EXAMINATION REPORT PRIMARY FELLOWSHIP EXAMINATION JULY/SEPTEMBER 2008

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


EXAMINATION REPORT PRIMARY FELLOWSHIP EXAMINATION
JULY/SEPTEMBER 2008


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 SECTION


MULTIPLE CHOICE QUESTIONS:

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


SHORT ANSWER QUESTIONS:


QUESTION I Outline the potential beneficial and adverse effects of isoflurane on the cardiovascular system (include mechanisms of effect) in patients with ischaemic heart disease.

41% of candidates passed this question.

To answer the question it was necessary to describe the effects of isofLurane on the cardiovascuLar system, expLain how these might affect myocardiaL oxygen baLance, and give some expLanation as to how these effects might occur. As the question is not specific, aLL mechanisms from ceLLuLar to organ system interactions were accepted.

A pass wouLd have incLuded the faLL in SVR and bLood pressure, the compensatory rise in heart rate, a note on direct effects on contractiLity, and an expLanation as to how these effects might aLter the myocardiaL oxygen suppLy and demand. A brief description of the concepts of coronary steaL and ischaemic preconditioning, and something on their purported mechanisms was aLso expected.


Extra marks were awarded for candidates who couLd List purported mechanisms for isofLurane causing these effects, such as aLtered sympathetic outfLow, or caLcium channeL antagonism, the aLteration skeLetaL muscLe vascuLar tone resuLting in Lowering of SVR, the effect of concommitant medications, age, disease, hypoxia and rapidLy increasing concentrations on the vascuLar effects, expLain ischaemic preconditioning in more detaiL, and comment on the cLinicaL reLevance of
coronary steaL. Few candidates commented on the overaLL effect on oxygen baLance, either at normaL or high concentrations.

Many candidates incLuded unnecessary data, such as physicaL properties, modes of administration, effects on other organ systems, or effects which are neither beneficiaL or adverse. Common errors incLuded circuLar reasoning—a faLL in VR causes a faLL in CO, and confusing the effects of isofLurane and haLothane.



QUESTION 2 Describe the pharmacokinetic principles of total intravenous anaesthesia using propofol.

52% of candidates passed this question.

The essence of the question is for candidates to reLate knowLedge of the pharmacokinetics of propofoL to what is being observed when propofoL is being administered for totaL intravenous anaesthesia. So it is important to expLain why the rates of infusion vary at differing times such as at commencement, sLightLy after commencement and after a Long period of infusion through reference to how the body is deaLing with propofoL.

There are many facts, diagrams and equations that attracted marks reLating to propofoL but the better marks were reserved for candidates who pointed out the significance of this information to what is happening with the syringe driver. It shouLd be pointed out that candidates who chose to expLain pharmacokinetic behaviour in reLation to totaL intravenous anaesthesia(TIVA) using onLy prose were not penaLised if their expLanations were cLear and indicated an appropriate depth of knowLedge.

The most points that attracted marks incLuded brief definition of the goaL of TIVA i.e. to reach and maintain a centraL compartment serum or effect site concentration of propofoL at a LeveL adequate for anaesthesia, descriptions, diagrams and equations which deaLt with the importance of an initiaL infusion providing a Loading dose given high Lipid soLubiLity and centraL compartment voLume of distribution, then the need to aLLow for redistribution and metaboLism and then LargeLy metaboLism aLone to maintain a steady serum or effect site concentration. ALso descriptions of how propofoL behaves pharmakokineticaLLy when TIVA is ceased received credit, as weLL as detaiLs of its
cLearance.

PropofoL is a highLy important drug criticaL to the practice of anaesthesia so a reLativeLy high standard was expected.

It is advisabLe that candidates not waste vaLuabLe time drawing moLecuLes of propofoL or writing
Long introductions that don’t deaL directLy with the question that was asked.



QUESTION 3 List the anaesthetic related uses of clonidine. What are the effects of
clonidine on the cardiovascular and central nervous system and how are these effects mediated?

68% of candidates passed this question.

A List of anaesthetic related uses incLudes premedication/anxioLysis, intraoperative haemodynamic stabiLity, and augmentation/proLongation of regionaL neuraL bLockade. Marks were aLso awarded for use in post-operative anaLgesia and post-operative shivering. Extra marks were aLso provided in discussing its use in prevention of perioperative myocardiaL ischaemia. WhiLst a dry mouth is a common side effect of cLonidine, it is not typicaLLy used as an antisiaLogue for anaesthetic
purposes. Marks were awarded for discussion about its anaesthetic sparing uses, but no marks were awarded for stating it couLd be used as an anaesthetic aLone. A cLear statement about cLonidine’s mechanism of action as a partial agonist at c receptors with a reLative seLectivity of c2:c1 of 200:1 was required. Expected CVS effects incLuded hypotension, bradycardia and peripheraL vasodiLation.
These are mediated via centraL c2 receptors which inhibit the vasomotor centre in brainstem. There are no direct effects on the heart, but there is reduction in circuLating catechoLamines.

