AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS

EXAMINERS?REPORT
PRIMARY EXAMINATION
AUGUST/SEPTEMBER 1995
PLEASE NOTE THAT THIS REPORT IS PREPARED TO PROVIDE CANDIDATES AND
THEIR TEACHERS AND SUPERVISORS OF TRAINING WITH INFORMATION ABOUT THE
WAY IN WHICH THE PERFORMANCE OF CANDIDATES IN THE RECENT EXAMINATION
WAS ASSESSED BY THE EXAMINERS, SO THAT CANDIDATES AND TEACHERS MAY
PREPARE APPROPRIATELY FOR FUTURE EXAMINATIONS. THE INDIVIDUAL REPORTS
ARE NOT INTENDED TO REPRESENT MODEL ANSWERS NOR IMPLY THAT ALL POINTS
MENTIONED ARE NECESSARY IN ORDER TO ACHIEVE A PASS. ALL TEACHERS AND
SUPERVISORS OF TRAINING ARE ENCOURAGED TO DISCUSS THIS REPORT IN
DETAIL WITH CANDIDATES THEY ARE PREPARING FOR FUTURE EXAMINATIONS.

PHYSIOLOGY
QUESTION Define "Venous Admixture". Briefly explain how venous admixture
1

influences arterial oxygen tension, and how an increase in inspired oxygen

concentration may affect this.
Thirty four percent passed this question.
The first part of this question was answered well by most of the candidates. Many
definitions of venous admixture/shunt were accepted.
Normal values were usually given, the sources of venous admixture and the
shunt equation were all well explained, complete with definitions of terms.
Thereafter some candidates faltered. There were two main problems. Firstly, an
incomplete understanding or poor explanation of how the slope of the
haemoglobin oxygen dissociation curve affects arterial oxygen tension in venous
admixture.
Secondly while most candidates mentioned the two main sources of venous
admixture being anatomical shunt and V/Q scatter; they concentrated only on
anatomical shunt when discussing the effects of increased inspired oxygen.

Diagrams eg. the haemoglobin oxygen dissociation curve and the iso-shunt
diagram were only useful if accompanied by an explanation.

QUESTION Explain the physiological processes which cause oliguria in response to

2

hypovolaemic shock.
Sixty three percent of candidates passed this question. However, good answers
were uncommon. Few candidates presented the overview that in hypovolemic
shock oliguria results from decreased renal blood flow and increased sodium and
water reabsorption from the renal tubules. Most candidates did not distinguish
between the factors affecting afferent and efferent arteriolar tone. In particular,
they failed to emphasise the importance of neural sympathetic afferent arteriolar
vasoconstriction in diminishing glomerular filtration in hypovolemic shock. Also
most candidates neglected to mention the efferent arteriolar vasoconstriction
produced by angiotensin II which helps to maintain glomerular filtration in this
situation. Many descriptions of the juxtaglomerular apparatus and the stimuli for
renin release were either superficial or contained errors. Glomerulotubular
balance and tubuloglomerular feedback were often confused with each other.
Many candidates produced lengthy descriptions of the cardiovascular responses
to hypovolemia and/or the baroreceptor reflexes. Unfortunately these efforts
gained candidates no additional marks and allowed less time to answer the
question asked.

QUESTION Briefly outline the differences between the pulmonary circulation and the
3

systemic circulation
This question was on a topic central to the practice of anaesthesia - fifty seven
percent of candidates passed. A good answer should have mentioned differences
in vessel structure, vascular resistance/impedance, compliance and capacity,
vascular pressures, control of blood flow, and the functions of the two
circulations.
Many candidates correctly quoted vascular pressures and resistances, and fifty
percent discussed structural differences between the two circulations. Although
2/3 of candidates mentioned hypoxic pulmonary vasoconstriction, surprisingly
few discussed other influences on pulmonary vascular resistance such as lung
volume, alveolar pressure, arterial carbon dioxide tension, autonomic receptors
or autacoids. Very few candidates mentioned the non-respiratory functions of the

pulmonary circulation.
Terminology in short-answer questions should be precise. Writing vague
expressions such as "control mechanisms include endocrine, neural and local"
takes valuable time and does not score marks. Several candidates stated that
the pulmonary and systemic circulations were "in parallel".

