SAQ 2023.1 Flashcards
[23A01] List the branches of the coronary arteries and the myocardial territories and structures they supply. Outline the electrocardiograph (ECG) leads that correspond to the blood supply. Describe the ECG changes in a non-ST-elevation myocardial infarct (NSTEMI). Pass Rate 48.9%
The coronary arteries and their myocardial territories, along with corresponding ECG leads and NSTEMI changes, are core topics in cardiovascular anatomy and perioperative management. Here’s a structured summary:
Coronary Artery Branches and Territories
### Left Coronary Artery
1. Left Anterior Descending (LAD):
- Supplies: Anterior wall, anterior septum, apex.
- Branches: Diagonal branches (anterolateral wall), septal perforators (septum).
-
Left Circumflex (LCx):
- Supplies: Lateral wall (left ventricle), posterior wall (in left-dominant systems).
- Branches: Obtuse marginal branches (lateral wall).
Right Coronary Artery (RCA):
- Supplies: Inferior wall, right ventricle, posterior septum (via posterior descending artery in right-dominant systems).
- Branches: Posterior descending artery (PDA), right marginal artery.
Overlap: Lateral wall may receive dual supply from LCx and RCA (in right-dominant systems)[1].
ECG Leads Corresponding to Blood Supply
- Anterior wall (LAD): V1–V4.
- Inferior wall (RCA): II, III, aVF.
- Lateral wall (LCx): I, aVL, V5–V6[1].
ECG Changes in NSTEMI
NSTEMI is characterized by ischemia without ST elevation:
1. ST-segment depression (>0.5 mm in ≥2 contiguous leads).
2. T-wave inversion (symmetrical, deep ≥2 mm).
3. Dynamic changes (transient ST elevation resolving with therapy).
Key features for diagnosis:
- Absence of persistent ST elevation.
- Biomarker elevation (troponin)[1].
Examiner Insights
- Overlap in coronary supply (e.g., LCx involvement in inferior leads) was noted in high-scoring answers.
- Candidates were required to link territories to ECG leads and identify ≥2 NSTEMI features for a pass[1].
This framework integrates anatomical knowledge with clinical correlation for perioperative assessment and management.
Citations:
[1] https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/49558506/7f06bef0-e09b-454f-81c6-c462ae592c04/2023.1-Final-Exam-Report.pdf
[2] https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/collection_65793a3a-12f3-4917-b8d9-24d50f295927/3692bdce-93b2-4aee-9e97-df1f27aa2ca8/2022.2-FEx-Examination-Report.pdf
[3] https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/collection_65793a3a-12f3-4917-b8d9-24d50f295927/5bf7e650-12b2-433f-9d62-685af9ffa428/2024.1-Final-Exam-Report.pdf
[4] https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/collection_65793a3a-12f3-4917-b8d9-24d50f295927/f02192b3-762f-400e-aed9-e105bd0c102e/2023.1-Final-Exam-Report.pdf
[5] https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/collection_65793a3a-12f3-4917-b8d9-24d50f295927/f024ed12-e8e6-48ef-8ef7-0401bdd85af7/2022.1-Final-Exam-Chair-s-report-v2.pdf
[6] https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/collection_65793a3a-12f3-4917-b8d9-24d50f295927/3578987c-01c4-4d61-8f11-d3fc75733d49/2024.2-Final-Examination-Report.pdf
[7] https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/collection_65793a3a-12f3-4917-b8d9-24d50f295927/840e79c1-fa2c-4f44-87de-927f4020284f/2023.2-Final-Exam-Report.pdf
Answer from Perplexity: pplx.ai/share
[23A02] Outline the immediate management of an unconscious trauma patient in the emergency department who has a suspected cervical spine injury. Pass Rate 65.5%
CABCD
A: secure early, MILS, VL bougie, unfasted
B: Lung protective
C/D/E: Uncon - GCS low
Early scan - CT C spine
ENT / Airway - subglottic stenosis
[23A03] A 30-year-old patient is scheduled for laser resection of a subglottic mass to relieve mild stridor. Justify your intraoperative anaesthetic management of this case. Pass Rate 74.0%
