L L C LL

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L LL X M M
Y 2008

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n preparing for the exam candidates should be mindful that the C modular curriculum
guides the range of content that may be assessed. t is important that candidates allow
appropriate time and resources for preparation for each section of the examination. s this is
the inal
ellowship examination, responses are expected to demonstrate a consultant level of prioritisation,
judgment, integration and decision-making. his report contains marking guides submitted by
examiners for the Q section of the paper to enable candidates to appreciate the standard of
response expected in this exam. he naesthesia viva section contains the opening scenario
and the main topics covered in the vivas.

MLLCC
verall 84% candidates passed the MCQ paper.
he table below outlines the number of questions in each subject category (noting that an individual
question may have more than one subject). nly subjects represented in 4 or more questions are
listed.
he subject spread in the MCQ paper varies from exam to exam, as it is partly determined by the
content of the short answer questions and viva sections of the exam, to ensure that an
appropriately wide range of subjects is covered by the whole examination.
hen sitting the MCQ paper candidates should be mindful that marks are not deducted for
mistakes, so every question should be attempted.

MCQ opics umber of Questions

applied pharmacology 22
paediatric anaesthesia 14
applied anatomy 10
regional anaesthesia 10
miscellaneous complications 10
monitoring 8
shock resuscitation 8
applied physiology 8
infection 8
medicine 7
pregnancy obstetrics 7
cardiac disease 6
haematological disorder investigation 6
renal disease & investigations 6
cardiac complications 5
pain 5
 2
statistics 5
endocrine disease 4
liver disease 4
critical care 4
equipment 4
neuromuscular skeletal 4

he overall pass rate for this section of the examination was 47%. Candidates are advised to
apportion their time equally amongst the short answer questions as all the questions are worth
equal marks.
Candidates are reminded to read the question carefully and answer the question asked. he use of
abbreviations is discouraged as these can be open to different interpretations. Logical, organised
answers with legible handwriting will attract better marks.

1. Outline how oxygen is stored at the hospital and delivered to operating theatres up to
and including the wall outlet. In your answer include features that ensure the safety of
the system.

52% of candidates passed this question

o pass candidates were required to outline the most important features of the oxygen supply
including: the presence of a back up supply for the hospital, an alarm system in theatre or the point
of use, the sleeve index or similar connection system, and a few details about the oxygen supply
itself. etter candidates included more details about the and cylinder storage, details about the piping
system, pressures at different points in the system, and mentioned commissioning. ome candidates
did not read the question and included unnecessary details about the anaesthetic machine. here was
often confusion between the sleeve index and pin index systems, and some candidates believed that the
pipeline pressure was further reduced at the wall outlet to prevent barotrauma. hile not being points
that particularly affected the allocation of marks, many candidates stated that oxygen is explosive,
and there was confusion about cylinder sizes and lettering.

2. Why is the radial artery a common site for arterial cannulation? What complications
may occur from radial artery cannulation and how may they be minimised?

69% of candidates passed this question

Marks were awarded for consideration of the reasons why the radial artery is frequently used:
 sually convenient
 elatively clean area
 uperficial
 Collateral circulation
 iscrete from nerves
 Correlates well with
Complications included:
 nfection
 hrombosis
 and ischaemia
 rug injection
 echnical aspects such as disconnection/bubbles etc
 t was not necessary to discuss all points to pass but it was necessary to relate the answer
specifically to the radial artery and strategies to minimize each complication needed to be
discussed.

. escribe the anatomy of the brachial plexus relevant to performing an interscalene

block under ultrasound guidance. nclude a drawing illustrating the real or sono-
anatomy you would expect to see in a transverse view of the brachial plexus at the
point of needle insertion.

49% of candidates passed this question

his applied anatomy question is very relevant to current regional anaesthetic practice. ood pass
answers included a well-labeled diagram of the relevant cross section noting the appropriate
components of the brachial plexus and importantly local structures relevant to potential
complications.
xcellent answers included commoner anatomical variations that may be seen in this region.

oor answers simply drew a schema of the brachial plexus, others described in unnecessary detail
the indications for and physics applicable to ultrasound. ome drew the anatomy relevant to a
supraclavicular block, rather than the region required. useful recent reference relevant to this
question is the review rticle- egional naesthesia meets ltrasound: specialty in transition, cta
naesthesiol cand;52:456-466 2008.

