2

A 52-year-old male patient is booked for an elective laparoscopic Nissen fundoplication to repair his hiatus hernia. He is diabetic and hypertensive and his body mass index (BMI) is 38kg/m2. His wife has told you during your pre-operative visit that he snores loudly when sleeping, occasionally becomes quiet and then seems to jerk awake before subsiding again. a) Describe in detail your further approach to the pre-operative assessment and a) optimisation of this patient for his elective surgery, by referring to the following: I) History. II) Examination. III) Special Investigations. IV) Optimisation. V) Premedication. (40) b) What would be your preferred method of airway management in this case and why?(15) c) During the case, you notice that airway pressures have markedly increased, tidal volume decreased and the saturation is falling. What are the possible causes of this phenomenon? How would you identify the true cause? (15) d) Post-operatively, in the recovery room, you notice that despite being awake when you left theatre, the patient has become obtunded. What are the possible causes of this phenomenon and how would you manage them? (20) e) Tabulate the postanaesthetic modified Aldrete recovery score. (10) [100] 52-Jarige man word geboek vir elektiewe laparoskopiese Nissen funduplikasie om sy hiatus hernia te herstel. Hy is hipertensief en diabeet, en sy liggaamsmassa-indeks (BMI) is 38 kg/m2. Gedurende die pre-operatiewe besoek, noem sy vrou dat hy hard snork wanneer hy slaap, dan stil raak en wakker word met ruk voordat hy verder slaap. a) Bespreek in detail u verdere benadering tot die pre-operatiewe benadering en optimalisasie van hierdie pasint vir sy elektiewe chirurgie deur te verwys na die volgende I) Geskiedenis. II) Ondersoek. III) Spesiale ondersoeke. IV) Optimalisasie. V) Premedikasie. (40) b) Wat is u metode van keuse vir lugweghantering in hierdie geval en waarom? (15) c) Gedurende die geval merk u dat die lugwegdruk beduidend vermeerder het, die getyvolume verminder het en die saturasie afneem. Wat is die moontlike oorsake van hierdie verskynsel? Hoe sal u die ware oorsaak identifiseer? (15) d) Post-operatief in die herstelkamer merk u dat die pasint nie wekbaar is nie, ten spyte van die feit dat hy wakker was toe hy die teater verlaat het. Wat is die moontlike oorsake van die verskynsel en hoe sal u die oorsake hanteer? (20) e) Tabuleer die post-narkose gemodifiseerde Aldrete hersteltelling. (10) [100] Physiology You are giving a normal, healthy 70 kg patient (whose temperature is 37C) a general anaesthetic (with muscle relaxation and positive-pressure ventilation through an endotracheal tube) and by mistake the set tidal volume is 140 ml (instead of 500 ml), there is no PEEP (positive end-inspiratory pressure) selected, the ventilatory rate is 10 breaths/minute and there is no end-inspiratory pause. At initial machine check the leak of the circle system was 80 ml/minute. Soda Lime is switched in. The fresh gas flow is 1.0 l/minute and the FiO2 is 40% (oxygen in air). A forced-air warmer is used (Bair Hugger set at maximum) and over time the patients temperature rises to 37.5C. What is likely to happen over time to ventilation and oxygenation in this case? Give normal values for measured and monitored parameters to describe this scenario and its consequences. Refer to respiratory physiology, arterial blood gas values and changes seen on the anaesthetic monitor. (25)

