Past RCoA Cardiothoracic. Final FRCA SAQ Questions with examiner comments. November 1996 Sept 2016

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1 Past RCoA Cardiothoracic Final FRCA SAQ Questions with examiner comments November 1996 Sept 2016

2 September 2016 Question 8 You are asked to review a 65-year-old woman on the cardiac intensive care unit who has undergone coronary artery bypass surgery earlier in the day. a) What clinical features might suggest the development of cardiac tamponade? (9 marks) b) Describe specific investigations with their findings that could confirm the diagnosis of cardiac tamponade. (2 marks) c) Outline the management of acute cardiac tamponade in this patient. (9 marks) Examiners Report: Cardiothoracic cardiac tamponade Pass Rate: 81.4%. This question had the highest pass rate in the paper. It is an important topic and it is good to see that candidates are aware of the signs and symptoms and treatment options for this emergency.

3 March 2016 Question 8 A 70-year-old woman with aortic stenosis presents for an open aortic valve replacement (AVR). a) What is the pathophysiology of worsening aortic stenosis? (8 marks) b) Which specific cardiac investigations may be used in assessing the severity of this woman s disease? (3 marks) c) Give values for the peak aortic flow velocity, mean pressure gradient and valve area that would indicate that this woman has severe aortic stenosis. (3 marks) d) What would be your haemodynamic goals for the perioperative management of this patient? (6 marks) Examiners Report: Aortic Stenosis Pass Rate: 41.8%. The pass rate for this question was the second lowest overall. Aortic stenosis is a common condition and its pathophysiology and management should be known to candidates sitting this exam. In part (a) many candidates simply gave the symptoms of aortic stenosis rather than describing the pathophysiology. This could have been due to not reading the question carefully enough but may also reflect lack of knowledge. As mentioned in previous reports, candidiates should endeavour to arrange taster sessions in modules such as cardiac anaesthesia if they have not done them prior to sitting the SAQ paper.

4 September 2015 Question 9 a) What are the central and peripheral neurological complications of coronary artery bypass surgery? (7 marks) b) What are the risk factors for central neurological complications? (6 marks) c) How can the incidence of central neurological complications be reduced? (7 marks) Examiners Report: Neurological complications of CABG Pass Rate: 54.6%. Candidates who did well in this question tended to do well overall. There was quite a spread of scores with some candidates having a very clear idea of the answers and others seemingly not very much idea at all. Whether this reflects the fact that some candidates sitting the exam have no experience of cardiac anaesthesia is not clear. However, as stated in previous reports, candidates who have no exposure to the mandatory units of training should endeavour to spend a few sessions gaining first hand experience prior to sitting the SAQ paper.

5 March 2015 Question 8 A 67 year-old patient is to undergo coronary artery surgery on cardiopulmonary bypass (CPB). a) What dose of heparin is used to achieve full anticoagulation for CPB and how is it given? (2 marks) b) Which laboratory and point-of-care tests determine the effectiveness of heparin anticoagulation in CPB patients? Give the advantages and/or disadvantages of each test. (10 marks) c) What are the causes of inadequate anticoagulation in a patient whom it is believed has already received heparin? (5 marks) d) Describe the possible adverse reactions to protamine. (3 marks) Examiners Report: Heparin for bypass surgery Pass Rate: 61.5%. (17.2% of candidates received a poor fail) This question proved straightforward to candidates who had rotated through a cardiac unit or had read a textbook on cardiothoracic anaesthesia. Many weak candidates neither had knowledge of the intraoperative dosing of heparin for bypass surgery nor aspects of appropriate monitoring. Again, inexperience was the predominating factor in success or failure in this item.

6 September 2014 Question 4 a) What are the purposes (3 marks), typical composition (4 marks) and physiological actions of cardioplegia solutions? (5 marks) b) By which routes can solutions of cardioplegia be administered? (2 marks) c) What are the possible complications of cardioplegia solution administration? (6 marks) Examiners Report: Cardioplegia Pass Rate: 16.5%. Cardioplegia is an important basic tool in cardiothoracic anaesthesia although not used invariably in current surgical procedures. It was evident from the answers which candidates had undertaken an attachment in this area of practice, or had read an appropriate textbook. The importance of considering the mandatory units of training in preparation for the Final FRCA examination has been emphasised above.

