EXAMINATION REPORT PRIMARY FELLOWSHIP EXAMINATION FEBRUARY/APRIL 2007

AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS
ABN 82 055 042 852

EXAMINATION REPORT PRIMARY FELLOWSHIP EXAMINATION


FEBRUARY/APRIL 2007


Please note that this report is prepared to provide candidates and their teachers and supervisors of training with information about the way in which the performance of candidates in the recent examination was assessed by the examiners, so that candidates and teachers may prepare appropriately for future examinations. The individual reports are not intended to represent model answers nor imply that all points mentioned are necessary in order to achieve a pass. All trainees are urged to read the questions carefully and answer the question asked. All teachers and supervisors of training are encouraged to discuss this report in detail with candidates they are preparing for future examinations.



PHARMACOLOGY – WRITTEN SECTI ON

MULTIPLE CHOICE QUESTIONS:

87% of candidates achieved a pass in this section of the Pharmacology Examination.

SHORT ANSWER QUESTIONS:


QUESTION 1 Describe the potential adverse effects of administering neostigmine post operatively.

68% of candidates passed this question.

This question examined the pharmacology of neostigmine, a drug that is being used in anaesthesia on a daily basis. An adequate description of adverse effects was therefore expected for candidates to obtain a pass mark.

The main points should include a discussion on the accumulation of acetylcholine at muscarinic (at low dose) and nicotinic (at higher dose) receptor sites after administration of neostigmine. The muscarinic effects are severe and hence the co-administration of antimuscarinic agent is important. The most worrying adverse effects are bradyarrhythmia with hypotension. Bronchoconstriction, salivation, tracheobronchial hypersecretion, postoperative nausea and vomiting, and enhanced peristalsis (and potential damage on bowel anastomosis) should be mentioned.

Additional marks were awarded for including potential drug interaction with suxamethonium and mivacurium. Marks were also awarded for depolarizing block after excessive doses of neostigmine. No credit was given for description of neuromuscular monitoring.

QUESTION 2 After epidural injection in a health term pregnant woman, discuss the factors influencing the distribution of bupivacaine to (a) the maternal CSF and spinal cord; (b) the maternal circulation; (c) the foetus.

46% of candidates passed this question.

The main points expected for a pass included a discussion of the factors affecting diffusion as described in Fick's Law and how these pertained to the three diffusion interfaces outlined in the question.

Solubility, ionization, tissue and protein binding, amount of drug, and concentration gradient all affect the distribution of bupivacaine from the epidural space to the CSF and maternal systemic circulation, and subsequently to the foetus. Demonstration of comprehension that there are physiological differences between these four compartments and how these determine bupivacaine's distribution was expected. Additional marks were awarded for the consequences of the addition of adrenaline or bicarbonate to the bupivacaine solution, a discussion on epidural depot of drug, the biphasic nature of systemic absorption and foetal acidosis effect on bupivacaine protein binding.

Common errors included discussing elements of bupivacaine that were not requested; such as drawing its structure or a pharmacodynamic discussion of its toxicity. Also, reproducing factual information, such as the pKa of the drug, without discussing how this affects its diffusion at the three interfaces, did not attract marks.

QUESTION 3 Discuss factors contributing to inter-individual variability in the therapeutic response to opioid analgesic medications.

69% of candidates passed this question.

A structured approach was expected dividing the issues along pharmacokinetic / pharmacodynamic lines. A patient factors approach or other structure was also acceptable. The discussion was expected to relate the underlying factors to opioid analgesics. The question was specifically related to inter- individual variability and a simple discussion of mechanisms of action or side effect profiles for varying opioid agents scored no additional marks.

Candidates were expected to outline that variability can be seen in areas of absorption, distribution, metabolism and elimination of these agents. Credit was given to candidates who outlined the potential impact of liver or renal disease with specific examples. The discussion would also include the impact of factors such as age, pregnancy, coexisting medical disease or concurrent medication use. Discussion of genetic influences on enzymes and receptors was expected and was well covered by most candidates. Discussion of tolerance, prior drug exposures and previous pain experiences in influencing individual responses attracted extra marks.

QUESTION 4 Discuss the suitability of ketamine as a total intravenous anaesthetic agent in comparison with propofol.

25% of candidates passed this question.

To reach a pass standard simple, relevant information on the pharmacokinetics and the neurological, cardiovascular and respiratory pharmacodynamics of both agents was sufficient.

