AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS EXAMINATION REPORT FINAL FELLOWSHIP EXAMINATION

AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS EXAMINATION REPORT FINAL FELLOWSHIP EXAMINATION

AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS
ABN 82 055 042 852
EXAMINATION REPORT
FINAL FELLOWSHIP EXAMINATION
May 2013
GENERAL COMMENTS
The mark allocation for the examination is as follows
SECTION
MCQ
SAQ
Medical Clinical
Anaesthesia vivas
TOTAL
FANZCA
20
20
12
48
100
Performance assessment
Vivas only
20 (25%)
12 (15%)
48 (60%)
80 (100%)
12 (20%)
48 (80%)
60 (100%)
The pass rates for candidates presenting for the Final Fellowship in March-May 2013 are presented below:
CATEGORY
ANZCA Trainees
MCQ
SAQ
No. sitting
184
184
184
167
184
% pass
75%
52.7%
78.8%
89.8%
76.1%
7
71.4%
7
28.6%
7
28.6%
5
60.0%
7
42.9%
11
11
11
11
18.2%
45.5%
54.5%
36.4%
3
100%
3
33.3%
3
33.3%
205
75.6%
186
86%
205
72.2%
IMGS – Full FFE
No. sitting
% pass
IMGS – Performance
Assessment
No. sitting
% pass
IMGS – No written
No. sitting
% pass
Total
No. sitting
% pass
191
74.9%
202
50%
Medical
VIVA
OVERALL
1
MCQ PAPER
Of the candidates who sat this section, 74.9% passed.
Each question is of the one best answer type; no marks are deducted for incorrect answers.
The table below outlines the number of questions in each subject category (noting that an
individual question may have more than one subject). Only subjects represented in four or
more questions are listed. The subject spread in the MCQ paper varies from exam to exam,
as it is partly determined by the content of the short answer and viva sections of the exam, to
ensure that an appropriately wide range of subjects is covered by the whole examination.
Topic
Number Of Questions
Percentage (%)
cardiac disease
20
13.33
applied pharmacology
16
10.67
equipment
15
10.00
paediatric anaesthesia
13
8.67
applied anatomy
12
8.00
regional anaesthesia
11
7.33
medicine
11
7.33
Obstetrics
10
6.67
thoracic anaesthesia
9
6.00
shock resuscitation
9
6.00
applied physiology
9
6.00
cardiac complications
7
4.67
neurosurgical anaesthesia
6
4.00
monitoring
6
4.00
preanaes assessment
5
3.33
endocrine disease
5
3.33
difficult airway
5
3.33
cardiac investigations
5
3.33
pulmonary disease
4
2.67
statistics
3
2.00
neuromuscular skeletal
3
2.00
miscellaneous
complications
haematological disorder
investigation
3
2.00
3
2.00
2
SHORT ANSWER QUESTION PAPER
Of the candidates who sat this section, 50% passed.
The average mark per question was 4.98/10
All questions are worth equal marks. The SAQ section tests a combination of knowledge
[content] and reasoning skills, above that tested by the MCQ section. The material covered is
mapped to the curriculum.
It is recognised that preparation and performance for this section is demanding. Candidates
are advised that practicing answering SAQ questions under exam conditions is a valuable
method of preparation for this section of the exam.
Of all the sections of the exam, the SAQ shows the best correlation with each other section of
the examination and the examination overall.
Responses that specifically answer the specific question asked require less time to write.
Writing must be legible and abbreviations should be avoided unless explained in the body of
an answer.
Logical, well-organised, clearly expressed answers that reflect safe practice, defensible
judgement and evidence-based practice attract higher marks.
The examiners acknowledge that there is often a great deal that the candidates can offer in
response to some of the short answer questions. Part of the challenge of this section is to
manage time and rank information that is included.
SAQ
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Topic
Manual in-line stabilization of neck; need and implications for intubation
Features of anaesthetic machine ensuring safe gas delivery
Arterial line damping and methods of ensuring accuracy
Sensory innervation of nasal airway and indications or nasal intubation
Perioperative issues in managing a patient with epilepsy
Patient with previous anaphylaxis for surgery; safe anaesthetic and
investigations for suspected anaphylaxis
Morbid obesity in pregnancy; implications for obstetric anaesthetic care.
