Study tip – start talking!

Now that the written exam is over it is time to start talking. This the the best tip I could give you for the vivas.

Find people to discuss your knowledge with, as expressing concepts verbally is a great way of making sure that you actually understand them. If you can’t find another human to talk to, talk to the cat, dog, pot plant or mirror…

Find someone to ask you questions. Consultants are often worried that their Primary Exam knowledge isn’t good enough to help out candidates. Don’t let them off the hook that easily. A lot of people have a pet topic which they feel comfortable with and, if worse comes to worst, you can give them some of your notes on a topic and get them to quiz you on those. Two past chairs of the Primary Exam have an article in the most recent Australian Anaesthesia aimed at helping consultants prepare candidates for the vivas. Read it yourself, it gives a good insight in to the type of questions you might be asked, and print off some copies to give to those you will be working with.

Registrars who have recently sat the exam, are also a great source of help. Most people are happy to inflict the vivas they were given on others. Bear in mind, people will alsways remember the questions they couldn’t answer better than those they could.

I hope you all have a fabulous and relaxing weekend but, on Monday, start talking!

PS. When you are in Melbourne for the vivas consider visiting the NGV to view the Triennial exhibition. The photo above is a work exhibited there by Xu Zhen

BT_GS 1.16 Describe alterations to drug response due to ageing

It is uncommon these days for me to have a day where I don’t anaesthetise at least one older patient. Approximately 15% of the Australian population is aged over 65. There are currently almost half a million Australians aged over 85 yrs of age and this number is expected to double in the next 20 yrs !


This elderly person (Fauja Singh) is a fairly amazing older person, completing a marathon aged 100!

Chronological age does not necessarily correspond to physiological age, but there are certain changes which occur fairly consistently with increasing age.  Acute Pain Management: scientific evidence (10.2.3 in case the link doesn’t work) has summary of the changes that occur with ageing and significance for drug dosing.

BT_GS 1.16 Describe alterations to drug response due to physiological change with particular reference to the elderly

A given bolus dose of propofol in an elderly person, compared with a 40yr old, will have an increased effect due to the decreased size of the central compartment   TRUE/FALSE

Changes in cardiac output in the elderly generally slow the rate of induction with volatile anaesthetic agents    TRUE/FALSE

GFR decreases by about 10% per decade after 50 yrs of age   TRUE/FASLE

Oral bioavailability of some drugs may be increased in the elderly due to a reduction in both liver blood flow and metabolic capacity    TRUE/FALSE

Both albumin and alpha1 acid glycoprotein levels fall equally in the elderly, increasing the free fraction of highly protein bound drugs   TRUE/FALSE





BT_PM 1.17 Pharmacokinetics of intravenous opioids and clinical relevance

I am not a massive fan on memorising a whole lot of numbers for the sake of it – boring!!

However, sometimes these pesky numbers can actually help us guide clinical practice and, in that situation, they take on a whole new level of relevance. The pharmacokinetics of opioids are a case in point.


Hopefully no opioids in this handbag (although to be honest, I couldn’t be sure) Cottesloe, WA

BT_PM 1.17 Describe the pharmacokinetics of intravenous opioids and their clinical applications

The high lipid solubility of fentanyl confers a long duration of action when given intrathecally  TRUE/FALSE

The rapid speed on onset of alfentanil is primarily due to its low pKa  TRUE/FALSE

Duration of action of remifentanil is determined by its elimination half life   TRUE/FALSE

The terminal elimination half life of morphine and fentanyl is similar   TRUE/FALSE

Active metabolites of both morphine and pethidine contribute to the duration of analgesic effect   TRUE/FALSE

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


A late post today, so that I could send a huge CONGRATULATIONS to all of you who sat the ANZCA Primary written paper today! I hope that it went well for all of you and that you were able to display your accumulated knowledge to your best advantage.

Remember it is normal to dwell on those things that didn’t go well. Inevitably, there will be some questions that didn’t feel quite as great as the rest. No need to be particularly worried by this, as the SAQ mark is an average of your all your scores.