Almost no candidates explained that ketamine is an effective, sole anaesthetic agent used widely in unsophisticated medical settings, nor the relevance of its particular pharmacodynamic properties in this situation. Many candidates understanding of total intravenous anaesthesia was limited to the use of propofol with pharmacokinetic model driven infusion pumps.

Frequently the "comparison" aspect of the answer was not well organized. Answers using parallel columns for each agent's features were generally more complete in their comparisons. In contrast, poorly laid out answers were also more likely to focus predominantly on either kinetic or dynamic features, and to commonly have incomplete comparisons between the two drugs.

QUESTION 5 Classify non-opioid drugs used for the treatment of neuropathic pain and indicate proposed mechanisms of analgesic action and potential adverse effects.

34% of candidates passed this question.

The key to successfully dealing with this question was to address each of the three components: classification, mechanisms, and adverse effects. The main points expected were a classification system that was coherent; for example: simple analgesics, anticonvulsants, antidepressant, membrane stabilizers and so on. Proposed mechanisms of action should have included how the drugs work, and (importantly) why this reduces pain. There are many drugs that can be used and there are many potential adverse effects. For this component of the question, emphasis on the more specific drugs (e.g. anticonvulsants and antidepressants), and on specific (e.g. anti-cholinergic effects with antidepressants) rather that generic (e.g. rash, gastrointestinal upset) adverse effects, were rewarded.

No marks were awarded for a definition of chronic pain, a description of the pathophysiology of chronic pain, or non–pharmacological therapies as these were not asked.

QUESTION 6 Briefly outline the acute management of malignant hyperthermia (during a relaxant general anaesthetic). Describe the important aspects of dantrolene pharmacology relevant to treating malignant hyperthermia.

54% of candidates passed this question.

Equal marks were devoted to each half of the question. Inclusion of the following points would have scored a good pass mark.

Management: life-threatening emergency, call for help and dantrolene, cease triggers (e.g. volatile agents), hyperventilate with oxygen, maintain anaesthesia with non-triggering agents, give dantrolene
2.5 mg/kg, repeat up to 10 mg/kg, active cooling to <38 degrees.

Pharmacology: skeletal muscle relaxant presented as orange powder containing dantolene 20 mg, mannitol 3g and sodium hydroxide to bring pH >9 with 60mls water. Difficult to mix. Metabolized by liver enzymes, eliminated in urine and bile with a half-life of about 10 hrs. Inhibits calcium release from sarcoplasmic reticulum. It can cause phlebitis, use of verapamil contraindicated.

Most candidates who did not achieve a pass mark wrote very little on dantrolene pharmacology. Many candidates gave long, detailed accounts of the etiology and pathology of malignant hyperthermia but this was not asked in the question and attracted minimal bonus marks.



QUESTION 7 Describe the pharmacology of midazolam including its mechanism of action.

66% of candidates passed this question.



Better answers were well organized and outlined the important aspects of midazolam pharmacology including:

• Pharmaceutics, pH dependent “ring opening”, ampoule pH

• Pharmacokinetics, administration, oral bio-availability, high lipid solubility and moderately fast onset, moderate hepatic clearance 7 mls/kg/min approx (cf diazepam), active metabolite, offset dependent on re-distribution and clearance, relatively short elimination half life

• Mechanism of action (MOA), benzodiazepine receptor on alpha subunit of GABAa receptor, enhanced action of GABA, increased chloride entry and neuronal hyper-polarization

• CNS effects, sedation, hypnosis, anxiolysis, amnesia, anti-convulsant, muscle relaxant

• CVS effects, hypotension, vaso-dilatation

• Respiratory effects, respiratory depression, potential airway obstruction, hypoxemia, interaction with opioids

• Clinical uses, pre-medication, sedation, induction agent, anti-convulsant, antagonized by flumazenil


Extra marks were awarded for an outline of; kinetics of offset including context sensitive half time, metabolism and excretion including CYP 3A4 and accumulation of metabolites, the GABA receptor and alpha sub-unit selectivity, effects on cerebral blood flow, oxygen requirements and the EEG, factors potentiating CVS and respiratory effects, dosages for particular clinical applications and clinically important structure activity.
Common errors included; not mentioning MOA, describing MOA as direct activation of GABA receptor, describing NMDA or cyclic AMP effects, frequent citing of very inaccurate kinetic data with no mention of clinical implications and frequent omission of adverse effects.

QUESTION 8 List the classes of drugs used clinically to treat chronic left ventricular failure. Outline their mechanisms of action.

65% of candidates passed this question.

