THE ROYAL COLLEGE OF ANAESTHETISTS
DIPLOMA OF FELLOW OF THE ROYAL COLLEGE OF ANAESTHETISTS
26th October 2004
9:30am to 12:30pm
Candidates are required to answer all twelve questions. Questions numbered 1 - 3 must be answered in Book A (Blue), 4 - 6 in Book B (Pink), 7 - 9 in Book C (Green) and 10 - 12 in Book D (Yellow). Candidates who fail to answer all 12 questions will not pass the Examination. All 12 questions carry equal marks. In multipart questions, the examiners have indicated the way in which marks are allocated by providing the maximum percentage mark available at the end of the part. Candidates are advised to allocate their time following this guidance. Candidates are informed that an examiner will be present during the time allowed for this paper, for consultation in case any question should not appear clear.
SECTION A (Book A - blue)
1. A patient is mechanically ventilated for acute lung injury in the ICU. Explain what practical steps you would take to turn the patient from the supine to the prone position. (70%)
List three common acute complications of the prone position. (30%)
2. A comatose, ventilated patient who has a head injury has an intracranial pressure of 35 mmHg. His CT scan excludes a surgically reversible cause. What immediate steps would you take to assess and treat the patient?
3. List the radiological investigations that are available to help exclude an unstable cervical spine injury in an unconscious, ventilated adult with multiple severe injuries. (25%)
What are the limitations of each technique? (75%)
SECTION B (Book B - pink)
4. What are the indications for a popliteal fossa block? (10%)
List the nerves that are affected and describe their cutaneous innervation. (35%)
What responses would you get on stimulating these nerves? (25%)
Briefly describe one technique for performing this block. (30%)
5. Compare the electrolyte content and osmolality of 0.9% sodium chloride (normal saline) and compound sodium lactate solution (Hartmann’s). (40%)
Why might compound sodium lactate solution be a better crystalloid replacement fluid than 0.9% sodium chloride? (40%)
Explain the effects of a large infusion of 0.9% sodium chloride on acid-base balance and electrolytes. (20%)
6. An obese 70-year-old man underwent an emergency abdominal aortic aneurysm repair yesterday evening. He is known to be a heavy smoker and is a treated hypertensive. He has been cardiovascularly stable overnight and is responding appropriately. Propofol and morphine infusions are stopped with a view to extubation. Agitation, tachycardia (heart rate 130 bpm) and hypertension develop (250/90 mmHg).
List the factors that could be important in precipitating this response. (40%)
Briefly outline your further management in the ICU of these factors. (60%)
SECTION C (Book C - green)
7. List the classes, with an example of each, of a) anticoagulants (20%) and b) antiplatelet drugs (20%) in current clinical practice.
How would you minimise the incidence of bleeding and haematoma formation associated with epidural anaesthesia in patients taking each of these drugs? (60%)
8. A patient on the ICU, who had cardiac surgery completed 3 hours ago, is still intubated.
What clinical features might suggest the development of acute cardiac tamponade? (55%)
How might you confirm the diagnosis? (5%)
Outline your management of acute cardiac tamponade? (40%)
9. You are asked to anaesthetise a 5-year-old child (weight 20 kg) for an emergency appendicectomy. Describe in detail the induction of anaesthesia with special reference to:-
Fluid management (20%)
The airway (50%)
Drug management, including doses (30%)
SECTION D (BOOK D - yellow)
10. Define primary postpartum haemorrhage (10%)
List the pharmacological agents that may be used postpartum to reduce uterine atony and any precautions with their use. (50%)
Outline the management of a significant primary postpartum haemorrhage. (40%)
11. What factors contribute to intravenous drug errors in anaesthetic practice? (40%)
What strategies are available to reduce the incidence of such errors? (60%)
12. What are the presenting clinical features of infective endocarditis? (40%)
What are the principles that guide the use of antibiotics as prophylaxis against this condition during surgery? (60%)