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

Medical Latin

We use Latin abbreviations all the time….. do you know the meanings of any of these terms?


T / F    PRN is the abbreviation for pro re nata which means “never actually given”

T / F    “stat” is short for statim which means “melodramatic”

T / F    “Q” (as in Q4H) is short for quaque, which means “every”

T / F    “PO” is the abbreviation for per os, meaning “through the mouth” – NOT “go away”

T / F    “TDS” (ter die sumendum) and “TID” (ter in die) are equally acceptable for “three times a day”


For those sitting the written exam on Tuesday – all the very best!!!

Ventilation / Perfusion (V/Q) Relationships

BT_PO 1.26 Discuss normal ventilation-perfusion matching

BT_PO 1.29 Discuss ventilation-perfusion inequalities, venous admixture and the effect on oxygenation and carbon dioxide elimination


T / F   the V/Q ratio at the apex of the upright lung is 3.3, because the apex receives most of the alveolar ventilation

T / F   in a conscious person lying on their left side, the left lung will receive more ventilation AND perfusion than the right lung

T / F   in an anaesthetised ventilated patient lying on their left side, the left lung will receive more ventilation AND perfusion than the right lung

T / F   atelectasis results in an increase in alveolar dead space, which can cause hypercapnoea

T / F   a decrease in cardiac output can decrease mixed venous PO2 – this will magnify the hypoxaemia produced by any alveolar shunt

Nitrous Oxide

BT_GS 1.27 Describe the pharmacology of nitrous oxide


T / F   nitrous oxide does not support combustion

T / F   nitrous oxide acts synergistically with volatile agents to produce anaesthesia

T / F   nitrous oxide does not cause any peripheral vasodilation

T / F   nitrous oxide acts on GABA receptors in the brain

T / F   nitrous oxide use is associated with post-operative MI

Serotonin Syndrome

BT_PO 1.102 Discuss the clinical features and management of serotonin syndrome


T / F   all serotonin receptors are ligand gated ion channels

T / F   tramadol, pethidine, fluoxetine, amphetamines and amitriptyline are all potentially serotonergic

T / F   monoamine oxidase inhibitors are not serotonergic

T / F   features of serotonin syndrome include: CNS excitation; hyperthermia; and hyper-reflexia

T / F   treatment is usually supportive, although cyproheptadine is a potential antidote


BT_SQ 1.5 Describe basic physics applicable to anaesthesia, in particular:
…. principles of humidification and use of humidifiers ….


T / F   during quiet breathing, air reaching the carina is close to 37 degrees C and 100% relative humidity

T / F   at 37 degrees C, air can hold a maximum of 44 mg/L of water vapour

T / F   during expiration, water vapour condenses onto the airway mucosa

T / F   absolute humidity depends upon both the temperature and the atmospheric pressure

T / F   a HME can warm inspired gases to about 30 degrees C, but this takes about 20 minutes