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Final SOE Questions December 2014 - Thanks to candidates from our courses

LONG CASE 1
67-year-old female presenting for urgent parotidectomy/neck dissection for malignancy. PMH: COPD, HTN, chronic
smoker, peripheral vascular disease (fem-fem bypass 3 yrs ago) exercise tolerance 50 yards. Medications -
Aspirin, Simvastatin, Bendrofluazide, Ramipril, Salbutamol, Becotide, Thyroxine.
Investigations
− FBC - Hb 16g/dL, otherwise normal, normal WCC and plt
− U&E’s - Creatinine 89, otherwise normal.
− Glu 6.5
− CXR - hyperinflation, narrow heart, flattened diaphragm
− ECG - Sinus Tachy, LAD, inferior T wave inversion
− PFT’s - Severe obstructive defect, some reversibility, markedly reduced TLCo (29%)
− ABG - pO2 8, HCO3 25, pH 7.45, CO2 normal Type I RF

• Summarise.
• Why is this lady polycythaemic?
• What is DLCO and causes?
• How do you assess this perioperative risks?
• What is exercise test?
• What other Ix would you want? talked about echo, shuttle walk, CPEX, TFTs
• Which drugs to continue on day of surgery?
• How would you optimise respiratory function? steroids and dose, antibiotics, physio etc
• Do you predict a difficult airway? They said not usually!
• How would you anaesthetise her? which drugs and type of ETT.
• What does RAE stand for?
• What nerve would the surgeons monitor? Talked about facial nerve assessment and remi v NMB.
• Where should she go postop?
• What factors are important postop in this patient? Talked about respiratory function, anticoagulation
(mechanical and pharmacological).
• ENT surgeon doesn’t want Heparin, what are the alternatives?
• How would you extubate?
• She deteriorates post-op in recovery, differential diagnosis?
• What is stridor?
• What is the course of phrenic and recurrent laryngeal nerve? What other nerves could be affected by surgery?
• Needs to return to theatre for expanding haematoma, anaesthetic management? Airway swelling on HDU. How
do you manage this?....releasing clips, ABC What methods available for re-intubation? Which would you choose.

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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 2

68 year old male radical nephrectomy for RCC.


PMH: COPD smoker. Systolic murmur. On haemodialysis. BMI 31. Angina, Pacemaker inserted
Investigations
− Normochromic normocytic anaemia Hb 90 g/L
− Low platelets
− Raised urea and creatinine urea 17.9, creatinine 586 (potassium normal).
− X-Ray: Cardiomegaly and dual chamber pacemaker, vascath
− ECG: Paced rhythm (atria and ventricles)
− PFTs: Moderate to severe obstruction, Low TLCO(FEV1 55%)
− Echo shows mild MR and LVH

• Summarize the case


• Talk through investigations
• Why is he anaemic?
• Would you transfuse him pre-op?
• Position of patient for nephrectomy. What happens to table? What are the physiological effects of breaking the
table? Effects of this position
• Open or laparoscopic for this patient? Name of incision?
• Advantages of laparoscopy
• Would you give him a PCA?
• Cardiac risk stratification of this patient
• How will you anaesthetise this patient
• Critical incident - Pneumothorax, DDs, Management
• Precautions with a pacemaker
• Post operative management

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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 3

You have been asked to see (in ED) a 50 something female involved in an RTC. Driver of car vs lorry. There was a
prolonged period of entrapment. There is a pelvic fracture and femur on X-ray, CT head/neck is normal and a FAST
scan shows free fluid in the abdomen. She complains of pain in the right side of her chest.
No medical history is available.
O/E GCS 15, RR is 40 with evidence of paradoxical movement of the right side of her chest. SpO2 is 98% on 15L of O2
via a non rebreathe mask. BP is 90 systolic, HR 105ish.
Weight ~100Kg

Investigations
− FBC Hb 11.5, WCC raised (think around 18), Plt Normal
− U&Es Normal
− Glucose 11
− ABG pH 7.28 PO2 ~24kPa PCO2 ~4.8 (No lactate provided) BE -10
− CXR AP, ~3 #ribs on right, subcutaneous emphysema on right, chest drain in situ R side, # of one rib left
side, bra clip visible.

