Bonus SBAs

1. Severe CAP management

A 55-year-old lady is admitted through the A&E with severe community acquired pneumonia.
She is extremely agitated and combative. Her saturations are 85% on a FiO2 of 0.6. A blood
gas shows PO2 = 7 kPa, PCO2 = 8.6 kPa and pH 7.28.
What would be the next most appropriate step?
a) IV Antibiotics according to hospital policy
b) Immediately intubate and ventilate
c) Apply CPAP
d) Increase FiO2 via facemask
e) Administer 0.9% saline 15 ml/kg

2. Splenectomy/#NOF coagulopathy
A 36-year-old man falls off his mountain bike sustaining a ruptured spleen and a fractured
femur. In the Emergency Department he receives 3 litres of crystalloid and 4 units packed red
cells. He is transferred to theatre for an emergency laparotomy and splenectomy where he is
found to have 2.5 litres of blood in his peritoneal cavity. He has the following observations and
blood results:
Pulse 130bpm, pH 7.3, APTT ratio 1.3, BP 95/45 mmHg, PCO2 4.2 kPa, INR 1.1, Temp 35ºC,
PO2 23.3 kPa, fibrinogen 0.15, lactate 4.2, Platelets 80.
The most likely explanation for his deranged coagulation is:
a) Combination of blood loss, hypothermia and acidosis
b) Disseminated intravascular coagulation due to a fat embolism
c) Hepatic impairment secondary to splanchnic hypoperfusion
d) Blood loss into peritoneal cavity
e) Blood transfusion mismatch

3. ECT drugs
What would be the best combination of drugs for 22-year-old ASA 1 gentleman for ECT?
a) Propofol 1-2.5mg/kg, vecuronium 0.1mg/kg, atropine 600 mcg
b) Thiopentone 2-5mg/kg, atropine 600mcg, suxamethonium 0.5mg/kg
c) Thiopentone 2-5mg/kg, atropine 600mcg, rocuronium 0.6mg/kg
d) Propofol 1-2.5mg/kg, suxamethonium 0.5mg/kg and glycopyrrolate 600mcg
e) Etomidate 0.15-0.3mg/kg, atracurium 0.5mg/kg and glycopyrrolate 600mg

4. Post-emergency THR analgesia

An elderly nursing home resident requires an emergency hip replacement following a
fractured neck of femur. She has mild dementia, hypertension, and osteoporosis.
Which of the following options gives optimal pain management for 24 hours?
a) Surgeon infiltrating local anaesthetic in wound
b) Lumbar epidural infusion
c) Morphine PCA
d) Sciatic nerve block on induction
e) Fascia iliaca block on induction

5. CPR Cardiac output

During the effective closed chest compressions:
a) Cardiac output is more than 2 L/min
b) Pressure achieved is at least above MAP 60mmHg
c) Pressures in the Right atrial and Aortic arch are equal
d) It would beneficial to add intermittent abdominal compressions
e) Arm to brain circulation within 90 secs

6. Intra-op abuse suspicions

You are anaesthetising a 5-year old girl for an elective inguinal herniotomy. After induction
you find extensive bruising on her back, thighs and perineum. Your Consultant shares your
concerns about abuse.
What is the next appropriate action to take?
a) Arrange for photos to be taken of the injuries
b) Ask a Consultant Paediatrician for advice
c) Ask the surgeon to perform an examination under anaesthetic
d) Contact social services
e) You and your Consultant discuss the bruising with the child’s parents

7. Pneumoperitoneum bradycardia
A healthy 56-year-old develops profound bradycardia (20 beats per minute) during induction
of a pneumoperitoneum for a laparoscopic cholecystectomy.
What is the most appropriate immediate measure you would take?
a) Immediate chest compressions and call for help
b) Atropine 0.3mg
c) Atropine 0.6mg
d) Glycopyrrolate 0.3mg
e) Ask the surgeon to deflate the abdomen

8. Levels of evidence
You have been approached by a pharmaceutical company who are marketing a new
product. They present to you evidence regarding their product.
Which of these is most likely to make you change your clinical practice?
a) A multi-centre, non-blinded, non-randomised trial.
b) An article published by the RCOA based on expert opinion
c) A prospective randomised control trial of the drug in a single centre
d) A retrospective audit of 5 years’ worth of the drug’s use in a single centre
e) Observational cohort study

9. Paed ETT size

You are called to see a two-year-old with septicaemia in ED. His blood pressure is 40/10
mmHg, heart rate is 200 beats per minute, oxygen saturations are 85% on supplemental
oxygen, and his temperature is 38oC. The blood pressure is unresponsive to fluid
resuscitation.
What is your next treatment?
a) CPAP and transfer to critical care for observation
b) Size 4.5 ETT and start inotropes with throat pack for leak
c) Size 4.5 ETT and start inotropes
d) Size 3.5 ETT and start inotropes. Cuff pressure limited to <20mmHg
e) Size 3.5 ETT and start inotropes. Cuff inflated until no leak heard

10. Simple forearm fracture

An 11-year-old female requires manipulation under anaesthesia for a simple forearm
fracture. She last ate 1 hour ago and has received morphine in A+E.
What would be the most appropriate next step?
a) Pass an NG tube, empty the patient's stomach, followed by a rapid sequence
induction
b) Wait 4 hours and then treat the patient as an elective general anaesthetic
c) Wait 12 hours and then treat the patient as an elective general anaesthetic
d) Immediate rapid sequence induction to allow manipulation of fracture
e) Perform an axillary nerve block with the patient awake and then manipulate the
fracture

11. Building site badly written

A young man falls and sustains a head injury at a building site. He doesn't open his eyes to
verbal command and makes incomprehensible sounds. When a pen is pushed against his
nail bed he withdraws to the stimulus and open his eyes.
What is the most appropriate management of this patient?
a) LMA
b) Hudson mask
c) Place in coma position
d) Intubation
e) Intubation and positive pressure ventilation

12. ARDS weaning

30-year-old man is day 8 on ICU post RTA. He is on vasopressor support and is no longer
absorbing his feed. His WCC is now 18 and his CRP is 250. He is pyrexial with a
temperature of 38oC. His FiO2 is now 0.55 but is requiring high amounts of respiratory
support.
What is the next most suitable (appropriate) step?
a) sedation hold with a view to extubate
b) stop sedation and trial on T-piece
c) continue on current settings until FiO2 weaned further
d) percutaneous tracheostomy
e) wean to getting him spontaneously breathing

13. Severe shock, initial management

A 65-year-old man has been admitted to ITU with abdominal pain and vomiting. He received
1L of Hartmann's in A&E. His BP is 70/50mmHg, pulse 120bpm, SpO2 95% on a non-
rebreathe mask. His ABG shows pH 7.2, PaO2 9.2 kPa, PaCO2 3.1 kPa, BE -9.0, lactate 6.1
mmol/L.
The next priority in his management should be:
a) commence cardiac output monitoring
b) commence vasopressor
c) further fluid resuscitation
d) obtain urgent CT abdomen
e) urgent surgical review

