FCA(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Final Examination for the Fellowship of the

College of Anaesthetists of South Africa

17 August 2010
Paper I

(3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one
is required for the one answer)
Al die vrae moet beantwoord word. Elke vraag moet in n aparte boek (of boeke indien meer as een nodig is vir
n vraag) geskryf word

Explain in detail why the patient in the recovery room is at risk of hypoxia after he or she
has been subjected to general anaesthesia.
[100]

Bespreek die redes in detail waarom die pasint in die herstelkamer n risiko loop om
hipoksies te word nadat algemene narkose toegedien is.
[100]

A four-year-old child requires an adenotonsillectomy for recurrent infection. There is no

significant past medical history of note and clinical evaluation at the premed visit reveals
no significant pathology. In the operating theatre you find your only anaesthetic assistant
is an inexperienced staff nurse with no paediatric experience. The surgeon is unwilling
to assist with any anaesthetic procedures. Discuss your anaesthetic management under
the following headings
a) Premedication.
(20)
b) Induction.
(30)
c) Maintenance.
(30)
d) Postoperative analgesia.
(20)
[100]

n Vierjarige kind benodig n andenotonsillektomie vir herhaalde infeksie. Daar is geen

noemenswaardige vorige mediese geskiedenis nie en die preoperatiewe kliniese
ondersoek bevind geen betekenisvolle patologie nie. In die operasieteater vind jy uit dat
jou enigste narkose-assistent n onervare stafverpleegster is sonder pediatriese
ondervinding. Die chirurg is nie bereid om te help met enige narkose-prosedures nie
Bespreek jou narkosehantering onder die volgende hoofde
a) Premedikasie.
(20)
b) Induksie.
(30)
c) Instandhouding.
(30)
d) Postoperatiewe pynverligting.
(20)
[100]

A patient is to have an interscalene block for shoulder surgery

a) What would you tell the patient regarding the risks involved with this block?

(20)

b) Describe your technique for performing the interscalene block.

(60)
c) How can medico-legal consequences be minimised should a complication from the
interscalene block occur?
(20)
[100]
3

n Pasint gaan n interskalenusblok vir skouerchirurgie ontvang

a) Aangaande watter risikos van die interskalenus blok sal jy die pasint inlig?
(20)
b) Beskryf jou tegniek vir die uitvoer van die interskalenusblok.
(60)
c) Hoe kan jy die medies-geregtelike
gevolge
tot n minimum beperk
indien nkomplikasie met die interskalenusblok ontstaan.
(20)
[100]

Discuss deliberate control of blood pressure (hypotensive anaesthesia) for surgical

procedures in normotensive patients under the following headings
a) Purpose and justification.
(20)
b) Controversies around Deliberate Hypotension.
(30)
c) Contra-indications.
(20)
d) Anaesthetic techniques to lessen the following
i) Venous bleeding.
(10)
ii) Arterial bleeding.
(10)
iii) Mucosal bleeding.
(10)
[100]

Bespreek doelgerigte bloeddrukbeheer (hipotensienarkose) vir sjirurgiese prosedure in

normotensiewe pasinte onder die volgende hoofde
a) Doel en reverdiging.
(20)
b) Kontroversies rakende doelgerigte hipotensie.
(30)
c) Kontraindikasies.
(20)
d) Narkosetegnieke om die volgende te minimaliseer
i) Veneuse bloeding.
(10)
ii) Arterile bloeding.
(10)
iii) Mukosale bloeding.
(10)
[100]

FCA(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain
Reg No 1955/000003/08

Final Examination for the Fellowship of the

College of Anaesthetists of South Africa

18 August 2010
Paper II

(3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one
is required for the one answer)
Al die vrae moet beantwoord word. Elke vraag moet in n aparte boek (of boeke indien meer as een nodig is vir
n vraag) geskryf word

A patient sustains severe blunt abdominal trauma and requires surgery for packing of a
ruptured liver and resection of a ruptured spleen. Discuss your management of blood
transfusion and the patients coagulation system to ensure the best possible outcome.
[100]

n Pasint ondergaan erge abdominale stomptrouma en benodig sjirurgie vir die pak
van n geruptuurde lewer en die reseksie van die geruptuurde milt. Bespreek u
bloedtransfusiehantering en die hantering van die pasint se stollingsisteem om die
beste moontlike uitkoms te verseker.
[100]

Write concise notes on each of the following

a) Anticoagulants and Neuraxial blocks.
b) Prevention of hypothermia under anaesthesia.