4. escribe the clinical features and treatment of at mbolism yndrome

7 % of candidates passed this question

Marks were awarded in the proportion of 6 for the clinical features and 4 for the treatment aspects.

ith regard to clinical features marks were given for situations where fat embolism syndrome is
likely to occur, the time course of the syndrome and the diagnostic features. he better answers
divided the diagnostic features of the condition into major (respiratory failure, characteristic
petechial rash, and neurological changes) and minor (fever, cardiovascular, renal failure,
thrombocytopenia etc).

Marks were awarded for discussion of early fracture fixation as having a preventative role and the
mainly supportive management involved in the majority of cases. brief discussion of ventilation
strategies and the management of failure/ Cardiovascular collapse was also expected. xtra credit
was given for mention of controversial therapies such as steroids and heparin.

he candidates who scored poorly tended to focus their answer on the fat embolism syndrome
developing intra-operatively as a result of intramedullary reaming. his limited their response both in
terms of the clinical features and the management approach.

5. 65 -year-old female who weighs 85kg and is 165 cm tall ( M 1) is scheduled for
total knee replacement surgery. he has no other health problems. iscuss the pros
and cons of intra-thecal morphine for post-operative analgesia in this patient.

48% of candidates passed this question

n integrated discussion of the pros and cons of M for this particular patient was required to
achieve a pass in this question. Marks were awarded as follows:
  oting the nature of pain after K , the need for adequate analgesia especially with passive M
devices and the dosage of morphine required for analgesia.
 iscussion of the pros of M including the simplicity of post-op pain management and
technical ease of administration, the dose-related prolonged duration of action, the absence
of motor block, the minimal C effects post-op if used with spinal L compared with
resulting in earlier oral intake post-op and earlier mobilisation, the reduction of costs with
no need for expensive equipment or frequent attendance by nurses for analgesia.

 iscussion of the cons of M, the complications of spinal technique, the side-effects of

M, the dosing issues, the limited duration of action with lack of titratability if a single
shot used.

 iscussion of the pros and cons with specific relevance to this patient including this patient's
risk of respiratory depression with need for higher level of monitoring.

etter answers included the incidence and correct treatment of side-effects of opioids the
recognition of early and late respiratory depression and an appropriate discussion of use of
intrathecal catheter/infusion.

6. The electrolyte results below were taken from a 38 year old woman found obtunded 30
hours after abdominal hysterectomy. She had no intercurrent illnesses prior to
surgery. Explain how these electrolyte abnormalities are most likely to have arisen and
describe how you would correct them.

Result Normal range mmol/L

mmol/L
Sodium 110 135-145
Potassium 3 3.0-5.0
Chloride 80 95-105
Bicarbonate 25 20-32
Glucose 5.0 3.0-5.5
Urea 3.0 3.0-8.0
Creatinine 0.06 0.06-0.12
Measured Osmolality 225 mosmol/kg 280-295mosmol/kg

5 % of candidates passed this question

Marks were awarded as follows: 6 marks for how they have arisen (diagnosis, pathogenesis and assessment)
and 4 marks for treatment.

Candidates who had thought about hyponatremia and the possible causes and treatment options did well.
Hyponatremia is not totally academic; patients have died in Australasian Hospitals secondary to
hyponatremia and cerebral oedema. To score well candidates needed too:
 Formulate a differential diagnosis for the electrolyte abnormality.
 Discuss intelligently how to discriminate between differentials
 Recognise that this patient was critically ill.
 Illustrate some understanding of free water and sodium homeostasis
 Discuss treatment options, including the use of strong saline.
Common errors:
 Lack of detail
 Failure to recognise that an obtunded patient is symptomatic.
 Failure to assess the volume status and urine analysis for sodium and osmolality.
 Inappropriate corrective fluid strategies.
 “Admission to ICU for correction of low sodium”, is not good enough for a fellowship answer.
7. 4-year-old woman presents at 6 weeks gestation with an anterior placenta praevia
and Caesarean section is scheduled. he has no intercurrent health problems. he
has a history of two previous Caesarean sections under regional anaesthesia.
escribe and justify the changes this history would make to your routine pre-
operative and intra- operative management plan for Caesarean section.

