Hong Kong College of Anaesthesiologists

Examiners’ Report

Final Examination : 21 Aug 1995 and 15/16 Sept 1995

Four out seven candidates passed this examination. The following comments are
provided by the examiners to assist supervisors of training and candidates for future
examinations.

Written

PAPER I. Overall four candidates passed this paper. One candidates passed each of
the nine questions and Scenario I presented the most difficulty.

Scenario I

A four year old boy presents in the emergency department. He is sitting on his
mother’s knee and appears to have airway obstruction and respiratory distress.
The presumptive diagnosis is acute epiglottis.

1) Describe the anatomy of the epiglottis in relation to the upper airway.

2) Outline your immediate management of the airway in this patient.
3) After successful immediate management, what longer term measures will be
needed?

This is a life threatening emergency that the candidates are expected to be able to
manage.

Question 1

The anatomy is straight forward. However, only four out of seven candidates passed
this question. A good answer should touch on the structure of epiglottis and its
relation with the upper airway in a four year old child. The more cephalic position of
the larynx at C2-3 vs C3-4 in adult and the floppiness of epiglottis should be
mentioned. The surrounding structures can be listed under the subheadings of
anterior, posterior, and lateral relations. For an anatomy question, a diagram is
helpful. Nerve supply, arterial supply, venous drainage and their relation with the
upper airway will score extra marks.

Question 2

It is a medical emergency and airway management and other items of resuscitation

should be discussed. The transport to the operating theatre for airway establishment
and safety measures including monitoring should be stressed. Most candidates chose
the classical correct anaesthetic management: intravenous line after anaesthesia,
intubation after halothane and oxygen induction with an NET surgeon standby.
Question 3

The longer term measures should be considered under the headings of supportive
(airway, ventilation and intracenous fluid) and specific (appropriate antibiotics)
management in the intensive care unit.

Scenario II

A 35 year old patient with chronic renal failure on regular haemodialysis is

scheduled for parathyroidectomy. The patient also required atenolol and
enalapril for control of high blood pressure.

4) Outline your preoperative assessment of this patient.

5) Discuss implications of the antihypertensive agents on your management of
this patient.
6) Describe the medical management of hypercalcaemia.

This was a reasonably straightforward question with six candidates passing Question 4
but the medical management of hypercalcaemia was poorly answered with only four
candidates passing.

Scenario III

A 55 year old previously healthy patient with right renal stone received general
anaesthesia for percutaneous nephrolithotripsy. The operation was quite
difficult and lasted 6 hours. At the end of the surgery, the patient appeared to
have adequate ventilation, but remained drowsy. The trachea was extubated
and the patient transferred to the recovery ward.

7) The patient’s SpO2 decreases to 70% after 5 minutes in recovery. What are
the possible explanations?
8) The patient remains drowsy and confused after one hour in recovery despite
improvement in oxygen saturation. Explain what you would do.
9) In the ward, the patient complains to the surgeon that he heard conversation
during the operation. How should this patient be managed?

Most candidates provided satisfactory answers overall. However, illegible

handwriting and the use of idiosyncratic abbreviations created a poor impression of
some candidates. For Question 7, some candidates wrote down a general list of
causes for postoperative hypoxia without much elaboration on the more likely causes
in this particular patient. It was unusual to note that one candidate answered Question
7, then 9 and then 8. This appeared to reflect some disorganization because Question
7 and 8 were obviously closely related. All candidates passed Question 9.
 Written

PAPER II. Overall four candidates passed this paper. Two candidates passed each of
the nine questions. The questions which were poorly answered were Questions 1, 8
and 9. The questions answered the best were Questions 2, 3 and 6.