Skryf bondige aantekeninge oor elk van die volgende

a) Antistol en neuraksiale bloke.
b) Voorkoming van hipotermie onder narkose.

(50)
(50)
[100]
(50)
(50)
[100]

You are called to theatre because the registrar suspects that he has inadvertently
injected antibiotic intra-arterially
a) What are the likely clinical features of intra-arterial antibiotic injection?
(25)
b) How do you confirm that intra-arterial injection has occurred?
(25)
c) How should the patient be managed after confirmation of intra-arterial injection? (50)
[100]

U word na die teater geroep omdat die kliniese assistent vermoed dat hy onwetend
antibiotika intra-arteriel ingespuit het
a) Wat is die waarskynlike kliniese tekens van die intra-arterile antibiotika inspuiting?
(25)
b) Hoe bevestig u dat die intra-arterile inspuiting wel plaasgevind het?
(25)
c) Hoe moet die pasint hanteer word na bevestiging van die
intra-arterile
inspuiting?
(50)

[100]
4

Address the following controversies in obstetric anaesthesia

a) The effects of epidural analgesia in labour on the progress and outcome of labour.
(40)
b) Phenylephrine versus ephedrine for the management of spinal hypotension during
Caesarean section.
(60)
[100]

Bespreek die volgende twispunte in obstetriese narkose

a) Die effekte van epidurale analgesie tydens kraam op die vordering en uitkoms
daarvan.
(40)
b) Fenielefrien teenoor efedrien vir die hantering van spinaalnarkose-genduseerde
hipotensie tydens Keisersnitverlossing.
(60)
[100]

The Colleges of Medicine of South Africa

Incorporated Association not for gain (Reg. No. 1955/000003/08)
Nonprofit Organisation (Reg No 009-874 NPO)

27 Rhodes Ave, PARKTOWN WEST 2193

Private Bag X23, BRAAMFONTEIN 2017
Tel: +27 11 726-7037/8/9
Fax: +27 11 726-4036
General:
admin@cmsa-jhb.co.za
Academic Registrar:
alv@cmsa-jhb.co.za
Website: http://www.collegemedsa.ac.za

FCA(SA) Part II
DATA INTERPRETATION
Question 1 - 20
19 AUGUST 2010

Time: 3 hours

CANDIDATE NUMBER

Question 1/Vraag 1
Using the following data, calculate the dead space.
FiO2 of 0.4
PaCO2 = 7.9

PaO2 is 28 kPa (at sea level)

pH = 7.23,

Standard Bicarbonate 25 mmol/ Mixed expired carbon dioxide = 5.3 %.

Gebruik die volgende data om die dooiespasie te bereken.
FiO2 is 0.4 PaO2 = 28 kPa (by seevlak)
PaCO2 = 7.9 pH = 7.23
Standaard Bikarbonaat 25 mmol/
Gemengde ekspiratoriese koolsuurgas = 5.3%.

[10]

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Question 2 /Vraag 2
A patient with severe sepsis is bleeding. The INR is 1.9, PTT is 85s, fibrinogen is 25% of
normal, d-dimers and fibrin degradation products significantly raised. The patient is not on
any drugs that can cause abnormal clotting.
n Pasint met ernstige sepsis bloei. Die INR = 1.9, GTT 85s, fibrogeen 25% van normaal, ddimers en fibrogeen-afbraakprodukte betekenisvol verhoog. Hy ontvang geen middels wat die
bloeding kan veroorsaak nie.
a) What is the functional diagnosis?
Wat is die funksionele diagnose?
(2)
.....................................................................................................................................................
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.....................................................................................................................................................
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b) Briefly note the options for correction of the clinical bleeding and give reasons for your
choices.
Noem kortliks die opsies vir die korreksie van die kliniese bloeding en gee redes vir u
keuses.
(8)
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[10]
Question 3 /Vraag 3
A patient is mechanically ventilated and the following values were obtained:
Tidal volume
Peak Inspiratory Pressure
Inspiratory flow

