Describe how you would perform a spinal anaesthetic in a patient presenting for transurethral resection of the prostate (TURP), demonstrating on an actor the appropriate positioning of the patient and the anatomical landmarks.
- Why do we choose L3/4?
- Name three absolute contraindications to spinal anaesthesia.
- How would you attach the syringe to the needle?
- You are shown two different needles: a 22 G one (what type of needle is this?) and a 25 G Whitacre needle; which would you use in this patient and why?
- Which ligaments will you pass through after piercing the skin and subcutaneous tissue?
- What level block will you require for TURP? Demonstrate this level on the “patient”.
2. Clinical anaesthesia
What do you need to check in the patient notes before giving a blood transfusion?
- What would you record in the notes before giving a transfusion?
- What would you check before giving a transfusion?
- What is the most common transfusion reaction?
- What percentage of patients given an incorrect blood type transfusion will die?
- What do they die of?
- What contraindications are there to giving blood to a patient?
Discuss radial artery invasive arterial blood pressure (IABP) measurement
- You are then shown an IABP measuring device and are asked to state any faults you find and explain why each fault is a problem.
- How would you zero this equipment?
- How would you perform the high-pressure calibration?
- You are then shown a trace after a flush with three oscillations before the baseline returns, followed by an overdamped trace and are asked to comment on it.
4. Anaesthetic hazards/resuscitation
You have been called to recovery by one of the nursing staff for a patient who had a cataract operation under local anaesthetic 50 minutes ago. She says she feels “awful”. Her heart rate is 150 bpm and blood pressure is 110/60 mmHg.
- You are shown an ECG (showing supraventricular tachycardia) and are asked to interpret it.
- What non-pharmacological treatment could you try first in this patient?
- What drug can you use if this does not work?
- What would you do if the patient does not improve?
- What signs might indicate that the patient is unstable?
- How would you manage an unstable patient?
- What energy settings would you use for the first and subsequent shocks on biphasic defibrillation?
- What would you do if the shocks fail to work?
You are asked to perform an airway assessment on an actor, describing what you are doing and any relevant findings. This includes checking nasal patency, commenting on mouth opening (how much is adequate?), and checking dentition, Mallampati score, tongue size and jaw pronation.
- What other investigations would you perform?
- You are shown an X-ray of the C-spine and are asked the following questions:
- Can you see all the vertebrae?
- Point out the atlanto-axial gap
- Point out the atlanto- occipital gap
- Is the neck in good alignment?
- How would you manage this patient’s airway?
You have been called to resuscitation as part of the cardiac arrest team. Cardiopulmonary resuscitation (CPR) is in progress and you can assume that there is no pulse and that the rhythm displayed is correct. On arrival in the station CPR is ongoing, with a laryngeal mask in situ. CPR is being performed by a paramedic and someone else is bagging the patient via the laryngeal mask. You are asked to proceed with managing the patient.
- Confirm cardiac arrest by stopping CPR, checking the pulse and assessing the rhythm on a monitor.
- Where are defibrillator pads placed and why do we choose these positions?
- You are asked to demonstrate the safe defibrillator technique.
- You are asked about the advanced life support (ALS) algorithm. What do you do after two cycles of CPR? And after three cycles CPR? What energy level is used for the first shock and how do you escalate it? What shock energy setting is used in a paediatric setting?
7. History taking
You are asked to take a history from a 45-year-old woman presenting for a mastectomy and breast reconstruction.
8. Simulator manikin
You are called to see a young asthmatic who has been admitted to the high-dependency unit for an acute exacerbation of asthma. He is intubated and ventilated, receiving intravenous salbutamol and theophylline and is also on steroids. The ST2 has asked you to come and help. Demonstrate your treatment on a manikin.
You are shown a chest X-ray of a 35-year-old woman awaiting surgery for removal of a thyroid nodule. It shows large retrosternal goitre with tracheal deviation.
- Is there any evidence of C-spine subluxation?
- Is it likely that the patient will have tracheomalacia?
- Is it likely that this patient might have a difficult intubation?
- Is this due to a thymoma?
- Would you routinely need to perform a thoracotomy on this patient?
- Is there a risk of recurrent laryngeal nerve damage?
- Do you need to monitor serum calcium levels for several weeks postoperatively for this patient?
You are called to change a tracheostomy tube for a patient in the intensive care unit who has had their tracheostomy for 2 weeks. The patient is sedated and ventilated.
- What will you need to do before changing the tracheostomy tube?
- Demonstrate how you will change the tracheostomy tube.
- What is the change in dead space when you insert a tracheostomy tube?
- At what level is the tracheostomy tube placed?
You are shown a lateral C-spine X-ray taken from a patient listed for an emergency appendicectomy.
- Are all the vertebrae visible?
- Are there any osteophytes between C3 and C5?
- Is there any evidence of cervical fusion?
- Is there a risk of neck fracture with application of cricoid pressure?
- Is this patient likely to have limited chest expansion?
- Do you need to exclude aortic regurgitation on this patient preoperatively?
- Is complete heart block a rare association?
- Will vital capacity be affected in this patient?
- Would a spinal be the most appropriate anaesthetic for this patient?
- Is the patient likely to have poor mouth opening?
You are shown a cross-section drawing of the diaphragm and asked to identify labelled structures: the inferior vena cava, aorta, oesophagus, the two crura of the diaphragm.
- At what levels do each of these structures pierce the diaphragm?
- Describe the muscular attachments of the diaphragm.
- Describe the nerve supply to the diaphragm.
- Where does the phrenic nerve pierce the diaphragm?
- What is the significance of the innervation of the diaphragm in laparoscopic surgery?
13. History taking
Take a history from a female patient listed for laparoscopic cholecystectomy and on-table cholangiogram.
- What will improve her reflux/gallstones?
- What are the symptoms of obstructive jaundice/gallstones?
- When was her last menstrual period?
- What medications is she on?
- What is she allergic to?
14. Anaesthetic equipment
You are told that you are going to be performing a rapid sequence induction (RSI) for an appendectomy, and are asked to check the equipment.
- You are then asked about the different stages of Difficult Airway Society Guidelines.
15. Anaesthetic equipment
You are shown line diagrams of a fuel cell, polarographic electrode and paramagnetic analyser and are asked to identify each.
- Apart from measuring O2 in a gas mixture, in which other substances can a polarographic electrode measure O2?
- You are asked to name labelled components of the polarographic electrode.
- You are shown the equations for four different chemical reactions at the cathode and are asked to identify them.
- What is the polarising voltage applied?
You are asked to identify structures labelled on a diagram of the fetal circulation.
- What is the purpose of the foramen ovale (FO)?
- What is the oxygen saturation in the umbilical vein and descending aorta?
- What are the changes that occur at birth in the FO/ductus arteriosus (DA)?
- What does the DA become at birth?
17. Communication skills
You are asked to speak to a patient listed for day case surgery by the preoperative nurse. He is obese and has obstructive sleep apnoea, and she feels he is not suitable for day case surgery.
You need to discuss this with him.
- What are the anaesthetic implications of obesity?
- Why is day case surgery not advisable with obesity and obstructive sleep apnoea?
- How would you manage him in the perioperative period?