Acute neuropathic pain post-op and management
EBM, systematic review and how it would influence your practice
Methods of preventing hypothermia during paediatric anaesthesia
Causes and investigation of systolic murmur in 25 yo for elective
surgery
Hazards of, and their minimization in prone position during GA
Aetiology and management of hypoxia during OLV
Diagnosis and management of LA toxicity during Intercostal blocks
Diagnosis and management of low preoperative Hb in patient for TKR
%pass
68.3%
23.8%
69.3%
85.1%
53.5%
37.1%
52%
75.2%
53%
66.8%
52.5%
37.6%
71.8%
67.3%
66.8%
Question 1
a.
How is the need for manual in-line stabilisation of the neck determined? (50%)
b.
What are the implications of inline stabilisation for endotracheal intubation of the
airway (50%).
68.3% of candidates passed this question.
Key components of an answer for this question related to
3
a. A structured and prioritised approach was important.
Discussion of the need to use the history, physical examination and investigations when
determining the need for manual inline stabilisation (MILS).
Acknowledging that MILS was necessary for patients requiring endotracheal intubation where
there is concern of instability of the cervical spine and potential spinal cord injury due to neck
movement during intubation.
mentioningthe need for MILS in clinical situations other the trauma and mentioned criteria for
clearing the cervical spine in trauma situations such as NEXUS and the Canadian C-spine
rule. It was considered impressive if a candidate had enough time to write a very brief
discussion of the controversy surrounding MRI versus CT scan to clear the cervical spine in
the obtunded patient.
b. Acknowledgment of difficulty in assessing the airway, the technical increase in difficulty and
the logistics of the need for additional staff and potentially equipment, along with
management of collar were considered important
Question 2.
Outline the features of the anaesthetic machine that ensure safe gas delivery to the patient.
28.3% of candidates passed this section.
Key components of an answer for this question related to outlining safety features present in
the
- Supply of gas to the machine and circuit
- Ensuring safe pressures delivered to the machine and in the patient circuit
- Monitoring of gas content
Question 3.
An elderly patient is to undergo operative fixation of a fractured neck of femur. A radial arterial
line is inserted prior to induction, and when transduced, the trace appears damped
a. What are the possible causes for the trace to appear damped in this patient? (50%)
b. Outline the steps you would take to ensure the accuracy of your arterial line (50%)
69.3% of candidates passed this section.
Key components of an answer for this question related to:
a. Possible causes for damp trace
- Actually damped and causes
- Inaccurate reading
- Accurate reading but clinical condition causing appearance
b. Steps to ensure accuracy of reading
- Exclude damping
- Check calibration
- Compare arterial line and NIBP
- Clinically assessing the patient
Question 4
a. Describe the sensory innervation of the respiratory passage from the nostrils to, and
including, the vocal cords (50%).
b. List the indications and contraindications for nasal intubation (50%).
85.1% of candidates passed this question.
4
Key components of an answer for this question related to:
a. description of the anatomical extent and shared and somewhat complex and overlapping
innervation of the “nasal portion” of the airway.
b. A list of relative an absolute indications and contraindications
i. Oral route not possible; in way of surgery; prolonged intiubation; where blind nasal
indicated
ii. Where route increases risk of trauma / injury; base of skull #; CSF leak; bleeding
disorders; previous naso-cranial surgery
Question 5
What are the perioperative concerns for the anaesthetist managing a patient with epilepsy?
53.5% of candidates passed this question.
Key components of an answer for this question related to
-knowing that epilepsy is a common condition and
-indication of knowledge of importance of maintaining anti-epileptic medications perioperatively
-awareness of risk factors for having a seizure related to anaesthesia
-awareness that anaesthesia and drugs used in association with anaesthesia can modulate
seizure threshold
-knowledge that treatment with antiepileptic drugs can effect enzyme activity, drug
metabolism and anaesthetic drug requirements
-awareness of some common associated medical conditions
-indication of a management plan if a seizure occurs
Question 6.