457 m
42 cmH2O
95 / minute

PEEP
Plateau Pressure

10 cmH2O
28 cmH2O

n Pasint word meganies geventileer. Die volgende waardes word verkry

Getyvolume
457 m
PEED
10 cmH2O
Piek Inspiratoriese Druk
42 cmH2O
Platodruk
28 cmH2O
Inspiratoriese vloeitempo
95/minuut
a) What is the lung-thorax compliance?
Wat is die long-toraks meegewendheid?
(2)
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b) What is the explanation for the difference between the peak and plateau inspiratory
pressure on the ventilator?
Wat is die verduideliking vir die verskil tussen die piek- en plato-inspiratoriese
ventilatordrukke?
(4)
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Also (NOT with reference to the above values)
c) Briefly explain the difference between standard and actual bicarbonate content.
Ook (NIE met verwysing na die waardes hierbo)
Verduidelik kortliks die verskil tussen standaard en werklike bikarbonaatinhoud.
(4)
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[10]
Question 4 /Vraag 4
During revision hip surgery, under general anaesthesia, it is noted that the patients core
temperature is 35C.
Tydens n revisie heupvervangingsoperasie onder algemene narkose merk jy dat die pasint
se kerntemperatuur 35C is.
a) What are the adverse outcomes associated with this body temperature?
Wat is die ongewenste effekte geassosieer met hierdie liggaamstemperatuur?
(5)
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b) How can this patients body temperature be corrected?
Hoe kan hierdie pasint se liggaamstemperatuur gekorrigeer word?
(5)
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[10]
Question 5 /Vraag 5
A 21-year-old woman has been given anaesthesia for an emergency appendicectomy.
Intubation was difficult as the patient was not completely relaxed despite an appropriate dose
of suxamethonium being administered. Ten minutes after induction of anaesthesia it is noted
that her end-tidal CO2 is 60mmHg and her heart rate has increased from 100 to 130 beats per
minute. She was pyrexial pre-operatively and her temperature has not changed.
n 21-jarige dame ontvang narkose vir n noodappendisektomie. Intubasie was moeilik
aangesien die pasint nie volledig verslap was nie, ten spyte van n voldoende dosis
suksametonium. Tien minute na induksie van narkose merk jy op dat haar endgety-CO2
60mmHg is en haar harttempo toegeneem het van 100 tot 130 slae per minuut. Sy was
koorsig preoperatief en haar temperatuur het konstant gebly.
a) What potentially serious anaesthetic complication could be arising in this patient?
Watter potensieel gevaarlike narkosekomplikasie kan besig wees om te ontwikkel in
hierdie pasint?
(1)

.....................................................................................................................................................
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b) What are the other clinical signs of this condition?
Wat is die ander kliniese tekens van die toestand?
(5)
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c) What is the differential diagnosis?
Wat is die differensile diagnose?
(4)
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[10]
Question 6 /Vraag 6
A 40-year-old man is to have surgery for removal of an adrenocortical tumour. Pre-operatively
his blood pressure is 190/120, despite treatment with a -blocker, and his serum potassium
remains at 2,8mmol/l, despite treatment with oral potassium
n 40-jarige man moet geopereer word vir die verwydering van n adrenokortikale tumor.
Preoperatief is sy bloeddruk 190/120, ten spyte van behandeling met n -blokker, en sy
serumkalium bly 2,8 mmol/l ten spyte van behandeling met orale kaliumsupplemente
a) What syndrome should be suspected in this patient?
Watter sindroom moet vermoed word in hierdie pasint?
(1)
.....................................................................................................................................................
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b) How can this diagnosis be confirmed?
Hoe kan die diagnose bevestig word?
(2)
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c) How can his blood pressure be controlled pre-operatively?
Hoe kan sy bloeddruk preoperatief beheer word?
(2)
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d) What are the potential cardiovascular problems that can arise during handling of the
adrenal gland during surgery and how can these be managed?

Wat is die potensile kardiovaskulre probleme wat kan opduik tydens chirurgiese
hantering van die bynier, en hoe kan dit hanteer word?
(5)
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[10]
Question 7 /Vraag 7
Study the following blood gas
Bestudeer the volgende bloedgas
pH
PaCO2
HCO3 BE
K+
ClAnion gap

7,46
8,1kPa (60,75mmHg)
43mmol/l
19,1 mmol/l
1,9 mmol/l
87mmol/l
8,1mmol/l

a) Describe the abnormalities seen in this report.

