Anaesthesia Vivas for M.

Med 2005

1) Pt with malignant pericardial effusion with possible cardiac tamponade

 Describe assessment of pt
 Pulsus paradoxus- definition and explain mechanism
 Monitors I want for this pt
 Describe/draw normal cvp waves... talked abt each component a,c,v x/y descent...
then what the wave would be like in this pt
 where would i site the central line and what complications of setting the line.. how i
would minimise complications
 If pt can't lie flat, how to prevent venous air embolism
 2D echo appearance of this patient

2) Awareness - patient previous hx of awareness during LSCS, now coming in for lap
chole
 what could have caused her previous awareness?
 How would you prevent awareness from happening this time? Amnesics
 + vigilance+ machine/drug check blah blah
 Monitors I want for this pt
 Asked aboutt incidence of pts with awareness which had intraop physiological
changes of HR/BP/tearing/sweating
 what is BIS? how to monitor/what values
 are you aware of any trials (B-Aware ?) What is its conclusion?
 What is the study population
 How would you prevent awareness if you have no BIS or other
 awareness monitor? -> how many MAC would you maintain?

This same pt now for this sx

Half hr into sx, airway alarm increase from 25 to 40
Describe mx/causes....

Same pt, surgeon decided convert open with IOC, few min after dye,
ETCO2 drop to 15mmHg, with severe hypotension
Mx...
went into discussion on tryptase.. when do i take samples.. how many
samples and why.. what is significant result

3) You have a case of xx for lithotomy position tomorrow & your MO

asked you what she should look out for in the preop assessment with
regarding litho position.
-> CVS (autotransfusion on leg up), Resp (splinting of diaphragm),
Joints (hip joints), Neurologic Assessment (nerve compression /
sciatic nerve stretching), Back (back pain from loss of lordosis) etc
Discussed abt physio changes/effects of litho position

Change scenario...
elderly pt with I/O with BP 100/60, HR120/min, nil urine output for
last few hrs for laparotomy
 assessment ...
 are u happy to anae pt...
 targets for resusc..use of cvp.. what are my targets
 what invs to guide..

4) Airway assessment
how to assess airway (details needed)? Bedside airway assessment... talked abt general
stuff, then each component. asked to comment on usefulness of Mallampati.
How predictive are this tests?
Any radiological investigations you know of that will predict difficult airway?
How would you approach airway in a patient with limited mouth opening (2-3fb) and
limited neck mobility and you suspect difficult intubation? (Doesn't want awake fibreoptic)
Do you routinely do awake fibreoptic in all patients that you suspect may have difficult
airway? How you would secure airway ? If No, so how to decide..
talked on factors of difficult ventilation..

So pt on table now for the elective sx.

Describe what u would do what's optimal position of head for intubation
how do u tell if bougie in airway or oeso

5) Elderly lady for laparotomy and risk factors for IHD.

Intraop – HR 120, BP80/40. ST elevations on ECG.
What ST is significant
What do you do?
Talked abt O2 supply demand…wanted very exact details on what to give, sequence,
when is appropriate to give what, how much and why
Which vasopressors would you choose? (no CVP line)
Now BP 110/60, HR130 -> would you bring down HR (yes), with what (esmolol?) Target
HR?
Would you consider GTN?(yes) IV or patch (IV chosen as evident ST elevation - more
control over infusion and titratable, patch delivery
is unpredictable). Beware of hypotension.

ST segment resolved after my mx.. pt now in PACU

Assessment...went briefly on Trop T/I and CK/MB
How long in PACU... go where after discharge from PACU
6) infrarenal AAA elective op
-preop Ax
--details of AHA criteria, clinical and sx risk
--indications for cardio referral
-preop Mx
--cardiac optimisation
--role and rationale for periop BBA incl studies

7) You're the registrar in a hospital that doesn't normally have a large pediatric load.
you've just been informed by EMD to expect in 15min a ped trauma, fell two storeys,
already intubated.
-preop prep while waiting for kid to arrive (does not want you to go see patient)

8) PDPH in a non-obs patient

-differential causes of headache
-clinical features
-how do you assess if it's PDPH
-management of PDPH, conservative and EBP
-how a blood patch is done (DETAILS like how fast to
give it and what order of symptoms the patient will
describe is preferred)
-cure rates
-can you quote any studies?

9) Prolonged QT
-how do you find out in preop Ax, clinical features
-causes, congenital, acquired, etc.
-drugs that cause it
-anaesthetic drugs?
- complications of porlong QT... torsades...