• Summarise the case


• What is a FAST Scan?
• How much blood needs to be present for detection on FAST Scan?
• How will you assess and manage the patient?
• How will you clear the C-Spine ?
• What does the CXR show?
• Do you think this patient needs to be intubated now?
• What makes you say that she is taking shallow breaths/ventilation ineffective?
• Where would you intubate? Now or in theatre? Potential difficult airway?
• What do you think of the FBC, Glucose and ABG (inc why HB may be normal)
• What might the cause of acidosis be? (He mentioned coming back to the anion gap if there was time)
• What makes you say Grade 3 shock, what volume of blood and where could this be?
• Asked about how the major haemorrhage pathway is activated, who is involved, what occurs and components in
my hospital.
• How can coagulation be assessed? (Also wanted ACT in addition to coag, TEG, ROTEM)
• Mentioned tranexamic acid and the asked mechanism, why used in trauma (CRASH 2) and dose
• What will you do with the patient (Theatre vs CT)
• Which surgeons will you allow to operate first (agreed with General for Laparotomy)
• Where and how will you anaesthetise this lady? (inc reasons and doses of drugs)
• What is your intraoperative management?
• How will you decide whether to extubate?
• What postoperative complications are expected in this lady?
• Destination post op?
• Pain management
o Options
o Why avoid NSAIDS
o Advantages of epidural
o Disadvantage of intercostals nerve blocks/ intrapleural block
• Assume she is extubated and how will you manage respiratory failure in the post op period (NIV, IPPV)
• Other management on ICU (People got asked reasons as to why NG aspirates might be high and management
strategy)
• How do you measure intraabdominal pressure?

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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 4

33y male, globe rupture after falling on a radiator. He has poorly controlled epilepsy (1-2 seizures per day) since
childhood but says his fall was not as a result of a fit.
DH- carbamazepine, levetiracetam, some others that I can't remember!
On examination height 167cm, weight kg, BMI 44.9
Capped upper incisors, MP 3, full beard

Investigations:
− CXR showing: obese, Vagal nerve stimulator
− ABG showing: pH normal range, pO2 8.9, pCO2 6.8, high bicarbonate, HB 170
− Sleep studies showing: AHI 77, 170 desaturations period hour, average says 85%
− PFTs showing normal fev1/fvc, PEFR 55% predicted (although footnote at the bottom mentioned technique
was poor), reduced vital capacity and residual volume

• Summarise case
• Talk through respiratory investigations
• Significance of sleep apnoea - any scoring systems you know of?
• Significance of his epilepsy and anti epileptic drugs
• Is this emergency surgery- globe has already ruptured so do you still need to take precautions to reduce the risk
of evisceration?
• What makes you say his airway is difficult?
• How would you manage his airway, what do you mean by ramped/adequate preoxygenation, what equipment
would you have on your difficult airway trolley?
• What ventilator settings would you use, wanted PEEP
• What analgesia would you use?
• How would you extubate him? Where would you send him post op? There are no HDU beds, what would you
do?
• He becomes confused in recovery, how do you manage?
• What about VTE prophylaxis

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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 5

78 male admitted with acute ischaemic lower limb. Radiological management attempted and failed. Listed for fem-
pop bypass. Also had an episode of chest pain lasting 20 mins, relieved by GTN
PMH: CABG 20 years ago, PVD, L3-5 spinal decompression but chronic back pain, takes GTN regularly for chest pain
Medications: ACE inhibitor, beta-blocker, oral nitrates, diuretic, MST (high dose), aspirin, statin
BP 135/70, HR60, chest clear, ECG LAD, ?RBBB, no CXR given, weight 75kg, ht 1.75m

Investigations:
− ECG – L axis deviation, LBBB, inferior q waves., slow AF?
− ECHO – moderate LV dysfunction, mild TR, EF 50%, no LVH
− Angio (from 2 years ago) – patent grafted vessels, complete occlusion of original vessels.
− Bloods - Hb 117 (normochromic, normocytic anaemia) U+Es normal, creat was 96 eGFR 64. Clotting normal.

• Asked to summarise case


• What are your concerns?
• What are the risks of him having surgery?
• Any cardiac scoring systems you can use? p possum, Lee's revised cardiac index.
• What is his risk of mortality? Wanted exact percentage
• What further tests required and how would you optimise patient?
• Patient has further episode of chest pain for 30 mins, no ECG changes, troponin 27 – what would I do?
Discussion about troponins.
• Has NSTEMI before surgery - what do you do?
• ACS – definitions, treatment of unstable angina – patient had high dose aspirin/clopidogrel on admission – asked
for doses. MONA + clopidogrel +/- tirofiban
• I said high flow oxygen controversial in MI.
• Further pre-op investigations wanted? Angio?
• Options for management of ischaemic limb in this patient - ?other radiological mx/palliation/amputation. Who
would I discuss with? Surgeons, family, patient and consultant obviously!
• Balance between myocardial supply and demand.
• How would you anaesthetise him? Would spinal be possible?
• Tell me the exact dose of each drug you would use on induction
• Goes into VF on table - what do you do?
• Once shocked he is in asystole - what do you do?
• He then has a good cardiac output, operation continued
• ABG at end of operation done - gas is all fine (ph7.38, lact 0.9, po2 34 be -0.9)
• Would you extubate? Given ABG at end of surgery – was normal. Said I would wake up and admit to HDU.
• What post-op analgesia would you give?
• How can you ensure graft survival is optimised?
• Asked about management, including specific monitoring of limb, cardiac management.
• Pain management – I stressed would be difficult in this patient. Talked about gabapentin, magnesium etc.
• Surgeons say op failed and want to go back (don't remember what procedure) I said high risk, realistically do we
need to counsel patient/surgeon re: amputation!