Beskryf die abnormaliteite in hierdie verslag.
(4)
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b) What are the possible aetiological factors leading to these abnormalities?
Wat is die moontlike etiologiese faktore wat kan aanleiding gee tot hierdie abnormaliteite?
(6)

[10]
Question 8 /Vraag 8
a) Describe the solution into which blood is donated.
Beskryf die oplossing waarin bloed geskenk word.

(4)

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b) How long can blood be stored at 4 degrees Celsius and still be safely transfused?
Hoe lank kan bloed gestoor word teen 4 grade Celsius en nog veilig oorgetap word? (2)

c) List the electrolyte contents of the supernatant fluid in a unit of blood within 2 days of
expiry.
Lys die elektrolietinhoud van die supernatante vog in n eenheid bloed 2 dae vanaf die
vervaldatum.
(4)
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[10]
Question 9 /Vraag 9
Tabulate the differences between starches and gelatins.
Tabuleer die verskille tussen stysel- en gelatienoplossings.
Starch / Stysel
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..
..

Gelatin / Gelatien
...
...
...
..
..
..
...
...
...
...
...
...
...
...
...
...

..
..
..
..
..
..
..
..

...
...
...
...
...
...
...
...
[10]

Question 10 /Vraag 10
a) Draw the left ventricular pressure volume loop for a patient with clinically significant mitral
regurgitation.
Teken die linker ventrikulre druk-volumekurwe vir n pasint met klinies betekenisvolle
mitraalreguritasie.
(6)
b) List the reasons for improvement of symptoms of mitral regurgitation during pregnancy.
Lys die redes vir die verbetering van die simptome van mitraalregurgitasie gedurende
swangerskap.
(4)
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10]
Question 11 /Vraag 11
a) Draw the left ventricular pressure volume loop for a patient with clinically significant mitral
stenosis.
Teken die linker ventrikulre druk-volumekurwe vir n pasint met klinies betekenisvolle
mitraalstenose.
(6)
b) List the reasons for worsening of symptoms of mitral stenosis during pregnancy.
Lys die redes vir die verslegting van die simptome van mitraalstenose gedurende
swangerskap.
(4)
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[10]
Question 12 /Vraag 12

a) Draw and label the normal waveform as a pulmonary artery catheter is advanced from the
right atrium to wedged position in a pulmonary artery. Indicate the normal pressures for
each as the catheter is moved.
Teken en benoem die normale golfpatroon soos verkry deur n pulmonale arteriekateter te
ryg vanaf die regter atrium tot in die wigposisie in n pulmonale arterie. Dui die normale
drukke aan soos die kateter beweeg.
(5)
b) Draw the waveforms for the following conditions clearly indicating the differences from the
normal trace in a)
i) Complete Heart Block.
ii) Primary Pulmonary Hypertension.
Teken die golfpatrone vir die onderstaande toestande met duidelike aanduiding van die
afwykings van die normale golfpatroon in a)
i) Totale Hartblok.
ii) Primre Pulmonale Hipertensie.
(5)
[10]
Question 16 /Vraag 16
Answer the following questions regarding ulnar nerve stimulation with a peripheral nerve
stimulator and monitoring the response of the adductor pollicis. Draw annotated diagrams of
the response to the application of a train-of-four (TOF) stimulus during the recovery phase of
a non-depolarising block (a d) and a depolarising block (e) to clearly illustrate the following
Beantwoord die volgende vrae oor ulnare senuweestimulasie met n perifere senustimulator
en monitering van die respons van die adduktor pollicis-spier. Teken geannoteerde
diagramme van die respons met die toediening van n rits-van-vier (TOF) stimulus
gedurende die herstelfase van n nie-depolariserende blok (a d) en n depolariserende blok
(e) om die volgende duidelik te illustreer
a) A top-up dose of muscle relaxant becomes indicated during a laparotomy.
n Aanvullende dosis (top-up) spierverslapper word benodig gedurende n laparotomie.(2)
b) The patient is ready to be reversed with neostigmine.
Die pasint is gereed vir omkering met neostigmien.

(2)

c) The TOF ratio is 25%.

Die TOF-verhouding is 25%

(2)

d) The patient fulfils the criteria for discharge to the ward.

Die pasint vervul die kriteria vir ontslag na die saal.