QUESTION 1

Discuss the clinical significance of pre-operative hypokalaemia

Points to be raised
1. Definition: less than 3.5 mmol/litre of blood
2. The clinical significance of conditions causing hypokalaemia associated with
hyperacute, acute or chronic loss:
a. abnormal body losses such as gastrointestinal associated with vomiting,
nasogastric tube aspiration, diarrhoea, bowel prep etc
b. Renal associated with diuretic use corticosteroids renal disease such as renal
tubular acidosis and
c. Syndromes such as Conn’s Syndrome, Cushing Syndrome.
d. Compartmental shifts such as alkalosis associated with hyperventilation, the
use of insulin and rarely hypokalaemia periodic paralysis.
e. Inadequate intake, dietary or intravenous.
3. Clinical features including arrhythmia’s, weakness, failure of reversal of muscle
relaxants, depression, ileus, or coma.
4. Replacement should be oral if possible with potassium chloride being used in the
presence of a metabolic alkalosis. Intravenous use should not exceed 0.5
mmol/kg/hr which should take place under ECG monitoring. Significance of this
condition rarely leads to the delay in operation as treatment is simple and
effective and should take place under ECG monitoring.

QUESTION 2

List the advantages and disadvantages of regional analgesia (anaesthesia) for

ambulatory surgery.

This question requires a list but elaboration on details of major headings were
rewarded with additional marks. Candidates who gave answers which were not
related to ambulatory surgery were penalised for this.
The advantages clearly relate to the avoidance of complications of general
anaesthesia including central sedation, airway management and post operative
recovery. Other advantages include avoidance of nausea and vomiting resulting from
general anaesthesia, the advantage of intra and post-operative analgesia which may
extend well into post operative period, early ambulation for regional techniques not
requiring spinal or epidural anaesthesia, and the avoidance of thromboembolic
complications. Other advantages are having a conscious and cooperative patient
during procedures and often early discharge for regional blocks. Central nervous
system monitoring is easier because of the conscious patient.
Specific advantages for minor procedures such as limb fractures, removal of
limps and bumps were rewarded if mentioned.
 Disadvantages include the higher failure rate of regional blocks and the
expertise required to place these. The problems of prolonged blockade which may
result in delayed discharge of an ambulatory patient. The problems of urinary
retention, particularly with major blocks such as spinal and epidurals and of course
problems specifically of headache with relation to spinal and occasionally epidural
anaesthesia. The disadvantage of still requiring full monitoring in a fasting patient
were mentioned by no candidates. Patient preference is also important here on both
sides of this equation. A disadvantage is restrictions placed on the surgeon regarding
the use of gentle techniques in the area of block. In general this question was well
answered.

QUESTION 3

Outline clinical signs and radiological changes in the diagnosis of cervical spine
injury.

In this question the examiners expected the clinical signs to commence with
some statement about the importance of the history of injury and a comment about
associated injuries and their significance on the likelihood of major cervical spine
injury. Candidates were expected to note the importance of neck tenderness, pain and
lack of movement and the importance of a palpable deformity such as a step deformity
or the prominence of a spinous process. Lack of neck mobility, the presence of
oedema or ecchymosis and muscle spasm, perhaps together with an abnormal head
position, would all be signs of neck injury. Tracheal tenderness or deviation, perhaps
associated with a retropharyngeal haematoma, would be another clinical sign.
Neurological signs may include signs of musculo-skeletal weakness, sensory
disturbances, loss of reflex or respiratory difficulties associated with a high cervical
lesion involving the diaphrahm or chest walls paralysis due to lower cervical spine
injury. Comment should have been made of autonomic dysfunction particularly
bladder, bowel or priapism and the presence of cardiac sympathetic blockade leading
to hypotension and bradycardia.
Acute spinal syndrome should have been mentioned with its associated
hypotension and vasodilation.
Radiological changes should describe the necessity for all seven cervical
vertebrae to be visualised and then specific injuries such as an arch injury of C1
(Jefferson fracture) fractures of the odontoid process as well as subluxation of C2 on
C1 (hangman fracture). Other radiological signs may involve loss of alignment of the
cervical vertebrae being diagnosed by a lack of continuity of one of the three major
ligamented structures. The presence of soft tissue injury particularly associated with
post laryngeal haematoma, overriding of the facets or a teardrop fracture. Comments
should have been made about the associated radiological diagnosis of skull fracture
and the presence of susceptible pathology such as cervical spondylosis.
In general this question was passed by most candidates though the standard of
answer was very variable. Most candidates covered the clinical side of things
reasonably well but the specifics of the radiological changes were scant. It is of note
that any candidate who had completed the EMST course should have had no difficulty
with this question.
QUESTION 4

List the predisposing factors and adverse effects of post-operative nausea and
vomiting.