59% of candidates passed this question

5 marks were awarded for each of preoperative and intra-operative management changes. Key
points to be considered were:

re-operative changes:
 Wider team consultation and planning than a routine Caesarean Section because of the risk of major
haemorrhage.
 Scheduling to maximize hospital resources.
 Procedure must be done by an experienced obstetrician perhaps with additional surgical support
capable dealing with potential for Caesarian hysterectomy and internal artery ligation.
 Blood bank/haematology support with X-matched blood in theatre
 Consideration of use of cell saver
 Discussion of risks and plans with Operating room personnel.
 Plans for post-op care.
 Discussion of risks and benefits of Regional anaesthesia or general anaesthesia for this procedure.
 Discussion of risks and management plans with patient and partner.

ntra-operative changes
 Fluid balance management and monitoring
o dditional large bore access with efficient fluid warmer
o dditions to routine monitoring perhaps intra-arterial monitoring+/- C
 Efficient patient warming and significance.
 Special pharmacology (ergotamine, PGF2a, prostin)
 Consideration of the need for a second anaesthetist

satisfactory answer required a good knowledge of the usual practice for the safe provision of
anaesthesia ( or ) for a Caesarean ection, and a clear and concise understanding of how and why
this may need to change in different circumstances.

Candidates who wasted time writing pages on either the pathophysiology of placenta praevia,
failed to gain any marks. surprising number of candidates did not seem to have read exactly what
the question was asking - and failed to mention either how their practice would change, or why.

8. You are asked to provide assistance to resuscitate a baby. ne minute after birth the
baby is apnoeic, grey/blue all over, floppy and unresponsive to stimulation, with a
pulse felt in the umbilical cord stump at 60/min. hat is this baby's score
escribe your resuscitation of the baby.

56% of candidates passed this question

here were two aspects to this question - calculation of score and neonatal resuscitation.

o obtain a pass, the points regarding neonatal resuscitation which needed to be discussed were:
 Airway and breathing - correction of hypoxia. IPPV at appropriate rate.
  Circulation - initiation of chest compression at appropriate rate and method.
 Resuscitation drugs/doses/routes - particularly Adrenaline
 General measures - keeping neonate warm and dry, checking glucose.

oints discussed in those answers which scored higher marks were: approximate weight of term
neonate, size and endotracheal tube position in term neonate, resuscitation drugs/dosing/routes, fluid
resuscitation, consideration of causes of neonatal arrest and management following resuscitation.

etter answers had a structured, clear and systematic approach, and were in fact often shorter
than those answers that scored less.

Most candidates were able to correctly calculate score. ome confused with lasgow
Coma cale ( C ) and calculated a number out of 15, while others spent too much time on this
part of the question and wrote an inadequate answer on neonatal resuscitation.

9. 25 year old man is to have laser surgery for a vocal cord papilloma. hat are
the hazards associated with the use of a laser in this situation and how can
they be minimised

70% of candidates passed this question

he response to this question was poor considering that there is an ustralian national standard on
this area of practice and all hospitals who are using L are required to have a policy and a L officer.
he better answers took a global approach and discussed the theatre environment and equipment,
the accreditation and safety measures for the staff, including fire drill and the protective
measures for the patient.

Many candidates chose to talk only about one or two of the above areas. his area of clinical
practice requires co-operation, discussion and ongoing co-ordination of the procedure with all
the staff in the theatre. his point was rarely made.

Question 10

10. patient with an automatic implanted cardiac defibrillator ( C ) with biventricular

pacing presents for elective surgery escribe how the presence of this device
influences your perioperative management of this patient.

