Past RCoA Final FRCA SAQ's relating to cardiothoracic anaesthesia and critical care with ...

26 Pages·2017·0.77 MB·English

Past RCoA Cardiothoracic

Final FRCA SAQ Questions
with examiner comments

November 1996 – Sept 2016

Compiled by Dr J Brand & Dr S Law
September 2016

Question 8
You are asked to review a 65-year-old woman on the cardiac intensive
care unit who has undergone coronary artery bypass surgery earlier in
the day.

a) What clinical features might suggest the development of cardiac
tamponade? (9 marks)

b) Describe specific investigations with their findings that could confirm the
diagnosis of cardiac tamponade. (2 marks)

c) Outline the management of acute cardiac tamponade in this patient. (9
marks)

Examiners Report: Cardiothoracic – cardiac tamponade

Pass Rate: 81.4%.

This question had the highest pass rate in the paper. It is an important topic and it is
good to see that candidates are aware of the signs and symptoms and treatment
options for this emergency.

Compiled by Dr J Brand & Dr S Law
March 2016

Question 8
A 70-year-old woman with aortic stenosis presents for an open aortic
valve replacement (AVR).
a) What is the pathophysiology of worsening aortic stenosis? (8 marks)
b) Which specific cardiac investigations may be used in assessing the severity
of this woman’s disease? (3 marks)
c) Give values for the peak aortic flow velocity, mean pressure gradient and
valve area that would indicate that this woman has severe aortic stenosis. (3
marks)
d) What would be your haemodynamic goals for the perioperative
management of this patient? (6 marks)

Examiners Report: Aortic Stenosis

Pass Rate: 41.8%.

The pass rate for this question was the second lowest overall. Aortic stenosis is a
common condition and its pathophysiology and management should be known to
candidates sitting this exam. In part (a) many candidates simply gave the symptoms of
aortic stenosis rather than describing the pathophysiology. This could have been due
to not reading the question carefully enough but may also reflect lack of knowledge. As
mentioned in previous reports, candidiates should endeavour to arrange taster
sessions in modules such as cardiac anaesthesia if they have not done them prior to
sitting the SAQ paper.

Compiled by Dr J Brand & Dr S Law
September 2015

Question 9

a) What are the central and peripheral neurological complications of coronary
artery bypass surgery? (7 marks)
b) What are the risk factors for central neurological complications? (6 marks)
c) How can the incidence of central neurological complications be reduced? (7
marks)

Examiners Report: Neurological complications of CABG

Pass Rate: 54.6%.

Candidates who did well in this question tended to do well overall. There was quite a
spread of scores with some candidates having a very clear idea of the answers and
others seemingly not very much idea at all. Whether this reflects the fact that some
candidates sitting the exam have no experience of cardiac anaesthesia is not clear.
However, as stated in previous reports, candidates who have no exposure to the
mandatory units of training should endeavour to spend a few sessions gaining first
hand experience prior to sitting the SAQ paper.

Compiled by Dr J Brand & Dr S Law
March 2015

Question 8

A 67 year-old patient is to undergo coronary artery surgery on
cardiopulmonary bypass (CPB).

a) What dose of heparin is used to achieve full anticoagulation for CPB and
how is it given? (2 marks)

b) Which laboratory and “point-of-care” tests determine the effectiveness of
heparin anticoagulation in CPB patients? Give the advantages and/or
disadvantages of each test. (10 marks)

c) What are the causes of inadequate anticoagulation in a patient whom it is
believed has already received heparin? (5 marks)

d) Describe the possible adverse reactions to protamine. (3 marks)

Examiners Report: Heparin for bypass surgery

Pass Rate: 61.5%. (17.2% of candidates received a poor fail)

This question proved straightforward to candidates who had rotated through a cardiac
unit or had read a textbook on cardiothoracic anaesthesia. Many weak candidates
neither had knowledge of the intraoperative dosing of heparin for bypass surgery nor
aspects of appropriate monitoring. Again, inexperience was the predominating factor
in success or failure in this item.

Compiled by Dr J Brand & Dr S Law
September 2014

Question 4

a) What are the purposes (3 marks), typical composition (4 marks) and
physiological actions of cardioplegia solutions? (5 marks)

b) By which routes can solutions of cardioplegia be administered? (2 marks)

c) What are the possible complications of cardioplegia solution
administration? (6 marks)

Examiners Report: Cardioplegia

Pass Rate: 16.5%.

Cardioplegia is an important basic tool in cardiothoracic anaesthesia although not used
invariably in current surgical procedures. It was evident from the answers which
candidates had undertaken an attachment in this area of practice, or had read an
appropriate textbook. The importance of considering the mandatory units of training in
preparation for the Final FRCA examination has been emphasised above.