I was looking for uplifting pictures to add to this post, perhaps of a beautiful holiday location or some cute little baby animals, but when I googled “best photos of 2017”, the world was not portrayed as a very happy place. It reminded me, that even when in the midst of stressful times, related to exams, study or work, we are actually very privileged to have the opportunity to do the job that we do.

I did find an amazing photo (the one above) and the accompanying story of this small group of Nepalese bee keepers, who harvest a rare psychotropic honey from hives on those cliffs!!. As a person who has a significant fear of heights, this job looks like one of my worst nightmares!! The article is a bit political, but you might find the description of the effects of the honey quite entertaining in your post exam stupor ( you may recognise the feeling 😉 )

I hope that you all find time to look after yourselves and indulge in something nice over the next few day. Well done again….

BT_PM 1.3 Pre-emptive and preventive analgesia


Glass poppies Andy Paiko


A few weeks ago I ran a series of posts on this LO.

I ran out of steam before reaching the last of the bullet points. This was partly because the area has held so much hope from a theoretical mechanistic viewpoint but there is little strong scientific evidence to support benefit from particular clinical practice – how disappointing….

I thought it might be timely to revisit now, just before the written exam. I wish there were a rapidly acting pre-emptive analgesic, I could prescribe, to make tomorrow less painful for those of you about to sit. However, the best prescription, to make the day easier, is to have studied well and practised lots – which I am sure all of you who read this blog will have done. BEST WISHES!!

The latest edition of Acute Pain Management: Scientific Evidence has a section on this topic (I hope that link takes you there. If it doesn’t, the book is freely available here [see section 1.5]).

BT_PM 1.3  Describe the basic physiological mechanisms of pain including:

· Pre-emptive and preventive analgesia

Pre-emptive analgesia, by definition, must be given before a noxious stimulus occurs TRUE/FALSE

The aim of pre-emptive and preventive analgesia is to reduce sensitisation   TRUE/FALSE

The NMDA receptor plays an important role in central sensitisation  TRUE/FALSE

Peri-operative ketamine infusions may have a role in preventing the development of chronic post-surgical pain    TRUE/FALSE

Outcomes in this area have been muddied by fraudulent research   TRUE?FALSE

Study tip : Capitalise on your freshness


Last week I hosted a webinar, through ANZCA, entitled “Tips for the Primary Exam”. For those of you who are registered with ANZCA, you can watch it via the College networks (it is a bit of a time investment, but the fast forward button is always available).

One of the other contributors to this blog, asked me whether there were any noteworthy points that could be highlighted here. A lot of what I discussed has already been touched in the previous study tips on this blog.

With the upcoming exam, there has been single, but significant change – the increase in reading time to 15 mins and the allowance for you to write on the question paper during that time. I discussed how to use this change to your best advantage in the webinar and that is the point I will focus on today.

The written portion of the exam is a real feat of endurance – 2.5hrs of MCQs in the morning, backed up with 2.5 hrs of writing the SAQs in the afternoon. Exhausting! None of us write for that long continuously these days. By the end of the afternoon, you will be very tired.

A the start of the SAQ paper however you will still be reasonably fresh – capitalise on your freshness in the 15 mins reading time:

1. Read the questions carefully – those that look like repeated questions may have had important changes made. The answer you have practised for the old question may not be able to be successfully transplanted into the new question

2. Highlight important words – this may include those important word changes, things you wish to define, anything that helps you ANSWER THE QUESTION

3. Jot down a couple of notes to help you structure your answer – your brain will be thinking quite well at this stage. If something great enters it, take 30 sec to write it down. This may be especially helpful for questions you plan to answer towards the end of the 2.5 hrs. To be able to refer back to your little notes, when your brain is fatigued, may provide that little spark that helps you through.

I suggest that you include “Reading Time” in any set of SAQs you practice (1 min per question). The more times you use that extra minute per question in practice, the more useful it is likely to be for you in the exam.

SS_PA 1.52 Pharmacokinetic differences in  neonates and children compared with adults and the implications for anaesthesia

A little person I know had an anaesthetic last week having swallowed a curtain hook, probably a couple of months ago. He had not been very keen to eat solid food!!

