BT_PO 1.17 Describe closing capacity and its relationship to airway closure and explain its clinical significance and measurement

T/F  closing capacity = residual volume + closing volume

T/F  in a healthy young upright adult, closing capacity is approx. 500 mL above residual volume

T/F  atelectasis occurs if the lung volume falls below the closing capacity

T/F  in an upright 75 year old, closing capacity = FRC

T/F the above statement is the major reason why there is a decrease in PaO2 with advancing age

T/F  closing volume is the same value in all parts of the lung

T/F  closing volume can be measured using a single breath N2 washout

References:
1. Nunn 8th ed pp 29, 38, 48, 298-299
2. Sprung, J etal. Review article: Age related alterations in respiratory
function – anesthetic considerations. Can J Anesth, 2006, 53: 1244-1257

 

BT_RA 1.15 Describe how the baricity of the agents used and positioning of patients may affect the extent of block in spinal anaesthesia

T/F  “baricity” refers to the density of a liquid in mg/L

T/F  “baricity” and “specific gravity” are the same thing

T/F  the baricity of local anaesthetic can be increased by adding glucose

T/F  “heavy” bupivacaine contains 8% glucose (8 mg glucose per mL)

T/F  the advantage of “heavy” bupivacaine is a more reliable spinal block, that ascends to a higher level than “plain”

T/F  if a spinal is injected with the patient in the lateral position, the use of “heavy” bupivacaine will result in a denser block on the dependent side

Coats of Arms and Mottoes

Now that the written exam is over, you might welcome a fun distraction in the form of Coats of Arms and mottoes. These are full of symbolism and history, and it is always fascinating to learn about the many layers of meaning that they each have.

Below are 5 examples related to anaesthesia. Can you guess them (and have a guess at the English translation of the motto)?

(1)  Corpus Curare Spiritumque

ANZCA-Crest

(2)  Fax Mentis Incendium Gloriae

RACS coat of arms

(3)  Divinum Sedare Dolorem

RCA coat of arms

(4)  Salus Dum Vigilamus

College-of-Anaesthetists Ireland coat of arms

(5)  Mente Perspicua Manuque Apta

RCPS Canada coat of arms

 

ANSWERS

(1) Hopefully you all spotted this one straight away as the Australian and New Zealand College of Anaesthetists! The motto translates as “to care for the body and its breath of life”. To read more about our College crest, click here.

(2) This one is the Royal Australasian College of Surgeons. Why, you may ask, is that included here? Many trainees don’t realise that ANZCA has only existed since 1992. Before that, we existed as the Faculty of Anaesthetists in the Royal Australasian College of Surgeons. So the FFARACS diploma had the surgeons’ crest on top! The RACS motto translates as “the torch of the mind is the flame of glory”. Hmmm…

(3) This one is the Royal College of Anaesthetists in the UK. The motto translates as “it is divine to alleviate pain”.

(4)  This is the College of Anaesthetists of Ireland. The motto translates as “safety while we watch”.

(5) This one is the Royal College of Physicians and Surgeons of Canada. All medical specialties in Canada come under the single Royal College. Fellows use either FRCPC or FRCSC depending on the specialty. Anesthesiologists use FRCPC. The motto translates as “with a keen mind and skillful hand”.

Which of the mottoes appeals to you the most? Perhaps you have an alternate favourite – maybe your school or university motto? 

SS_OB 1.15 Outline the potential effects on the neonate of drug administration in association with lactation

T / F  drug transfer into breast milk occurs by passive diffusion (therefore, influenced by Fick’s law)

T / F  for weak bases, a high pKa would slow the rate of transfer into breast milk, compared with a low pKa *

T / F  neuromuscular blocking drugs are not transferred into breast milk

T / F  neonatal deaths have occurred with mothers taking codeine while breast feeding – this risk is increased in mothers who are ultrarapid metabolisers (see also reference 3)

T / F  propofol is transferred into breast milk – however, studies have not shown any clinically detectable effect on the infant **

T / F  generally speaking, there is no need for interrupting breast feeding and/or discarding milk in the postoperative period

 

References:
1. Evers & Maze 2nd edition, p 950-951
2. Priti etal, Safety of the breast feeding infant after maternal anesthesia. Pediatric Anesth, 2014, 24: 359-371
3. SPANZA advisory on the use of Tramadol during breastfeeding, click here

Discussion Points
* what other PK properties of weak bases would determine drug transfer?
** are you surprised by this? can you explain why?

SS_OB 1.14 Outline the potential effects on the foetus and neonate of drugs administered during pregnancy

T / F  warfarin is potentailly teratogenic – but heparin and LMWH are safe during pregnancy

T / F  pregnancy induced hypertension may be managed with ACE inhibitors

T / F  phenytoin can cause foetal abnormalities – but levetiracetam is safe during pregnancy

T / F  morphine has a “category C” rating for use in pregnancy – this means that it is contraindicated

T / F  if propofol, suxamethonium, sevoflurane and vecuronium are given to a woman for an emergency GA Caesarian – the neonate would be born anaesthetised, but not paralysed

T / F  general anaesthetic agents may potentially be neurotoxic to a developing foetus

Today is done….