QUESTION Draw a labelled diagram of a cardiac muscle action potential highlighting

4

the sequence of changes in ionic conductances. Explain the terms

"threshold", "excitability", and "irritability" with the aid of the diagram.
This question was surprisingly poorly done. Only thirty nine percent of candidates
managed to pass, and most were bare passes. There were only a handful of
good answers.
A ten minute time limit necessitates ruthless distillation of information. Many
candidates drew scrappy, inaccurate and poorly labelled diagrams and then
launched into an extraordinarily detailed essay style description of the ionic
fluxes, the ionic basis of the resting membrane potential, the Goldman Constant
Field Equation and the various Nernst potentials, leaving no time for an
appropriate answer to the question.
Good answers centred on a carefully drawn, well labelled diagram, with labelled
axes, normal values and units, and the phases correctly identified. A good
diagram explained conductance changes without the need for reams of text.
hreshold?needed to be carefully identified on the diagram and a normal value
and definition given.
There was an extraordinarily poor understanding of excitability and irritability. To
describe, and mark on the diagram absolute and relative refractory periods, often
incorrectly, and then state that there is increased excitability because the
membrane potential is closer to threshold shows a fundamental lack of
understanding shared by many candidates. During the relative refractory period
excitability is reduced and the characteristics of the fast response evoked vary
with the membrane potential that exists at the time of stimulation; the Phase 0
slope increasing progressively as the stimulus occurs later in the relative
refractory period until the resting membrane potential is reached, full excitability
is restored and the Phase 0 slope returns to its steepest. (This is nicely

demonstrated with a diagram (as asked for) in Berne and Levy, Cardiovascular
Physiology, chapter on Electrical Activity and the Heart). The vital relationship
between the slope of Phase 0 (excitability) and the conduction velocity was not
understood by candidates.
Irritability refers to a diminished potential between resting membrane potential
and threshold; the cell membrane is easier to depolarise but there is decreased
gradient of Phase 0 and decreased conduction velocity.
Confusion about the effects of potassium on resting membrane potential was
astonishing.

QUESTION Outline the effects of intravenously administering 500 ml of 20% mannitol,

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and the potential problems associated with its use.

This question was answered well by most candidates with an overall pass of
eighty percent.
It was expected that candidates would mention that mannitol was hyperosmotic,
acted as a blood volume expander, and an osmotic diuretic. The hyperosmotic
effect on the blood volume will lead to the movement of water from the
intracellular compartment and thus cause a decrease in intracellular volume
leading to the therapeutic effects on the intracranial and intra-occular pressure.
Some discussion on the potential electrolyte changes that would occur due to the
diuresis was expected.
Some candidates failed to discuss the adverse effects, although this was
specifically asked. These should have included volume overload potentially
leading to left ventricular failure and later dehydration due to the diuretic effect of
the mannitol. Minor effects including vein irritation and anaphylaxis were
mentioned by a number of candidates.

QUESTION List the physiological factors which determine intracranial pressure and
6

explain briefly how it is controlled.

Sixty-seven percent candidates passed the question with 27 answers awarded
seven or more marks out of ten. Definitions and normal values were expected.
The physiological concepts sought were of a rigid cranial vault, cerebral blood
volume, cerebrospinal fluid translocation and absorption, and the influences of

posture and intrathoracic pressure. The control areas sought were those of
cerebrospinal fluid volume and control of cerebral blood flow/volume.
The concepts of flow and volume were frequently confused. Many candidates
failed to demonstrate that an increase in intracranial contents would be
accompanied by either an increase in pressure or a displacement of either
cerebrospinal fluid or blood.
Good answers often made use of a compliance/elastance diagram and
commented on the effect of time on the vascular responsiveness to carbon
dioxide.
Diagrams of cerebrospinal fluid production/absorption versus intracranial
pressure were effectively used to convey information succinctly as were
diagrams of pressure versus cerebral blood flow. Frequently mm Hg and mm
cerebrospinal fluid were erroneously transposed. Physiological intracranial
pressure exceeding arterial pressure was frequently quoted, probably as an error
in units.
A number of answers attempted to display a graph of cerebral flood flow versus
pressure for mean blood pressure, partial pressure of carbon dioxide and partial
pressure of oxygen all on the one set of axes. This was rarely successfully.
Separate axes for each point being made showed fewer errors, was of
comparable speed and is recommended.
Inclusion of clinical examples detracted from answers with resultant omissions in
relevant areas.