Based on the search results, several airway management strategies can be employed for laser resection of a subglottic mass:
Tubeless Field Techniques
Jet Ventilation
- Supraglottic jet ventilation using a specialized laryngoscope with an integrated jet ventilation port[1][3]
- Transglottic or transtracheal jet ventilation via a small-caliber catheter[4]
Intermittent Apnea
- Periods of apnea alternating with ventilation via face mask or repeated intubation[7]
Spontaneous Ventilation
- Maintaining spontaneous breathing with a laryngeal mask airway (LMA)[5][10]
Intubation Techniques
Specialized Endotracheal Tubes
- Small-caliber laser-resistant endotracheal tubes[4]
- Microlaryngoscopy tubes (MLTs) for intermittent positive-pressure ventilation[13]
Flexible Bronchoscopy with LMA
- Passing a flexible bronchoscope through an LMA to deliver laser fiber or balloon dilators[1][3][5]
Advanced Techniques
Extracorporeal Membrane Oxygenation (ECMO)
- Venovenous ECMO for oxygenation during complex cases[10]
Anesthetic Considerations
- Total intravenous anesthesia (TIVA) is preferred to avoid airway irritation and eliminate the risk of laser ignition of volatile anesthetics[1][3][13]
- Profound muscle relaxation is essential for optimal surgical conditions and to facilitate jet ventilation[1][13]
Each technique has its advantages and limitations, and the choice depends on factors such as the extent of stenosis, patient characteristics, and surgical requirements. The goal is to maintain oxygenation and ventilation while providing optimal surgical access and minimizing the risk of airway fires or other complications.
Sources
[1] Airway Management and Endoscopic Treatment of Subglottic and … https://pmc.ncbi.nlm.nih.gov/articles/PMC4317367/
[2] Flexible Laser Bronchoscopy for Subglottic Stenosis in the Awake … https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/410139
[3] [PDF] Airway management and CO2 laser treatment of subglottic and … https://www.uclahealth.org/sites/default/files/documents/Chhetri%20and%20Long_Airway%20stenosis%20management%20using%20the%20LMA%20technique.pdf
[4] Airway for Laser Surgery - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK564406/
[5] Endoscopic treatment of subglottic stenosis with flexible … https://onlinelibrary.wiley.com/doi/full/10.1002/lary.31229
[6] [PDF] Perioperative management of glottic and supraglottic tumors https://openairway.org/wp-content/uploads/2021/10/OTOHNS-2020-Hofmeyr-et-al-Multidisciplinary-difficult-airway-challenges-glottic-supraglottic-tumours.pdf
[7] The management of laryngeal and subglottic stenosis https://www.bjanaesthesia.org.uk/article/S0007-0912(17)35106-1/fulltext
[8] Airway Management and Anesthesia for Tracheal Resection in a 68 … https://onlinelibrary.wiley.com/doi/10.1155/2021/5548105
[9] [PDF] Anesthesia for Laser Surgery of the Airway https://www.aijoc.com/doi/pdf/10.5005/jp-journals-10003-1250
[10] Anesthesia airway management for tracheal resection and … https://apm.amegroups.org/article/view/65736/html
[11] Airway Management and Endoscopic Treatment of Subglottic and … https://journals.sagepub.com/doi/10.1177/0003489414525340?icid=int.sj-abstract.citing-articles.175
[12] Challenging airway management in a patient having subglottic … https://pmc.ncbi.nlm.nih.gov/articles/PMC11033880/
[13] Anaesthesia for airway surgery | BJA Education - Oxford Academic https://academic.oup.com/bjaed/article/6/1/28/346997
[14] Anaesthesia for laryngo-tracheal surgery, including tubeless field … https://academic.oup.com/bjaed/article/17/7/242/3921240
Transphenoidal
[23A04] Discuss the perioperative management of a previously well patient presenting for transsphenoidal resection of a non-secretory pituitary macroadenoma. Pass Rate 25.6%
The perioperative management of a non-secretory pituitary macroadenoma resection requires addressing preoperative endocrine and mass effects, intraoperative hemodynamic goals, and postoperative complications.
