns regarding this patient? (5)
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b) What are the safety concerns for the patient and staff during this procedure? (5)

Question 18

Question 8
Discuss the anaesthetic implications of the re-feeding syndrome under the following headings
a) Patients at risk of this condition. (2)
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b) Electrolyte changes. (2)
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c) Vitamins and hormones. (2)
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d) Cardiovascular consequences. (2)
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e) ECG changes. (2)
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Question 19

Question 9
What are the advantages and disadvantages of the use of cuffed endotracheal tubes in infants and
children?
a) Advantages. (5)
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b) Disadvantages.

Question 20

Question 10
What is the Abdominal Compartment Syndrome, and how will you manage this problem in the
intensive care unit

Question 21

Question 11
a) You are asked to provide procedural sedation for a gastroscopy list in a surgeon’s rooms
i) What level of sedation will be required? (1)
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ii) Which patients will you agree to sedate? (1)
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iii) How will you monitor the patient? (3)
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b) Give a validated sedation scale that you will use (i), and indicate the clinical characteristics
of each sedation plane/level of sedation for this scale (ii) (5)
i) Name of sedation scale. _______________________________________________
ii) Levels/planes of sedation and clinical characteristics/signs

Question 22

Question 12
Regarding ethical research considerations
a) Mention 6 ethical principles that would encompass the Declaration of Helsinki. (6)
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b) With regards to clinical trials, explain the basic principles of
i) Beneficence. (2)
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ii) Justice. (2)
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Question 23

Question 13
Regarding the World Health Organisation (WHO) Surgical Safety Checklist
a) What is the rationale behind the implementation of the WHO Surgical Safety Checklist? (2.5)
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b) Name the 3 phases, corresponding to specific periods during the normal flow of an operation,
where it is required to carry out the WHO checklist. (1.5)
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c) If asked to modify the WHO checklist for caesarean sections at your institution, which 3
factors specific to caesarean sections do you want to be included in the last phase of the
checklist?

Question 24

Question 14
A 4-year-old is booked for tonsillectomy and electro-cautery is used during the procedure
a) What are the components of the “fire triad” in the context of fire in theatre? (1)
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b) What are the possible predisposing factors that may put this patient at high risk for airway
burns, and what is the solution (preventative management strategy) for each predisposing
factor? (4)
c) How will you manage an airway fire during a tonsillectomy? (5)

Question 25

Question 15
A 13-year-old boy presents for an emergency laparotomy for blunt abdominal trauma
a) List 4 people who may legally give consent for the procedure, and state under which
circumstances you will approach each of these. (8)
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b) Post-operatively the same boy develops signs of severe anaemia. You wish to give him a
blood transfusion. He agrees, but his parent refuses for religious reasons. What will you do
and why?

Question 26

Question 16
a) When deciding whether to continue with anaesthesia for a child with an upper respiratory
tract infection (URTI), which infective signs and symptoms would increase the risk for adverse
peri-operative respiratory events (give 6)? (3)
i) ___________________________________________________________________
ii) ___________________________________________________________________
iii) ___________________________________________________________________
iv) ___________________________________________________________________
v) ___________________________________________________________________
vi) ___________________________________________________________________
b) What anaesthetic techniques and therapies can be used to minimise the risk of adverse
peri-operative respiratory events in the child mentioned above?

Question 27

Question 17
You are required to anaesthetise an 11-year-old child for an emergency open appendectomy. The
mother informs you that previously he had cardiac surgery for tricuspid atresia and now has a
modified Fontan circulation
a) What is a modified Fontan circulation? (2)
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b) What is your goal for this patient’s pulmonary vascular resistance? (1)
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c) Give the primary reason for your answer in (b) above. (1)
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d) How are you going to achieve your goal in (b) above? (6)

Question 28

Question 18
A 5-week-old male infant presents with projectile vomiting and severe dehydration, diagnosed as
pyloric stenosis. The surgeon wants to bring the child to theatre urgently due to his poor condition
and the need to promptly relieve the obstruction
a) How are you going to advise him on the timing of surgery? Explain your reasoning. (1)
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b) What are your pre-operative resuscitation goals for this child? Provide values where
applicable. (9)

Question 29

Question 19
Anatomy: Interscalene block
Transverse section through the neck at the 6th cervical vertebra (C6) level
a) Complete the labels 1 – 10 for the accompanying diagram above
Note: (n)=neural structure; (v)=vascular structure; (m)=muscular structure
b) Which complication(s) occurs when blocking
i) Structure 1.
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ii) Structure 3.
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iii) Structure 4.
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(3)
c) Give two reasons why the transverse section depicted in the above diagram is not through
vertebra C7.

Question 30

Question 20
You are required to manage the peri-operative acute pain for a patient having hip surgery. She is
chronically taking large doses of oral morphine for cancer related pain, secondary to bowel cancer.
What are the pre-, intra-, and post-operative pain management considerations relevant to the
patient’s self-reported dependence on morphine?