7 March 2014 Question 2 a) What are the indications for insertion of an implantable cardiac defibrillator (ICD)? (20%) b) How might surgical diathermy affect the ICD? (20%) c) A patient with an ICD is listed for elective surgery; what preparations are necessary preoperatively, intra-operatively and postoperatively? (45%) d) How does the management differ if this patient requires emergency surgery? (15%) Examiners Report: Implantable cardiac defibrillator Pass Rate: 67.1%. Generally well answered. Indications for a pacemaker are part of core knowledge incorporating many conditions, which have a bearing on the management of anaesthesia. For section (c), some candidates gave generalised answers and failed to focus on the specifics of how the risk of an ICD working inappropriately, or failing to work when necessary, would influences anaesthetic practice. In an emergency situation, deactivation of the ICD would be a reasonable balance of risks action.

8 March 2014 (cont.) Question 7 A 71-year-old patient requires a rigid bronchoscopy for biopsy and possible laser resection of an endobronchial tumour. a) Outline the options available to maintain anaesthesia (20%) and manage gas exchange. (30%) b) How will use of the laser change the management of anaesthesia? (15%) c) What are the possible complications of rigid bronchoscopy? (35%) Examiners Report: Rigid bronchoscopy Pass Rate: 60.8%. This question proved discriminatory between candidates who gave a mature and thoughtful answer and those that did not understand the implications of tubeless ENT / thoracic surgery. Weaker candidates proposed the use of laser-proof endotracheal tubes, and even double lumen endobronchial tubes and cardiac bypass to facilitate gas exchange. Part (a) tended to score scored badly whilst parts (b) and (c) were better known. Focus in part (c) was dominated by traumatic complications with candidates forgetting anaesthetic issues such as; laryngospasm and bronchospasm, pneumothorax / barotrauma / volutrauma from jet ventilation, cardiovascular disturbances, pulmonary infection, hypoxaemia, hypercarbia and awareness.

9 September 2013 Question 1 You are asked to anaesthetise a 75-year-old man for an urgent DC cardioversion on the Coronary Care Unit (CCU). He has a broad complex tachycardia of 150 beats/minute, but is maintaining a systolic blood pressure of 70 mmhg and has a Glasgow Coma Score of 13/15. a) List the advantages and disadvantages of providing anaesthesia in the CCU. (30%) b) What factors must be taken into consideration when choosing an anaesthetic technique for this patient? (30%) c) What complications may occur as a consequence of the procedure? (40%) Examiners Report: DCCV on CCU Pass Rate: 45.7%. This question proved difficult for many candidates. The advantages of providing anaesthesia in a Coronary Care Unit for a maximum of three marks included: Avoiding the transfer an unstable patient to theatre Cardiology Department skills readily available Specialist equipment and drugs are immediately accessible Allows earlier treatment The most important disadvantage was anaesthetising a patient in a remote and unfamiliar environment. This statement needed to be expanded to include the potential lack of monitoring (capnography), anaesthetic drugs, recovery and skilled assistance. Few candidates mentioned the difficulty in complying with the filling in of a WHO checklist. Some of the factors that should have been considered before commencing anaesthesia included valid consent, recent investigations, starvation status and a potential need for intra- or inter-hospital transfer. Required both anaesthetic and cardiological complications, the latter included arterial embolism, myocardial ischaemia, pulmonary oedema, burns to the patient and electrical injury to staff.

10 September 2013 (cont.) Question 7 You are asked to review a 65-year-old man on the Cardiac Intensive Care Unit who underwent coronary artery bypass surgery earlier in the day. a) Which clinical signs suggest the development of acute cardiac tamponade? (40%) b) List the investigations and their associated derangements that could confirm the diagnosis of acute cardiac tamponade. (15%) c) What is the management of acute cardiac tamponade in this patient? (45%) Examiners Report: Tamponade on CITU Pass Rate: 57.6%. This question was designated an easy question by the exam board and was a good discriminator. The investigations and associated derangements were linked and one mark was awarded for both correct answers. The management of acute pericardial tamponade was generally answered in a generic way (ABC, call for help etc.) but a number of candidates wasted time and effort on managing an anaesthetic in this situation. Many failed to monitor the clotting and administer blood products or reversing agents if indicated.