QUESTION Briefly differentiate between the terms "heat" and "temperature". explain
7

briefly the principles of a thermistor indicating its advantages and

disadvantages.
Forty percent of candidates passed this question. The examiners expected
candidates to define eat?and emperature? and to indicate the difference
between the two terms. Definitions were accepted as long as they indicated that
heat was a form of energy related to the amount of kinetic energy of the
molecules in a substance, and that temperature was an index of the direction of
flow of heat energy (from an area of high average kinetic energy to an area of
lower average kinetic energy), expressed using arbitrary scales such as degrees

Fahrenheit, Centigrade or Kelvin. Additional marks were given to candidates who

indicated that heat and temperature are related by the specific heat (or specific
heat capacity) of a substance.
A brief explanation of the principles of a thermistor was required. This should
have included the thermal sensitive resistor itself, the need for an electrical
circuit, an the non-linear change in resistance with change in temperature (with
either a positive or negative temperature coefficient). Additional marks were given
for an explanation of the time constants in relation to response times. Several
candidates provided detailed descriptions of Wheatstone bridge circuits which
was not required. Few candidates mentioned the need for zeroing and
calibration.
The list of advantages could have included the small size, the ability to obtain
continuous and remote readings, and the relatively rapid response (such that
thermistors are used in thermodilution cardiac output measurement).
Disadvantages could have included the non-linearity of response, aging, batch
variation, hysteresis, and sensitivity to high temperatures (such as autoclaves).
Many candidates included terms such as ccurate?and xpensive? However,
these are meaningful only if compared to other methods.

QUESTION Outline the physiological consequences of hyperosmolar diabetic keto

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acidosis
Thirty-nine percent of candidates passed this question. The underlining of the
word physiological in the question, was not a formatting exercise. It was a
demand of some relevance in answer to physiological derangements and
principles. yet some candidates managed to ignore this fundamental component.
An unqualified, "the conditions untreated leads to collapse.." does not generate
much enthusiasm in the marker. Few attempted a definition, but those who did
were suitably rewarded. A large number of candidates showed a blatant
ignorance of the condition. One candidates went as far as stating the primary
problem was hypoglycaemia, with a glucose level less than 3 to 5 mmo1/L! The
few good answers opened with an introduction including the relevance of insulin
lack and hyperglycaemia. They went on to explain the derangement including the
hyperosmosis resulting primarily from hyperglycaemia, the acidosis from ketone
bodies, with a short outline of why these come to exist. Then the direct effects of
these derangements, rounding off with a short explanation f compensatory
mechanisms, including the sympathetic output, the hyperventilation secondary to

chemoreceptor stimulation, etc. Candidates should perhaps spend some time

practising answering short answer questions under time duress, before the real
quiz.

QUESTION List the physiological factors which increase respiratory rate and include a
9

brief explanation of the mechanism by which each achieves this increase.

This question was quite specific in requiring a list of physiological factors
followed by a brief explanation. It tested a very basic and important area of
physiology relevant to clinical anaesthesia and intensive care; however, only sixty
candidates (forty percent) passed this question and only one candidate scored
well.
Of the numerous factors responsible for increasing respiratory rate it was
necessary to consider hypoxia, hypercapnoea, acidosis, and any two other
factors in order to obtain a pass in this question. The fact that sixty percent of
candidates were unable to achieve this level indicates that this basic area needs
further consideration by trainees and tutors.
Some candidates made vague statements that respiratory rate could be
increased by PaO2, PaCO2, and pH without indicating the direction of change
necessary to achieve the increase in respiratory rate. Such non-specific
statements did not attract marks. Hypercarbia was frequently interchanged with
hypercapnoea and although marks were not deducted candidates are well
advised to ensure they use correct terminology. Some candidates dwelt on
details of control mechanisms which were not necessary and this detracted from
the time available to cover the rest of the question.
Finally, a number of candidates wasted time presenting introductions and
overviews which were neither relevant nor required in such a specific question.
Also, a number of candidates included drugs as a cause of increased respiratory
rate despite the fact that the question specifically asked for physiological causes.
Please read the question and answer the question asked.

QUESTION Briefly explain the changes that occur in stored whole blood.
10
The standard of answer to this question was poor. It is considered that
anaesthetic trainees should have a working knowledge in this core area.