This question was not answered well with many candidates not mentioning pre-
disposing factors such as opioids either as pre-medication, intra operatively or post
operatively, nor mentioning unrelieved pain as causes of nausea and vomiting.
Several candidates did not even mention any drugs at all where as this question was
best answered by listing patient factors, anaesthetic factors and surgical factors.
Adverse effects should have raised the problems associated with fluid aspects
of vomiting such as loss of potassium, hydrogen ions and fluid itself; the problems of
raised venous, intraocular, intracranial and gastric pressures, including ruptured
oesophagus. Other problems are those associated with bleeding following head and
neck procedures as well as delayed discharge, patient discomfort and the occasional
complications of management.

QUESTION 5

Discuss the role of ECG monitoring in anaesthesia.

This question was poorly answered and candidates who gave lists without
attempting any discussion were penalised. Candidates were expected to state that the
main use of ECG monitoring was to monitor rhythm and its changes, heart rate and
ischaemia. Reward was given when examples were quoted and candidates were
expected to orientate each of these for example by describing lead placement and the
importance of the diagnostic mode on a monitor as well as the use of CM5 lead.
Candidates were expected to discuss the limitations of ECG monitoring particularly
with its poor record for critical incident monitoring.
Most answers were very brief and scant with information and irrelevancies such
as the problems of irritation due to stickiness of the electrodes.

QUESTION 6

You are resuscitating a patient in the operating room following rapid blood loss.
You notice that a unit of blood which has been partly transfused is not the
patient’s blood group. Describe how you would manage this situation.

This question required that the transfusion be immediately stopped with a quick
clerical check and if the group is not O negative then should be immediately replaced
and treatment instituted for haemolytic reactions. The treatment should involve the
management of hypotension with fluids and ionotropes, monitoring of central venous
pressure etc, the protection of the kidney in acute renal failure with fluids, frusemide
and mannitol. There should also be management of DIC which occurs in these cases
with replacement of blood products and monitoring of bleeding and coagulation
profiles. There must be support of the circulatory system with oxygen
supplementation, communication with the surgeon and completion of or cessation of
surgery as soon as possible. The patient should be transferred to ICU for follow-up
care and the management of delayed reactions.
In general this question was answered reasonably though one candidate thought
that the problem was insignificant compared to the need for blood originally being
transfused. The management of DIC was not well handled by this group but most
appreciated the problems of circulatory and renal failure.

QUESTION 7

What is meant by “cross-infection”? Discuss the measures you would take to

prevent cross-infection in anaesthetized patients.

Cross infection refers to the transmission of infection from patient to patient,

from patient to health workers and vice versa. Measures taken should involve the
management of all body substances and their isolation and disposal. This will involve
the management of sharps which must be adequately isolated, handled and disposed
of, and the prevention and the non-use of any re-useable items between patients and
the management of waste.
Comments can be made about sterile solutions, avoiding multidosed ampoules,
anaesthetic breathing circuits and any invasive lines. The cleaning by
decontamination and subsequent disinfection and sterilisation of all instrumrntation is
important. There should be a discussion of ‘universal precautions’ as they relate to
the anaesthetized patient and the operating room environment. This will involve not
just hand washing and akin protection but also the use of gowns and gloves, eye
protection and the isolation of contaminated items and ongoing education process.

QUESTION 8

List the indications for limbar sympathectomy. Describe a technique of lumbar

sympathectomy.

Indications:
1) Pain:
Renal colic
Obliterative artery disease
Paget’s disease of bone
Reflex sympathetic dystrophy
other causalgia : phantom limb pain, frostbite
2) Increase Blood Flow:
Vasospastic diseases
Frostbite
Obliterative artery disease
With vascular surgery
3) Improve drainage of local edema
Technique:
Pre-op preparation
Needle placement, multiple for lytic block (L2, L3, L4)
Check with Image Intensifier
Check with local anaesthetics
 Chemical block : alcohol or phenol
Post-op management

QUESTION 9

You are in the process of placing an epidural catheter placement for caesarean
section in a patient with obstructed labour, who is otherwise well and has had a
normal pregnancy. The obstetrician notices a sustained fetal bradycardia of 60
beats per minute and wishes to proceed immediately with the caesarean section.
Describe how you would proceed and justify the steps to be taken.