A fit 37-year-old female presents for laparoscopic appendicectomy. She reports a “severe
allergic reaction” during her a laparoscopy 5 years ago. There were no tests performed and
the records are not available.
a. Outline your strategy for managing this case. (70%)
b. List the investigations that are recommended following any suspected anaphylaxis and
when they should be performed. (30%)
37.1% of candidates passed this question.
Key components of an answer for this question related to
a. demonstration of a logical approach including
History of previous episode; allergic risk/tendency; discuss with surgeon; inform patient of
likely risks; make low risk plan for this case including drug choice’s; monitoring and
contingency plans if problems.
b. serum levels of reaction / anaphylaxis markers [histamine; tryptase]; skin testing and
timing of all.
Question 7
A 25 year old woman at 28 weeks gestation, with a body mass index (BMI) of 45 attends the
high risk obstetric clinic
Outline the pathophysiology of morbid obesity affecting pregnancy and describe the
implications for obstetric anaesthetic care.
5
52% of candidates passed this question.
Key components of an answer for this question related to outlining the effects of obesity on
respiratory and airway; cardiovascular issues; endocrine problems; gastrointestinal problems
and wound healing / infection with an overall increase in maternal mortality and morbidity.
Also acknowledging the impact on anaesthesia provision
- regional and general techniques
- pharmacokinetics
- equipment / practical issues
- along higher incidence of obstetric complications.
Question 8
a. In a patient who complains of post operative pain, which features of the history and
examination suggest a diagnosis of acute neuropathic pain? (50%)
b. How would the diagnosis affect your postoperative pain management plan? (50%)
75.2% of candidates passed this question.
Key components of an answer for this question related to
a. identifying at risk populations; key clinical features of ANP on history and exam;
appropriate pain assessment scales;
b. Recognition of risk and preventative measures commenced pre-op; reducing symptoms
with appropriate pharmacotherapy; management of psychosocial stressors that may be in
play.
Question 9
a. What is evidence based medicine. (30%)
b. Describe the features of a systematic review, indicating how it may influence your practice
of anaesthesia. (70%)
53% of candidates passed this question.
Key components of an answer for this question related to:
a. defining EBM as a process of identifying a clinical practice; reviewing the evidence for
clinical practice robustly and then modifying practice as a result of the review.
b. features of systematic review – framing question; identifying relevant work; assessing
quality of studies; summarizing evidence; interpreting findings / drawing conclusions. Role in
changing practice: development of guidelines based on best care and evidence and review
effectiveness of same.
Question 10
List methods to prevent hypothermia in paediatric patients during anaesthesia and surgery,
commenting on the effectiveness of each.
66.8% of candidates passed this question.
Key components of an answer for this question related to listing methods and giving some
information about efficacy. Modalities to be mentioned:
Forced air warming
Insulating layer
Warming OR
6
Circulating water mattress
IV fluid warming
Humidification of gases
Preop warming
Radiant heaters
Question 11
A 25-year-old male scheduled for elective surgery is found to have a systolic murmur on the
day of surgery
a. What are the clinical features and ECG findings in this patient that would prompt you to
postpone the case to allow further investigation? (70%)
b. What are the likely causes of this murmur? (30%)
52.5% of candidates passed this question.
Key components of an answer for this question related to candidates describing what clinical
features of a systolic murmur and its associated absence or presence of symptoms and other
sign would be indicative of severe enough cardiovascular disease to cancel the case; timing,
nature, radiations, exacerbating maneuvers, and symptoms of dyspnea, exercise limitation, or
chest pain. ECG showing LVH, arrhythmia or ischaemia would be a concern in a 25 yo.
A list of causes with perspective of what is likely would be important.
Question 12
What are the hazards of the prone position for patients under general anaesthesia and how
can they be minimized?
37.6% of candidates passed this question.
Key components of an answer for this question required noting the potential hazards of the
prone position under the headings of CNS; PNS; pressure injuries; others – including
vascular occlusion, eye injury, visceral compression, and equipment/monitoring/ intervention
problems etc.