Only 32% of candidates complied with the first part of the question, to LIST the classes of drugs used. In order to satisfy the requirements of this question, candidates need to relate facts about drugs to their mechanisms of action. Many answers included a definition of heart failure then attempted to relate the benefits of classes to this, however since no mention was made of diastolic dysfunction, many responses were incomplete. It was common for candidates to outline the effects of an agent but not describe the mechanisms of those effects or their consequences. This information needs to be explicit. Thus many failed to acknowledge the influence of renin and how its levels are affected by different agents (eg. beta blockers). Most candidates gave the mechanism of action for the management of myocardial ischaemia for nitrates and beta blockers; while this is often relevant, it is not the prime therapeutic goal for these agents in heart failure. Beta blockers are not used to achieve a decrease in cardiac output. Pre- and after load were frequently confused with few candidates mentioning Starling curves. Although this question related to chronic failure, many candidates discussed drugs typically used for acute systolic dysfunction. Credit was given for a description of digoxin and its benefits in atrial fibrillation and other after-load reducing agents including prazosin and hydralazine.

PHARMACOLOGY – VIVA SECTION

PHARMACOLOGY TOPICS/INTRODUCTORY QUESTIONS:


General topics
• Pharmaceutics; thiopentone, local anaesthetics, benzodiazepines
• Pharmacokinetics; absorption, bioavailability; hepatic clearance; renal drug handling, pharmacokinetic modelling, clearances, volumes of distribution, AUC
• Concentration-time curves
• Hepatic biotransformation
• Mechanism of drug action
• Dose response
• Pharmacogenetics
• Drugs and gastric acidity
• Treatment of poisoning
• Chemotherapeutic agents, adverse effects, drug interactions

Inhalational agents
• Induction kinetics
• Recovery
• Washout curves
• Inhalational depth
• Measurement of depth
• MAC; MAC awake
• Structure-activity relationships
• CVS effects
• Children and adults, kinetic, dynamic differences

Local anaesthetics
• Structure activity
• Pharmacokinetics
• Toxicity, factors affecting toxicity, toxic doses
• Mechanisms of action
• Cocaine toxicity
• Topical anaesthesia

Induction agents
• Factors affecting induction dose and maintenance infusion rate
• Propofol pharmaceutics
• Propofol pharmacokinetics
• Thiopentone

Neuropharmacology
• Anti-convulsants
• Phenytoin
• Benzodiazepines

Neuromuscular blocking agents
• Classification
• Atracurium, cisatracurium
• Isomers
• Factors affecting clinical choice and dose

• Recovery from neuromuscular blockade
• Neuromuscular monitoring
• Inter-individual variability
• Potency
• Suxamethonium; dose response curve, side effects

Opioid agonists and antagonists
• Mechanism of action
• Receptors
• Effect site concentration
• Tramadol

Anticholinesterase and anticholinergics
• Classification
• Drug interactions and myasthenia gravis
• Scopolamine, atropine

Cardiovascular drugs
• Drugs that increase blood pressure
• Catecholamines
• Vasopressors
• Alpha 2 agonists
• Antiarrhythmics; classification, lignocaine, amiodarone
• Beta blockers
• Drug therapy of myocardial ischemia
• Anaesthetic agents and cardiac output
• Nitric oxide
• Vasodilators; GTN and SNP

Diuretics
• Classification
• MOA
• Mannitol

Respiratory pharmacology
• Anti-asthma drugs
• Nitric oxide


Drugs and coagulation
• Unfractionated heparin, low molecular weight heparin
• Warfarin
• Antiplatelet drugs
• Protamine

Pain
• Oral analgesics
• Mechanisms of action
• Bio-availability
• Paracetamol

Statistics
• Data

• Clinical trial design
• Power
• Bias
• Regression, correlation
• Drug development and trials
• Selection of appropriate statistical tests
• Randomised controlled trials
• Confidence intervals
• NNT

Endocrine
• Oral hypoglycaemic agents
• Insulin
• Corticosteroids

Obstetric pharmacology
• Tocolytics
• Magnesium, salbutamol
• Oxytocics; adverse effects

Antiemetics
• Clinical effectiveness
• Adverse effects
• 5HT3 antagonists, ondansetron, tropisetron
• Dexamethasone

PHYSIOLOGY – WRITTEN SECTION



MULTIPLE CHOICE QUESTIONS:

84% of candidates achieved a pass in this section of the Physiology Examination.