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Final SOE Questions December 2014 - Thanks to candidates from our courses
LONG CASE 6

Patient with known hypothyroidism, with a history of fatigue and malaise. Presents with a history of vomiting and
severe abdominal pain, and jaundice. Surgeons want to perform an urgent laparoscopy and exploration of the biliary
tree. She is normally on levothyroxine but she has been unable to take it. She has no other medical problems.
BMI 46.
BP 103/60, Hr 60
Temp 38.1
Investigations
− FBC – anaemia, elevated WBCs
− Coag – Prolonged PT, normal APTT, INR 3.1
− U&E – normal urea, creat, TSH in 200, Free T4 unrecordable. Abnormal ALT and ALP.
− ECG – sinus bradycardia, with artefact interference in lead V3.
− TSH raised, T4 undetectable

• Summarise the case


• What do the blood tests show? Why is she anaemic?
• What does the ECG show? I said it showed sinus bradycardia, but because there was artefact interference in V3
it was inadequate and needed to be repeated. They seemed happy with that.
• What is the biggest issue? Sepsis or Hypothyroidism?
• How will hypothyroidism affect your anaesthetic?
• What do you need to do to optimise her pre-operatively?
• What is the dose of IV thyroxine, and what other medications will you give her peri-operatively? How would you
optimise her coagulopathy?
• How would you give her an anaesthetic? What monitoring do you need?
• What antibiotics would you give her and why?
• What are the physiological changes associated with capnoperitoneum?
• They convert to open on the table, what incision are they likely to make, what are the analgesic options now the
case is open?
• Shown a blood gas: something like
− Fi02 50%
− pH 7.42
− P02 15.4
− Pc02 5.3
− Bicarboate 30
− BE 0.0
− Lactate normal
• Will you extubate this patient?
• I said bearing in mind all other parameters –cardiac, respiratory pattern and effort etc. I said I would, they
seemed happy with that.
• Where does she need to go post-operatively?
• You arrive in ITU and the patient’s GCS drops, what is your approach?
• Have you heard of NELA? What is it?

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Final SOE Questions December 2014 - Thanks to candidates from our courses
LNOG CASE 7

4 year old child with cerebral palsy, poorly controlled epilepsy and recurrent LRTI over last year.
For nissen fundoplication.

Chest xray showed r middle lobe consilodation


Hyponatraemic 128 and mild microcytic anaemia
Meds: lamotrigine, hyoscine, sodium valproate
Weight 10kg

• Why is he on hyoscine
• What weight would I expect a 4yr old to be – why is he underweight
• Why hyponatraemic – casues and treatment options
• Would you anaesthetize him today
• How would you optomise him
• How would you put him to sleep – durug doses/tube sizes in this child as he is small
• Options for analgesia – talked about caudals in particular
• Intra op hypoxia – causes and management

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Final SOE Questions December 2014 - Thanks to candidates from our courses
SHORT CASES

1. Critical illness polyneuropathy


• Causes, recognising it eg, slow to wean
• What investigations?
• What would a nerve conduction study show?
• How do you prevent it?
• Treatment.

2. SAH
• 55 yr old, sudden onset occipital headache and nausea.
• Likely diagnosis?
• Other causes of Sudden onset headache.
• She is for clipping of aneurysm, GCS 7.
• How do you manage this? Talked about intubation, arterial line.
• Complications during procedure specifically those that are vasculature related?
• Talked about vasospasm - presentation, treatment.
• Rebleeding.
• They mentioned dislodged coil.

3. 2yr old SVT


• in recovery post grommet insertion, agitated.
• How would you assess this - talked about ABCDE, look at chart.
• What drugs may have been given that would precipitate this.
• ECG shows SVT - how to manage this, maneouvres/drugs,DC synchronised cardioversion.
• At end talked about DC dose, adenosine dose.