In a straight forward question which requires little deductive thinking and

synthesis, only forty percent of candidates passed, of which seven percent
presented good answers; in contrast, twenty percent gave poor answers.
Candidates must read the question. Briefly explain does not equate with
providing a list. Much time was wasted by candidates describing the effects of
transfusion/massive transfusion which was not relevant. Illegible handwriting and
non-standard abbreviations were a source of irritation, despite having been
mentioned in previous Examiner Reports.
The areas which showed weaknesses were:
1. Methods of blood storage and duration;
2. Coagulation Factors;
3. Platelets:
4. DPG and the oxygen dissociation curve;
5. Biochemical changes, the direction and extent of changes
Introductory Physiology Questions to the Oral Examination

Cardiovascular system
o

Ejection fraction

Head up tilt

Peep

Loss of 25% of blood volume

Contractility

Definition and Measurement

Foetal circulation / changes at birth

Left atrial/left ventricle pressure wave form

Myocardial cell metabolism

Shunts

Left ventricular compliance

Coronary blood flow

Aortic pressure wave form

Definition of mean blood pressure

CVS response to standing in water up to the neck

Renal

Renal response to water load/sodium load/potassium load

Counter current mechanism

Loop of Henley

Endocrine function of kidney

Metabolism/Cellular
o

Definition of an acid

Buffers

Significance of pKa

Removal of H+ from the cell

Carbonic anbydrase

Cell membrane

Transport across the cell membrane

Tricarboxylic Acid Cycle general principles

Total body water

Osmotic/oncotic pressure

Glucose metabolism

Lactate formation

Ketone bodies

Response to 8.4% HCO3 infusion

Respiratory System
o

O2 dissociation curve

Venous admixture

Effects of breathing 100% N2

Effects of breathing 100% O2

A-a gradient for oxygen

Blood gases - pattern in hyperventilation

Pattern in pregnancy

Respiratory changes in pregnancy, neonate

Lung volumes in adult/neonate

Measurement of FRC/RV

The respiratory changes occuring with open pneumothorax

Lung compliance/static and dynamic

Functions of the nose/humidification

Aging and the respiratory system

Carbon dioxide content curve of blood

Pleural pressures during the respiratory cycle

End tidal carbon dioxide tension

Dead space - measurement

- significance

Cyanosis

Airway closure

Chemoreceptors

Breath holding

Surfactant

Blood Components
o

Blood coagulation

Platelets - structure
- function

Coagulation factors

Stability in storage

Functions of plasma proteins

Structure of haemoglobin and synthesis

Body defence of infection

Measurement/Physics
o

Pulse oximetry

Carbon dioxide

Transducers

Humidity

Venturi

Temperature

Oxygen in anaesthesia circuit

Central Nervous System

o

Formation/composition/absorption of cerebral spinal fluid

Nerve action potential

Resting membrane potential

Neuromuscular transmission

Cholinergic receptors

Intracerebral pressure

Pain pathways

Muscle spindle

Monosynoptic reflex

Liver blood flow - control

GIT
- measurement
o

Portal circulation

Absorption of glucose from gut

Formation of bile

Gastric secretions

Endocrine
o

Thyroid hormone - formation/action

Insulin action on cells

Antidiuretic hormone

Adrenal gland

Most of the above topics were generally answered well. However, the areas where candidates
demonstrated a poor standard of understanding included static and dynamic compliance of
the lung, renal handling of a water load, and the body response to breathing an hypoxic
mixture.

PHARMACOLOGY
QUESTION Describe the clearance of drugs by the kidney.
1
The pass rate for this question was eighty-five percent.
The question required the three mechanisms (glomerular filtration, active tubular
secretion and passive tubular reabsorption) to be explained and some examples
of drug clearance via these routes. Examples were necessary for a good mark,
but not a pass. Even in a short answer question simply listing the mechanisms is
not adequate, the description must indicate that the candidate understands the
process. This is best achieved by describing ways in which the process may be
modified. For example, glomerular filtration depends on the free concentration of
a drug and varies with changes in protein binding. Acid or alkaline diuresis will
vary the clearance of an ionised drug.

QUESTION Briefly describe the pharmacological effects of paracetamol. List its clinical
2

indications and outline the mechanisms for its toxicity.