62% of candidates passed this question

Marks were divided between preoperative ( ), intra-operative (5) and post-operative (1)
management with an additional mark for understanding that biventricular pacing is both pacing of
the right and left ventricle (usually via coronary sinus) to restore ventricular synchrony in
patients with poor left ventricular function and heart failure.
Marks were awarded for the following points:
n preoperative management hese patients are high risk and need to be optimised for surgery and
only surgery that is absolutely necessary should be done. atient history and examination should
focus on signs and symptoms of congestive heart failure and poor L function, ventricular
arrhythmia's and pacemaker dependency. evice history should be checked and device performance
optimised.
ppropriate investigations reviewed including recent echo report.

ntraoperative: n view of poor L function and CC invasive monitoring esp. arterial line should almost
be mandatory. he antitachycardiac function of C should be switched off by technician or magnet
placed over device but biventricular pacing should be maintained to optimize L function i.e. do not
change to asynchronous pacing unless patient is pacemaker dependant and diathermy is very close to
the device. witch off rate responsiveness only if surgery and use of diathermy is close to the device.
ack plates for external defibrillation and external pacing should be applied. iathermy precautions
should be adhered to.

ost op: he antitachycardiac function should be switched back on. igh dependency area utilised for
monitoring. ood post op analgesia ordered

he majority of candidates did not appreciate that biventricular pacing is put in for patients with
severe heart failure and poor L function. he majority talked generically about pacemakers. Most did
not appreciate that these patients should be left in biventricular pacing and not changed to as a lot
of candidates suggested.

he use of and effect of the magnet is poorly understood by most candidates.

Most candidates appreciated the effect of diathermy and precautions thereof as well as getting advice
from pacemaker company and cardiology support.

11. You are the anaesthetist at a children's hospital. three- year-old child scheduled
for dental restoration and extractions is found to have a systolic murmur during
your preoperative assessment on the day of surgery. hey have been on a
waiting list for 6 months and have had a dental abscess that settled with
antibiotics. escribe how you would evaluate the significance of this murmur and
how this evaluation would affect your decision to proceed or not with surgery.

67% of candidates passed this question

Marks were awarded for appropriately evaluating the significance of the murmur by history and
examination (6 marks) and integrating the information obtained into a decision to proceed or not (4
marks).

ood answers addressed the key elements of the question including the setting in a Children's
ospital where ready access to cardiology services is likely, it is a three year old with a systolic
murmur, the commonest age for common innocent murmurs, the procedure is at a high risk for
bacteraemia and bleeding, the parents have been waiting for six months, have already treated a
complication and would be anxious and probably very keen for the case to proceed, there are
stresses and costs involved in cancelling elective surgery for families and staff.

o pass candidates had to note that the aim in evaluation is to differentiate between innocent
physiological murmurs that are of little consequence and structural abnormalities that warrant
investigation pre-operatively. Candidates had to mention some of the symptoms and signs of heart
failure and heart disease in children and the distinguishing characteristics of an innocent vs
pathological murmur. etter answers noted that bacterial endocarditis is also possible with a history
of dental abscess and the possibility of a new heart murmur. etter answers also noted that a
happy, active thriving child is unlikely to have a significant murmur, and the place of pulse oximetry
and an C as simple investigations

here were various appropriate options for proceeding or not depending on evaluation as to the
significance of the murmur and any reasonable discussion gained a pass. n the absence of symptoms or
signs, with a typical innocent murmur, with a normal C , it would be reasonable to proceed with the
surgery. n a Children's ospital, if this was the first time the murmur had been noted and or the
anaesthetist was inexperienced, it would be very reasonable to consult a cardiologist on the day of
surgery, alter the operating list accordingly and schedule the operation for later in the list. he
cardiologist would then have time to perform an echocardiogram if indicated.

ntibiotic prophylaxis with amoxycillin pre op or at induction would not be indicated for an innocent
murmur but would be if pathological.

ny delay for a suspected pathological murmur would require a sympathetic and informed
discussion with the parents and the surgery should proceed without in-ordinate delay after
cardiological review perhaps with an overnight admission and surgery the next day.

xtra marks were gained by: low Chart showing a Management lgorithm, appreciation of an
ability to re-organize consultations and operating lists in referral hospitals, brief mention of new C
and ndocarditis prophylaxis guidelines, and the role of pre-operative trans-thoracic echo by
experienced anaesthetists.

12. utline the issues involved in the pre-operative assessment specific to a

patient presenting for transsphenoidal hypophysectomy for acromegaly.