Ensure cause is not maternal factors : hypotension, supine hypotension syndrome,

hypoxia.
Given oxygen to mother and proceeds immediately to operating room.
Give general anaesthesia with all precautions for full stomach and Caesarean section.
Beware of potential airway problems.
Possible need for fetal resuscitation.

Oral

Five candidates passed the oral section. There were three tables of two examiners and
30 minutes was spent at each table. Half the time of each viva was spent discussing
the management of a clinical scenario. The three scenarios were:

A patient with subarachnoid haemorrhage from a ruptured cerebral aneurysm

preoperative neurological assessment, hypertension at tracheal intubation,
methods to reduce ICP, hyperventilation, hypothermia, air embolism.
A diabetic patient with hypertension requiring a lower limb orthopaedic operation,
preoperative assessment, spinal anaesthesia, failed spinal anaesthesia.
A patient with stable angina for elective hemicolectomy
preoperative assessment, anaemia, stable angina, combined general and
epidural
anaesthesia, postoperative analgesia.

The other half of each viva was used to discuss individual topics. The list of topics
included:

Laryngeal mask airway

Assessment of the airway
Difficult intubation
Regional anaesthesia for caesarean section
Dural puncture headache
Preeclampsia
Clinical trials: blinding, power, randomization
Severity of illness scoring systems
Intravenous induction agents
Nerve stimulator
Postoperative spnea
Ulnar nerve injury
Ethics committee
Cross infection
Sterilization of equipment
Retrobulbar block
Intraoperative tachycardia
Malignant hyperpyrexia
Brachial plexus block
Calibration of monitors
Crisis Management
Acute hypotension
Acute hypertension
Oxygen desaturation
Fractured mandible
Circumcision

Clinical

Four candidates passed the clinical which was composed of ten stations each of 10
minutes duration with 2 minutes before each station when some preliminary
information was given. There were also rest stations where nothing was required
from the candidate.

The following stations were used:

Two Medical Examination:

A patient scheduled for elective TURP but giving a history of shortness of
breath. Candidates were asked to examine the relevant systems. The patient had a left
pleural effusion. Time was not managed well and many candidates did not complete
the examination of the cardiovascular and respiratory systems. Several candidates had
difficulty describing their findings as they looked for them. Candidates should also
comment ablut absence of signs such as cyanosis and clubbing. In general, candidates
should also bear in mind that the clinical examination should be conducted with
relevance to anaesthesia for the patient. Additional points were scored for comment
about the lower spine, the airway, (asking) to exercise the patient and checking to see
if the patient could lie flat. Four candidates passed this station.
Examination of the cardiovascular system in a patient with mitral regurgitation
and aortic sclerosis scheduled for surgery. The aortic sclerosis was difficult and not
detected by any candidate. Several candidates required considerable prompting before
they mentioned in their plan of management that they would give prophylactic
antibiotics. Nevertheless, all candidates passed.

One History: A patient with myasthenia gravis. A translator for English was available
if the candidate did not wish to take the history in Cantonese.
One Communication: Explanation to a relative of the anaesthetic choices for an
elderly confused patient requiring hip surgery. A translator for English was available
if the candidate did not wish to speak in Cantonese.

One Resuscitation: Advanced life support for persistent ventricular fibrillation. This
was a difficult station requiring candidates to lead the resuscitation. Only one
candidate passed.

One Crisis Management: Failure to ventilate through an endotracheal tube,

pneumothorax. This was a difficult station requiring practical skill and four
candidates passed.

One Anatomy: Regional anaesthesia for surgery on the hand and ankle block for
anaesthesia of the foot. Only one candidate failed this station.

One Equipment: Checking an anaesthetic machine and Bain circuit. Only one
candidate passed this station.

Two Investigations: ECGs, CXRs, capnograph and lung function tests. These two
stations were generally well done.