14. Pacemaker problems

A 45-year-old with arrhythmogenic right ventricular cardiomyopathy and an ICD/pacemaker
device presents for elective cholecystectomy.
What is the most appropriate management of the ICD/PPM?
a) Application of fixed magnet
b) Deactivation of defibrillation
c) Deactivation of device
d) Reprogramme to DDD mode
e) Reprogramme to DOO mode

15. Know your AV definitions

The fitness of a 65-year-old woman is being assessed pre-operatively for knee surgery. At
assessment a cardiac murmur is heard and an echocardiogram is performed. The
ultrasound investigation shows calcification of the aortic valve cusps, concentric left
ventricular hypertrophy, and mild hypokinesia. The mean gradient across the valve in systole
is 51mmHg and the diastolic half time velocity is 600ms. What is the likely diagnosis?
a) Severe aortic stenosis, mild aortic regurgitation
b) Severe aortic stenosis, severe aortic regurgitation
c) Moderate aortic stenosis, mild aortic regurgitation
d) Moderate aortic stenosis, moderate aortic regurgitation
e) Moderate aortic stenosis, severe aortic regurgitation
16. Pre-oxygenation
You are pre-oxygenating a patient for RSI prior to appendicectomy. The fresh gas flow is
equal to the patient's minute ventilation.
What is the best circuit to use?
a) Mapleson A
b) Mapleson B
c) Mapleson C
d) Mapleson D
e) Mapleson E

17. Elective surgery on-table arrest

You are anaesthetising a patient on your solo list for an elective laparoscopic
cholecystectomy. Midway through the procedure, he suffers an unexpected on-table arrest,
and resuscitation is unsuccessful. You break the news to the family, along with your
Consultant, the surgical Consultant and the theatre Sister.
What is the most appropriate action for you to take next?
a) Isolate the anaesthetic equipment and drug ampoules used
b) Document the events in the notes and on the anaesthetic chart
c) Inform the Coroner
d) Transfer the patient, with lines in-situ, to a quiet area where the relatives can attend
e) Hold a de-briefing session with all the theatre staff

18. Naughty child refusing tonsils

You are assessing a 7-year-old boy with his mum pre-operatively for an adenotonsillectomy.
His mum says she is glad he is having the operation as he has missed a lot of school. The
child seems cooperative on your pre-op visit, so you decide on an IV induction and prescribe
EMLA, paracetamol and ibuprofen. On arrival to the anaesthetic room the child becomes
very distressed and says he does not want the operation. What would you do next?
a) Continue with IV induction as planned
b) Send him back to the ward for premedication
c) Discuss the options with the mum
d) Proceed with a gas induction
e) Cancel the procedure and reschedule for a later date

19. Post-ictal eclampsia

An ASA 1 primigravida of 33 weeks gestation arrives in the emergency department following
a generalised seizure of 5 minutes duration. On arrival, she is drowsy. Oxygen saturations
are 98% on a non-rebreathe oxygen mask, and BP is 155/95. Tendon reflexes are brisk.
What is the most appropriate initial drug management?
a) Diazepam
b) Labetalol
c) Magnesium
d) Nifedipine
e) Phenytoin

20. Post-ORIF pain/CRPS

A 39-year-old undergoes an open reduction and internal fixation of a forearm fracture. 3
months later he presents with a painful, tender, sweaty forearm. CRP and WCC are normal.
The most likely diagnosis is:
a) Compartment syndrome
b) Non-union
c) Osteomyelitis
d) CRPS1
e) CRPS 2
21. Post-op laryngospasm (paed)
You are called urgently to recovery: a 4-year-old who had undergoing an elective procedure
develops laryngospasm in recovery. Her sats are 65% and you administer 100% O2 and
perform an RSI. Her sats are now 85%, with pink frothy sputum coming up the ETT.
What is the most likely cause?
a) Anaphylaxis secondary to suxamethonium
b) Cardiogenic shock
c) Negative pressure pulmonary oedema
d) Aspiration prior to intubation
e) Neurogenic shock

22. Cochlear implant local anaesthetic

A ten-month-old baby weighing 10kg is undergoing bilateral cochlear implants. The surgeon
has asked how much local anaesthetic he can infiltrate on the first side.
a) 3.5ml 2% lignocaine + adrenaline 1:200000
b) 3.5ml 1% lignocaine + adrenaline 1:200000
c) 4ml 0.25% bupivacaine + adrenaline 1:200000
d) 2ml 0.5% bupivacaine + adrenaline 1:200000
e) 7ml 1% lignocaine + adrenaline 1:200000

23. Blatant croup

A 1-year-old child presents with one week history of cough and coryzal symptoms. She is
alert and playing, with loud inspiratory stridor but no cyanosis. Her temperature is 37.8C.
What is the most likely diagnosis?
a) Bronchiolitis
b) Epiglottitis
c) Inhaled foreign body
d) Laryngotracheobronchitis
e) Retropharyngeal abscess

24. Pregnant CPR

A 30 weeks’ pregnant woman collapses on the ward. She is found to be in asystolic arrest.
CPR in commenced, with satisfactory bag/mask ventilation. On your arrival, what is the first
thing you do?
a) Adrenaline 1 mg
b) Atropine 3mg
c) Left pelvic tilt / manual displacement of uterus
d) Endotracheal intubation
e) LMA insertion

25. Terrible hypercapnoea question

Hypercapnia is associated with
a) somnolence
b) hypertension
c) confusion
d) headache
e) all the above

26. Periop steroid supplementation

A 73-year-old lady with rheumatoid arthritis is having a general anaesthetic for an inguinal
hernia repair. She normally takes 20mg prednisolone for her rheumatoid arthritis.
The best steroid management plan is:
a) 25mg IV hydrocortisone on induction
b) usual dose of prednisolone plus 25mg iv hydrocortisone on induction
 c) usual dose of prednisolone plus 25mg hydrocortisone 6 hourly for 24 hours
d) no steroid cover needed
e) 8mg IV dexamethasone on induction

27. Burns/Hyperbaric O2 therapy

A 45-year-old man in a house fire is taken to A+E. He is already intubated and ventilated. His
ABG shows: pH 7.29, PO2 7.5 kPa, PCO2 5.7 kPa, BE -5. He is being ventilated with FiO2 of
1.0, minute volume is 6L/min, and PEEP is 5 cmH2O. His carboxyhaemoglobin is 35%.
What is your respiratory strategy?
a) Drop the FiO2 to 0.7 to avoid injury from too much oxygen
b) Reduce the FiO2 when his carboxyhaemoglobin is 10%
c) Keep him on 100% for 48 hrs
d) Increase his PEEP as guided by his ABGs
e) Hyperbaric oxygen therapy

28. Asthma deterioration

An 18-year-old male presented to the Emergency Department with an acute asthma attack.
He improved after he was given a salbutamol nebuliser. Shortly afterwards, he deteriorates
with worsening shortness of breath. He has bilateral quiet breath sounds and a central
trachea. His ABG shows: pH 7.37, pCO2 3.0, pO2 10.0, Base excess -5.0 mEq/L.
What is the most urgent initial investigation to perform?
a) blood cultures
b) chest X-ray
c) peak flow
d) spirometry
e) sputum culture