52% of candidates passed this question

pass required the following points to be addressed:

 ecognition of effects of hypersecretion of , especially on the airway and C
 ecognition of potential mass effect of pituitary tumour

herefore it required a careful assessment of airway, cardiovascular assessment, with assessment of

functional capacity, specialist endocrinological consultation, review of the M , recent serum
electrolytes & L.

etter answers addressed the following points:

 isk of hyposecretion or hypersecretion of other anterior pituitary hormones; risk of
preoperative pituitary apoplexy; need for measurement of / / 4, C /cortisol, prolactin,
/L , /.....1. articularly exclude Cushing's syndrome and hypopituitarism.
 reoperative pharmacological treatments
 Measurement of visual acuity and fields
 ffects on blood chemistry and glucose homeostasis

1 . valuate the role of gabapentin in acute and chronic post surgical pain management.

Marks were divided between a brief introduction on the applied pharmacology of the drug which
applied to both areas of the question (2 marks) and its specific role in acute and chronic post
surgical pain for the remainder of the marks

2% of candidates passed this question

ole in acute post surgical pain

  Most trials involve a single pre-operative dose.
 ccumulating evidence indicates that gabapentin, may have important benefits on
pain following surgery if given peri-operatively.
 Multiple trials have demonstrated both improved analgesia and opioid-sparing efficacy
following various surgical procedures similar to non-steroidal anti-inflammatory agents. t
has anti- allodynia and anti- hyperalgesia effects.
 abapentin reduces movement-evoked pain and this can lead to enhanced functional
postoperative recovery.
 ostoperative opioid sparing may be of questionable relevance as few trials have shown
reduced opioid-related adverse effect.
 Limitations on its use include increased levels of sedation when combined with opioids
and the fact that it is only available as an oral preparation.
 nproven whether it use will decrease the incidence of chronic pain states following
surgery though it is used in at risk groups.

Chronic post surgical pain

 t is used in chromic post surgical pain states where a neuropathic component of the
pain is identified or in patients are in at risk groups.
 he safety and efficacy of gabapentin has been demonstrated in neuropathic pain
particularly diabetic neuropathy, pain following spinal cord injury and phantom limb pain
 hile may be used in other chronic post-surgical pain states specific trials in these areas
are lacking.
 t has equal efficacy to tricyclics in neuropathic pain but with a safer side effect profile for
many patients.

n general the question was answered poorly. Many described neuropathic pain and talked about
the treatment of chronic neuropathic pain often giving correct information but not answering the
question about acute and chronic post surgical pain. Knowledge of basic applied pharmacology and the
effects of gabpentin in the acute pain setting were especially lacking.

14. escribe the advantages and disadvantages of multi-centre clinical trials in anaesthesia
research

61% of candidates passed this question

Coverage of most of the following points would have been necessary to pass this question:

:
 Can undertake studies that are not feasible at a single institution
 ecruitment of large numbers of patients.
 reater statistical power (e.g. for assessing rare events like
death) Quicker patient recruitment.
 ider range of patients and clinical settings, and therefore better generalizability of results
than a single site study.
:
 Logistics of managing many centres and staff at remote locations. (e.g. main investigator,
site investigator, patients).
 upervision, reliability, honesty and protocol compliance of remote investigators.
 xpensive. eed to source large funds usually from competitive grants.
 rotocol must be applicable and approvable at all centres.
  rotocol must conform with local standards and practices, and ethics.
 Logistics of getting protocol through different ethics committees. ariable review standards;
but this is being streamlined through single ethical review (e.g. )
 tudies of procedures depend on level of skill at each centre (e.g. epidural analgesia)
 ome sites may not recruit adequately, and not offset set-up costs
 dditional cost of central administration

etter answers included the following points

:
 ew researchers develop skills and beneficial relationships with experienced investigators.
 evelops relationships for future trials and research collaboration.
 atients have benefit of closer supervision than in usual standard of care.

:
 urden of ensuring data quality, data queries and data cleanup.
 eed to develop method of remote data submission.
 eed 24 hour support for troubleshooting; especially for centres in different time zones.
 May have industry sponsorship that may bias protocol and outcome.
 Control of data analysis, writing of paper and publication relinquished to another body.
 ata analysis more complicated than single centre study; as it needs to adjust for effect of
centres (i.e. cannot pool all patients as if similar).
 Little ability for an individual site to change or influence protocol
 pproval of international studies has possible problems of variable national standards, practices,
consent, ethics.
 Local review of multicentre studies is a burden for local ethics committees.

ew candidates scored highly. his is surprising given the influence and publicity of recent large
multi- centre trials in anaesthesia conducted throughout ustralia, ew ealand and ong Kong (e.g.
M , - ware, M , poise). Many candidates would have been in departments that have
contributed to these studies.