3.1

3.2 Pharmacology 3.2.1 List the clinical uses of adrenaline with dosages, concentrations and routes of administration. (10) 3.2.2 a) Explain what 1:1000 (one in one thousand) preparation means. Give an example. (2) b) When a solution is expressed as a percentage, what does this mean? Give an example. (2) c) How much bupivacaine and how much adrenaline is in 20 ml of 0.5% bupivacaine with 1:200 000 adrenaline? (2) d) If a concentration is expressed in parts per million, what does this mean? Give an example. (2) 3.2.3 a) What is the difference in mechanism of action between ephedrine and phenylephrine? (3) b) How would you prepare and administer ephedrine? (2) c) How much phenylephrine is in 1 ampoule and how would you prepare it for administration? (2) [25] 3.3 Physics a) List the components of a circle system. (10) b) How is carbon dioxide removed from the circle system? (1) c) How does this device work? (4) d) When should this device be replaced? (2) e) How does bipolar diathermy differ from standard diathermy? (2) f) What are the 3 requirements which need to be present for a fire to break out in theatre? Give an example of each found in theatre. (6) [25] 3.4 Procedures a) List the different approaches which can be used to perform a brachial plexus block. (4) b) Which approaches can be used to provide an optimal block for i) Shoulder, arm and forearm surgery ii) Elbow and hand surgery. iii) Arm, forearm and hand surgery. (6) c) Describe how you would perform a nerve block using a nerve stimulator. (7) d) When a peripheral nerve stimulator is used to determine adequate reversal of a neuromuscular blockade, fade may occur. What does the presence of fade indicate? (2) e) Which nerves and muscles are commonly monitored when using a nerve stimulator to monitor muscle relaxants? (4) f) Give 2 other clinical indicators of adequate recovery from neuromuscular blockade. (2) [25] Fisiologie U dien algemene narkose toe vir normale, gesonde 70 kg pasint (met temperatuur van 37C). U het spierverslapper toegedien, en ventileer die pasint met positiewe drukventilasie deur endotrageale buis. U stel per abuis die getyvolume op 140 ml (in plaas van 500 ml). Daar is geen PEEP (positiewe eind-ekspiratoriese druk) geselekteer nie en die ventilatoriese tempo is 10 asemhalings per minuut met geen eind-ekspiratoriese pouse nie. Toe die masjien aanvanklik nagegaan is, was die lek in die sirkelsisteem 80 ml/minuut. Die natronkalk is ingesluit in die sisteem. Die varsgasvloei is 1.0 l/min en die F1O2 is 40% (suurstof in lug). Geforseerde lugverwarmer (Bair Hugger) word gebruik en is op maksimum gestel. Die pasint se temperatuur verhoog met verloop van tyd tot 37.5C. Wat sal waarskynlik met verloop van tyd gebeur met die ventilasie en oksiginasie in hierdie geval? Gee normale waardes vir gemete en gemoniteerde parameters om die scenario en gevolge te beskryf. Verwys na respiratoriese fisiologie, arterile bloedgaswaardes en verandering gesien op die narkose monitor. (25) 3.2 Farmakologie 3.2.1 Lys die kliniese gebruike van adrenalien met dosisse, konsentrasies en roetes van toediening.

3.1

3.2.2 a) b) c) d) 3.2.3 a) b) c) 3.3

(10) Verduidelik wat 1:1000 (een in eenduisend) oplossing beteken. Gee voorbeeld (2) Wat beteken dit as oplossing uitgedruk word in persentasie? Gee voorbeeld. (2) Hoeveel bupivakaen en hoeveel adrenalien is in 20 ml 0.5% bupivakaen met 1:200 000 adrenalien? (2) Wat beteken dit as konsentrasie uitgedruk word in dele per miljoen? Gee voorbeeld. (2) Hoe verskil die meganisme van werking tussen efedrien en fenielefrien? (3) Hoe sal u efedrien voorberei en toedien? (2) Hoeveel fenielefrien is in 1 ampule en hoe sal u dit voorberei vir toediening? (2) [25]