29. Beta-blocker overdose

A patient is brought into A&E following an atenolol overdose. They are unresponsive and the
ECG shows a broad complex rhythm with a rate of 30. Basic life support has commenced.
What is the best therapeutic intervention?
a) 1mg Adrenaline IV
b) 600mcg Atropine IV
c) 3mg Atropine IV
d) External pacing
e) 10mcg adrenaline boluses titrated to response

30. Vascular surgery perioperative complications

A 72-year-old is booked for elective open AAA repair. He smokes 10 cigarettes per day, is on
antihypertensives and his ECG shows Q waves in V4-V6. Full blood count and biochemistry
are within normal limits. What potential peri-operative complication poses the greatest risk of
mortality?
a) Acute MI
b) Acute renal failure
c) Respiratory failure
d) Massive blood loss
e) CVA

31. Cerebral hyperperfusion (± cardiac ischaemia)

A patient has undergone carotid endarterectomy under local anaesthesia. Later on, the HDU
he is confused, his BP is 220/100 mmHg. His heart rate is 57 beats/min. He shows ST
elevation on his ECG >6 mm. What should you do next?
a) IV atenolol
b) IV esmolol bolus and infusion
c) IV hydralazine bolus
 d) IV nitrate bolus and infusion
e) IV phentolamine

32. Oozy post AAA

An 84-year-old man is undergoing an emergency open AAA repair. Towards the end of the
case the surgeon tells you he is bleeding/oozing. Bloods taken intraoperatively were as
follows: Hb 10 g/dL, Plt 75 x109/L, INR 1.6.
What is your immediate action?
a) Give factor VIIa
b) Give FFP as soon as it has thawed
c) Send a repeat FBC and clotting
d) Give platelets
e) Give vitamin K 10mg IV

33. Post cross-clamp changes

A patient is undergoing AAA repair. Pre-operative test showed the patient to have normal left
ventricular function and an ejection fraction of 70%. The patient has a PA catheter in situ.
An infra-renal cross-clamp is placed. Which of the following best describes the physiological
change that occurs immediately after an infra-renal cross-clamp is applied?
a) Decreased arterial blood pressure
b) Decreased cardiac output
c) Increase central venous pressure
d) Increase heart rate
e) Increase systemic vascular resistance

34. Dodgy art line?

On your list is a 67-year-old man with severe peripheral vascular disease for a laparoscopic
cholecystectomy. You insert an arterial line ‘awake’. Following induction, his blood pressure
drops but responds well to a bolus of metaraminol. After transfer to theatre the arterial line
reads 60/40 mmHg, but the non-invasive blood pressure reads 105/70 mmHg.
What is the most likely cause of this?
a) Faulty transducer
b) Transducer too high
c) Excessive damping
d) BP cuff wrong size
e) Peripheral vasodilatation

35. Labouring woman, mean husband

A pregnant lady requests epidural analgesia for labour. She has no contraindications. She has
had one dose of IM pethidine. Her husband does not want her to have it since in their antenatal
birth plan, they had planned not to have epidural placed. What is most appropriate action?
a) Place the epidural as per mother’s request
b) Don't place epidural as per husband request
c) Set up a morphine PCA
d) Suggest Entonox
e) Give further IM pethidine

36. FH MH
You review a 19-year-old patient with appendicitis. He is tachycardic (120 beats per
minute), pyrexial (temperature 38.3oC) and is showing signs of peritonism. His uncle had a
reaction to anaesthetic called 'malignant hyperpyrexia'. He is very worried and anxious
about having an anaesthetic.
What would you tell him?
a) General anaesthesia is safe, but will be modified in his case
 b) He is at increased risk of death from an anaesthetic
c) Advise to proceed under spinal anaesthetic
d) Postpone until the uncle's case notes are available
e) Postpone until he is tested for malignant hyperpyrexia

37. Headache investigation

A 54-year-old male presents to the emergency department with sudden onset occipital
headache, vomiting, confusion and photophobia.
What is the most appropriate immediate management?
a) Lumbar puncture to rule out meningitis
b) Intubation and ventilate
c) Iv mannitol 0.5 g/kg
d) Non-contrast CT scan
e) Neurosurgical referral

38. Pyloric stenosis

A 6 week old infant presents with signs and symptoms of pyloric stenosis.
What is your immediate management?
a) Give 10 ml/kg 0.9% saline bolus
b) Give 4ml/kg/hr 0.45% saline and 5% dextrose
c) Arrange surgical opinion
d) Confirm diagnosis with ultrasound
e) Insert nasogastric tube

39. Pancreatitis severity assessment

A patient is admitted to ICU with acute pancreatitis. Which of the following investigation is the
best to assess the severity of complications?
a) abdominal ultrasound
b) CT abdomen
c) series of serum amylase
d) series of serum calcium
e) exploratory laparotomy

40. Post-thyroidectomy stridor

You are called to see a patient in recovery one hour following a thyroidectomy. He has
difficulty breathing and his O2 saturation has dropped to 89% from 97% despite an FiO2 of
60%. The front of his neck appears swollen despite no blood in the suction drain.
What will be your next line of action?
a) Get the surgeons to re-explore the wound
b) Open the clips in the front of the neck
c) Give CPAP using a non-invasive ventilation mask
d) Nebulised adrenaline
e) Urgent ultrasound scan of the neck

41. Naughty child refusing tonsils

You are assessing a 7-year-old boy with his mum pre-operatively for an adenotonsillectomy.
His mum says she is glad he is having the operation as he has missed a lot of school. The
child seems cooperative on your pre-op visit, so you decide on an IV induction and prescribe
EMLA, paracetamol and ibuprofen. On arrival to the anaesthetic room the child becomes
very distressed and says he does not want the operation. What would you do next?
a) Continue with IV induction as planned
b) Send him back to the ward for premedication
c) Discuss the options with the mum
d) Proceed with a gas induction
 e) Cancel the procedure and reschedule for a later date

42. Apparent pathological paediatric murmur

A 10-year-old girl with Down’s syndrome presents for adenotonsillectomy. Her family are
refugees and have recently arrived in the UK from Somalia. She has recurrent respiratory
infections and tires easily when playing. On examination SpO2 is 93% in air, aural
temperature 37.2°C and she has a non-radiating grade 3/6 systolic murmur.
What is the most appropriate management of this case?
a) Reassure parents that this is probably an innocent flow murmur and surgery may
proceed today
b) Defer the case pending a full cardiological assessment including an echocardiogram
c) Ask the paediatric StR to examine the patient and proceed if they think the murmur is
innocent
d) Proceed with the case but ensure that the patient receives antibiotic endocarditis
prophylaxis
e) Measure her BP and obtain a 12-lead ECG and proceed with surgery if these are
both normal

43. Rescue antiemesis

An 18-year-old with a new diagnosis of lymphoma has a Hickman line inserted under
general anaesthesia. You give him 1.2mg droperidol intraoperatively to prevent nausea, but
he still vomits in the recovery room.
Which is the best drug to give him in recovery?
a) Dexamethasone 4mg i.v.
b) A further 1.25mg Droperidol i.v.
c) Metoclopramide 10mg i.v.
d) Ondansetron 4mg i.v.
e) Prochlorperazine 12.5mg i.m.