4. Enhanced recovery hemicolectomy - anaemia


• 50 year old woman with bowel cancer, Hb 9 and MCV 70, seen in pre-op clinic.
• What type of anaemia?
• Why is she anaemic?
• What will you do next?
• What about transfusing?
• She also has IHD. Does this change your management?
• What non invasive cardiac tests?
• Echocardiography - What information does it give us
• How do you perform CPET testing? What information does it give us?
• What is enhanced recovery?

5. Boy for adenotonsillectomy for OSAwith FHx of MH


• His grandfather is known to have had MH.
• What is the boy’s probability of having MH?
• Type of inheritance? Chromosome involved?
• Pathophysiology of MH? What receptor involved?
• Who will you test?
• Father refuses to be tested – what will you do?

6. Elderly hypothermia, GCS 3


• 81 year old found on floor at home, unheated house. Hypothermic 28 degrees, GCS 3.
• Management?
• Define hypothermia.
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Final SOE Questions December 2014 - Thanks to candidates from our courses

• Shown ECG – broad complex tachycardia – how will you manage?


• Why intubate? What drugs for intubation?
• Why re-warm slowly? How?

7. 19 yrs old Afro Caribbean Sickledex test positive, for urgent appendicectomy
• Pathophysiology of sickle cell disease
• Other abnormal hbs, difference between them
• Management of sickle cell disease and trait
• Confirmatory tests
• Anaesthetic management
• Will a sickle dex test tell you whether the patient is sickle trait or sickle disease? How can you tell the
difference?
• What happens if a patient has sickle cell trait and thalassemia, is this better than sickle cell disease or worse?
• Why do they develop pe/dvt?
• What else could this diagnosis be aside from appendicitis?
• How would you anaesthetise this patient?

8. 65 yrs old, severe, stable COPD, Knee arthroscopy, wants a spinal anaesthetic
• What are the criteria for day surgery?
• Does having severe COPD mean you cannot have day surgery?
• Shown a CXR: What does the CXR show?
• My interpretation – hyperinflated lung fields, opacity left upper lobe
• What could the opacity be?
• What makes you say hyperinflated? What are the criteria?
• The patient wants a spinal for her arthroscopy, are you going to do it?
• What medication would you use for a day case spinal anaesthetic?
• How would you perform a spinal anaesthetic?
• If you can’t pass the needle at L3/4, would you go L1/2? Why not?

9. 25 year old cystic fibrosis, awaiting lung transplant, laceration right antecubital fossa: median nerve and
brachial artery repair.
• What is cystic fibrosis?
• How common is it? What is it’s incidence?
• What multi-system effects does it have?
• What are the issues associated with anaesthetizing patients with cystic fibrosis?
• What are the anaesthetic options for this procedure?
• Axillary block – describe your axillary block?
• Why wouldn’t you perform an interscalene block?

10. Cord Prolapse


• You are on the delivery suite, paramedics phone to inform the unit that a pregnant lady 34 weeks was out
shopping and the cord is seen protruding from the vagina.
• What is the diagnosis
• What will you do? (focused on preparation e.g theatre team, drugs for GA, notes/computer notes etc)
• What are the anaesthetic options?
• Assume that there is fetal bradycardia, how will you anaesthetise her (inc preparation, premed, position,
draped and surgeon scrubbed etc)?
• Asked whether I would really take such a detailed history (wanted quick, focused hx)
• Doses of drugs
• Maintenance
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Final SOE Questions December 2014 - Thanks to candidates from our courses

• Analgesia options
• Oxytocic drugs
• How will you extubate her?

11. A 9 year old fitting for 30 minutes


• What are the differential diagnoses?
• Could this be a febrile convulsion ?
• What is the incidence of febrile convulsions in this age group?
• How will you approach this? (ABC Approach, Collat hx, bed side Ix, Pharmacological Management of status)
• What other drugs might you use prior to GA (paraldehyde)?
• If hypotensive what and how much fluid
• When would you resort to GA and exact dose of drugs, tube etc
• What other investigations would you do? (CT Head)
• Where does the patient need to go?
• How will you transfer the patient to scan and PICU
• What sedation would you use ?
• Would you really use muscle relaxants ? (risks of undetected seizures vs coughing during transfer etc)

12. Tracheostomy problem


• 25 year old male has been ventilated for a period of time for an isolated traumatic brain injury, he has had a
tracheostomy for 2 weeks and has been spontaneously ventilating for the last 3 days. The Nurse/Physio has
asked you to see him as he is “struggling” with his breathing.
• What are the indications for tracheostomy?
• How will you assess and manage the patient? (essentially patent upper airway algorithm, mentioned NTSP
guidelines)
• Differential Diagnosis (inc Resp causes)
• Unable to pass suction catheter (inc when inner tube removed), SpO2 80%
• What will you do now?
• What will you do differently if this was a laryngectomy patient?