Preoperative
- Endocrine evaluation: Assess cortisol (8 AM serum cortisol), thyroid function (TSH, free T4), and gonadal axes to detect hypopituitarism[6][7]. Initiate stress-dose hydrocortisone if adrenal insufficiency is suspected[6].
- Mass effect assessment: MRI to evaluate optic chiasm compression and cavernous sinus invasion. Formal visual field testing if suprasellar extension[1][5].
- Airway assessment: Exclude obstructive sleep apnea (acromegaly excluded in this case)[7].
Intraoperative
- Hemodynamic goals: Maintain MAP 70–80 mmHg to balance cerebral perfusion and surgical field visibility[4][5]. Anticipate hypertension from intranasal vasoconstrictors (e.g., phenylephrine) and rebound hypotension[4][7].
- Anesthetic technique: Use remifentanil-propofol TIVA for controlled hypotension and rapid emergence[7]. Avoid coughing during extubation to prevent CSF leak[7].
- Positioning: 15–30° head elevation to reduce venous pressure[4][7].
Postoperative
- Extubation strategy: Deep extubation or dexmedetomidine infusion to avoid coughing/Valsalva[7]. Nasal airway precautions (avoid nasal tubes for ≥14 days)[7].
- Complication monitoring:
- Diabetes insipidus (DI): Monitor urine output (>250 mL/hr for 2–3 hours) and serum sodium every 6 hours for 48 hours. Treat transient DI with DDAVP[1][4][5].
- SIADH: Screen for hyponatremia (serum Na <135 mmol/L) on postoperative day 7[1][5].
- Adrenal insufficiency: Check morning cortisol on postoperative days 1–2. Start hydrocortisone if <10 µg/dL[1][6].
- Multidisciplinary care: Daily endocrine review, nasal saline sprays, and avoid straining/Valsalva[1][5].
Key omissions in poor answers included insufficient detail on cortisol assessment, DI monitoring thresholds, and precise hemodynamic targets. Optimal management integrates endocrine vigilance with controlled emergence to mitigate CSF leak risks.
Citations:
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC3198670/
[2] https://academic.oup.com/jes/article/6/3/bvac010/6516798
[3] https://pmc.ncbi.nlm.nih.gov/articles/PMC7296486/
[4] https://www.thieme-connect.com/products/ejournals/pdf/10.4103/2348-0548.190066.pdf
[5] https://thejns.org/focus/view/journals/neurosurg-focus/48/6/article-pE2.xml
[6] https://pmc.ncbi.nlm.nih.gov/articles/PMC5363454/
[7] https://www.anestesinorr.se/onewebmedia/Op%202/hypofys(169341).pdf
Answer from Perplexity: pplx.ai/share
SAQ An 82-year-old patient is booked for excision of a floor of mouth squamous cell carcinoma and neck dissection with radial forearm free flap reconstruction. Discuss the issues relevant to the intraoperative anaesthetic management for this procedure. Pass Rate 62.8%
Airway plan
North facing RAE/reinforced ETT –> convert to tracheostomy
RAFF -
blood supply
Prolonged procedure
- airway management plan,
- appreciation of long surgery and its implications,
- a fluid management plan and optimization of conditions for flap survival.
Better answers were able to expand on these and add other relevant material.
SAQ Discuss the implications of anticoagulation as well as an appropriate anticoagulant management strategy for a 25-year-old with a mechanical aortic valve for the duration of pregnancy delivery and the postpartum period. Pass Rate 43.9%
Warfarin embryopathy
Worst in T1
Enoxaparin in T1 and Warfarin T2 - T3
Risk vs benefit
- Continuation of anticoagulation up until close to delivery
- Potential effects of anticoagulation on the fetus, including teratogenicity and
fetal loss risks due to haemorrhage * - Implications for neuraxial techniques * Risk of major bleeding
- high risk pregnancies, with death and thromboembolic complications possible in the mother, and
- the place of other therapeutic options pre- and post-delivery such as low molecular weight heparin.
SAQ Describe your technique to provide caudal epidural analgesia for an infant weighing 10 kg undergoing hypospadias surgery. Pass Rate 43.9%
the correct surface anatomy, using correct anatomical terms.