Fisika a) Lys die komponente van sirkelsisteem. (10) b) Hoe word koolsuurgas uit die sirkelsisteem verwyder? (1) c) Hoe werk hierdie toestel? (4) d) Wanneer moet hierdie toestel vervang word? (2) e) Hoe verskil bipolre diatermie van standaard diatermie? (2) f) Watter 3 voorvereistes is nodig vir brand om in teater uit te breek? Gee voorbeeld van elke komponent. (6) [25] Prosedures a) Lys die verskillende toegange wat gebruik kan word om bragiaalpleksusblok uit te voer. (4) b) Watter toegange kan gebruik word om optimale blok te verseker vir i) Skouer, arm en voorarm chirurgie. ii) Elmboog en hand chirurgie. iii) Arm, voorarm en hand chirurgie. (6) c) Beskryf hoe u senuweeblok sal uitvoer deur gebruik te maak van senuweestimulator. (7) d) Wanneer perifere senuweestimulator gebruik word om voldoende omkeer van neuromuskulre blokkade te bepaal, mag kwyning (fade) voorkom. Waarop dui die teenwoordigheid van kwyning? (2) e) Watter senuwees en spiere word algemeen gemoniteer wanneer senuweestimulator gebruik word om spierverslappers te monitor? (4) f) Noem 2 ander kliniese indikators van voldoende omkeer van neuromuskulre blokkade. (2) [25]

3.4

2.1

A 35-year-old P4G4 woman has had a Caesarean section for all her deliveries. She has been in the ward for 4 hours post operatively after the last caesarean section, when the registrar is called to see her. Her Caesarean section was conducted under a spinal anaesthetic. On examination, her blood pressure is 100/80 and her pulse rate is 110 per minute. The registrar has performed an ultrasound assessment and noted a cystic collection in the parametrium and free fluid in the peritoneum. He books the patient for an exploratory laparotomy. a) Based on the history, list five key additional pieces of information which you will look for in preparing this patient for her surgery. Discuss why each is important and what action you will take in response to that information. (10) b) Discuss briefly your selection of drugs for the anaesthetic in this patient. (5) c) The procedure takes 3 hours to complete and at the end of the procedure the following data are recorded: Blood pressure is 100/60, pulse rate is 110/minute, temperature is 34C. You have also started the patient on an infusion of adrenaline. There is oozing from the surgical wound. An arterial blood gas shows a pH of 7.25. i) Discuss this information and the possible reasons for these. (5) ii) Discuss your plan for the post-operative management of this patient. (5) [25] A 23-year-old male patient was in the passenger seat alongside the driver, when they were involved in a motor vehicle accident. He was not wearing a seat belt, and hit his head on the windscreen. He is booked to come to theatre for drainage of an acute intracerebral bleed. a) What is the Glascow Coma Scale scoring system? (5) b) What is the formula for cerebral perfusion pressure? (1) i) What is the autoregulatory range for cerebral blood flow? (1) ii) Name two essential substrates for cerebral metabolism. (1) iv) How does the PaCO2 influence cerebral blood flow? (2) c) What special investigations do you want on this patient pre-operatively? Motivate your choices. (5) d) What is your intraoperative approach to this patient? (10) [25] A 25-year-old, P1G2 patient is presented for evacuation of the uterus for confirmed molar pregnancy. The height of fundus is approximately 25 weeks. She complains of dyspnoea. a) Discuss the potential perioperative problems of importance to the anaesthetist associated with this condition. (10) b) Name the special investigations that you would request preoperatively and motivate the indications for each test. (5) c) Shortly discuss your anaesthetic technique. (10) [25] A 55-year-old, well-controlled hypertensive patient undergoes shoulder surgery in the sitting (beach chair) position. a) What potential problems do you anticipate with a patient in this position? (5) b) While positioning the patient, the surgeon first lowers the patients legs before raising the patients upper body. The heart rate drops to 30 beats per minute. What is this reflex called? Describe the pathophysiology of the reflex in this case. (5) c) Name causes for delayed awakening in this patient and state how you will go about excluding these causes. (15) [25] 35-Jarige P4G4 vrou het keisersnit gehad vir al haar verlossings. Sy was in die saal 4 ure post-operatief na die laaste keiser toe die kliniese assistent geroep word om haar te kom sien. Die keisersnit was onder spinale narkose gedoen. Met ondersoek, is haar bloeddruk 100/80 en haar polstempo 110 per minuut. Die kliniese assistent het ultraklank ondersoek uitgevoer, en kisteuse kolleksie in die parametrium gesien asook vry vog in die peritoneum. Hy boek die pasint vir eksploratiewe laparotomie

