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    Exm Soe2 Example Question 1

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    karatasmustafaali
    This document provides information about an 18-year-old male requiring robotic-assisted pelvic surgery who has a history of testicular cancer with cerebral and possible lung metastases. Key considerations for anesthesia include assessing the patient's anemia, the effects of chronic cannabis use, and restrictive lung disease. The perioperative plan outlined involves intubation, invasive monitoring, TIVA or volatile anesthesia, pneumoperitoneum risks, and postoperative analgesia. Intraoperatively, increased airway pressures could indicate multiple potential issues requiring immediate intervention to decompress the pneumoperitoneum.

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    Exm Soe2 Example Question 1

    Uploaded by

    karatasmustafaali
    4 views3 pages
    This document provides information about an 18-year-old male requiring robotic-assisted pelvic surgery who has a history of testicular cancer with cerebral and possible lung metastases. Key considerations for anesthesia include assessing the patient's anemia, the effects of chronic cannabis use, and restrictive lung disease. The perioperative plan outlined involves intubation, invasive monitoring, TIVA or volatile anesthesia, pneumoperitoneum risks, and postoperative analgesia. Intraoperatively, increased airway pressures could indicate multiple potential issues requiring immediate intervention to decompress the pneumoperitoneum.

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    This document provides information about an 18-year-old male requiring robotic-assisted pelvic surgery who has a history of testicular cancer with cerebral and possible lung metastases. Key considerations for anesthesia include assessing the patient's anemia, the effects of chronic cannabis use, and restrictive lung disease. The perioperative plan outlined involves intubation, invasive monitoring, TIVA or volatile anesthesia, pneumoperitoneum risks, and postoperative analgesia. Intraoperatively, increased airway pressures could indicate multiple potential issues requiring immediate intervention to decompress the pneumoperitoneum.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    4 views3 pages

    Exm Soe2 Example Question 1

    Uploaded by

    karatasmustafaali
    This document provides information about an 18-year-old male requiring robotic-assisted pelvic surgery who has a history of testicular cancer with cerebral and possible lung metastases. Key considerations for anesthesia include assessing the patient's anemia, the effects of chronic cannabis use, and restrictive lung disease. The perioperative plan outlined involves intubation, invasive monitoring, TIVA or volatile anesthesia, pneumoperitoneum risks, and postoperative analgesia. Intraoperatively, increased airway pressures could indicate multiple potential issues requiring immediate intervention to decompress the pneumoperitoneum.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 3

    FRCA Final SOE 2 Example Question:

    Clinical Anaesthesia

    FINAL SOE
    Category Long

    Information given to candidate:


    An 18 year old male with a history of testicular teratoma requires elective robotic-assisted
    radical pelvic lymph node dissection. He has cerebral metastases, possible lung metastases
    which have responded well to recent bleomycin chemotherapy. He is asthmatic, and
    frequently smokes recreational cannabis but not cigarettes.
    Supporting information:
    Height 1.75 m, Weight 70 kg, BMI 23
    Medications: Beclomethasone and Salbutamol inhalers, Codeine Phosphate 30-60 mg qds,
    Paracetamol prn
    Bloods: Hb 113
    ECG: normal.
    CXR: normal
    PFTs: FEV1 / FVC: 3.4/4.2, ratio 0.81

    A: Assessment
    Why is he anaemic? Candidate should ask for FBC: normochromic normocytic profile,
    possible anaemia chronic disease, renal failure, uncommon effect bleomycin Rx. Show
    candidate U&Es: normal except slightly raised glucose, why? (good candidate may
    guess possible recent steroid Rx)
    Does chronic cannabis smoking affect anaesthesia? Lung function impairment similar to
    tobacco smoking, possible post-op withdrawal effects, a/w oropharyngitis & uvular
    oedema which may increase risk acute airway obstruction in pts receiving GA.
    PFTs: candidate should recognise higher than expected FEV 1 / FVC ratio in an asthmatic
    patient, why? (= restrictive lung disease, ? effect pulmonary metastases or bleomycin-
    induced pulmonary fibrosis)
    Patient has cerebral metastases. Symptoms & signs of raised ICP? Headache, vomiting,
    visual disturbances, altered GCS or personality change, cranial nerve palsies (III, IV, VI),
    back pain, papillodema. Show candidate CT head, shows ventricular lesion no
    evidence mass effect
    Any other investigations required? LFTs & coagulation screen (tell candidate both normal).
    What position will patient be in for robot-assisted pelvic surgery? Steep 30-45o
    Trendelenburg, arms adducted, large robot over patient’s abdomen & chest rigidly
    fixed to port insertion sites. What are practical problems of this position – firmly secure
    patient to table with bindings to prevent gravity slippage, limited intra-op access to
    peripheral lines, meticulous padding pressure points / peripheral nerves, eye protection,
    cannot quickly move patient with robot trocars in situ (impediment to CPR).