Minimization strategies to be included; pre-op assess; staff and equipment for positioning,
appropriate support for head / neck as well as secure, preemptive placement of monitors and
rescue device, and of course meticulous attention to padding/positioning of at risk tissues.
Question 13
a. Why can hypoxaemia occur after changing from two lung to one lung ventilation? 50%
b. Describe the treatment of hypoxaemia in one lung ventilation (50%)
71.8% of candidates passed this question.
Key components of an answer for this question:
a. discussion of causes in a structured manner: general unrelated to OLV; problems with
ventilation; problems with pulmonary blood flow; other patient factors.
b. a stepwise increase in level of interventions dependent on severity / urgency: increased
FiO2; tube positioning/issues ; cardiac function optimised; Hb adequate; PEEP/CPAP to
down/up lung respectively; intermittent inflation of “collapsed” lung; clamp PA [ depending
on surgery]; alter PVR.
7
Question 14
You perform multiple intercostal blocks using 300mg ropivavcaine for flail chest
a. What features would make you suspect systemic local anaesthetic toxicity? (50%)
b. How would you manage the situation? (50%)
67.3% of candidates passed this question.
Key components of an answer for this question are:
a. recognizing that this clinical scenario is a high risk for LA toxicity; acknowledging the
potential for relative or absolute overdose; outlining symptoms/signs consistent with
toxicity.
b. general and specific therapy/supportive management for toxicity – intralipid use and
willingness to support circulation for prolonged period [ECMO CPB] important.
Question 15
A female patient scheduled requiring a total knee replacement is seen in clinic. A date has not
yet been scheduled for surgery.
On investigation she has a haemoglobin of 105 g/L
1. What are the most likely causes of this result, and how would confirm this?
(50%)
2. What preoperative treatment would you undertake and why? What advice would you give
for scheduling time of surgery? (50%)
66.8% of candidates passed this question.
Key components of an answer for this question:
a. Require recognition that this is anaemic and have an outline of likely causes and what
findings would point in what direction [Hb, Ferritin, CRP stratified].
b. noting that perioperative issues if proceed with low Hb are increased; that a plan of
diagnosis [outlined], treatment [options dependent on etiology]should be undertaken
before proceeding.
8
MEDICAL CLINICAL VIVAS
75.6% of candidates passed this section of the examination.
Marks are allocated for
an appropriate history and examination which explore risk factors, degrees of
severity, progression, response to therapy and long-term management (where
appropriate) for a disease state
physical examination should elicit key signs and follow an efficient, logical sequence
an organised presentation of findings which synthesises and interprets history,
examination and investigations
professionalism in dealing with patients
The following is a list of the primary medical conditions of patients used for this exam.
Different scenarios were used to introduce the organ system chosen for the focus of the viva.
Cardiovascular system
Valvular heart disease
Post cardiac transplantation
Heart failure
Atrial fibrillation/flutter
Ischaemic heart disease
Pulmonary hypertension
Marfan’s Syndrome
Congenital heart disease
Hypertrophic obstructive cardiomyopathy
Other cardiomyopathy
Respiratory system
-
Chronic obstructive pulmonary disease
Asthma
Pulmonary fibrosis
Fibrosing alveolitis
Post lung transplantation
Bronchiectasis
Obstructive sleep apnoea
Nervous Sytem / Musculoskeletal
Peripheral neuropathy
Guillain-Barre
Spinal cord AV malformation with neuropathic pain
Ankylosing spondylitis
Rheumatoid arthritis
Acromegaly
Myotonic dystrophy
Scleroderma
Myasthenia
Other
Liver cirrhosis
Chronic renal failure
Haemochromatosis
Diabetes and its complications
-
9
ANAESTHESIA VIVAS
Of candidates who presented for the anaesthetic vivas, 86% passed this section.
The aim of this section of the examination is to assess the ability to
Apply principles of acceptable, safe practice and demonstrate sound clinical judgment.
Plan and prioritise clinical actions and to anticipate their sequelae.
Demonstrate organizational and communication skill.
Marks are awarded for
showing sound judgement in decision making
demonstrating adaptability to changing clinical situations
applying basic scientific principles to clinical practice and the ability to
organise and express thoughts clearly.