Details for an appropriate safe technique, including positioning, monitoring, and personnel, as well as appropriate drugs and drug doses to be administered were also required for a pass to this question.
Many candidates simply referred to “ANZCA monitoring” or “as per PS18”. This was so prevalent that a pass mark was allowed if the answer met all other minimum criteria, however candidates are cautioned to avoid the use of such short-cuts in future answers.
Better answered also described the ultrasonographic anatomy, and provided some details of the potential complications and contraindications of caudal blocks.
SAQ A 56-year-old patient with a phaeochromocytoma is scheduled for a laparoscopic adrenalectomy. Justify your preoperative investigations for this patient (30%). Discuss your goals for preoperative optimisation and how to achieve them (70%). Pass Rate 78.9%
Preop
- arterial pressure control,
- reversal of chronic circulating volume depletion,
- heart rate and arrhythmia control,
- assessment and optimization of myocardial function,
- reversal of glucose and electrolyte disturbances.
Hx
Ex
Ix/Dx
Echo - r/o CM, diastolic dysfx **
** BSL - HYPERgly
BJAED / OHA P.716
https://www.bjaed.org/article/S2058-5349(17)30072-0/fulltext
Knowledge concerning the perioperative care of patients with a range of medical conditions is often tested in the SAQ paper.
In this question the instructions limited answers to the preoperative anaesthesia considerations for phaeochromocytoma only.
To achieve a pass, candidates were required to
justify the use of preoperative echocardiography, ECG, and blood tests (FBC, U&E) at a minimum as part of an assessment of haemodynamic status.
A discussion of initial alpha blockade, with appropriate blood pressure and heart rate control,
volume status assessment and
pharmacological agents to achieve these goals was also required, as was the mention of anaesthesia as part of a multidisciplinary team approach to optimisation.
SAQ Justify strategies used to mitigate postoperative delirium in an elderly patient requiring hip fracture fixation. Pass Rate 65.9%
Pt / Surg/ Anaes
Pt
This was a relatively straight forward question covering core anaesthesia knowledge, which was in the most part was well answered.
Candidates failing to achieve a pass often limited their answers to the postoperative period, possibly misreading the question and not considering perioperative factors that influence the risk of developing postoperative delirium. Careful consideration of question wording is advised.
At a minimum, candidates were required to
identify risk factors for developing postoperative delirium, and
justifying interventions around early surgery,
perioperative aahvoidance of drugs known to cause delirium,
analgesia planning and
postoperative interventions such as minimizing physiologic and sensory disturbances.
SAQ Describe the innervation relevant to the stages of labour (30%). Evaluate the regional analgesia options for each stage (70%). Pass Rate 60.1%
SAQ Outline the major considerations for organ donation after circulatory death (DCD). Pass Rate 51.6%
SAQ Outline the circumstances where the dosing of paracetamol requires modification (50%). Describe the management principles of paracetamol toxicity (50%). Pass Rate 56.1%
SAQ Data regarding the conduct and outcomes of anaesthesia are now widely collected (e.g. National Anesthesia Clinical Outcomes Registry (NACOR)). Outline the benefits and the potential errors that can occur when using this data for research. Pass Rate 44.4%
SAQ Discuss the preoperative elements of an Enhanced Recovery After Surgery (ERAS) program for a patient requiring major colorectal surgery. Pass Rate 62.3%
PINA C
This was a reasonably well-answered question, with candidates displaying adequate knowledge of the basic principles of an ERAS program.
Despite the question requesting discussion of preoperative ERAS elements, some candidates were included intraoperative and postoperative elements in their answers, which did not attract marks.
A discussion of at least three of the following for elements were required to achieve a pass:
* Anaemia screening
* Nutritional screening
* Information/ education
* Preoperative optimisation/prehabilitation
Better answers elaborated on other preoperative elements, particularly the early identification and optimisation of other modifiable risk factors such as smoking and alcohol cessation.
SAQ A) Identify the axes A and B (with units)
and the points labelled C through H on the following spirometry loop: (normal spirometry loop provided) B) Outline how these spirometry parameters change in: * Chronic obstructive pulmonary disease * Idiopathic pulmonary fibrosis * Extrathoracic tracheal obstruction Pass Rate 75.8%