44. Brain dead, mean family

A man is declared brain stem dead on the ITU. He is on the organ donation register and
carries a donor card but his family do not want to go ahead with donation.
How do you best proceed?
a) Take a blood sample for HLA typing
b) Discuss the case with the transplant surgeon
c) Respect the patient’s wish for donation
d) Respect the family’s wishes
e) Refer the case to the Coroner’s office

45. Lap-chole sympathetic overdrive

A 47-year-old woman who weighs 70kg is undergoing a laparoscopic cholecystectomy under
general anaesthetic. She is induced with propofol, remifentanil 0.2microgram/kg/min and
atracurium and tracheal intubation is uneventful. Maintenance with oxygen, air and
sevoflurane is commenced. After 15 minutes her blood pressure is 190/90, and her heart
rate 120 beats per minute.
What is the most likely explanation?
a) Carbon dioxide absorption
b) Inadequate anaesthesia
c) Inadequate muscle paralysis
d) Intraperitoneal haemorrhage
e) Pulmonary oedema

Answers
1. Correct answer: B
Clearly, antibiotics should be administered early in sepsis, ideally <1 hour. However, this
lady's most immediate life-threatening problem is hypoxaemia. The options for treating this
are increasing FiO2, or applying CPAP. But her extreme agitation means that both of these
are unlikely to be tolerated. Intubation will be required. (March 2012, Sep 2015)
Sep 2015 variations:
possibly 95% sats.
Possibly less hypercapnoic
c) NIV
d) CPAP and O2
Still thought on balance to warrant I&V

2. Correct answer: A
This patient has clearly suffered major blood loss (potentially from the femoral fracture site as
well as the peritoneal cavity) which has only partially been replaced with red cells, and no
other blood products. However, there are other features which will contribute to his deranged
coagulation. In hypothermic states there is reduced platelet function, increased fibrinolysis,
and altered enzyme kinetics, leading to a 33% effective reduction in coagulation function at
35ºC. Acidosis contributes to coagulopathy (a fall in pH from 7.4 to 7.0 causes an effective
reduction to prothrombin activation of 70%). These factors would be more likely than DIC due
to fat embolism. Hepatic impairment would be reflected in deranged vitamin K-dependent
factors; in fact, the INR is not deranged. There is no evidence of transfusion mismatch. (Sept
2012)
Further reading: Ridley S et al. Medical management of bleeding in critically ill patients. Contin
Edu in Anaesth, Crit Care Pain, 2007; 7(4)

3. Correct answer: D
The aim of anaesthesia for ECT is to induce a generalised seizure of optimal length (not
clear what this is, but not too short (<10s) or too long (>120s)) without complications.
Traditionally, methohexital was used as the induction agent, as it had minimal anticonvulsant
properties. A recent systematic review concluded that all currently available induction
agents are suitable for ECT. Neuromuscular blocking agents reduce muscular contractions
thereby decreasing the risk of serious injury (the Bolam case involved a patient who
sustained a vertebral fracture when sux wasn't used for ECT). Suxamethonium (0.5mg/kg)
is most commonly used due to its rapid offset, but mivacurium can also be used (or
rocuronium + sugammadex). The cardiovascular response to ECT is initially
parasympathetic, producing bradycardia, hypotension or even asystole. This is followed by
a sympathetic response, so glycopyrrolate is the better drug to use as it results in less post-
ECT tachycardia, which may increase myocardial work / O2 demand. (Sept 2014).
Sept 2016: variants: 55yr old (still ASA 1), no atropine/glyco, options otherwise identical
V Uppal, J Dourish, A Macfarlane. Anaesthesia for electroconvulsive therapy. Cont Edu
Anaesth Crit Care Pain, 2010; 10(6): 192-6.

4. Correct answer: E
Morphine PCA is contraindicated in this case due to dementia. Neither local infiltration nor
sciatic nerve block would provide good analgesia for hip replacement surgery. The
advantages of a fascia iliaca block over an epidural infusion would be ease of placement,
minimal motor block (as dilute solutions are used), targeted unilateral analgesia, and fewer
haemodynamic side effects.
Very similar to: (Sept 2012)
A 78yr old lady with osteoarthritis of both hips lives in a nursing home. She has mild dementia
and COPD. She is admitted for a Hemiarthroplasty following a hip fracture following a fall.
What mode of analgesia would be appropriate for her following a general anaesthetic?
a) Sciatic nerve block
 b) PCA Morphine
c) Ilioinguinal block at induction
d) Epidural infusion
e) Local anaesthetic infiltration by surgeon

5. Correct answer: E
This is a process of elimination - effective chest compressions apparently generate a cardiac
output of 20-30% normal (i.e. <1.5 L/min). Effective chest compressions can achieve systolic
BP > 60 mmHg, but MAN seldom exceeds 40 mmHg. During chest compression, the pressure
in the RA and aorta are equal, but when the chest is released, the aortic valve closes and the
aortic pressure becomes higher than RA pressure. There is a theory that intermittent
abdominal counterpulsation can compress the aorta, increasing aortic diastolic pressure (and
therefore coronary perfusion/flow), a bit like a balloon pump. Animal studies have been
equivocal, and there have been no studies in humans. Blood flow to the brain is 50-90% of
normal (most blood flows to organs above the diaphragm). Therefore, the arm-to-brain
circulation time is <90 seconds.
Y.P. Munjai, S. K. Sharma, A. Agarwal, P. Gupta. Api Textbook of Medicine. N.A. Paradis,
H.R. Lalperin, K.B. Kern, et al. Cardiac arrest: the science and practice of resuscitation
medicine.
(March 2011)

6. Correct answer: B
Joint safeguarding children guidelines published by the RCoA, RCPCH and AHA clearly
state any concerns regarding anaesthetised children should be discussed with a consultant
paediatrician (or other appropriate local person responsible for child protection) in the first
instance. If these concerns are then shared by both parties, the issue should be discussed
with the parents and CP procedures commenced. In both cases, documentation is essential.
Further reading: Melarkode K, Wilkinson K. Child protection issues and the anaesthetist.
Contin Edu in Anaesth, Crit Care Pain, 2012, 12 (3). 123-127. (Sept 2013).

7. Correct answer: E
Nodal rhythm, sinus bradycardia and asystole are more pronounced at the beginning of
insufflation, as the rate of stretching of the peritoneum is greatest. CPR is not indicated, as
the patient is an adult and there is still a cardiac output. The anti-muscarinic effects of
atropine are greater than those of glycopyrrolate, but neither is as quick or as effective as
stopping the vagal stimulation by stopping insufflation. (Sept 2013, March 2016).