10) Man with 6 years RA, asymptomatic neck for knee arthroscopy
-Preop Ax
-Airway Ax
-Cx spine Ax
--indications for Cx Spine XR
--what incidences?
-Airway Mx, Choice of airway for above op
--I chose LMA proseal - asked to defend
--noticed gastric fluid in oral cavity shortly after LMA insertion
---Crisis management
-Aspiration pneumonitis
--immediate management, indications for postponing op
--late management
--sequelae of pneumonitis
--role of Abx? --> NONE for prophylaxis

11)Transfusion reactions
-all the usual part one stuff
Methods to reduce need for blood transfusion perioperatively

12) Causes of maternal morbidity...go read UK confidential enquiry into maternal deaths,
available online...

13) LSCS unanticipated difficult airway management

- cannot intubate, can ventilate, must operate scenario.
- cannot intubate, cannot ventilate scenario

14) 75 yo man. Smoker with hypertension for TURP.

- discuss anaesthetic technique of choice, pros and cons
- mx of post spinal hypotension
- mx of intraop confusion
- problems of lithotomy position

15) How would u obtain consent from a parturient who wants a labour epidural?
- outline the risks/problems and quote the various incidence of each risk factor
- when is the ideal time to obtain consent?
- if this patient were to present with a birth plan for delivery in a water bath and NO
epidural but at 8cm, changes her mind and DEMANDS an epidural due to severe pain,
how would you proceed? Is this still acceptable for her to give consent?

16) Draw Tracheobronchial tree and the bronchopulmonary segments

17) Adolescent for scoliosis surgery in prone position:

- what would you ask your MO to look out for during preop evaluation of this patient
- what are the physiological changes associated with the prone position

18) 20yo female with acute abdominal pain in A&E. Last meal 4 hours ago. Surgeon
wants to do laparotomy now.
- what preop investigations would you order
- how would you assess this patient

19) Rheumatoid arthritis

- discuss anaesthetic problems
- focus was mainly on the airway problems
- mechanism of atlanto-axial subluxation
- relevant Ix ie Lateral C-spine film and what you expect to see
- how would you intubate? I said Awake FOB but was asked to compare this with an
iLMA
- List extra-articular manifestations of RA
- Discuss of RA drug therapy and its associated problems

Med Viva

72 yo man for scheduled bowel Ca resection in PACE clinic

Gives a history of chronic smoking and an effort tolerance of 100-200m but appears
mildly breathless in the clinic.

Current medications are ipratropium, salmeterol + fluticasone inhaler & aspirin

How would you evaluate him?

Investigations given
a) FBC- Hb 9-10 with normal MCV, Tw 10.3, Platelets and Hematocrit normal
b) U/E/Cr- Na 133, fasting BSL 10, the rest normal
c) PT/PTT normal
d) CXR- COPD picture with bi-apical fibrosis L>>R
e) ECG- NSR, RAD, RBBB

Questions
1) Summarise the case. What are his risk factors for postop pulmonary complications
(PPC)?
2) Are you surprised that he appears breathless despite having a decent effort
tolerance?
2) Is ipratropium appropriate for this patient? why?
3) What do you think about giving aspirin to such a patient? Alluding to
bronchoconstriction and PGEs - leukotrienes
4) Is it surprising to find a Hb of 10 in this patient -> expect to see polycthemia in COPD
5) What do you see on the CXR?
6) Was then shown lung function test which shows reduced FEV1, FVC, FEV1/FVC
ratio, FEF25-75 & DLCO
7) Also show ABG
8) How would you optimise his lung condition for op?
9) Are you aware of any risk index for PPC?
10) What do you think of the use of an epidural to reduce PPC in this case?
SPOT DX
1) PA and Lateral CXR showing Left UL Abcess with air-fluid levels
2) AP CXR with probable cardiomegaly, bat's wing and Kerley B lines
3) PA CXR with multiple cannon ball lesions, small left pleural effusion and a left
pneumothorax
4) CXR of tracheostomised patient with CVP and ARDS picture
5) ABG showing Resp acidosis with PaCO2 of 91 and adequate metabolic
compensation
6) Ask to correlate ARDS CXR with ABG= low tidal ventilation strategy with permissive
hypercapnoea
7) Rhythm strip showing SVT. Ask about treatment
8) ECG showing 8:1 atrial flutter