2.2

2.3

2.4

2.1

a) b) c)

Gebaseer op die geskiedenis, lys vyf addisionele stukke inligting waarvoor u sal kyk wanneer die pasint voorberei word vir teater. Bespreek waarom elkeen belangrik is en watter aksie u sal neem in reaksie op die informasie (10) Bespreek kortliks u keuse van narkosemiddels vir die narkose van hierdie pasint. (5) Die prosedure neem 3 ure en aan die einde word die volgende inligting gekaart: Bloeddruk is 100/60, polstempo is 110/minuut, temperatuur is 34C. U het ook adrenalieninfusie begin. Daar is sypeling (oozing) uit die chirurgiese wond en op arterile bloedgas is die pH 7.25. i. Bespreek hierdie inligting en die waarskynlike redes daarvoor (5) ii. Bespreek u plan vir die post-operatiewe hantering van hierdie pasint. (5) [25]

2.2

23-Jarige manlike pasint was passassier langs die bestuurder toe hulle in motorongeluk betrokke was. Hy het nie veiligheidsgordel gedra nie, en het sy kop teen die voorruit gestamp. Hy is geboek om teater toe te kom vir dreinasie van akute intraserebrale bloeding a) Wat is die Glascow-komaskaal evaluasiesisteem? (5) b) i) Wat is die formule vir serebrale perfusiedruk? (1) ii) Wat is die outoregulatoriese reikwydte vir serebrale bloedvloei? (1) iii) Noem twee essensile substrate vir serebrale metabolisme. (1) iv) Hoe benvloed PaCO2 serebrale bloedvloei? (2) c) Watter spesiale ondersoeke sal u pre-operatief aanvra vir hierdie pasint? Motiveer u keuses. (5) d) Wat is u intra-operatiewe benadering tot hierdie pasint? (10) [25] 25-Jarige P1G2 pasint word aangebied vir evakuasie van die uterus vir bevestigde mola swangerskap. Die fundus hoogte is ongeveer 25 weke. Sy kla van dispnee. a) Bespreek die moontlike peri-operatiewe probleme geassosieer met hierdie toestand wat van belang is vir die narkotiseur. (10) b) Noem die spesiale ondersoeke wat u pre-operatief sal aanvra en motiveer die indikasie vir elke toets. (5) c) Bespreek kortliks u narkosetegniek. (10) [25] 55-Jarige, goedbeheerde hipertensiewe pasint ondergaan skouer chirurgie in die sittende (beach chair) posisie. a) Noem potensile probleme wat u met pasint in hierdie posisie mag ondervind. (5) b) Terwyl die chirurg die pasint posisioneer, laat hy eers die bene sak voordat die bolyf opgelig word. Die hartspoed val na 30 slae per minuut. Wat word hierdie refleks genoem? Beskryf die patofisiologie van die refleks in hierdie geval (5) c) Noem oorsake van vertraagde ontwaking in hierdie pasint en noem hoe u te werk sal gaan om die oorsake uit te skakel. (15) [25] a) b) List 6 possible causes of hypertension in the recovery room. (3) Name 4 drugs that can be used to blunt the hypertensive response during intubation and the doses you would use. (2)

2.3

2.4

3.1

3.2

A 5-year-old, 20kg child is booked for circumcision a) Calculate his maintenance fluid requirement. (1) b) Name one drug that you would administer as oral preoperative sedation and state the dose. (2) c) Name 4 different groups of drugs that you can use for perioperative analgesia in this patient and give one example from each group. (2) a) b) What does the term massive blood transfusion mean? List 4 complications of a massive blood transfusion. (1) (4)

3.3

3.4 3.5

a) b) a) b)

Which type of patient is most likely to get a post dural puncture headache? Outline your management of a patient who has a post dural puncture headache.