8. Correct answer: C
Levels of evidence:
1A Meta-analysis of RCTs; 1B individual RCT with narrow confidence interval
2A low quality RCT; 2B Cohort studies
3ASystematic review of case control studies 3B Case control studies
4A Case series (and poor-quality case control)
5 Expert opinion
(Aug 2011, March 2013)
Similar March 2014: antiemetic:
a) A case control study
b) A consensus statement from RCoA
c) A multi-centre prospective audit
d) A prospective randomised control trial vs Placebo in a single centre
e) A retrospective case notes from the last 5 years form a district general hospital
Correct answer: D

9. Correct answer: C
The low sats may be a measurement error due to hypotension rather than true hypoxaemia.
The hypotension is resistant to fluid resuscitation so inotropes are indicated. This child is
clearly critically ill and will require intubation as part of initial stabilisation. For uncuffed ET
tubes (traditionally used in paediatrics to prevent tracheal stenosis) the age-based formula is
age/4+4. ‘Microcuffed’ tubes are now increasingly used, and the recommended rule of
thumb is age/4+3.5. Although d and e presumably refer to microcuffed tubes, the sizes given
would be too small going by the above calculation, and manufacturer’s recommendations
(the manufacturers recommend 3.5mm for below two years old). Using a throat pack to
prevent leak seems a bit odd - given that stems (d) and (e) talk about cuff pressures etc,
even the RCoA now believes in cuffed ETTs in children. Therefore, stem (c) is correct.
(March 2013. Repeated March 2015 & sept 2016 but with fluid bolus (240ml) instead of
inotropes)

10. Correct answer: C

Manipulation of a simple forearm fracture is not an emergency: RSI is not indicated, whether
with or without an NG tube. Doing an awake axillary block in a child sounds challenging and
unnecessary. Waiting 4 hours in addition to the 1 hour already starved = less than 6 hours
starvation. Therefore, the answer is C.
(March 2014, Feb 2017).

11. Correct answer: E

The GCS in this case is E2V2M4 = 8/15. As this patient has a suspected significant
traumatic brain injury, there are a number of indications for intubation: primary airway
protection / prevention of pulmonary aspiration (GCS ≤8 = loss of airway reflexes) and
prevention of secondary brain injury (prevention of hypoxia and hypercapnoea). Stem D
presumably means intubate and allow to breathe spontaneously, which (along with the drugs
required to tolerate a tube in the trachea) would likely result in hypercapnoea. Stems A, B
and C would not achieve airway protection. Only stem E would allow you to achieve TBI
targets of PaO2 > 13kPa, PaCO2 4.5-5.0 kPa.
Judith Dinsmore. Traumatic brain injury: an evidence-based review of management.
CEACCP 2013; 13(6):189-95. (March 2017)

12. Correct answer: C

March 2015
This is an annoying question! Clearly there is variation in weaning strategies and performing
tracheostomies between hospitals and physicians. However, in this question the process of
elimination should enable you to reach the correct answer. Many units would perform a
tracheostomy at this stage, but it's still early days. The patient is clearly not yet in the
improvement phase, and may have a VAP. He is unlikely to manage a T-piece trial or
extubation. Similarly, it seems the wrong time to be attempting spontaneous breathing.
Similar to:
A polytrauma patient is day 8 post-admission to ITU, being treated for ARDS. He remains on
vasopressors, pyrexial (temp=38.0°C) and with an elevated white cell count. His oxygenation
has improved in the last two days, with the FiO2 being reduced to 0.55. He remains heavily
sedated.
What would you consider next, in the early management plan for this patient?
a) Wean him off to ASB/PS mode
b) Sedation hold, then trial of extubation after a ‘T-piece’ trial
c) Continue same ventilator settings for the next 48 hours
d) Put him on CPAP
e) Perform a tracheostomy
Correct answer: A
(March 2012)
A decision to continue ventilation settings for 48 hours is irrational and too rigid. He is highly
unlikely to manage spontaneous ventilation on a T-piece or CPAP given his current settings.
A or E are the most sensible. However, weaning to ASB/PS may be possible and there
would be little to lose in attempting this, and would be potentially very beneficial if it allows a
tracheostomy to be avoided.
Correct answer: C

13. Correct answer: C

This man will likely require all of these things, however further fluid is the quickest
intervention in this case, and given the history and examination he appears underfilled.
(March 2013, Feb 2017)
Similar question: March 2014:
A 65-year-old man has been admitted to the ICU with abdominal pain and distension. He is
tachycardic and hypotensive (120bpm and 75/45mmHg respectively). He is anuric and
hypoxaemic (SpO2 85% on air). His blood gas shows pH 7.22, BE -13, lactate 4.7 mmol/L.
What is the best immediate course of action?
a) Arrange CT abdomen
b) Start CVVH
c) Fluid resuscitate to CVP 8-12 mmHg and MAP >65 mmHg using colloid or crystalloid
d) Optimise cardiac output using either PICCO or a pulmonary artery catheter
e) Start dobutamine aiming for a cardiac index of 3.5l/min/m2

14. Correct answer: B

During an elective laparoscopic cholecystectomy, the surgeon should be using bipolar
diathermy. The risk is that diathermy will be registered by the ICD as VF, and a shock
delivered. Defibrillation therefore needs to be deactivated. This cannot necessarily be
achieved by placing a magnet over the device (with some manufacturers a magnet
deactivates, others it doesn't. And applying a magnet also has variable results with the
pacing function). So, the defib function should be switched off prior to surgery, switched on
after surgery and an alternative form of defibrillation available during the intervening time.
ME Stone, B Salter, A Fischer. Perioperative management of patients with cardiac
implantable electronic devices. Br J Anaesth 2011; 107(Suppl. 1): i16-26.

15. Correct answer: A

See BSE guidelines for definitions (Sept 2015, Feb 2018 confirmed on RCoA codes, Sept
2018 – confirmed with RCoA codes)

16. Correct answer: A

The Mapleson A (of which the Lack is a version) is efficient for spontaneous ventilation
(AMV=FGF) (Variant involving LSCS Sept 2012)
Variation: (Aug 2011)
What is the most effective way of preoxygenating a patient with a BMI of 35 for an RSI?
a) O2 6l/min, circle, patient supine, 3min
b) O2 6l/min, mapleson A, patient 30degrees head up, 4 vital capacity breaths
c) O2 6l/min, mapleson A, supine, 3min
d) O2 6l/min, mapleson A, 30-degree head up, 3min
e) O2 6l/min, mapleson D, supine, 3 min
Correct answer: D (March 2013, March 2015)

17. Correct answer: B

All these actions need to be taken, however only you can document your account of events
and this should be done at the earliest opportunity. The other options may be done by others
or delayed until following your documentation. (Sept 2013, very similar question Sept 2012,
March 2013).