Compiled by Dr J Brand & Dr S Law
March 2014

Question 2
a) What are the indications for insertion of an implantable cardiac defibrillator
(ICD)? (20%)
b) How might surgical diathermy affect the ICD? (20%)
c) A patient with an ICD is listed for elective surgery; what preparations are
necessary preoperatively, intra-operatively and postoperatively? (45%)

d) How does the management differ if this patient requires emergency
surgery? (15%)

Examiners Report: Implantable cardiac defibrillator

Pass Rate: 67.1%.

Generally well answered. Indications for a pacemaker are part of core knowledge
incorporating many conditions, which have a bearing on the management of
anaesthesia. For section (c), some candidates gave generalised answers and failed to
focus on the specifics of how the risk of an ICD working inappropriately, or failing to
work when necessary, would influences anaesthetic practice. In an emergency
situation, deactivation of the ICD would be a reasonable “balance of risks” action.

Compiled by Dr J Brand & Dr S Law
March 2014 (cont.)

Question 7
A 71-year-old patient requires a rigid bronchoscopy for biopsy and
possible laser resection of an endobronchial tumour.
a) Outline the options available to maintain anaesthesia (20%) and manage
gas exchange. (30%)
b) How will use of the laser change the management of anaesthesia? (15%)
c) What are the possible complications of rigid bronchoscopy? (35%)

Examiners Report: Rigid bronchoscopy

Pass Rate: 60.8%.

This question proved discriminatory between candidates who gave a mature and
thoughtful answer and those that did not understand the implications of “tubeless” ENT
/ thoracic surgery. Weaker candidates proposed the use of laser-proof endotracheal
tubes, and even double lumen endobronchial tubes and cardiac bypass to facilitate gas
exchange. Part (a) tended to score scored badly whilst parts (b) and (c) were better
known. Focus in part (c) was dominated by traumatic complications with candidates
forgetting “anaesthetic” issues such as; laryngospasm and bronchospasm,
pneumothorax / barotrauma / volutrauma from jet ventilation, cardiovascular
disturbances, pulmonary infection, hypoxaemia, hypercarbia and awareness.

Compiled by Dr J Brand & Dr S Law
September 2013

Question 1

You are asked to anaesthetise a 75-year-old man for an urgent DC
cardioversion on the Coronary Care Unit (CCU). He has a broad complex
tachycardia of 150 beats/minute, but is maintaining a systolic blood
pressure of 70 mmHg and has a Glasgow Coma Score of 13/15.
a) List the advantages and disadvantages of providing anaesthesia in the
CCU. (30%)
b) What factors must be taken into consideration when choosing an
anaesthetic technique for this patient? (30%)
c) What complications may occur as a consequence of the procedure? (40%)

Examiners Report: DCCV on CCU

Pass Rate: 45.7%.

This question proved difficult for many candidates.

The advantages of providing anaesthesia in a Coronary Care Unit for a maximum of
three marks included:
• Avoiding the transfer an unstable patient to theatre
• Cardiology Department skills readily available
• Specialist equipment and drugs are immediately accessible
• Allows earlier treatment

The most important disadvantage was anaesthetising a patient in a remote and
unfamiliar environment. This statement needed to be expanded to include the potential
lack of monitoring (capnography), anaesthetic drugs, recovery and skilled assistance.
Few candidates mentioned the difficulty in complying with the filling in of a WHO
checklist. Some of the factors that should have been considered before commencing
anaesthesia included valid consent, recent investigations, starvation status and a
potential need for intra- or inter-hospital transfer. Required both anaesthetic and
cardiological complications, the latter included arterial embolism, myocardial
ischaemia, pulmonary oedema, burns to the patient and electrical injury to staff.

Compiled by Dr J Brand & Dr S Law
September 2013 (cont.)

Question 7

You are asked to review a 65-year-old man on the Cardiac Intensive Care
Unit who underwent coronary artery bypass surgery earlier in the day.
a) Which clinical signs suggest the development of acute cardiac tamponade?
(40%)
b) List the investigations and their associated derangements that could
confirm the diagnosis of acute cardiac tamponade. (15%)
c) What is the management of acute cardiac tamponade in this patient? (45%)

Examiners Report: Tamponade on CITU

Pass Rate: 57.6%.

This question was designated an “easy” question by the exam board and was a good
discriminator. The investigations and associated derangements were linked and
one mark was awarded for both correct answers. The management of acute pericardial
tamponade was generally answered in a generic way (ABC, call for help etc.) but
a number of candidates wasted time and effort on managing an anaesthetic in this
situation. Many failed to monitor the clotting and administer blood products or reversing
agents if indicated.

Compiled by Dr J Brand & Dr S Law