Sixty-five percent passed this question.
Paracetamol is a weak prostaglandin inhibitor, antipyretic, and analgesic, but
does not have significant anti-inflammatory effect. Its clinical indications are
analgesia, especially when no anti-inflammatory is required, and as an
antipyretic, especially where aspirin is indicated. This would include patients with

a history of peptic ulceration and aspirin allergy, and in paediatrics.

Two metabolic pathways exist for paracetamol. One pathway involves phase I
reaction (N-oxidation) followed by phase II reactions, of glucuronidation and
sulphate conjugation. The minor pathway leads to an active metabolite. This is
normally conjugated with glutathione in the liver. In paracetamol overdose, this
minor pathway becomes a major pathway, saturating the mechanisms of
detoxification, resulting in liver toxicity occurring. Treatment includes
administration of acetylcysteine. Doses of paracetamol causing this toxicity are
greater than 300mg/kg.
Candidates were required to correctly identify effects and at least one of the
clinical indications. It was necessary to recognise that an active metabolite was
responsible for causing hepatic necrosis in overdose.
Considerable latitude was extended to candidates. It is apparent that with older
drugs such as paracetamol, much of the information in the basic texts varies.
Credit was given where a knowledge of pharmacological principles was evident.
Reference: Goodman & Gillman (current edition)

QUESTION Give a brief account of drug protein binding and outline its significance.
3
On the whole the answers to the question were adequate. Sixty-five percent
passed.
The emphasis in the answers to this question on protein binding were directed
towards plasma protein binding as expected, representing the knowledge base.
Those candidates who for completeness briefly mentioned drug binding in other
tissues, for example, the epidural space, cell membranes, receptors and
enzymes were awarded credit.
Drug binding in the plasma, usually a reversible process due to weak bonds eg.
ionic and van der waal , occurs between drugs and albumin, -1acidglycoprotein, and to some extent lipoproteins and red blood cells. Albumin
has a high binding capacity and possesses multiple binding sites mainly for
acidic drugs. -1-acidglycoprotein has a low binding capacity and few binding
sites, mainly for basic drugs. The extent of protein binding is determined by the

concentrations of drug and protein, competition between drugs and other

exogenous and endogenous substances, the pka of the drug and changes in pH
of the plasma. The significance of protein binding is that it affects diffusibility,
volume of distribution, clearance and toxicity.

QUESTION Outline the chemistry of heparin. Describe its mechanism of action and list
4

its toxic effects.

A minimum required to pass included information regarding structure (a mixture
of variable molecular weight acidic polysaccharide polymers); mode of action
enhancing the inhibitory effect of antithrombin 3 and factor Xa; use as an
anticoagulant for prevention and treatment of thromboembolism; adverse effects
of thrombocytopaenia; heparin induced thrombocytopaenia syndrome and
bleeding.
Fifty-eight percent of candidates passed. Errors in the mechanism of action and
insufficient information on side effects were the major reasons for low marks.
Additional marks were gained by providing information on:
1. Half life, volume of distribution, absorption, naturally occurring sites
manufacture by extraction from animal intestines
2. Differences between high and low molecular weight heparin
3. Adverse effects such as alopecia, osteoporosis, anaphylactoid reactions
4. Reversal by protamine
5. Definition of a unit of heparin
6. Lipid lowering effect
7. Use of coagulation tests to measure its effect
8. Dosage and administration
Few mentioned that HITS causes thromboembolism or explained what HITS
stands for.
Very few candidates mentioned that:
1. The heparin protamine complex activates complement
2. Polybrene and anti heparin antibiotics can be used for reversal in
protamine allergy
3. HITS causes adrenal insufficiency in 2-5% of patients
4. Heparin has anti asthmatic effect

Heparin is used to prevent clotting of lines during bypass and in intensive care
(NO candidates mentioned this).

QUESTION Briefly outline the effects of the volatile agents on muscle tissues. Include
5

a description of how these effects are mediated and their clinical

significance.
Although this question was straightforward, only fifty-five percent passed. Almost
all those that failed did so because they wrote only about skeletal muscle,
forgetting cardiac and smooth muscle. Some candidates did not write about
mediators, or the clinical significance of the effects, despite the question asking
specifically for these details. Although the mechanism for some of the effects
may be uncertain, it was surprising that some candidates did not even mention
the role of calcium. The best answers included malignant hyperpyrexia as an
abnormal response of skeletal muscle, arrhythmogenicity in cardiac muscle, and
the clinical significance of the effects on regional vascular, bronchial and uterine
smooth muscle. Some candidates included nitrous oxide in their answers. A
volatile substance has a relatively high vapour pressure at ambient temperature.
Although nitrous oxide is a vapour at room temperature, it is not usually
considered one of the volatile anaesthetic agents.