18. Correct answer: C

Whilst this operation is elective, it sounds like there would be considerable maternal
disappointment if the procedure was cancelled. At 7 years old, the child is too young to be
Gillick competent, and therefore cannot competently refuse the operation. Gaining iv access
in an uncooperative child is difficult, and would entail some physical restraint. Likewise, a
gas induction is unlikely to be without physical restraint. Restraint should be a last resort,
and consent would need to be gained from the mother. In any case, other options have not
yet been explored. The options of cancelling the op, returning to the ward for pre-med and
physical restraint all need to be discussed with mum and consent sought. (Sept 2014).
L Tan, GH Meakin. Anaesthesia for the uncooperative child. Cont Edu Anaesth Crit Care
Pain 2010; 10(2): 48-52.

19. Correct answer: C

The hypertension, brisk reflexes and the lack of a past history of epilepsy suggests that this
parturient has suffered an eclamptic seizure. Eclampsia has a significant mortality, and the
priority is prophylaxis of further seizures over treatment of moderate hypertension, i.e.
magnesium loading and infusion. If this question had severe hypertension, magnesium
would probably still be the correct initial management (swiftly followed by labetalol), as the
vasodilatation associated with magnesium would treat both hypertension and eclampsia.
NICE hypertension in pregnancy guideline (CG107), 1.8.1.1: If a woman in a critical care
setting who has severe hypertension of severe pre-eclampsia has or previously had an
eclamptic fit, give intravenous magnesium sulphate. (Sept 2016)

20. Correct answer: D

CRPS Type 2 occurs following a distinct nerve injury.
(Aug 2011, March 2013, repeat March 2014, Sept 2016, Sept 2018 – confirmed with RCoA
codes)

21. Correct answer: C

Presumably, the question asks the cause of hypoxia and pink frothy sputum, which is
suggestive of pulmonary oedema. Given the sequence of events, negative pressure
pulmonary oedema (secondary to highly negative intrathoracic pressure during the period of
laryngospasm) is more likely than cardiogenic pulmonary oedema. Aspiration prior to
intubation would cause hypoxia but not pink frothy sputum.
(March 2014)

22. Correct answer: C

Cochlear implants are often accompanied by a surgeon-placed great auricular nerve block
(great auricular nerve = union of C2 and C3). NB pre-incision timing of the block confers no
additional benefit (APA guidelines). Adrenaline is useful to reduce scalp bleeding. A 10kg
child can have a maximum of 70mg lignocaine with adrenaline or 20mg bupivacaine with or
without adrenaline. The maximum LA that can be given on each side is therefore half of this.
According to children's BNF, available preparations are: lignocaine 1% and 2% + 1:200,000
adrenaline (i.e. not 1:80,000 adrenaline), bupivacaine 0.25% and 0.5% + 1:200,000
adrenaline.
Of the options, 3.5ml 2% lignocaine + adrenaline 1:200000 = 70mg lignocaine (i.e. toxic
dose) and 7ml 1% lignocaine + adrenaline 1:200000 = 70mg lignocaine (toxic dose). Given
there is no advantage to pre-emptive nerve block, bupivacaine would seem more sensible
than lignocaine, as it will last longer into the post-operative period. 4ml 0.25% bupivacaine
probably the best choice as greater volume allows great auricular nerve block and some
infiltration around the incision site to prevent scalp bleeding.
APA guideline: good practice in postoperative and procedural pain.
http://www.apagbi.org.uk/sites/default/files/APA%20Guideline%20part%201.pdf
(Sept 2014, Feb 2017)

23. Correct answer: D

The onset (relatively delayed), stridor and relatively well nature of the patient all favour
croup. (March 2017, Sept 2017 Sept 2017 confirmed RCoA codes)

24. Correct answer: C

Manual displacement would be a simple, easily performed manoeuvre which is indicated in
this patient. Atropine is no longer in the ALS algorithm, and adrenaline may just have been
given prior to your arrival! (March 2011).
Variant Feb 2017: LMA option changed to “deliver baby via caesarean section”

25. Answer: E
No explanation required. Unlikely to be repeated due to unusual format? (March 2011)

26. Correct answer: B

The BNF states: in patients who have taken more than 10mg prednisolone within 3 months
of minor surgery under GA should have 25-50mg hydrocortisone at induction plus usual
dose of medication. For moderate / major surgery: 25-50mg hydrocortisone at induction plus
usual dose of medication, followed by 25-50mg tds for 24h (moderate surgery) or 48-72h
(major surgery). Modified John Hopkins surgical severity criteria:
Class 1 (minor) - minimal to moderately invasive procedure, blood loss potential
<500ml. E.g.s include inguinal hernia repair
Class 2 (moderate) - moderately to significantly invasive procedures, potential blood loss
500-1500ml, e.g.s hysterectomy, laminectomy
Class 3 (major) - Highly invasive, blood loss potential >1500ml, ICU post-op with invasive
monitoring, e.g.s major GI, cardiothoracic, intracranial.
Minor surgery = subcutaneous (tooth extractions, line insertion), major = body cavity
entered, organ removed, anatomy altered. Moderate is somewhere inbetween. Therefore,
this case is minor surgery, so the answer is B. (March 2016)

27. Correct answer: D

Something else is going on other than just carboxyhaemoglobin, e.g. airway burn. PO2 is
low, so PEEP to maximise alveolar recruitment.
Regarding the COHb, he has severe poisoning (>25%), warranting I&V. However, he is
below the threshold suggested by Oxford Desk Reference (2008), which is 40%. Moreover,
the CEACCP 2012 article (Bishop & Maguire) notes even when indicated, hyperbaric oxygen
therapy is often not undertaken for practical purposes.
The half-life of carboxyhaemoglobin is 4 hours when breathing air, 40 mins with 100% O2
and 20 mins with hyperbaric O2. However, it is important to avoid unnecessarily prolonged
O2 therapy, as there is a risk of O2 toxicity. Whilst hyperbaric O2 is indicated in this case
(presuming the reason for intubation is loss of consciousness), it is more likely that
carboxyhaemoglobin % will decrease to safer levels with 100% O2 alone faster than the time
it takes to arrange a transfer to a hyperbaric unit. Other indications for hyperbaric O2
include: cognitive impairment, chest pain / ECG changes, pregnancy.
(March 2012, Sept 2015)

28. Correct answer: B

Blood cultures and sputum culture are fairly useless in the immediate management.
Spirometry is more useful for diagnosis of asthma rather than management of acute asthma.
According to the British Thoracic Society / SIGN asthma guidelines: peak flow is a useful
test, both to categorise the asthma attack into severe or life-threatening, and to determine its
management - magnesium 2g in acute severe asthma PEFR < 50% best / predicted, who
have not had a good initial response to inhaled bronchodilator therapy. But this patient did
have a good initial response. Chest X-ray is not routinely recommended in the absence of
various bad features, e.g. suspected pneumothorax / consolidation, life-threatening asthma,
failure to respond to treatment satisfactorily. A sudden deterioration with quiet breath
sounds may represent a pneumothorax, which could be diagnosed on CXR. (March 2016,
Sept 2018 RCoA codes confirm answer is not peak flow)

29. Correct answer: A

As BLS has commenced, this patient should be considered to have no output. The rhythm is
not shockable, and according to the non-shockable ALS algorithm 1mg adrenaline should be
given.
Answer confirmed with RCOA codes. Sept 2018 – confirmed with RCoA codes