(1) (4)

Name 4 different classes of drugs used for prophylaxis against regurgitation and name an example from each class. (4) Name a medical condition that is associated with a high risk of regurgitation and aspiration even after prolonged starvation and explain the reason for this. (1)

3.6 3.7

Name the end-organ damage that can occur in 5 different organ systems in the diabetic patient, and state how each of these will influence the anaesthetist. (5) a) b) c) List 4 absolute contra-indications to spinal anaesthesia. (2) At what spinal level is the local anaesthetic drug administered for a spinal anaesthetic and why? (1) Name 2 drugs that you would use to treat hypotension following a spinal block and the receptors that each drug acts on. (2) List the ECG changes in a patient with hyperkalaemia. List the treatment options for hyperkalaemia in theatre. Give 2 benefits of steroid administration during anaesthesia. List 6 complications of long term steroid therapy. What is the normal partial pressure of oxygen in arterial blood? What is the normal partial pressure of oxygen in venous blood? What is the haemoglobin oxygen saturation in arterial blood? What is the haemoglobin oxygen saturation in venous blood? At what partial pressure is normal adult haemoglobin 50% saturated with oxygen? (3) (2) (2) (3) (1) (1) (1) (1) (1)

3.8 3.9 3.10

a) b) a) b) a) b) c) d) e) a)

3.11

b) c) d) 3.12 a) b) c) a) b) c) a) b) c)

How are the following gas cylinders colour coded? i) Oxygen. ii) Air. (1) iii) Nitrous oxide (N2O). By what system do the manufacturers avoid wrong connection of these cylinders? () Explain the safety concept in preventing a hypoxic mixture. (1) How does the oxygen flush valve function? Name the risks associated with its use and protective measures taken to avoid said risks. (2) Describe the sensory nerve supply of the airway. How would a patient present should injury of these nerves occur? What type of surgery presents the biggest risk of injury of these nerves? (3) (1) (1)

3.13

List the anatomical difference in a paediatric airway compared to an adult airway. (2) What equation can be used to calculate the endotracheal tube size in a child? (2) What complications are associated with cuffed endotracheal tubes used in children. (1) List 4 factors that would increase the uptake of inhalation agents. What is the definition of minimum alveolar concentration (MAC)? Give the MAC of the following agents: i) Halothane. ii) Sevoflurane. iii) Desflurane. iv) N2O. (2) (1)

3.14

(2) (5) (5)

3.15 3.16 3.17

Draw and label a diagram illustrating the various lung volumes and capacities. Mention the side effects of cholinesterase inhibitors to 5 organs. a) b)

Classify the 2 main groups of local anaesthetics and name an example of each. (2) Explain what factors determine the systemic absorption of injected local anaesthetics. (3)

3.18 3.19

List factors affecting the myocardial oxygen supply and demand balance. a) b) c) a) b) c) How are pacemakers classified? If placed in a patient, how can its function be evaluated? What intraoperative conditions may cause the pacemaker to malfunction?

(5) (2) (2) (1)

3.20

Define a hyponatraemia. (1) Classify the causes of hyponatraemia. (3) What formula would be used to determine the amount of NaCl necessary to correct the hyponatraemia? (1) [100] Lys 6 moontlike oorsake van hipertensie in die herstelkamer. (3) Noem 4 middels wat gebruik kan word om die hipertensiewe respons op intubasie te onderdruk en noem die dosis wat u sal gebruik. (2)

3.1

a) b)

3.2

5-Jarige 20kg kind is geboek vir sirkumsisie a) Bereken sy instandhoudingsvog benodigdhede. (1) b) Noem een orale middel wat u pre-operatief vir sedasie sal toedien en gee die dosis. (2) c) Noem 4 verskillende groepe middels wat gebruik kan word vir peri-operatiewe analgesie in hierdie kind en gee een voorbeeld per groep. (2) a) b) a) b) Wat beteken die term massiewe bloedtransfusie? Lys 4 komplikasies van massiewe bloedtransfusie. Watter soort pasinte is geneig om post-durale punksiehoofpyn te kry? Beskryf die behandeling van pasint met post-durale punksiehoofpyn. (1) (4) (1) (4)