SHORT ANSWER QUESTIONS:


QUESTION 9 Define “Venous Admixture”. Briefly explain how venous admixture influences arterial oxygen tension and how an increase in inspired oxygen concentration may effect this.

43% of candidates passed this question.


Main points expected for a pass included: definition, sources of venous admixture with brief description of each, appreciation that venous admixture is a concept which may be expressed by the shunt equation, statement of effect on PaO2 of venous admixture with reference to the oxyhaemoglobin dissociation curve (demonstrating relation of oxygen tension to haemoglobin saturation), and the effect of increased inspired oxygen concentration on venous admixture.

Additional marks were allocated for more detail with respect to sources of venous admixture (e.g. relative contribution, magnitude effect), demonstration that small and large amounts of venous admixture affect PaO2 differently, explanation of relative effect of high versus low V/Q units, reference to isoshunt diagram and quantifying effect of increased inspired oxygen.

Mistakes commonly made included: imprecise or interchangeable use of terms (e.g. oxygen content for PaO2 and shunt or mixed venous blood for venous admixture); and use of oxyhaemoglobin dissociation curve to justify arguments regarding the effect of increased PaO2 on oxygen content. Credit was not given for vague, non-directional statements of effect, or for discussion of carbon dioxide or factors which affect mixed venous PO2.


QUESTION 10 Explain the mechanisms that prevent blood clotting in intact blood vessels
(do not draw the clotting cascade).

57% of candidates passed this question.

For a pass, an understanding of the balance between pro and anticoagulant processes that occur in the blood, and a brief outline of the mechanisms that prevent blood from clotting was required. Candidates who followed the structure of Virchow’s triad to elucidate these factors tended to score well by demonstrating understanding.

Many candidates would have benefited by providing a clear introductory statement, outlining the balance between pro and anticoagulant factors, and then explaining the factors that prevent coagulation.

As general advice regarding examination technique, candidates may wish to consider that if confronted by a question that they may not have considered in preparation for the examination, by considering the basis of everyday clinical practice, they may yet be able to achieve a good score. In this case, common clinical practices for prevention or perioperative deep venous thrombosis may have provided the key to an answer.

QUESTION 11 Discuss how the body handles a metabolic acidosis.

57% of candidates passed this question.

The main points to be covered were a definition of a metabolic acidosis, discussion of extracellular and intracellular buffering systems, respiratory compensation, the renal mechanisms to excrete non-volatile acids (titratable acidity, ammonium and ammonia), and resorption and regeneration of bicarbonate.

Extra marks were awarded for the mechanism of respiratory compensation, explaining that respiratory compensation does not lead to acid excretion, description of buffering by long as well as short term mechanisms, specific details of ammonia and ammonium production and bicarbonate regeneration, understanding that H+ ions can not be excreted unbound, the amount of acid that can be excreted by different renal mechanisms, and aldosterone’s effect on H+ excretion.

QUESTION 12 Explain the physiological principles underlying the use of peritoneal dialysis in a patient with chronic renal failure with this dialysate solution.


17% of candidates passed this question.

The purpose of this question is to show an understanding of basic physiological principles involved in peritoneal dialysis and not its clinical applications or indications.

The main points expected for a pass were:
PD takes places across a membrane (peritoneum) by exchange between dialysate and the patient’s blood.
The main processes are:
a) Osmosis - movement of solvent from low to high solute concentration
b) Diffusion – movement of solute from region of high to low concentration c) Solvent drag

Definitions of these processes were required. Many candidates showed a lack of understanding of these basic processes.

The factors which influence these processes are:
a) movement of solvent
• tonicity – definition, dialysate is hypertonic mainly due to it’s hight glucose concentration, osmolarity approx. 400 mmol/L (2[Na]+ 0.055 [Glucose]+ 0.36 [BUN]
b) movement of solute
• Fick’s law of diffusion
• Donnan effect – due to effect of charged plasma proteins

Many candidates wasted time on detailed description of what happens to individual solutes at the expense of explaining the basis physiological principles of diffusion and giving an example e.g. K+

Other points which gained marks:
• purpose of PD- i.e. achieve balance of fluids, electrolytes, acid-base and excretion of toxins wastes
• osmosis is a relatively fast process compared to diffusion
• glucose absorption can cause hyperglycaemia

• lactate is provided for conversion to bicarbonate by the liver helping with acid/base balance
• protein transfer into dialysate can result in loss

QUESTION 13 Describe the determinants of Venous Return and the effect general anaesthesia would have on these.

60% of candidates passed this question.