    B: Management
    Outline your peri-operative plan:
    ETT & IPPV. Continuous intra-op total patient immobility required so must use NMB.
    Prolonged intra-op CO2 pneumoperitoneum so need to adjust vent settings to maintain
    both normocarbia and acceptable Paw. Risk endobronchial intubation in steep
    Trendelenburg position. Oro-gastric tube.
    Standard AAGBI monitoring. Arterial line probably indicated due to raised ICP risk. CVC
    need debatable. Interpretation intra-op CO monitoring w/ intra-vascular device limited
    in presence of pneumoperitoneum, but may consider ODM. NMB monitoring difficult

    Page 1 of 3
    FRCA Final SOE 2 Example Question:
    Clinical Anaesthesia

    due to access problems


    TIVA vs. volatile. No proven advantage (volatile may increase incidence of recurrence.
    Desflurane maintenance probably preferable to other VAAs. BIS monitoring if TIVA.
    Remifentanil TCI may be advantageous.
    What intra-op FIO2 would you choose? Trendelenburg + pneumoperitoneum a/w increased
    V/Q mismatch so need moderately raised FIO2. Good candidates: bleomycin Rx + high
    intra-op FIO2 a/w risk post-op resp failure. Effects high peri-op FIO2 on long-term cancer
    outcomes – controversial, ? may promote metastasis.
    Normothermia: prolonged dry cold gas pneumoperitoneum promotes hypothermia. Active
    warming strategies: forced-air warming device, i.v. fluid warming, increasing operating
    room temperature.
    VTE prophylaxis: calf compression stockings. Intermittent pneumatic calf compression e.g.
    Flowtron but consider rare risk lower-limb ischaemia in prolonged steep Trendelenburg
    position.
    Post-Op Analgesia? Robotic pelvic surgery less pain than standard laparoscopic approach.
    Likely low analgesic requirement after 24 hr, oral route available early, WHO ladder.
    Avoid NSAID in asthmatic. Neuraxial analgesia: probably not indicated in view of risk of
    dural puncture on CNS hydrostatics in this patient. So paracetamol, codeine, oral opioid
    / tramadol, possible short-term opioid PCA
    One hour into surgery there’s a sudden increase in airway pressure. Possible causes?
    Coughing / straining 2o to light anaesthesia or NMB, blocked or kinked ETT or circuit,
    endobronchial intubation, gastric aspiration, pneumothorax.
    Management? 100% O2, call for help, immediately alert surgical team to remove all robotic
    arms from patient (takes up to 60s) and decompress pneumoperitoneum, oro-
    pharyngeal & ETT suction. If significant signs of aspiration consider manual IPPV, patient
    head-down lateral once robot disengaged. Consider abandoning surgery if patient
    unstable (e.g. high Paw or low SpO2 despite above measures).

    Guidance for examiners: This case is about candidates’ understanding about adult robotic
    pelvic surgery, intra-op pneumoperitoneum, pre-op chemotherapy for cancer, raised ICP,
    and associated practical & physiological consequences. The case also addresses
    anaesthetic implications of chronic cannabis use.
    Curriculum Mapping: GU_IK_02, GU_IS_06, PB_IK_23, PB_IK_28, AM_IK_02, AM_IK_03

    Page 2 of 3
    FRCA Final SOE 2 Example Question:
    Clinical Anaesthesia

    Haematology: FBC
    Units Normal Range
    130 - 180 M adult
    Hb 113 g/l
    115 - 165 F adult
    WBC 7.9 109/l 4.0 - 11.0
    Platelets 208 109/l 150 - 450
    0.40 - 0.54 M adult
    HCT 0.36 l/l
    0.37 - 0.47 F adult
    MCV 85 fl 80 - 100
    MCHC 30 pg 27 - 32
    Reticulocytes 0.2 % 0.2 - 2.0 Adult
    ESR mm/hr 1 - 10
    HbA1c 39 mmol/mol 20 - 42

    Haematology: Coagulation
    Units Normal Range
    PT s 10.5 - 14.5
    INR 1.1
    APTT 27.0 s 24.0 - 35.0
    APTT ratio
    Fibrinogen g/l 1.50 - 4.50

    Biochemistry: Plasma Renal & Glucose


    Units Normal Range
    Sodium 141 mmol/l 136 - 145
    Potassium 4.2 mmol/l 3.6 - 5.4
    Urea 6.7 mmol/l 2.5 - 7.5
    Creatinine 110 μmol/l 58 - 110
    Glucose 7.8 mmol/l 3.0 7.7

    Biochemistry: Serum Liver


    Units Normal Range
    Bilirubin μmol/l 0 - 22
    ALT IU/l 3 - 53
    Alk Phos IU/l 30 - 130
    Albumin g/l 35 - 50
    Gamma-GT IU/l 0 - 65

    Page 3 of 3

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