13. Carotid endarterectomy


• A man had a TIA 3 days ago, carotid USS shows 70% stenosis on left and 40% stenosis on left
• When should he have surgery?
• What investigations would you expect the surgeons to have done already?
• How soon after his TIA should carotid ultrasound be performed?
• What problems might there be pre/intra op? Anaesthetic and surgical?
• Would you continue his anti platelets?
• What are the advantages of GA over RA, RA over GA.
• If you did a GA, what extra equipment would you need?
• What anaesthetic would you do? Does it make a difference?
• Where would you send him post op.? What would you ask the nurses to monitor?

14. Drowsy after labour epidural top-up


• Pregnant woman in labour, you top up epidural for lscs then she becomes drowsy
• What's your differential?
• How would LA toxicity present?
• What specific ECG changes are there?
• How would you manage it?
• What would you use to treat seizures?
• If you had to give her a GA what would you do?
• What's the advantage of l-bupivacaine over bupivacaine in terms of toxicity?
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Final SOE Questions December 2014 - Thanks to candidates from our courses

• Say you had excluded all differentials and she's just drowsy, how would you manage her for section now?
• What would you do if her blood pressure was low?

15. Elective hernia repair, previous MI


• 60 year old man for inguinal hernia repair, previous MI
• Given an ECG- what does it show? Now look at his ECG: RBB, inferior Q waves Acute inferior MI
• Which coronary artery is affected?
• He had a drug eluting stent
• What anti platelets would you expect him to be on
• What is the mechanism behind drug eluting stents?
• Why do they need dual anti platelets for 1 year?
• He had been on dual anti platelets for 6 months? What would you do? (Hernia is not incarcerated)

16. Obese neck stabbing, afro-caribbean


• Asked to describe clinical findings on examination
• Likely to have OSA
• Shown AP and lateral neck xrays – blade in neck, had been taken with contrast.
• Asked what structures in the neck may have been damaged
• How would I manage the airway?
• Told sickle negative
• What are your concerns?
• What further tests would you do? CT, naso-endoscopy
• How would you assess airway?
• What structures could be damaged?
• What are the options to secure airway for surgery?
• Which one would you do? Talk me through it

17. 4 male for day case squint surgery


• What are your concerns?
• Are squints associated with any conditions?
• Would you give a pre-med? What would you give and why?
• How would you reduce the risk of PONV?
• What are the risk factors for PONV in children?
• Drugs and doses?
• Patient becomes bradycardic during surgery. Why? What would you do?
• Apart from anti-emetics, how else can you reduce risk of PONV?
• Are squints related to MH?
• How would you approach the anaesthetic if you suspect MH?
• Tell me what you would use for peri-op and post-op analgesia?

18. Lung ca patient undergoing lung resection


• 60 female with SCC for RLL resection
• Shown spirometry test results - obstructive picture, low TLCO DLCO 50%, FEV1 1.48
• What is FEV25-75? What is its significance?
• What is TLCO? How do you perform the test? Conditions where it is affected?
• What is the criteria for lobectomy and lung resection? FEV1, ppo TLCO/FEV1, vo2 max etc
• How do you work out ppo FEV1?
• How many segments are there?
• Lung function criteria for lobectomy/pneumonectomy
• Other pre-op investigations

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Final SOE Questions December 2014 - Thanks to candidates from our courses

• Other factors to consider in patients with cancer


• Exercise testing/CPEX

19. Laryngeal tumour


• I was shown an endoscopic view if the vocal cords which showed a mass invading the vocal cords. Asked
what it is?
• They asked me my concerns.
• Asked what else I would want to know from the history?
• Then asked what other investigations I would like, I said CXR and CT.
• Then shown a CT scan- which showed deviated and narrowed trachea.
• What would you want to know in the history from this patient?
• Options for putting her to sleep for ent procedure
• How do you anaesthetize for an asleep tracheostomy
• How do you confirm trache position
• Management of a trache that gets pulled out later that night on ITU
• Asked how would I anaesthetise. In my head, I wanted to say induction, but for some reason I started talking
about awake fibreoptics. The examiner didn't seem so keen on the awake fibreoptics. Unfortunately the bell
went and I didn't get to discuss this.