30. Correct answer: A

Mortality is MI > CCF > Renal failure > Haemorrhage > Stroke > Respiratory failure (Ann Surg.
1983 January; 197(1): 49–56) (March 2012, March 2014, Feb 2017, Feb 2018 confirmed on
RCoA codes)
Similar version Sept 2014:
Which patient coming in for emergency AAA repair has the highest chance of perioperative
MI.
a) 65 male insulin dependent diabetic, had MI 10 years ago, can climb flight stairs, has
LBBB on ECG
b) 75 female, CKD with creatinine 250 micromol/L, history of CCF on ACEi and diuretic,
can walk 200 yds
c) 60 female, controlled hypertension, chronic AF
d) BMI 35, OSA, smoker with reduced exercise tolerance
e) 55 male, controlled hypertension, drug eluting stent inserted 20 weeks ago for raised
troponin
Correct answer B

31. Correct answer: C

This question is infuriatingly hard, mixing cerebral hyperperfusion syndrome, hypertension
associated with cardiac ischaemia, and some strange answers.
The key elements are:
• Cerebral hyperperfusion syndrome (Top tip: CHS=hyperaemia of ipsilateral cerebral
hemisphere, is a past SBA answer in itself!). The key is mitigating cerebral hyperaemia
without critically reducing cerebral perfusion. All vasoactive drugs have potential
downsides as they interfere with autoregulation, however this effect is likely to be greater
with directly-acting vasodilators such as hydralazine or GTN. The example protocols
given in the appropriate BJA article give the 1st line option at labetalol, with the 2nd line as
hydralazine.
• Cardiac ischaemia. In isolation, hypertension with ischaemic changes in the absence of
tachycardia would be suitably treated by a nitrate infusion. However, the answer (and all
versions we could find on the internet) of a nitrate bolus prior to an infusion is potentially
dangerous and should make you suspicious.
So, there is no ideal answer. However, a pure beta-blocker (as opposed to labetalol, an
alpha and beta blocker, which is not an option!) would not affect afterload and may
precipitously drop cardiac output and exacerbate cardiac ischaemia. Phentolamine is
indicated in catecholamine-secreting tumours. Nitrates should not be given as a bolus, and
are relatively contraindicated in CHS (due to the aforementioned effect on autoregulation).
Hydralazine, which may be given as an IV bolus, is therefore the most appropriate answer.
(Sept 2012)
Further reading: Stoneham M & Thompson JP. Arterial pressure management and carotid
endarterectomy. BJA, 2009; 102(4): 442-452 Foex P. The surgical hypertensive patient.
Contin Edu in Anaesth, Crit Care Pain, 2004; 4(5)
Variation: (Sept 2013, Sept 2015)
75-year-old man post op right carotid endarterectomy. His blood pressure 210/95 and he is
complaining of a 'throbbing headache'. He has no neurological deficit. Which best explains
his symptoms?
 a) Hyperaemia of the right carotid body
b) Hyperaemia of the right cerebral hemisphere
c) Ischaemia of the right carotid body
d) Ischaemia of the right carotid sinus
e) Ischaemia of the right cerebral hemisphere
Similar variant:
An elderly patient is in recovery, following a carotid endarterectomy. He has got a high
blood pressure of 200/110 and he is complaining of headache and irritable. The possible
explanation for this would be:
a) hyperaemia of ipsilateral cerebral hemisphere.
b) ischaemia of ipsilateral cerebral hemisphere.
c) hyperaemia of contralateral cerebral hemisphere
d) ischaemia of contralateral cerebral hemisphere.
e) bleeding in the ipsilateral cerebral hemisphere
(March 2011)
Cerebral hyperperfusion syndrome: hyperaemia of ipsilateral cerebral hemisphere

32. Correct answer: B.

Given the clinical situation, the cause of the ooze is likely to be dilutional coagulopathy. The
usual haematologist's advice regarding platelet transfusion is to transfuse if Plat <10, or <20
and bleeding, maybe <50 if bleeding during surgery. Vitamin K takes many hours to take
effect, and only restores vitamin K-dependent clotting factors. Recombinant factor VIIa
(NoVo seven) is essentially only indicated for uncontrollable haemorrhage, but risks
thrombotic events. Sending a clotting screen will take >1 hour of ooze, with a potential loss
of further clotting factors. Whilst INR is not dramatically high, giving FFP is probably the best
option.
(March 2014).

33. Correct answer: B

The physiological changes associated with aortic cross-clamping are:
• Increased afterload, with an increase in proximal aortic pressure
• Elevated LV wall tension, which increases myocardial O2 demand, potentially leading to
ischaemia.
• Sometimes an increase in preload, due to decreased venous capacitance below the
level of the cross-clamp
This is a bit of a trick question. Whilst aortic cross clamping increases the afterload, SVR
(the overall resistance of the systemic arterial tree) decreases, as there is peripheral
vasodilatation distal to the cross clamp. Increased afterload results in an increase in arterial
blood pressure with a reflex bradycardia. The increase in preload (i.e. CVP (c)) is
inconsistent in infra-renal clamps (but is much more likely with supra-coeliac clamps).
However, an increase in afterload results in a reduction in stroke volume. In combination
with a reduced HR, cardiac output decreases (CO = HR x SV). (Sept 2013)
LF Chu, AJ Fuller. Manual of Clinical Anesthesiology. Lippincott, Williams & Wilkins, 2011.

34. Correct answer: B

Too small a BP cuff = falsely high NIBP reading, so differential readings but this is a big
difference and presumably would have been noted pre-induction. Also confirmed from Sept
2018 RCoA codes that this is not the answer. It is unlikely that the same transducer
becomes faulty between the anaesthetic room and theatre. Can't be damping - MAP would
still be the same. Peripheral vasodilatation would not result in a BP discrepancy, and in
other versions this option was replaced with 'compression of cannula'. IABP MAP =
39mmHg, NIBP MAP = 67 - transducer would have to be 37cm too high (7.5mmHg mercury
difference = 10cm vertical height) It is unlikely that you would attach a transducer too high
(dropping on floor is more common) but it is probably the most likely explanation of a
differential BP reading. (March 2015, Sept 2018)
Cohn JN. Blood pressure measurement in shock. JAMA 1967; 199(13): 972-6.
(Sept 2014 version with 'compression of cannula' in place of peripheral vasodilatation)
Sept 2016:
You are anaesthetising a 75-year-old man for relief of acute small bowel obstruction. He has
a long history of peripheral vascular disease and you insert an arterial line prior to induction.
Following fluid resuscitation and RSI he has a moderate fall in blood pressure which is
corrected with a small dose of metaraminol. Following transfer to theatre, the arterial line
reads 80/60 and the NIBP 108/62. What is the reason for this discrepancy?
a) Excessive damping
b) Faulty transducer
c) Transducer above patient’s head
d) Vasodilatation
e) Inappropriate NIBP cuff

35. Correct Answer: A

(Aug 2011, March 2013, Feb 2017, Feb 2018 confirmed with RCoA codes)
Clearly, she is able to change her mind! As she has stated clearly her wishes, and has no
contraindications, this overrides her earlier birth plan.