11 March 2013 Question 2 a) What are the indications for one lung ventilation (OLV)? (30%) b) How can the risks associated with lung resection be quantified preoperatively? (30%) c) How would you manage the development of hypoxaemia during OLV? (40%) Examiners Report: One Lung Ventilation Pass Rate: 88.6%. This area has been covered in previous SAQ exams (2006 and 2009), and was a very straightforward test of knowledge. Significant numbers of candidates scored 16/20 or more.

12 March 2013 (cont.) Question 7 A 56-year-old man is listed for elective surgery. He received an orthotopic heart transplant 12 years before. a) What key alterations in cardiac physiology and function must be considered when planning general anaesthesia? (50%) b) What are the implications of the patient s immunosuppressant therapy for perioperative care? (30%) c) What long-term health issues may occur in this type of patient? (20%) Examiners Report: Heart Transplant Pass Rate: 27%. It is not uncommon to have a patient presenting for surgery that has received a transplanted organ and is on immunosuppressive therapy. A similar question was asked in October This question proved to be the most difficult question on the paper. A majority of the candidates demonstrated poor understanding of the physiology of a transplanted heart and the side effects of immunosuppressive therapy of relevance to the anaesthetist. Increased infection risk may need antibiotic prophylaxis/ strict asepis Common agents cause a degree of chronic kidney disease Avoid NSAIDs enhanced side effects Important to maintain stable plasma levels ensure drugs taken / given IV steroid cover may be required Cyclosporine enhances and azothioprine reduces aminosteroid NMB action

13 September 2012 Question 9 a) What are the theoretical advantages of off pump coronary artery bypass grafting (OPCAB) compared to on bypass technique? (35%) b) What causes haemodynamic instability during OPCAB? (20%) c) Which strategies help to minimise this haemodynamic instability? (25%) d) Outline the measures that help to minimise perioperative hypothermia during OPCAB. (20%) Examiners Report: Off pump CABG Pass Rate: 37.3%. Cardiothoracic anaesthesia is currently a mandatory unit of training and as such a question will feature in each SAQ paper. The Royal College recognizes that candidates taking the exam at ST3 level may not have yet had significant experience of this subspeciality and for this reason this question was designated as difficult. Nevertheless it was felt that this question would be able to be answered by candidates using some basic principles, (similar to question 4). Again, this question was poorly answered. Many candidates answered b) and c) with on-pump rather than off-pump issues. A pass would have been achieved by writing these ten key points: a) Theoretical advantages of OPCPB. Reduced platelet dysfunction. Reduced neurological injury b) Causes of haemodynamic instability. Mechanical displacement of heart. Arrhythmias c) Strategies to minimize haemodynamic instability. Avoid electrolyte disturbance. Suspend surgical manipulation e) Minimising perioperative hypothermia (as with any anaesthetic). Increase ambient theatre temperature, Warm IV fluids, Use hot-air warmers The only answers that were specific to OPCPB surgery were in a), the other answers were generic. There were 24 key facts in the model answer. Factors contributing to poor performance were lack of knowledge, inexperience and failure to read the question. This question was the best Compiled discriminator by Dr J in Brand the paper. & Dr S Law

14 March 2012 No question on Cardiothoracic Anaesthesia and Intensive Care September 2011 Question 7 a) What are the cerebral physiological benefits of induced hypothermia following successful resuscitation from cardiac arrest? (25%) b) How can a patient be cooled in these circumstances? (20%) c) What adverse effects may occur due to the use of induced hypothermia? (35%) d) In what other non-surgical clinical scenarios may the use of induced hypothermia be beneficial? (20%) March 2011 Question 11 a) What are the diagnostic (25%) and therapeutic (25%) indications for bronchoscopy? b) List the major contraindications for bronchoscopy. (20%) c) How should a fibreoptic bronchoscope be reprocessed after use? (30%) September 2010 No question on Cardiothoracic Anaesthesia and Intensive Care