20. Placenta abruption


• 38weeks, uneventful pregnancy. Obstetricians have declared a Cat 1 CS due to suspected abruption.
• What does Cat1 mean?
• What are the concerns and issues?
• How would you anaesthetise (I said if it would check the urgency, then they pushed for an answer and said
they estimated 2L blood loss so I said GA)
• Asked about levels of shock.
• They asked about Massive obstetric haemorrhage protocol.
• How much blood would I give?
• Complications of massive transfusion
• DIC and MOF
• What drugs could I use and surgical methods for stopping the bleeding

21. Hip revision on warfarin


• Elderly gentleman. They didn't give much medical history. I think he was on warfarin but they didn't tell you
why. His inr was 2.1.
• Asked the main issues regarding this case.
• Any investigations I would like?
• Why might he be on warfarin?
• Asked pros and cons of various techniques
• Asked what my preference was - asked what would you be looking for in the
history/examination/investigations.
• Explained guidelines regarding hip surgery.

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Final SOE Questions December 2014 - Thanks to candidates from our courses

Anatomy

1. Autonomic nervous system


• Patient with a heart transplant. What are your anaesthetic concerns with this patient?
• Describe the anatomy of the autonomic nervous system. What neurotransmitters involved?
• Parasympathetic cranial output – which nerves?

2. Blood supply spinal cord


• Can you describe the blood supply to the spinal cord? What would happen if compromised?
• How many radicular arteries?
• Tell me more about the Artery of Adamkiewicz?
• What is its importance?
• What other symptoms might a patient present with if anterior spinal artery compromised? (forgot to
mention weakness earlier)
• How may perfusion of cord be compromised?
• What is the incidence post thoracoabdominal aneurysm surgery ?
• What can be done to attempt to minimise cord ischaemia?
• What is the mechanism by which lumbar drain improves perfusion?
• What is the venous supply and where do they drain?
• Where exactly are the veins located?
• A man 4 days post thoracic aneurysm repair presents with weakness of legs, what is the differential and
investigations?
• Incidence of haematoma
• Risk factors for haematoma
• What are the guidelines regarding performance of a central neuraxial therapy with regards to anticoagulants
? (inc various antiplatelet, warfarin, LMWH, heparin, newer agents)

3. T10
• What do you understand by the level T10?
• Shown CT scan at T10 following a barium swallow. Identify the structures (stomach, liver, spleen, diaphragm)
• There was free air on the CT. What could be the cause?
• Went on to management of the patient with perforated viscus for surgery.

4. Cerebral blood flow


• Which patients is it important to monitor CBF
• Cerebral blood supply from the aorta
• Relation of circle of Willis to other structures
• Where do aneurysms commonly occur
• Cerebral vasospasm – what is it? How may it be recognized?
• Why does vasospasm occur?
• Mechanism?
• How do you treat it?
• How do calcium channel blockers work?

5. Paravertebral block
• Can you draw the paravertebral space?
• Then shown diagram of paravertebral space, asked to name structures
• What are the indications for paravertebral block?
• Compare and contrast paravertebral block versus thoracic epidural?
• What are the complications of thoracic epidural
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Final SOE Questions December 2014 - Thanks to candidates from our courses

• Would I expect a significant sympathetic block with a paravertebral block?

6. Stellate ganglion block


• They started this question strangely, they asked what are the ethical issues about performing this block.
asked a lot about consenting for this block – what ricks do I tell the patient, what if they have dementia or
learning disabilities.
• I talked about how to consent and assess capacity. They seemed happy with this.
• Anatomy of the ganglion
• How to block it with a landmark technique
• How to consent
• Drug doses
• Contraindications
• Complications

7. Arterial supply lower limb


• Anatomy
• How would an ischaemic leg present.
• Causes of acutely ischaemic leg - talked about AF, trauma, compression, intra-arterial Thio.
• They asked how it would occur in an IVDU.
• How would you anaesthetise a patient for lower limb vascular procedure?
• Any studies that have shown benefit with regional versus GA.
• What would help you decide GA v Regional.
• Contraindications to regional.

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Final SOE Questions December 2014 - Thanks to candidates from our courses

PHYSIOLOGY

1. Incompatible blood transfusion


• Why does it occur?
• What measures can be put in place to stop it from happening?
• Incidence?
• Pathophysiology of incompatible blood transfusion?
• Explain blood groups and different types (including incidence of types A/B/AB/O and rhesus positive)
• How will you diagnose
• How will you treat
• Who is it reported to
• Why do they occur- Human error
• Guidelines to avoid- Checking of blood, collection of samples

2. Ventilator associated pneumonia?


• What is the incidence?
• How can it be diagnosed?
• What are the most common organisms?
• What are the risk factors?
• What can be done to reduce the risk?
• What are the implications of VAP?
• What can be done to reduce duration of ventilation?
• What are the causes of failure to wean from ventilation?