15. utline the problems in providing general anaesthesia for an adult in the M suite

65% of candidates passed this

question Marks were awarded as

follows:
 he remote location of M suites with implications for personnel, assessment, transfer and
recovery. 1.5
 he naesthesia specific issues with regard to M suite
(access/airway/monitoring/drugs/emergency). 1.5
 he Magnet specific environment including absolute and relative contraindications for
patient or personnel, ferromagnetic equipment, noise, burns. 2
 Management of positioning and quenching magnet. 1
 he implications of requirement for in adult claustrophobic/confused/impaired/unstable/etc.
1
 ecovery issues (how, where, by whom, efficiency). 1
 ange of solutions to various problems of anaesthesia. 1
 xtra marks for more sophisticated analysis 1

eneral comments:
verall the standard of answers was poor, with few candidates achieving a high mark. his may have
partly reflected the fact that this question was the last on the paper.
M C L CL C L

7 % percent of candidates passed this section.

Marks are allocated for:

 n appropriate history which elicits key symptoms using relevant interviewing skills
including listening to the patient and responding to their non-verbal cues.
 n appropriate examination which elicits key signs using an examination technique
which follows an efficient, logical sequence.
 rofessionalism in dealing with patients i.e. showing respect to the patient and being
sensitive to patient comfort and modesty.
 n organised and efficient presentation of findings and knowledge of the medical condition
and its implications for anaesthesia.

82% of candidates passed this section.

he aim of this section of the examination is to assess the candidates' ability to:

 pply principles of acceptable safe practice and demonstrate sound clinical judgement

 lan and prioritise clinical actions and anticipate sequelae

 nterpret complex situations and demonstrate ability to adapt to changing clinical situations

Marks are awarded for showing sound judgement in decision making, demonstrating adaptability
to changing clinical situations, applying basic scientific principles to clinical practice and the
ability to organiser and express thoughts clearly. volving clinical scenarios are used in this
section of the exam.

he introductory scenarios, initial questions and overall aims of the vivas were as follows:

1. 25year old primigravida patient presents to delivery suite at 8 weeks gestation

complaining of a headache and difficulty with her vision. er is 170/110 and she
has ++++protein in her urine. oon after arrival she has a seizure.

hat are your priorities in assessment and resuscitation of this patient

AIMS OF THE VIVA

 Candidate can describe appropriate assessment and resuscitation of a woman presenting
with eclampsia.
 Discuss options for anaesthesia for Emergency Caesarean section
 Diagnose and appropriately treat pulmonary oedema and coagulopathy
 Interpret CXR showing pulmonary oedema.
 Interpret Coagulation studies showing coagulopathy 2ndy to hypofibrinogenemia.

2. 2 year old boy was a passenger in a car when he was struck in the head by a
flying brick lost from a passing truck.
n arrival at your hospital the paramedics report he responds to pain and they
have not been able to establish intravenous access.
 is initial observations are:
eart rate: 120
lood ressure: 75 systolic
espiratory ate: 25
p 2: 99%
e is receiving oxygen by mask via a self inflating bag and has a bandage
wrapped around his head. e has a hard cervical collar in place.
utline the initial management of this patient.

AIMS OF THE VIVA

 escribe appropriate initial assessment and resuscitation.
 iscuss options for access when this is difficult.
 iscuss strategies to control raised intracranial pressure.
 escribe a safe technique of anaesthesia for decompressive craniotomy.
 iscuss the and management of intraoperative hypoxia

3 You are called by your dentist colleague to the emergency department. e has
asked you to assess a 17 year old autistic boy who has a suspected tooth
abscess that requires drainage.
he boy has a large left submandibular swelling in the left submandibular region
and has complained to his parents of localised pain.
n arrival to the you observe a fearful young man who is curled up in the corner
being comforted by his parents.
is vital signs are as follows:
120, 110/70, 8.5

hat are the important aspects of your pre-anaesthetic assessment of this boy

AIMS OF THE VIVA

 escribe an appropriate assessment and plan for anaesthesia in this patient.
 iscuss the management of gaseous induction/difficult intubation in this patient.
 escribe appropriate diagnosis and management of aspiration.