15 March 2010 Question 2 a) Describe the principles of using an intra aortic balloon pump (IABP). (30%) b) What are the indications (20%) and contraindications (15%) to use of an IABP? c) List the main complications of using this device. (25%) September 2009 Question 3 a) What features in the clinical history and examination would suggest a diagnosis of acute aortic dissection? (30%) b) Which investigations may be used in making the diagnosis? (20%) c) Describe your initial management of a patient with confirmed aortic dissection in the district general hospital environment. (40%) Examiners Report: With regard to question 3 (acute aortic dissection), which had the second lowest pass rate in the paper, it appeared construction of a management plan (section c) caused candidates the greatest difficulties. Question 10 a) List the indications for placement of a double lumen tube in anaesthesia and critical care. (25%) b) List, giving appropriate threshold values for each, the methods of preoperative respiratory assessment you would use in an adult to decide whether a patient could tolerate lung resection. (25%) c) How would you manage the development of hypoxaemia during one-lung anaesthesia? (40%)

16 April 2009 Question 4 a) Describe how atrial fibrillation may present. (10%) b) List 5 causes of atrial fibrillation. (25%) c) What principles underlie the management of atrial fibrillation? (25%) d) What are the main anaesthetic considerations when performing elective Direct Current Cardioversion? (30%) Examiners Report: Question 4 (atrial fibrillation) compared with questions 3 and 5, but the majority of candidates still failed. Again, given the frequency with which established and newonset atrial fibrillation is encountered in clinical practice, the low pass rate was disappointing. The anaesthetic considerations, for performing elective direct current cardioversion, was notably poor.

17 October 2008 Question 3 A parturient, (Gravida 2 Para 1), arrives at a DGH in labour with signs of fetal distress at 38 weeks gestation. She has had her antenatal care elsewhere. She refuses a regional technique and a decision is made to proceed with an emergency caesarean section under general anaesthetic. She is known to have a medium- size secundum atrial septal defect (ASD), is currently asymptomatic and has turned down cardiac surgery. She is followed up regularly by her cardiologist and has had a recent echocardiogram confirming the diagnosis. a) Describe your understanding of the cardiac pathophysiology of ASD. (20%) b) What are your considerations specific to the cardiac condition in this patient? i) Preoperatively (20%) ii) General anaesthetic principles focused on the cardiac condition (30%) c) Immediately following delivery by caesarean section under general anaesthesia, the SpO2 falls to 70%. You confirm that ventilation is not an issue. What are the possible causes? What are your immediate actions in theatre? (20%) Examiners Report: The question on Grown Up Congenital Heart disease was set due to the increasing number of such patients who could easily present as an emergency to any hospital. The obstetric scenario was chosen so that the candidates had to describe what they would do and an ASD was felt to be one of the simplest conditions that might be encountered. The question had proven particularly difficult to develop and had been modified and reviewed by numerous well known cardiac and obstetric anaesthetists over more than a year. As GUCH is an important cause of maternal morbidity and mortality in pregnancy it was legitimate to test the understanding of the principle of managing such a patient. It was disappointing that only 34% of candidates achieved the pass mark.

18 April 2008 Question 1 a) Describe the anatomy of the thoracic paravertebral space. (35%) b) What are the indications for paravertebral nerve blockade? (25%) c) List the complications of a paravertebral nerve block. (30%) Examiners Report: Question1 (paravertebral space) was generally well done but few candidates did a really good anatomy section. The diagrams were especially poor examiners assumed this was due to lack of knowledge. Many candidates did not mention the ribs. They gave indications that were mainly common sense but surprisingly few mentioned the unilateral nature of the indications and the complications given were generic (toxicity, IV injection etc) with some local factors (pneumothorax etc). October 2007 Question 5 a) What clinical features would suggest to you that a patient has a pleural fluid collection? (45%) b) Describe investigations that assess the size (30%) and nature (15%) of a pleural fluid collection, and indicate how results of each can guide management.

19 May 2007 Question 6 a) How are implantable cardiac pacemakers and implantable cardioverter defibrillators classified? (25%) b) What information should be sought relating to these devices preoperatively? (30%) c) What precautions should you take perioperatively when anaesthetising patients with these devices, where the use of surgical diathermy / electrocautery is anticipated? (35%) Question 9 a) Describe the anatomy of an intercostal nerve. (25%) b) How does this influence your technique of intercostal nerve blockade for a fractured rib? (35%) c) List the complications that may arise and explain the anatomical reasons for these complications. (30%) October 2006 No question on Cardiothoracic Anaesthesia and Intensive Care May 2006 Question 1 a) What are the indications for one lung anaesthesia? (30%) b) List the methods of pre-operative assessment you would use to decide whether an adult could tolerate one lung anaesthesia. (30%) c) How could you manage the development of hypoxaemia during one lung anaesthesia? (40%)