Evolving clinical scenarios are used in this section of the exam.
The introductory scenarios, and initial questions are listed below
VIVA 1
You are called to the Emergency Department where a 20-year-old man has been brought in
by ambulance with burns. He has burns to his chest, abdomen and legs, sustained when he
threw petrol onto a fire two hours ago. He is screaming and unco-operative. Ambulance
officers report the man had been picked up from a campsite where he and his friends had
been drinking. His friends report that he is usually fit and healthy. No other injuries have been
identified.
His observations on arrival are: Heart rate 130/minute
Blood pressure 140/80 mmHg
Temperature 37.5⁰ C
An arterial blood gas taken on arrival shows the following:
pH
7.2
pCO₂
32 mmHg
pO₂
95 mmHg
HCO₃⁻
20 mmol/L
SpO₂
100%
Lactate 5 mmol/L
Base excess
-9
Haematocrit
55
How would you assess his volume status at presentation?
10
VIVA 2
You go to review a 60-year-old man on the ward booked for rigid bronchoscopy and laser
treatment to a right main bronchus lesion on tomorrow’s thoracic list. He is an ex-smoker with
a twelve week history of breathlessness. His investigations are shown below. [CT,
SPIROMETRY, ABG’s]
Please assess his test results.
VIVA 3
You are asked to assess a 72-year-old lady who presents to your local Emergency
Department with a buttock abscess for surgical drainage.
She has a background history of:
Type II diabetes mellitus requiring insulin therapy
Ischaemic heart disease
Hyperlipidaemi
In the Emergency Department, the patient asks you whether the drugs used for anaesthesia
will cause memory problems after surgery.
What is your response?
VIVA 4
You are asked to see a 32-year-old primipara in early labour at 38 weeks gestation. She has
had extensive spinal surgery for scoliosis.
She would like to ask you about analgesia in labour. Her pregnancy has been uneventful and
the obstetric plan is for a vaginal delivery.
Her X-ray is shown below.
Is regional anaesthesia feasible in this woman?
VIVA 5
A 50-year-old man presents for elective pulmonary vein isolation and radiofrequency ablation
for atrial fibrillation.
His past history includes hypertension and paroxysmal atrial fibrillation.
Outline your preoperative cardiovascular assessment of this man.
VIVA 6
You are a new consultant at your hospital and have been called down to help in the
Emergency Department one evening as the staff are extremely busy dealing with multiple
victims from an accident.
You are expected to receive an 18-year-old male who was found to be unresponsive, lying on
his back, just outside his front door. The patient appears to have fallen down the front steps
and hit his head on the footpath. He was intubated at the scene by the paramedics.
What do you want to do in managing this situation?
11
VIVA 7
You are asked to assess an 80-year-old woman with a traumatic hip dislocation following a
motor vehicle accident. She is booked for an urgent closed (possibly open) reduction of her
left hip in Theatre.
She has a background history of hypertension.
Her primary and secondary trauma surveys and trauma X-rays are complete.
Her blood pressure on admission is 240/130 mmHg.
What are the possible causes for severe hypertension in this patient?
VIVA 8
You are asked to anaesthetise a 6-week-old infant, born at 36 weeks, with a five day history
of vomiting. The provisional diagnosis is pyloric stenosis.
His current weight is 3.6 kg.
His laboratory data is shown below.
Na⁺
137 mmol/L
K⁺
5.4 mmol/L
Cl⁻
104 mmol/L
(135–145 mmol/L)
(4.5–5.5 mmol/L)
(99–107 mmol/L)
HCO₃⁻
Glucose
Creatinine
(17–24 mmol/L)
(3.6–5.4 mmol/L)
(18–48 µmol/L)
17 mmol/L
4.5 mmol/L
55 µmol/L
How would you evaluate the volume status and hydration of this infant?
VIVA 9
A previously healthy 28-year-old male electrician was electrocuted at a construction site and
fell four metres. He was initially unresponsive and was defibrillated by an on-site first aid
officer with an automated external defibrillator, after which he regained consciousness.