4. 50 Year old urkish man with Motor eurone isease on nocturnal is

scheduled to have a ( ercutaneous ndoscopic astrotomy) tube inserted for
nutrition. he nursing staff tells you that the patient does not want to be
resuscitated in the event of life- threatening complications from anaesthesia or
surgery.

hat are the important issues to consider regarding this patient's request not
to be resuscitated

AIMS OF THE VIVA

 escribe an appropriate response and understanding of the issues
involved in patient's initial request.
 iscuss options for anaesthesia/sedation for patent for insertion
 nterpret 's showing mixed respiratory and metabolic acidosis when patient
develops peritonitis.
 Candidates can discuss issues surrounding further surgery or palliative care for
this
 patient.

5. 70 year old male requires a left lower lobectomy for squamous cell lung cancer.
e has ankylosing spondylitis, ceased smoking 25 years ago and is otherwise
healthy.
ne week ago under general anaesthesia for bronchoscopy and mediastinoscopy he
was noted to be a rade 4 laryngoscopy.

ow would you manage this man's airway for this surgical procedure

AIMS OF THE VIVA

 iscuss strategies for lung separation in a patient with difficult airway.
 rouble shoot problems with ventilation during one-lung ventilation
 Describe pain management options in thoracotomy including use of paravertebral
catheters.

6. 65 year old male is booked for an elective endoluminal repair of his abdominal
aortic aneurysm in the angiography suite. e has had a history of ischaemic
heart disease with an episode of cardiac failure years ago; other medical
history includes controlled hypertension. is previous was 5 years ago for knee
arthroscopy.
Medications: trandolapril, carvedilol, simvastatin. il known allergies
utline your approach to assessing his cardiac risk for this procedure.

AIMS OF THE VIVA

ndertake appropriate preoperative cardiac risk evaluation.
 escribe an appropriate anaesthesia technique for this procedure.
 escribe and justify their anaesthesia machine check.
 escribe appropriate dd and management of severe hypotension due to
reaction to contrast

7. 75 year old man presents to your pre-operative assessment clinic prior to

an inguinal hernia repair.
e has a smoked a packet of cigarettes a day for the past 50 years.
o assess his respiratory system what do you want to know from his history
and physical examination

AIMS OF THE VIVA

 escribe appropriate reoperative respiratory assessment and interpret respiratory
function tests
 iscuss options for regional anaesthesia for this patient and demonstrate
knowledge of the innervation of the inguinal region.
 escribe the and management of postoperative delirium (due to alcohol
withdrawal).

8 55 year old male scheduled for open radical prostatectomy is seen in the pre-
operative clinic one week prior to operation. e had a laminectomy for lumbar
radiculopathy three years prior and is on long term oxycodone for chronic back
pain.
e is otherwise well.
uring your discussion of the procedure he asks you if he's likely to need a blood
 transfusion.
ow will you respond to his enquiry

AIMS OF THE VIVA

 iscuss hazards of blood transfusion and lood conservation strategies to
reduce allogenic blood transfusion in this patient.
 escribe dd and management of intra-operative hypotension (due to air embolism)
 iscuss appropriate pain management options for this patient.

9. he obstetricians call you from their antenatal clinic. hey would like you to review
a woman aged years with a M of 8 who is 6 weeks gestation as they are
concerned about her. he says she has become very short of breath recently
and she has marked peripheral oedema.
ow will you evaluate her dyspnoea and set about making a diagnosis

AIMS OF THE VIVA

 iscuss differential diagnosis of initial presentation and evaluation of dyspnoea in
pregnancy.
 escribe principles of treatment of heart failure
 escribe safe plan for anaesthesia including regional s general anaesthesia for L
C , monitoring and postpartum care.
 nterpret basic echo data

10. he hospital mergency epartment requests your assistance with an 18 month

boy who is en route to hospital having been run over by a car in the driveway.
mbulance staff communicate that the patient is conscious, shocked with a
bruised and distended abdomen.