In general candidates answered the question fairly well, reflecting an understanding of a physiological variable of major clinical relevance to anaesthetists.

The most successful approach used to answer this question was to address specific physiological and anatomical factors, which influence venous return (e.g. blood volume, venous tone, posture). The inclusion of simple formulae (e.g. VR = MSFP-RAP/RVR, Guytonian model) allowed these factors to be related to an effect on VR, and readily demonstrated a good comprehension of the issues. Whilst obvious factors (such as venous tone) were usually mentioned, common omissions included intrathoracic pressures, venous valves and muscle pumps, all important factors both physiologically and in a clinical anaesthesia setting.

Guyton curves were used by some candidates. They did illustrate some factors quite well, but for some candidates the time spent with these curves came at the expense of descriptions of either how some determinants actually affected VR or ommission of specific determinants such as venous valves or posture.
Most candidates were able to relate the responses to the first part of the question to the second part (effects of anaesthesia). Major omissions or errors in answering the first part often carried over into effects of anaesthesia.

A few candidates provided the answer in table form, with each determinant listed along with its effects on VR and changes with anaesthesia. Whilst this approach provided succinct answers, it sometimes proved difficult to describe the net effect of individual determinants using this somewhat abbreviated format.

QUESTION 14 Explain the mechanisms whereby oxygen transfer is facilitated at the placenta.

59% of candidates passed this question.

Oxygen passes from the mother to the fetus at the placenta by diffusion. This process is facilitated by a large number of factors including:

1. The placental structure is designed to facilitate diffusion, best summarised by the factors in the Fick equation.
2. The increased affinity for oxygen of fetal compared to maternal haemoglobin
3. The increased concentration of fetal haemoglobin.
4. The (double) Bohr effect.

Other factors which could be discussed included the potential role for maternal hyperventilation (with increased maternal PaO2 and changes in acid base metabolism) associated with pregnancy and the (double) Haldane effect (relevant due to the increased carbon dioxide flux amplifying the Bohr effects).

The commonest difficulties with the question arose from taking too narrow a focus. Many candidates confining themselves to describing the double Bohr effect almost in isolation, perhaps supplemented with reference to the differences between fetal and adult haemoglobin oxygen affinity. How the

structure of the placenta facilitates diffusion and the role of the high concentration of fetal haemoglobin were the commonest omissions.

The double Bohr effect was generally well described, but, those that had difficulty mostly misunderstood the concept that the Bohr effect concerned:

1. The decrease in haemoglobin oxygen affinity from arterial to venous on the maternal side of the placenta due to increased concentration of carbon dioxide, and
2. Increase haemoglobin oxygen affinity from arterial to venous on the fetal side due to decreased carbon dioxide concentration.

QUESTION 15 Describe the effects of resonance and damping on an invasive arterial blood pressure tracing.

21% of candidates passed this question. For a pass, most of the following information was required:
• Some attempt at a definition of the concepts
• Evidence of understanding that the system’s f0 needs to be several fold the frequency of the pulse and the consequences for the pressure waveform of not being so
• Means whereby the f0 of the system can be maximised
• Effects of under, over and optimal damping on the arterial pressure waveform
• Causes of damping in the system

Marks were awarded for other information, including that the measured MAP tends not to be affected by resonance and inappropriate damping; clear diagrams explaining the waveform changes; correct explanation of damping co-efficients and the meaning of the term, especially if a correct diagram of the response to a step change in pressure was included; that the transducers used today have high natural resonant frequency but the other components of the measuring system are the main cause of low f0 in the system; correct use of an equation relating f0 to mass, elasticity and area and especially if this could then be related to practical means of increasing f0 in the measuring system; difference between optimal and critical damping.

Common problems in the answers were:

• Very few answers included a good attempt at defining the concepts especially damping (delay in response due to frictional resistance, or similar)

• Discussion of resonance and damping without any attempt at describing the effects on an arterial waveform (at least half the candidates)

• Wasting time with long descriptions of the components of the measuring system or of zeroing or of indications for arterial line placement. Zeroing is irrelevant to the question;

• Quoting figures for damping coefficients with no evidence of any understanding of the meaning of the term

• Using vague terms like “interfere with the trace” with no mention of in what way;

• Stating that damping is used or added to the transducer in order to combat resonance-damping and resonance are features of any oscillating system and the measuring systems used must in some way optimise these inherent features;

• Those candidates who attempted a diagram demonstrating response to a step change in pressure in various damping situations were often wrong

• Several dozen answers compared the radial and aortic pressure traces and described the differences in terms of resonance and damping in the arterial tree. When this information was correct, marks were given but it was not possible to get a pass mark for this information only.