(2)

e) The patient has developed a phase II block after repeated doses of only suxamethonium.
Die pasint het n fase 2-blok ontwikkel na herhaaldoserings suxamethonium.
(2)
Question 17 /Vraag 17
An obese 68-year-old man is brought by ambulance to the emergency unit following a
collapse at home. He has apparently been unwell and generally tired for several months, but
his condition deteriorated over the last few days. On examination his level of consciousness is
depressed, he has cold peripheries with a blood pressure recorded as 80/40 and is
tachypnoeic. His CXR is shown below

n 68-Jarige man is deur n ambulans na die noodeenheid gebring nadat hy by die huis
gekollabeer het. Hy was waarskynlik vir n paar maande sieklik en algemeen moeg, maar sy
toestand het oor die laaste paar dae versleg. Met ondersoek is sy bewussynsvlak onderdruk,
hy is perifeer koud met n bloeddruk van 80/40 en haal vinnig asem. Sy borskas X-straalfoto
word hieronder vertoon

a) Describe the abnormalities on this CXR.

Beskryf die afwykings op hierdie borskas X-straalfoto.
(2)
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b) What is the diagnosis?
Wat is die diagnose?
(1)
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c) List three possible causes for this condition.

Lys die drie moontlike oorsake van hierdie toestand.
(1)
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d) What physical signs would help confirm the diagnosis?
Watter fisiese tekens sou help om die diagnose te bevestig?
(1)
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e) What further investigations may be indicated?
Watter verdere ondersoeke mag nodig wees?
(1)
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f) What are the most important considerations for anaesthesia?
Wat is die belangrikste narkose-oorwegings?
(3)
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10]
Question 18 /Vraag 18
An 8-year-old boy falls off his bicycle and under a car. When admitted to hospital, he is
drowsy and pale, with a respiratory rate of 40/min, a heart rate of 160/min and a blood
pressure of 40/20 mmHg. He feels icy cold and his capillary refill time is more than 7 seconds.
He has tyre marks across his abdomen, which is visibly distended. His pelvic radiograph
shows widening of the pubic symphysis and left sacro-iliac joint.
n 8-jarige seuntjie val van sy fiets onder n motor. Met opname in die hospitaal is hy slaperig
en bleek met n asemhalingstempo van 40/min, n harttempo van 160/min en n bloeddruk van
40/20 mmHg. Hy voel yskoud en sy kapillre hervultyd is meer as 7 sekondes. Hy het
motorbandmerke oor sy buik, wat duidelik opgeset is. Sy bekken X-straalfoto wys verbreding
van sy pubiese simfise en linker sakro-iliakgewrig
a) What would be the normal range for heart rate and blood pressure for this child?
Wat sou die normale omvang van hartspoed en bloeddruk wees vir hierdie kind?
(2)
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b) What is the severity of his injury?
Hoe erg is hierdie besering?
(2)
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c) What percentage of his blood volume do you estimate has been lost (show your

calculation)? Watter persentasie van sy bloedvolume sou jy skat het hy verloor (wys jou
berekening)?
(2)
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d) What fluid resuscitation will you give and how much?
Watter vogresusitasie sou jy toedien en hoeveel?
(4)
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Question 19 /Vraag 19
Interpret the following findings in the investigation of a patient for possible hyperthyroidism
n Pasint het moontlik hipertireose. Interpreteer die volgende bevindings
a) Normal TSH and T3.
Normale TSH en T3.
(2.5)
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b) Low TSH, high T4.
Lae TSH, ho T4.
(2.5)
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c) High TSH, high T4.
Ho TSH, ho T4.
(2.5)
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d) Low TSH, normal T4.
Lae TSH, normale T4.
(2.5)
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[10]
Question 20 /Vraag 20
Give examples of clinical conditions which may be associated with hyponatraemia in the
following circumstances

Gee voorbeelde van kliniese toestande wat geassosieer mag word met hiponatremie in die
volgende omstandighede
a) Total body water deficit with a large sodium deficit.
Totale liggaamswatertekort met n groot natriumtekort.
(5)
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b) Excess total body water.
Oormatige totale liggaamswater.
(3)
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c) Excess total body sodium with a large total body water excess.
Oormatige totale liggaamsnatrium met n groot totale liggaamswater oormaat.
(2)
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[10]