20 October 2005 Question 2 What tests of lung function can be used to predict whether a patient will tolerate a pulmonary resection? (60%) Indicate minimum values for lobectomy and pneumonectomy. (40%) Question 11 What information may be obtained from preoperative, resting transthoracic echocardiography in adults? (60%) What are the limitations of this investigation? (40%)

21 May 2005 Question 12 An adult patient requires insertion of a chest drain for management of a spontaneous pneumothorax. The patient is not in acute distress. Describe your technique for insertion of a chest drain in this patient. (50%) The diagram shows an underwater seal device. Comment on its suitability for connection to the drain you have inserted. (50%)

22 October 2004 Question 8 A patient on the ICU, who had cardiac surgery completed 3 hours ago, is still intubated. What clinical features might suggest the development of acute cardiac tamponade? (55%) How might you confirm the diagnosis? (5%) Outline your management of acute cardiac tamponade? (40%) Question 12 What are the presenting clinical features of infective endocarditis? (40%) What are the principles that guide the use of antibiotics as prophylaxis against this condition during surgery? (60%) May 2004 Question 8 List the causes of perioperative atrial fibrillation. What are the dangers of acute onset atrial fibrillation? How would you manage acute atrial fibrillation in the postoperative period?

23 October 2003 Question 6 What are the risks and benefits of thoracic epidural anaesthesia/analgesia for coronary artery surgery? Question 8 Draw the following diagrams (with values): A spirometer trace showing normal lung volumes, FEV1/FVC graphs and flow volume loops. How are these altered by the following diseases: asthma, emphysema, pulmonary fibrosis, chest wall restriction and respiratory muscle disease? Question 12 Outline the pathology of acute coronary syndromes. What pharmacological treatments are available for patients with an acute coronary syndrome? May 2003 Question 10 A patient with aortic stenosis presents for non-cardiac surgery. What are the clinical features of aortic stenosis and how would pre-operative investigations influence your peri-operative management? October 2002 Question 3 Define contractility. Outline the methods available to the clinician to assess myocardial contractility in the peri-operative period. Question 7 What are the possible deleterious consequences of cardiopulmonary bypass when used in coronary artery surgery? How may these be reduced?

24 April 2002 No question on Cardiothoracic Anaesthesia and Intensive Care October 2001 Question 2 What tests may be done to evaluate the adequacy of pulmonary oxygen transfer? Briefly describe how you would interpret the results. Question 8 A patient who has undergone a heart transplant requires non-cardiac surgery. What problems may this present for the anaesthetist? May 2001 No question on Cardiothoracic Anaesthesia and Intensive Care October 2000 No question on Cardiothoracic Anaesthesia and Intensive Care May 2000 No question on Cardiothoracic Anaesthesia and Intensive Care November 1999 Question 11 Classify the types of heart block. Outline appropriate treatment in the intraoperative period.

25 May 1999 Question 6 How do you confirm that a double-lumen endobronchial tube has been placed correctly? Outline the possible complications associated with the use of this equipment. Question 10 What are the principles of adult cardio-pulmonary bypass? What are the common complications of this procedure? November 1998 Question 1 List, with reasons, the factors which affect the incidence of perioperative myocardial infarction. Question 9 How would you determine the mixed venous oxygen content in the intensive care patient? What is the usefulness of this measurement? May 1998 No question on Cardiothoracic Anaesthesia and Intensive Care

26 November 1997 Question 8 What are the postoperative problems in the first 24 hrs after coronary artery bypass graft? How are they prevented? May 1997 Question 3 The first patient on your operating theatre list tomorrow morning has an implanted (permanent) cardiac pacemaker. List, with reasons, the relevant factors in your preoperative assessment. Question 9 What measurements and derived values can be made from pulmonary artery catheters used in the intensive care unit? Suggest a clinical application for each one. November 1996 Question 6 What is your choice of anaesthesia for pericardectomy in constrictive pericarditis? Give reasons for your choice. Question 8 Make a simple drawing, with labels, to show the trachea, main and segmental bronchi.