QUESTION Outline the influence of pregnancy on pharmacokinetics.

6
This question was answered quite well with sixty-four percent of candidates
passing with the majority of remaining candidates gaining 4/10. Most answers
were organised well, discussing in order the major aspects of pharmacokinetics,
namely absorption, distribution, metabolism and excretion.
Most candidates realised that pregnancy is associated with marked physiological
changes which potentially have considerable effects on pharmacokinetic
parameters although data on the effects of pregnancy on pharmacokinetics is
often limited. There has been a variety of statements on drug absorption during
pregnancy although most recent evidence indicates that gastric absorption is not
greatly affected, except late in pregnancy or if narcotic analgesics are taken.
Vomiting obviously limits gastrointestinal absorption and was discussed by many
candidates. The increased ventilation favours a faster uptake of volatile
anaesthetics but this is balanced by a greater cardiac output and induction with
volatile agents is not greatly altered in pregnancy. The effect of the high cardiac
output in increasing the rate of onset of intravenous agents and neuromuscular

blocking agents was often discussed well, as was the change in the epidural
space and the consequent effect on local anaesthetics. Pregnancy has a variable
effect on the metabolism of drugs, any effect depending very largely on the drug.
The increased metabolism of phenytoin is well recognised and dosage generally
should be reduced after delivery. The effect of the increased renal blood flow on
the renal clearance of drugs was correctly included in most answers.

QUESTION What is meant by "95% confidence interval"? Explain the practical

7

applications of confidence intervals and indicate why they may be

preferred to p-values.
Only thirty-three percent of candidates passed this question. Most candidates
failed to demonstrate an understanding of confidence intervals although it is used
increasingly, and is required by most journals.
A 95% confidence interval (CI) represents the range of values for which there is a
95% probability of including the true population estimate (eg. mean, proportions,
correlation, etc). In a normal distribution, a 95% CI is equivalent to the mean +/1.96 SEM. Thus, the confidence interval gives an indication of the precision or
imprecision of the sample estimates as a population value. Further, 95% CI gives
an indication of the magnitude of any differences of a measured outcome
between groups, and also an indication of clinical (or biological) significance. For
hypothesis testing, one can graphically look for overlap of confidence intervals.
In contrast, p-values give only the probability of rejecting the Null Hypothesis,
thereby indicating a statistical significance. There is no indication of the
magnitude of differences or the clinical (or biological) significance.
Hence, confidence intervals provide more information for the reader to judge.
Reference: M.J. Gardner & D.G. Altman, Statistics With Confidence, 1989
published by BMJ; London

QUESTION Outline the factors that determine recovery (offset of effect) after ceasing a
8

drug infusion. Explain the relevance of a drug elimination half time.

Six percent passed this question.
The minimum essentials to pass this question were an appreciation of the
pharmacokinetic as well as pharmacodynamic factors, including receptor site

interactions, and a correct answer to the relevance of the drug elimination halftime. Very few candidates mentioned anything about pharmacodynamics and
most candidates were not correct in their answer to the relevance of elimination
half-time.
Pharmacokinetic factors included the rate of transport of the drug from the
biophase to the plasma (including the affinity of the drug for its receptors) which
in turn could be influenced by the rate of redistribution and elimination. The
plasma concentration at cessation of infusion is also relevant. The majority of
candidates focussed mainly on factors affecting the rate of decline of plasma
concentration, dealing mainly with factors affecting metabolism, but this was only
one component of the answer. Quite a few candidates discussed nonlinear
elimination, but this is a rarity. Very few indicated that the elimination half-time is
largely irrelevant for most drugs, because it usually describes the slow decline in
plasma concentrations at levels too low to have any effects. The so-called
context-sensitive half-time is relevant as it describes the apparent half-time for
decline of plasma concentrations after cessation of infusion and it depends on
the dose administered and the duration of the infusion.
Pharmacodynamic factors included interactions which may increase or decrease
the effects of the drug, the use of antagonists, synergism, hypothermia and
tachyphylaxis.