36. Correct answer: A

Clearly this man requires an emergency appendicectomy, which will not allow time for either
review of the uncle's case notes or testing for malignant hyperpyrexia. A spinal does avoid
exposure to MH-triggering agents (sux and volatiles), but is inadvisable for intraperitoneal
surgery (and what would your Plan B be in any case?). He is at increased risk of death, but
only if he hadn't told you about the family's MH susceptibility, because this allows you to do a
modified RSI (using intubating-dose rocuronium) with TIVA maintenance. (Sept 2013)

37. Correct answer: D

The history is suggestive of a subarachnoid haemorrhage - sudden onset headache with
meningeal symptoms and higher cortical dysfunction. The diagnostic test is obviously a non-
contrast CT. There is no current indication for intubation, unless the confusion means that
the patient cannot lie still for the scan. Doing an LP prior to a CT head is risky. There is not
yet an indication for mannitol: i.e. confirmed intracerebral pathology with radiological / clinical
signs of raised ICP e.g. dilated non-reactive pupil, midline shift. The neurosurgeons would
laugh at you if you phoned to refer a SAH patient without a CT or xanthochromia on LP.
(Sept 2014, repeated Sept 2017 with gadolinium contrast MRI instead of LP, repeated Sept
2017 with gadolinium contrast MRI instead of LP, confirmed RCoA codes).

38. Correct answer: A

Classically patients are dehydrated with hypokalaemic hypochloraemic metabolic acidosis.
Pyloric stenosis is a medical (i.e. not surgical) emergency. Patients can safely wait for
surgery while they are rehydrated and their electrolyte abnormalities and alkalosis are
corrected. The immediate management is therefore resuscitation with isotonic fluid. 0.45%
saline / 5% dextrose is a maintenance fluid.
Further reading: R Craig, A Deeley. Anaesthesia for pyloromyotomy. BJA Education 2018;
18(6): 173-7.

39. Correct answer: B

The question asks about the 'severity of complications'. Serum amylase, if elevated
significantly, supports the diagnosis of pancreatitis, but is non-specific. Ultrasound is superior
to CT in imaging gallstones. However, contrast-enhancing CT is able to indicate necrosis,
local pathology such as abscesses, thrombosis, haemorrhage and pseudocysts, and forms
the basis of modern severity predictor models (e.g. Balthazar CT severity index). (Sept 2010,
March 2015, Sept 2016, Feb 2018 confirmed on RCoA codes)
Further reading: Young S, Thompson J. Severe acute pancreatitis. Contin Edu in Anaesth,
Crit Care Pain, 2008, 8 (4).

40. Correct answer: B

There are a number of possible causes of post-thyroidectomy respiratory distress and
stridor; the stem suggests an expanding wound haematoma. In this scenario, the most
appropriate action is to remove the clips, which may relieve the airway obstruction, prior to
an urgent return to theatre. (Sept 2012, Sept 2016, Sept 2017, Sept 2017 confirmed RCoA
codes)
Variation on this question (Sept 2010, Feb 2017):
A 35 years old lady presents in the recovery after undergoing partial thyroidectomy with
increasing respiratory distress and inspiratory stridor. On examination she has a swollen
neck with no blood in the drain. She is saturating 89% on 60% oxygen through a Venturi
facemask. The most appropriate next action is:
a) Racemic nebulised adrenaline
b) Urgent ultrasound scan of the neck
c) Prepare for neck exploration by the surgeon
d) Fibreoptic intubation
e) 100% oxygen and CPAP

41. Correct answer: C

Whilst this operation is elective, it sounds like there would be considerable maternal
disappointment if the procedure was cancelled. At 7 years old, the child is too young to be
Gillick competent, and therefore cannot competently refuse the operation. Gaining iv access
in an uncooperative child is difficult, and would entail some physical restraint. Likewise, a
gas induction is unlikely to be without physical restraint. Restraint should be a last resort,
and consent would need to be gained from the mother. In any case, other options have not
yet been explored. The options of cancelling the op, returning to the ward for pre-med and
physical restraint all need to be discussed with mum and consent sought. (Sept 2014).
L Tan, GH Meakin. Anaesthesia for the uncooperative child. Cont Edu Anaesth Crit Care
Pain 2010; 10(2): 48-52.

42. Correct answer: B

According to the CEACCP article cited below: in an asymptomatic child over 1 year with an
innocent murmur (i.e. venous hum or soft, early systolic with no thrill) and a normal ECG,
there is general consensus that it is safe to proceed with surgery and to refer for
investigation after operation. However, if there is any doubt about the nature of a murmur,
transthoracic echocardiography is a simple and non-invasive way to resolve the matter in
most cases.
Lots of features ring alarm bells for a pathological murmur: low sats, tires easily when
playing, recurrent respiratory infections. It's not clear exactly what the cardiac lesion is,
possibility a right-to-left shunt through an AVSD given the lowish sats and respiratory
infections with Down's syndrome. Either way, in the setting of elective surgery an echo is
required before proceeding. Antibiotic prophylaxis is no longer indicated for pretty much
anyone. (repeated Sept 2016)
N Bhatia, N Barber. Dilemmas in the preoperative assessment of children. Contin Edu in
Anaesth, Crit Care Pain, 2011; 11(6): 214-8.

43. Correct answer: D

Dexamethasone, droperidol and ondansetron are similarly effective at preventing PONV.
Dexamethasone is most effective at induction of anaesthesia. In general, agents used in the
treatment of PONV should be different to those which have failed in the prevention, and so
droperidol should not be repeated. Ondansetron is the remaining first-line recommended
agent (As rescue therapy, ondansetron is no better than placebo if it has already been given
intra-operatively, which in this case it has not) (Sept 2010)
Further reading: Pierre S, Whelan R. Nausea and vomiting after surgery. Contin Edu in
Anaesth, Crit Care Pain, 2012

44. Correct answer: D

This is a difficult question: the 'legal' answer is that the patient has consented to organ
donation during life, and that the family do not have the authority to overrule this consent.
However, no intensivist who values his/her GMC registration is going to go against the
family's wishes in this situation. Therefore, there is little point doing any option other than D.
(March 2012, repeated Sept 2012, March 2014, Feb 2018 confirmed on RCoA codes)

45. Correct answer: B

Hypercarbia is possible, however there is no mention of the CO2 level, and 15 mins would
not seem enough time (in the absence of hypoventilation) to develop significant hypercarbia
(maximum absorption time is around 40mins (Koivusalo & Lindgren 2000)).
Inadequate muscle paralysis would be unlikely in the absence of other signs such as
movement or raised IAP.
There is no evidence of pulmonary oedema, and haemorrhage would be likely to cause
hypotension.
Inadequate anaesthesia would be the best fit (and also more likely as there was no report of
any mention of synergistic analgesia)
Answer not confirmed as no obvious match with RCOA question codes.
March 2018)