3. Thyroid
• What signs/symptoms might you see in a patient with hypothyroidism who is on the wrong dose of
thyroxine? Wanted hypo and hyper.
• What condition would you see in a neonate with hypothyroidism?
• How does thyroid hormone work, how does it act at receptors?
• What are the problems with surgery/ anaesthesia in hyper- and hypo- thyroidism?
• What cardiac problems in hypothyroidism?

4. 02 toxicity
• What are the problems associated with high FiO2?
• What percentage of oxygen is safe and for how long?
• Which patients at risk?
• Recommended maximum times at different fi02s
• What effects does it have on babies? Who at most risk? - premature
• How is neonatal retinopathy minimized?
• Which systems does it affect?
• Why does oxygen toxicity occur?
• What is the molecular process?
• Are there any drugs that can cause O2 toxicity?
• When is a high level of oxygen good?

5. Carbon monoxide
• Harmful effects on body of smoking - Tar, carcinogens, carbon monoxide.
• When to stop smoking, will it be useful if stopped a day before
• How does carbon monoxide affect anaesthesia? What are the effects on the oxygen-haemooglobin
dissociation curve?

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Final SOE Questions December 2014 - Thanks to candidates from our courses

• What other effects of smoking are there on surgery?


• How does carbon monoxide in the maternal circulation affect fetal oxygenation?
• What is normal carbon monoxide levels? What are the signs and symptoms of CO poisoning?
• How do you treat carbon monoxide poisoning?
• How does hyperbaric therapy reduce the half life?
• How do you measure carbon monoxide?
• Aside from co-oximeter, how else can we measure carbon monoxide? Where else do we use it?
• I said infra-red absorption, and we use it to measure diffusion co-efficient in lung function tests DLCO

6. Starvation
• Describe the physiology of starvation
• Then ng feeding, benefits, components, how does this change in a critically ill pt.
• TPN – complications and benefits
• How does the body meet demands in first 24 hours?
• What happens after 24 hours?
• Where are ketones produced?
• How many calories does the body need?
• What electrolytes and how much is needed?
• Then talked about patients in hospital, asked why we need to focus on nutrition?

7. Immunity
• Types
• How do B cells work?
• What types of T cells are there?
• Where do you find these cells?
• Immunoglobulins - different types, sizes of them.
• How do you we use them therapeutically?
• Antigens - where are they found? How do they work?

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Final SOE Questions December 2014 - Thanks to candidates from our courses

PHARMACOLOGY

1. Parkinsons disease
• Signs
• Pathophysiology of Parkinsons?
• What drugs are there to treat it?
• How do they work?
• Classify into different types plus example from each type.
• Dopamine synthesis and metabolism.
• Anaesthetic management of patients with Parkinsons.
• Any drugs that should be avoided?

2. TIVA
• Why is TIVA suitable for daycase?
• What procedures might be used for in the day-case setting? (wanted shared airway, bronchoscopy)
• What are the advantages of TIVA?
• What Pharmacockinetic properties of Propofol make it suitable for TIVA?
• What is the context sensitive half life?
• What is the elimination half life of propofol?
• Why then does a patient wake up when you switch off the propofol? (Essentially 3 compartment model,
constants, volumes etc explanation of what happens to various concentrations during an infusion maintain
steady state and when switched off)
• What models are you aware of and how do they differ?
• Which gives bigger dose- Marsh or Schneider?
• What about targeting effect site?
• Which compartment most closely resembles brain in three compartment model?

3. Remifentanil
• What situations is Remifentanil used for?
• How is it given? What dose?
• What receptors does it act on?
• How is it metabolised?
• What pharmacokinetic model?
• What information does the model require?
• What are the advantages/ disadvantages of remifentanil?
• Why is it useful in neurosurgery (as well as it being titratable to stimulus)?

4. Bioavailability
• What are the different ways we can administer drugs?
• What are the options if someone has had bowel surgery and you want to avoid oral route?
• What is bioavailability?
• Can you draw me the graph explaining it?
• What factors affect bioavailability?
• What is first pass metabolism?
• What factors affect this?
• What drugs do you know that undergo significant first pass metabolism? High and low first pass?
• Alternative routes than oral administration of medication – wanted list.
• Focused on transdermal delivery

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Final SOE Questions December 2014 - Thanks to candidates from our courses

5. Suxamethonium
• Mechanism of action
• P’kinetics and P’dynamics
• Diffn b/w acetylcholinesterases and psedocholinesterases
• Can you tell me the side effects of suxamethonium
• Which patient groups would you avoid using it?
• What is the mechanism of anaphylaxis to suxamthenonium?
• What is the structure of suxamethonium?
• Why does it cause bradycardia?
• Why does it cause hyperkalaemia?
• What happens when you give repeated doses?
• What do you tell patients regarding myalgia and avoiding severe myalgia? Which patients are most at risk?