 

IMG_2804.JPG

Sunset Split, Croatia

To those of you who sat the ANZCA Primary Exam today – congratulations!!

You deserve a huge pat on the back.

I have posted several times now following the written paper and you can view my past posts at these links:

Well done today: there are worse things you could be doing

Phew – well done!

This too shall pass

It can be difficult to find peace after such a high stakes experience, but now is the time to look after yourselves and those around you, have a rest, do something fun and get ready to refocus your energy towards the viva.

I hope you all have a lovely and relaxing week, free from the burdens of study.

Best wishes for the exam

 

 

 

That time has arrived again….

A very warm and heartfelt best wishes for those of you sitting the exam tomorrow

You have done the hard work and now is the time to use your knowledge to its best effect.

Think positively – you are sitting this exam for a good reason.

The above series of photos is specifically designed to improve your sense of wellbeing heading into the exam- I hope it works!

(thanks to Google and Twitter for some of the images)

SAQ Exam Tip #4

The most important thing is to answer the question.

Another statement of the obvious. Thank you cynical anaesthetist!

How many times does the exam report contain the phrases “candidates didn’t address the question”, “candidates responses contained irrelevant information”, “candidates only addressed one part of the question”?

No matter how obvious or intuitive it is to answer the question, candidates still make this very basic error far too often. It would undoubtedly be the commonest problem I encounter while marking practice (and actual) SAQs.

Some examples again from recent papers:

Discuss the potential adverse effects of suxamethonium– Don’t tell me what sux is or classify it. Don’t tell me what it is used for or how it works. Tell me about adverse effects.

Outline the hazards associated with the use of CO2 absorbents within a circle breathing system and how the risks can be minimized- Don’t tell us how absorbents work. Don’t tell me why they are in a circle circuit, tell me what the hazards are. If the question has two parts to it like this one, then if you just answer one part you can’t hope to pass the question. Half of the marks are for detailing how the risks can be minimized. More commonly if a question has several components it will be explicitly detailed how many marks relate to each part.

Outline how hyperventilation may reduce intracranial pressure– this is not an invitation to write down everything you know about intracranial pressure or cerebral blood flow or bang on about the Monro-Kellie doctrine at the expense of everything else. Nor do you want to tell the examiner what propofol does to intracranial pressure.

Compare and contrast the pharmacology of ephedrine and norepinephrine– a profoundly depressing thing is to realise you’ve compared adrenaline and noradrenaline which wasn’t asked for…. Yet this error was still made.

Resist the temptation to define every component of the question. Sure, if you’re asked about CSHT then you need to define it but if you’re asked a question about adverse effects of opioids then you don’t need to tell me what opioids are or what they are used for. Cut to the chase.

Vallecula posted recently about making the most of the perusal time https://primarydailylo.wordpress.com/2018/08/03/reading-time-make-it-count/ and I strongly endorse those comments. Read the questions when you are fresh and underline the key components. Jot down the main points. Answer the question that is asked. Answer every question.

Good luck (not that luck has anything to do with it).

 

SAQ Exam Tip #3

SAQ chart

You are aiming for a 3.

I am not trying to be obtuse. I am referring to scoring 3 out of 5 for each SAQ. As you know we are marking SAQs out of 5 using a ‘holistic’ grid. A mark of 2 equates to 40% and 3 equates to 60%. The grids are non-linear; i.e. get 0 if you write nothing, get 1 if write a little that is mostly nonsense, get 2 if you write a few relevant points and no major errors or write lots of points including several with errors. A ‘3’ is a pass and contains most (not all) of the relevant (main) points for a SAQ without major errors. A ‘4’ represents a very good answer incorporating significant detail and we can all dream about getting 5s.

The diagram above (histogram) comes from the most recent exam report and makes a very important point. I suspect you would get a very similar diagram if you used data from previous exams. Although the majority of candidates achieve the invitation mark for the vivas (40% or average of 2/5 for each question), the majority of candidates don’t actually pass (>50%) this component of the paper. To pass the exam overall you need more than 50%, so if you go into the vivas with just over 40% you need to score almost 60% to pass. Of course the candidate who achieved a just adequate SAQ result is unlikely to over achieve in the vivas.  Consequently, most of those who failed the exam are in the 40-45% band above. If you go into the viva with 60% then you have an impressive buffer and I suspect none of those candidates failed the exam (I don’t know for sure but you get the gist).

You should get a 3 if you do all of the following:

  • Answer the question that was asked (see Tip #4 tomorrow)
  • Address the main points of the answer
  • Don’t commit major errors
  • Attempt every question on the paper- a blank paper is a crime
  • Have attempted the question before– practiced it as per Tip #1.

You should be able to fit all the pertinent points on one page of paper, micrographia notwithstanding. It can be helpful to ask yourself- what is the clinical relevance of this question? Why is the examiner asking this question of anaesthetic trainees?