QUESTION 16 Briefly outline the components of parenteral nutrition, explaining the rationale for the use of each component.

42% of candidates passed this question.

A good answer would have included a definition of parenteral nutrition and a rationale for its use. Normal daily requirements should have been described. The components of parenteral nutrition include water and electrolytes, a common omission in many papers. Most candidates covered well the caloric components of lipids, carbohydrates and proteins with a rationale for use. Many answers also included the addition of vitamins, minerals and trace elements, which was pleasing, but the rationale of “to maintain normal levels” was insufficient to score marks. Extra marks were awarded for discussing how the patients requirements alter in normal physiological circumstances, for example age, gender and pregnancy and in disease states such as sepsis and burns.



PHYSIOLOGY - VIVA SECTION

PHYSIOLOGY TOPICS/INTRODUCTORY QUESTIONS:


Cardiovascular
• Draw LV pressure vs. time curve.
• What useful information can be obtained from the ECG?
• What is an electrocardiogram?
• What are the determinants of cardiac output?
• Draw a pressure-volume loop for the LV.
• What controls regional circulation?
• Draw an LA pressure wave versus time.
• Draw a sino-atrial node action potential.
• Discuss the determinants of pulmonary blood flow.
• What are the assumptions associated with capillary wedge pressure measurement?
• What are the determinants of myocardial perfusion?
• Discuss the role of arterioles in the CVS.
• What does the term "venous capacitance" mean?
• What are the determinants of RV function?
• What is the coronary sinus blood oxygen level?
• Draw a PA catheter tip pressure trace as the device is inserted.
• Draw an ECG and an RA pressure trace.
• What is the blood supply to the heart?
• Factors determining cerebral blood flow.
• Changes in the CVS with aging.

Renal
• Control of renal blood flow.
• Define GFR and discuss its determinants
• How is urine diluted?
• What is serum osmolarity?
• Discuss the renal response to acute haemorrhage.

Respiratory
• Discuss the effects of hypercapnea.
• Effect of increasing FiO2 on blood gases.
• Determinants of arterial oxygen tension.
• How is carbon dioxide transported in blood.

• Draw the oxygen cascade.
• Discuss the control of ventilation.
• What is Laplace's law?
• Respiratory changes of pregnancy.
• What is PEEP?
• Discuss FRC and closing capacity.
• Discuss the changes that occur with a Valsalva manoeuvre
• What is dead space?
• Draw a respiratory pressure-volume loop for a paralyzed patient.
• Draw a normal capnograph.
• Draw an intra-pleural pressure versus time curve during quiet respiration.
• Discuss the consequences of a sudden obstruction of the left pulmonary artery.
• Discuss the effect of application of CPAP to a spontaneously breathing patient.
• Define compliance.
• How is diffusing capacity measured?
• Define closing capacity.
• What are typical values for mixed venous gases?
• What is the oxygen tension in fetal umbilical arteries? Veins?
• What happens to alveolar ventilation and perfusion as you move from the lung apex to the base?

Nervous
• What is a nerve fibre?
• What is sleep?
• What is normal cerebral metabolism?
• Normal values of cerebral blood flow.
• How are membrane resting potentials maintained?
• What is the blood brain barrier?
• What is CSF?

Measurement
• What waves are seen on an EEG?
• What is pulse oximetry?
• What is saturated vapour pressure?
• What is heat? What is temperature?
• When will a pulse oximeter give an incorrect reading?
• Define humidity.
• Principles of measurement of levels of consciousness.

Hormones/Metabolism
• Definition of a hormone
• How are serum glucose levels maintained during a fast
• Consequences of a 24 hour fast.
• How does the body handle glucose?

Haematology
• Definition of anemia
• What are the features of a RBC?
• Lifecycle of a platelet
• How is a unit of packed cells prepared?
• What are blood groups?

GIT
• Functions of the liver
• What happens when you swallow?
• Regulation of gastric pH
• Physiological principles of prevention of gastro-oesophageal reflux
• Determinants of gastric emptying

Pain
• What is pain?
• Describe the mechanisms that are associated with acute pain
• What happens if you touch something hot?

Temperature
• How does an awake subject respond to a decrease in ambient temperature?
• Discuss heat loss under anaesthesia.

Acid-base
• What is a buffer?








DR NOEL ROBERTS
CHAIRMAN, PRIMARY EXAMINATION COMMITTEE