QUESTION Using opioids as examples, describe and illustrate with graphs what you
9

understand by the terms "potency", "efficacy", "partial agonis",

"competitive antagonist", and "therapeutic index".
This question is very straight forward having been asked repeatedly in the past
and is well described in many of the recommended texts. Furthermore, it
unambiguously requests a set of clear definitions.
Almost seventy percent of candidates achieved a pass and ten percent of
candidates scored more than seven out of ten. However, there were still a
number of commonly occurring problems. In particular, some candidates
confused the concepts of efficacy and potency or had a very vague concept of
therapeutic index. Graphs were mislabelled with dose instead of log dose while
some candidates superimposed all graphs as a maze on a single set of axes.
Spreading out the answer to make use of the available pages would have been a

better approach.
Marks were not deducted for considering codeine a partial agonist as this was
such a commonly held view. Interestingly, Codeine is metabolised to morphine
and so one would expect it to be rather a less potent full agonist. However,
references to support either view have not been found.
In summary this question illustrated the importance of reading past examiner
reports as a part of each candidate preparations.

QUESTION Draw a graph comparing the ratio of inspired to alveolar concentrations

10

during the first half hour of administration for nitrous oxide, isoflurane, and
halothane. Outline the reasons for the observed differences between the
agents and indicate the effects of non concurrent increases in alveolar
ventilation and cardiac output.
It was encouraging that this basic pharmacology question was attempted by most
candidates and 52% attained a satisfactory pass. A majority of candidates were
able to draw a reasonable graphical illustration of wash-in curves that related
alveolar and inspired concentrations of halothane, nitrous oxide and isoflurane to
time. Unfortunately, a significant number of candidates incorrectly labelled the
ordinate with a wash-out ratio and then constructed wash-in curves. Marks were
deducted for inadequate detail and labelling of both axes. Some candidates
positioned the three curves in incorrect order. The majority managed to ascribe
differences in rate of uptake to relative differences in blood/gas partition
coefficients, however, few mentioned the lesser importance of other tissue/blood
partition coefficients Although the second-gas and concentration effects were
included in many answers, only a minority of candidates understood the
mechanisms of how these two effects enhanced uptake of anaesthetic agents.
Effects of the agents themselves on ventilation and cardiac output were rarely
included. Metabolism and non-pulmonary excretion as factors were largely
ignored. Most candidates demonstrated an adequate understanding of the
effects of non concurrent increases in alveolar ventilation and cardiac output on
the uptake of the three agents.

Introductory Pharmacology Questions to the Oral Examination

Structure - Activity relationships of barbiturates

Outline pharmacokinetic drug interactions

Contents of an ampoule of Vecuronium

Drugs acting on sodium channels

Classification of anti-emetics

Classify positive inotropic drugs

Effects of additives to drugs

Structure - Activity - Relations of catecholamines

Structural features of non-depolarising muscle relaxants

Cardiovascular effects of opioids

Adenosine

Explain clearance

Structure - Activity - Relationships of local anaesthetics

MAC - Definition, factors

Differences between diazepam and midazolam

Factors predisposing to thrombogenicity of drugs

Haemmaccel

Infusion kinetics

Renal failure and use of muscle relaxants

Tests of significance

Bias

Differences between propofol and thiopentone

Pre-convulsant anaesthetic agents

Classification of anti-arrhythmic drugs

Pharmacogenetics

First order and zero order kinetics

Cardiovascular effects of ketamine

Nitrous oxide - indications

Advantages and disadvantages of enflurane

Drugs acting on calcium channels

Power of statistical tests

Type I and II errors

Standard normal distribution

Structure of opioids

Define dissociative anaesthesia

Epidural administration of bupivacane

Methods to reduce stress response in anaesthesia

Uptake of nitrous-oxide

Cardiovascular effects of isoflurane

2 agonists

Adverse effects of nitrous-oxide

Bioavailability

Define saturated vapour pressure and boiling point

Action of warfarin

Respiratory effects of volatile anaesthetic agents

Classify vasodilators

Vecuronium infusion

Non-steroidal anti-inflammatory drugs

Effects of propofol on cardiovascular system

Pentazocine

Cardiovascular effects of opioids

EMLA

Diuretics

Drugs that affect blood sugar

Clonidine

Tolerance - tachyphylaxis

Henderson - Hasselbalch equation

Steady state

Correlation

X2 test

Adverse effects of suxamethonium