POSTGRADUATE INSTI)'l)TE OF MEDICINE UNIVERSITY OF COLOMBO MD (ANAESTHESIOLOGY) PART II EXAMINATION MARCH 2009 ESSAY PAPER - LONG ANSWER

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1 POSTGRADUATE INSTI)'l)TE OF MEDICINE UNIVERSITY OF COLOMBO MD (ANAESTHESIOLOGY) PART II EXAMINATION MARCH 2009 Date: 13 th March 2009 Time: 1.00 p.m p,m. Answer any three questions. Answer each question in a separate book. ESSAY PAPER - LONG ANSWER 1 Discuss the factors that need to be considered when providing a general anaesthetic to a pregnant patient for non obstetric surgery. 2. Discuss the post"extubation airway complications and their management. 3. Brain-stem death has been diagnosed in a 20 year old man in your ICU. How would you shift your emphasis of care for preservation and optimization of his organ function for organ donation? 4. A forty year old male admitted for repair of a para-umbilical hernia gives a history of haematemesis for which banding was done six months ago. (a) (b) Describe how you would assess this patient with regard to his liver functions. What special precautions would you take when anaesthetising this Patient? 1

2 POSTGRADUATE INSTITUTE OF MEDICINE UNIVERSI)TY OF COLOMBO MD (ANAESTHESIOLOGYl) PART II (FINAL) EXAMINATION MARCH 2009 Date: 16 th March 2009 Time : 1.00 p.m p.m. ESSAY PAPER (SHORT ANSWER QUESTIONS) Candidates are required to answer all twelve questions. Candidates who fail to attempt anyone question will not pass the examination. All questions carry equal marks. Answer each part in a separate book marked A & B. PART A 1. You have been called to attend a patient in ICU urgently because he has become agitated, hypertensive and acutely hypoxic. The patient is suffering from Guillian Barre syndrome and has a tracheostomy. He is being maintained on 30% oxygen, 8cm H 2 0 CPAP. The percutaneous tracheostomy was performed 18 hours ago without complications List possible causes for his acute hypoxia Describe your immediate assessment How would you manage an airway problem.in this patient? 2. Classify bronchodilators. Briefly ooutline the mechanisms of action and side effects of bronchodilators. 2

3 Explain the possible adverse consequences of hypotension during anaesthesia What factors may increase the morbidity of hypotension? 3.3. What principles would help you decide on the lowest acceptable blood pressure in each of the following patients undergoing anaesthesia for major abdominal surgery? The preoperative blood pressure was 140/80 mmhg and there is no requirement for hypotensive anaesthesia A fit healthy 35 year old A fit healthy 75 year old A treated hypertensive 75 year old 4. What would you consider as lninimal standard of monitoring for a 3 year old child who is undergoing repair of inguinal hernia under general anaesthesia? What may cause bradycardia in this child during anaesthesia and surgery? Why can touching a piece of faulty domestic electrical apparatus cause ventricular fibrillation? 5.2. What is microshock and how does this cause ventricular fibrillation? 5.3. List the factors which mclke an anaesthetised patient in the operating room at particular risk from electrical hazards What precautions are taken to reduce electrical hazards in the operating room? 3

4 6. A 53 year old chronic smoker is admitted for elective surgery. 6.1 What symptoms and signs will help you to assess the severity of pulmonary involvement? 6.2 Comment on the following pulmonary function test results of this patient? Predicted Actual % Predicted FVC (Litres) % FEV 1 (litres) % FEV 1/FVC 32.5% PART B 7. After a fall at her home, an 84 year old woman needs surgical repair of a fractured neck of femur. You sec her pre-operatively on the hospital ward, where her blood pressure is 140/80 and her pulse is i7regular, 90 beats per minute. Her ECG reveals atrial fibrillation. Her usual medications are warfarin, furosemide and digoxin. She appears fully alert for her age What underling medical conditions may have caused her fall? 7.2. What are the advantages and disadvantages of general versus regional anaesthesia in this patient? 7.3. How could her warfarin medication affect her anaesthetic management? 8. Draw a diagram of the gross anatomy of the aorta and describe the medical management of aortic dissection. 4

5 8. A 35 year old otherwise healthy man sustained a fractured mandible during a fight yesterday evening, outside a restaurant. He was reportedly "unconscious" for "several minutes" after the event. You are asked to see him 18 hours post-injury, as he needs surgery to stabilise his fracture. He cannot remember the fight. He has no other apparent injuries Outline your pre-operative assessment of this patient What pre-operative factors may lead you to postpone surgery? 9.3. What are the anaesthetic options for surgery? 10. Concerning the cardiovascular risk evaluation for elective non-cardiac surgery Identify "high risk" cardiovascular patient-specific factors that must be. evaluated and treated before elective surgery Identify "intermediate and low risk" cardiovascular and non cardiovascular patient-specific factors that may need further investigation and treatment before elective surgery What are the causes of hypercarbia during general anaesthesia? What clinical signs help in the diagnosis? What is morbid obesity? What are the problems in anaesthetising such patients? 5