He has just been brought into the Emergency Department by ambulance. He is alert and
complaining of pain. He has obvious closed fractures of his left ankle and elbow, and an
electrical burn entry wound to his right palm. He has a hard cervical collar fitted.
You are present to assist in his management as a member of the trauma team.
What potential injuries are you concerned about in this man?
VIVA 10
An otherwise well 38-year-old woman presents to the Emergency Department with gradually
worsening exertional stridor over several weeks. There is no stridor at rest.
At nasendoscopy she is found to have a large papilloma involving the posterior laryngeal inlet.
The ENT surgeon wishes to treat this with CO₂ laser therapy under general anaesthesia. The
diameter of the laryngeal inlet was estimated during nasendoscopy as 6 mm. Recent hospital
records indicated that there have been no previous difficulties with laryngoscopy or
endotracheal intubation. The patient has never smoked and does not take any medications.
Please describe your anaesthetic management plan for this patient.
12
VIVA 11
A 68-year-old obese woman with a body mass index of 36 is booked to undergo laparoscopic
cholecystectomy for recurrent biliary colic. She has known pulmonary artery hypertension,
secondary to recurrent pulmonary emboli, and has an inferior vena cava filter in situ as well
as being anticoagulated.
Her current medications include:
Sildenafil 50 mg tds
Dabigatran 150 mg bd
Diltiazem (slow release) 240 mg daily
Spironolactone 25 mg tds
Frusemide 40 mg bd
She is under the care of a heart failure specialist in the tertiary centre where you work.
What features would you seek on preoperative assessment that would indicate a high
risk of perioperative mortality for this patient?
VIVA 12
A 34-year-old multigravida (G₂P₁) at 32 weeks gestation has been sent by her obstetrician to
the Delivery Suite of a tertiary obstetric hospital for management of her hypertension.
In the obstetrician’s rooms, she was complaining of severe headache and her blood pressure
was noted to be elevated.
She presents to Delivery Suite with the following observations:
Heart rate 85/minute, noted to be regular
Blood pressure 170/110 mmHg
She appears agitated. She is NOT in labour.
How will you assess this patient?
VIVA 13
V A 57-year-old man presents to the Emergency Department with severe chest pain and
acute onset paraplegia.
He is hypertensive.
His chest X-ray is shown.
Describe the findings on this chest X-ray.
VIVA 14
You are the anaesthetist designated to the Medical Emergency Team (MET) for the day. You
respond to a MET call to the medical ward, which was prompted by deteriorating respiratory
parameters in a 54-year-old man who was admitted during the night with pancreatitis.
When you arrive you find the patient has obvious respiratory distress and is tachypnoeic at
30/minute. He is cyanosed and his Sp02 is 85% on oxygen via facemask at 8 litres/minute.
He is drowsy but rousable to command, and appears to be in considerable abdominal pain.
His abdomen is mildly distended. He looks to be about 80 kg.
13
You note that his pulse rate is 135/minute and his blood pressure is 110/40 mmHg. He has
received two litres of crystalloid since his admission. He has not passed urine since he has
been in hospital.
What is your immediate management priority?
VIVA 15
You are called to assess a 75-year-old lady in the Emergency Department. She has fractured
the shaft of her femur and is due for surgery later that day. She has a past history of stable
angina and colon cancer. She is known to have two liver metastases as well as bony
metastases to the femur, pelvis and spine.
Her current medications are:
Atenolol 50 mg daily
Irbesartan 150 mg / hydrochlorothiazide 12.5 mg
daily
Morphine sulphate (oral) 30 mg bd
(plus oral morphine mixture prn for breakthrough
pain)
Aspirin 100 mg daily
Paracetamol prn
Coloxyl with senna prn
What are the important issues that you need to address when assessing this lady?
VIVA 16
You have been called by the on-call paediatric surgeon to book a 10-year-old boy for rigid
bronchoscopy for suspected foreign body removal this evening.
You are told he is obese and intellectually impaired. He has presented with a cough and
shortness of breath following a choking incident earlier today while playing with Lego.
He is currently in the Emergency Department and is uncooperative.
Outline how you will decide how urgently to proceed to Theatre.
Dr Mark Buckland
Chair, Final Examinations.
14