6. Anticoagulants
• Asked how warfarin works, what is it?
• How can we reverse INR?
• Discuss alternative anticoagulants
• How do we monitor factor Xa and direct thrombin anticoagulants
• Uses in medicine
• Describe clotting cascade
• Timeframe after stopping common drugs and time when it's safe to perform blocks

7. Opioid Tolerance
• Problems with chronic abuse eg IVDU. Co-existing medical problems, nutrition, iv access.
• What is tolerance? How does it affect periop management?
• Mechanism of tolerance of opioids?
• Problems with opioids - withdrawal, and again tolerance, hyperalgesia
• How do opioids work?
• Management of patient - talked of multimodal approach, NMDA antagonists (where are these receptors)
• Benefits of PCA in these patients. Background on PCA in these patients?

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Final SOE Questions December 2014 - Thanks to candidates from our courses

PHYSICS

1. Theatre pollution.
• What causes it?
• What makes it more likely to occur?
• How can it be prevented?
• Which anaesthetists are most at risk from anaesthetic gas pollution?
• Which staff most at risk?
• Name of standards
• How does theatre ventilation work?
• Methods of scavenging.

2. ICU Scoring systems


• Which ones are you aware of?
• Other than APACHE choose one and describe it? (Most other people got asked to detail the exact
components of APACHE II, Score ranges, APACHE III)
• What can they be used for?
• What are the limitations?
• What is ICNARC and what data is collected and how is it used?
• Advantages and Disadvantages of SMR
• What is NEWS and what are the components and score ranges
• What is PEWS?
• What do scores/traffic signals trigger?
• Sedation scoring systems and describe one.

3. RRT
• What types of renal replacement therapies are there?
• What are the advantages / disadvantages of peritoneal dialysis?
• What method is used most commonly in critical care? Why?
• What are the physical principles underlying CVVH, dialysis?
• What are the indications for CVVH on ICU?
• What complications can occur?
• Alternatives to heparin?
• Principles behind arteriovenous techniques?
• Complications occurring at dialysis- fistula related.

4. TEG
• What bedside tests are you aware of? Bm, ABG, TEG, ACT
• What is TEG?
• How does it work? In detail
• What is added to help make the blood clot?
• What are the benefits of it?
• What other tests for clotting are there?
• Shown TEG diagram - explain the different points and what they represent?
• Shown 4 different TEG graphs and asked about the abnormalities and possible causes

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Final SOE Questions December 2014 - Thanks to candidates from our courses
5. CPEX
• Asked about METs
• Asked why investigations I do for elderly patients. I mentioned bloods, ECG, CXR, echo.
• They asked what information an echo provides.
• Asked what other things we can do: 6 min shuttle walk and CPEX, dobutamine stress test.
• Asked to explain what CPEX is and what variables we monitor, and what information it provided.
• Then shown a 9 plot and asked to explain what it shows. I talked about anaerobic threshold.
• They asked why CPEX was useful and how easy it is to perform.
• How is the flow measured, what do the values mean for VO2max and AT
• How is oxygen measured in cpex?
• Why is cpex beneficiao in oesophagectomy patients

6. Humidity
• Who is it especially important in? - mentioned old and very young, trache, ICU, long op.
• Why?
• Absolute and relative definitions, values at alveoli and room temp.
• Methods of humidification - HME, how does it work, what does 70% efficiency mean, problems with them,
explain low resistance.
• Nebulisers - mentioned venturi effect and they asked if there were any other principles.
• How water bath, problems, electrical safety.
• Would low flow circle system ensure adequate HME humidification? What else helps in circuit, started to
talk about soda lime.
• Problems with over humidification, which patients are more susceptible?

7. Delirium
• What is delirium?
• Can you classify delirium?
• What tools do we have to assess delirium?
• I said CAM-ICU, they asked for others…:
• I said GCS wasn’t designed for delirium assessment, but that it could be use to asesss change in level of
consciousness, they asked me to explain GCS
• Any others?
• I said AMT or MMSE, Abreviated Mental test Score – what is in this, what score suggests a problem?
• What is RASS? What scale is used? What do we aim for on ITU?
• What are the components of CAM-ICU?
• Who is at risk of delirium?

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