3.3 3.4

3.5 a) Noem 4 verskillende klasse middels wat gebruik kan word vir profilakse teen regurgitasie en noem voorbeeld uit elke klas. (4) b) Noem mediese toestand geassosieer met ho risiko van regurgitasie en aspirasie selfs na voldoende vasting. Verduidelik die rede daarvoor. (1) 3.6 3.7 Noem die potensile eind-orgaanskade wat in 5 verskillende orgaansisteme in die diabeet kan voorkom, en noem hoe elkeen die narkotiseur kan benvloed. (5) a) b) c) 3.8 3.9 3.10 a) b) a) b) a) b) c) d) e) a) Lys 4 absolute kontra-indikasies tot spinale narkose. (2) Op watter spinaalvlak word die lokaalverdower toegedien vir spinaal en waarom? (1) Noem 2 middels wat toegedien kan word om hipotensie na spinaalblok te behandel en noem die reseptore waarop elke middel werk. (2) Lys die EKG veranderinge in pasint met hiperkalemie. Lys die behandelingsopsies vir hiperkalemie in teater. Noem 2 voordele van steroedtoediening tydens narkose. Lys 6 komplikasies van langtermyn steroedterapie. (3) (2) (2) (3)

Wat is die normale parsile druk van suurstof in arterile bloed? (1) Wat is die normale parsile druk van suurstof in veneuse bloed? (1) Wat is die hemoglobien suurstofsaturasie in arterile bloed? (1) Wat is die hemoglobien suurstofsaturasie in veneuse bloed? (1) By watter parsile druk is normale volwasse hemoglobien 50% versadig met suurstof? (1) Watter kleur is die volgende gassilinders? Suurstof. Lug. Laggas (N2O).

3.11

(1)

b) c) d) 3.12 a) b) c) a) b) c) 3.14 a) b) c)

Watter sisteem gebruik die vervaardigers om die verkeerde konneksie van hierdie silinders te voorkom? () Beskryf die veiligheidskonsep om hipoksiese mengsel te voorkom. (1) Hoe werk die suurstofspoelklep (flush valve)? Noem die risikos geassosieer met die gebruik daarvan en die beskermende maatrels om die risikos te voorkom. (2) Beskryf die sensoriese senuweevoorsiening van die lugwe. Hoe sal pasint presenteer as hierdie senuwees beseer word? Watter tipe chirurgie is die meeste geneig tot besering van hierdie senuwees? (3) (1) (1)

3.13

Lys die anatomiese verskille van pediatriese lugweg in vergelyking met volwasse lugweg. (2) Watter vergelyking word gebruik om die grootte van die endotrageale buis in kind te bereken? (2) Watter komplikasies word geassosieer met die gebruik van endotrageale buise met mansjette (cuffs) in kinders? (1) Noem 4 faktore wat die opname van inhalasiemiddels verhoog. Definieer minimum alveolre konsentrasie (MAK). Gee die MAK van die volgende middels: Halotaan. Sevofluraan. Desfluraan. N2O. (2) (1)

(2)

3.15 3.16 3.17

Teken en benoem diagram om die verskillende longvolumes en kapasiteite te illustreer. (5) Noem die newe-effekte van cholienesterase inhibitore in 5 orgaansisteme. a) b) (5) Klassifiseer die 2 hoofgroepe lokaalverdowers, en noem voorbeeld uit elke groep. (2) Verduidelik watter faktore die sistemiese absorpsie van ingespuite lokaal-verdowers bepaal. (3) (5) (2) (2) (1)

3.18 3.19

Lys faktore wat die balans tussen miokard suurstoftoevoer en verbruik affekteer. a) b) c) a) b) c) Hoe word pasaangers geklassifiseer? Hoe word die funksie van pasaanger in pasint gevalueer? Watter intra-operatiewe toestande kan lei tot pasaanger wanfunksie?

3.20

Definieer hiponatremie. (1) Klassifiseer die oorsake van hiponatremie. (3) Watter formule word gebruik om die hoeveelheid NaCl te bereken wat benodig word om die hiponatremie te herstel? (1) [100]