You are the lead care giver. ive an overview of your preparation for the child's
arrival in the mergency epartment.

M
 escribe appropriate initial assessment and resuscitation.
 iscuss transfusion strategies for massive blood loss in this child.
 iscuss the principles of conservative vs operative management of blunt
trauma in children.
 iscuss and management of hypoxia due to pulmonary contusions during
laparotomy.

11 5 year old obese male ( M of 5) presents to the mergency epartment with

severe stridor.
e has had a sore throat with dyspagia for 2
days You are called down urgently to review
him.
hat possible diagnoses will you consider as you approach the mergency
epartment

M
  iscuss the differential diagnosis of stridor in this patient.
 iscuss options to secure airway.
 ecognise and manage hypoxia and difficulty with ventilation from
misplaced tracheostomy tube.

12. male anaesthetic trainee in his rd year of training ( Y1) is rostered to be with
you on your routine gynaecology list. You meet the trainee the night before the
list and discuss the management of the booked cases.
he first case is a previously well 66-year old woman undergoing
laparoscopy for pelvic pain.
he other two cases have also been seen in clinic and are previously well
patients undergoing diagnostic laparoscopies for infertility.

hat are your expectations of a trainee at this level of training during this
operating list

AIMS OF THE VIVA

 escribe the objectives of in training assessment.
 escribe an appropriate plan for assessment of trainees at this level.
 ecognise the signs of possible drug abuse in a colleague and describe
appropriate short-term strategy for dealing with the trainee.

13. You are asked to review a 1year old woman in the re-admission clinic. he
has myasthenia gravis and is booked to have a thymectomy via a median
sternotomy.

hat are your major concerns regarding this patient

AIMS OF THE VIVA

 escribe appropriate peri-operative management of myasthenic patient
 nterpret and trouble shoot changes in Co2 traces
 iscuss pain management options following sternotomy.
 nterpret euromuscular monitoring and discuss criteria for safe extubation

14. You are contacted by the nurse-in-charge of the Cardiac nvestigation unit, the
morning of your elective list in the catheterisation laboratory. ue to the
breakdown of the X-ray equipment in the regular cath lab, your list has been
transferred to another fluoroscopy suite which has satisfactory cardiac
investigation equipment. You have never been to this location.
Your first case is:
M . . 5M
L C Y L Y Y +/-
Q CY L

ow would you normally approach anaesthetising in an unfamiliar location

 AIMS OF THE VIVA
 escribe the minimum standards required for providing anaesthesia services to the
lab.
 nterpret C showing
 iscuss options for anaesthesia/sedation for studies
 iscuss and management of profound hypotension due to tamponade.

15. You are doing a locum for a private group. here is an addition to tomorrow's
list that has been emailed to you at 16.00.
60 year old woman presents for an elective left ankle arthrodesis. he has
had rheumatoid arthritis for 20 years.
er present medications include prednisone 20mg/day, long acting morphine
60mg/day, methotrexate and the C X-2 inhibitor, etorcoxib.
he preoperative questionnaire indicates she has some neck pain and back pain,
with non-specific intermittent pain down one leg. he has indicated she wants the
operation performed under 'some sort of local block'

hat further information do you need from your preoperative phone call the night
before

AIMS OF THE VIVA

 iscuss the options for regional anaesthesia in this patient and describe
the innervation of the ankle.
 iscuss the implications of heumatoid arthritis and long- term steroid therapy for
anaesthesia/surgery.
 iscuss appropriate perioperative pain management in patient on long term opioids
16. 60 year old man with long standing diabetes managed on insulin presents
with acute right iliac fossa pain. e is distressed, febrile, sweating and has
signs of peritonism. You are asked to anaesthetise him for a laparotomy.

hat are the implications of diabetes for this patient

AIMS OF THE VIVA

 iscuss the preoperative assessment of a diabetic patient
 Correctly interpret s showing ketoacidosis and describe appropriate
perioperative management of fluids and electrolytes n this patient.
 escribe the and x and management of post-operative cognitive dysfunction
(due to stroke)

C M
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College Council upervisors of raining

egional ducation fficers anel of xaminers
egistered rainees