SS_PA 1.52 Describe how the pharmacokinetics of drugs commonly used in anaesthesia in neonates and children differ from adults and the implications for anaesthesia

Water soluble drugs have a larger volume of distribution in neonates TRUE/FALSE

Drugs that depend on redistribution into fat compartments for their termination of action have longer durations of action in neonates    TRUE/FALSE

The absorption of oral drugs is more rapid in neonates compared with adults   TRUE/FALSE

The relationship between weight and drug elimination is linear in children  TRUE/FALSE

Remifentanil’s half life is unchanged in neonates    TRUE/FALSE

BT_GS 1.12 Context sensitive half time

A topical area for us as we often run intra-operative infusions of drugs, sometimes for quite long periods of time!

The topic is not brilliantly covered in that many books. Pharmacology and Physiology for Anaesthesia Ch 2 by Hemmings and Egan, is a great chapter full stop and does discuss the topic. This article in BJA Education also gives a good little summary.


Another photo from beautiful Tasmania today, Wineglass Bay

The context sensitive half time of a drug will never be longer than its elimination half life   TRUE/FALSE

The “context” is the duration of the infusion   TRUE/FALSE

Following cessation an infusion, the fall in plasma concentration is proportional to elimination of drug from the body  TRUE/FALSE

Prolongation of the half time, as the duration of the infusion increases, is directly proportional to the lipid solubility of the drug  TRUE/FALSE

Context sensitive half time is a term that only applies to multi compartmental models   TRUE/FALSE

BT_GS 1.21 Isomers

I think isomerism is a very cool little trick of nature! How amazing to think that one chemical structure can have such different properties due to the orientation of the same atoms on a single carbon, and also that our bodies are able to recognise these differentially.

We sometimes talk about enantiomers as being non superimposable mirror images of each other, which made me think of mirror twins ( apologies for the high class nature of the “journal” I took this from! However, if you are interested in twins, these episodes of Insight from SBS may interest you)


No photos of mirrors today, just this (not perfect) reflection of Cradle Mountain in Dove Lake, Tasmania. One of my favourite parts of the world. I have seen the lake surface truly glass like, but do not have an image of it to share with you.

BT_GS 1.21 Describe and give examples of the clinical importance of isomerism

Ketamine, propofol and bupivacaine are all presented as racemic mixtures for use in Australia TRUE/FALSE

The D isomer of amphetamine is more potent as a CNS stimulant than the L isomer TRUE/FALSE

The (+) enantiomer of tramadol is more potent inhibitor of serotonin reuptake than the   (-) enantiomer TRUE/FALSE

D isomers of naturally occurring catecholamimes are 10x more potent than the L isomers TRUE/FALSE

Thiopentone is a drug which has stereoisomers TRUE/FALSE

BT_GS 1.68 Describe the physiological responses to lowered and raised environmental temperature, and the effects of anaesthesia on these responses

I have been fortunate enough to have had a recent holiday on a Japanese ski field, where the temperature was consistently about -30°C with wind chill factor. Whilst we were away, (and unfortunately since my return) the temperature in my hometown of Adelaide was well above 40°C.

Humans have a range of adaptations to enable them to cope with these widely diverse environmental temperatures. Anaesthesia has an important effect on our ability to regulate out own body temperature and the theatre environment is often a cold one (although it is all relative 😉)


The hills beyond Nozawa Onsen, Japan

BT_GS 1.68  Describe the physiological responses to lowered and raised environmental temperature, and the effects of anaesthesia on these responses

The “thermoneutral zone” is the range of body temperatures at which metabolic rate is minimal  TRUE/FALSE

Cutaneous blood flow can increase 30 fold in heat stress  TRUE/FALSE

Shivering thermogenesis DOES NOT significantly increase adult metabolic rate TRUE/FALSE

In the neonate non-shivering thermogenesis can increase the metabolic rate to twice the resting rate TRUE/FALSE

General anaesthesia doubles the size of the interthreshold range   TRUE/FALSE