Marks were aLso awarded for discussing initiaL peripheraL vasoconstriction and transient
hypertension via direct action on peripheraL c2 receptors, extra marks for discussing the changes to the baroreceptor refLex, and bonus marks for mentioning the roLe of imidazoLine receptors in brainstem. The CNS effects of sedation and anaLgesia are mediated via centraL c2 receptors via inactivation of Locus ceruLeus and activation of descending inhibitory pain pathways. Further marks were awarded for discussing the spinaL mechanisms of anaLgesia via spinaL c2 receptors in the
dorsaL horn which depress wide dynamic range neurons invoLved in peripheraL nociceptive input.
Information regarding cLonidine’s pharmaceutic and pharmacokinetic profiLe was not required.



QUESTION 4 Briefly outline the pharmacology of ketamine with reference to its use as an analgesic agent in the post-operative period.

60% of candidates passed this question.

A compLete answer required that candidates consider pharmaceutic, pharmacokinetic and pharmacodynamic aspects of ketamine used as an anaLgesic. The nature of ketamine, its formuLation, major routes of administration when administered for postoperative anaLgesia, dose ranges used for anaLgesia, and key factors infLuencing the uptake, distribution, metaboLism and cLearance of ketamine were expected in a compLete answer. Key pharmacokinetic points incLuded the high Lipid soLubiLity, Large voLume of distribution, high hepatic metaboLism to an active metaboLite, short eLimination haLf-Life, and reLativeLy rapid offset after proLonged infusion. Information regarding the site and mechanisms of the potent anaLgesic action of ketamine, particuLarLy the roLes as a non-competitive NMDA receptor antagonist, and both a preventive and opioid-sparing anaLgesic, were expected. Dose-dependent adverse effects that may Limit the use as a postoperative anaLgesic, and the advantages, incLuding Lack of respiratory depression, were important. Whereas most candidates indicated the racemic nature of ketamine, few indicated the reLative differences of the isomers, in particuLar the increased anaLgesic potency of the S(>)- isomer.

AdditionaL points which attracted higher marks incLuded information regarding aLternate routes of administration, abuse potentiaL, specific actions on nociceptive pathways and actions on other receptor systems. Common mistakes incLuded misinterpretation of the question with discussion of ketamine as an anaesthetic agent, undue focus on the physioLogy of NMDA receptors and nociceptive pathways, and confusion between the actions of norketamine and norpethidine.
Few appreciated that hepatic metaboLism of ketamine is high and fLow-dependent. Dosages expressed as mg/kg are preferabLe. Many candidates appeared to describe LocaL practice and formuLations without being aware of core information weLL described in the key texts.



QUESTION 5 Outline how the pharmacokinetics of morphine, bupivacaine and suxamethonium differ in the neonate compared to the adult. Briefly describe the clinical implications of these differences.

73% of candidates passed this question.

This question asked candidates for some appLied pharmacoLogy, Looking at the effect of age on pharmacokinetics of three commonLy used drugs.

The question was generaLLy weLL answered, and a pass mark couLd be obtained by citing the criticaL features of each. With regard to morphine, both cLearance and gLucuronidation is decreased in the neonate, Leading to a proLonged haLf Life. The more permeabLe bLood brain barrier and reLativeLy increased brain bLood fLow in neonates contributes to a greater sensitivity to the drug in the neonate. With regard to bupivacaine there is an enhanced propensity for toxicity as a resuLt of
decreased protein binding, because of decreased aLpha 1 gLycoprotein LeveLs, and decreased hepatic cLearance. Marks were aLso awarded for mention of the infLuence of pH on toxicity in the neonate. With regard to suxamethonium, there are opposite forces at work. An enhanced ECF voLume wouLd Lead to an increased voLume of distribution which wouLd tend to reduce activity, but this couLd be countered for by a decrease in pseudochoLinesterase LeveLs in the neonate. The end resuLt cLinicaLLy is LittLe change in duration of action. Extra marks were awarded where candidates were abLe to give approximate dosages, or dosage ranges appropriate for the different drugs.



QUESTION 6 Outline the ideal properties of a colloid intravenous fluid. Give examples of colloids and briefly describe the features of each.



41% of candidates passed this question.

Few candidates were abLe to describe the ideaL properties of a coLLoid in adequate detaiL and frequentLy made statements that impLied a Lack of understanding about the fundamentaL properties of a coLLoid as opposed to a crystaLLoid. A significant number of candidates onLy managed to
mention two or three of the four main cLasses, nameLy poLygeLines, starches, dextrans and aLbumin. Descriptions of their features were often vague and imprecise, with a poor understanding of what sort of moLecuLes they are, where they distribute in the body, their duration of action, their eLimination and risks or side effects of their use.



QUESTION 7 List the agents used therapeutically to reduce platelet function. Outline their mechanisms of action, adverse effects, mode of elimination and duration of action.

82% of candidates passed this question.

ReLevant agents for this question incLude aspirin, pro-drugs at ADP receptor, antagonists at the
IIB/IIIA receptor and phosphodiesterase inhibitors.

This question had the option of being answered in the form of a ‘tabLe’ format using dot points outLining the components asked for about pLateLet function reduction. Marks were enhanced by incLuding expLanation of how the drug action interferes e.g. bLocking the IIB/IIIA receptor interrupts the binding of fibrinogen hence the faiLure of adhesion and aggregation of pLateLets.

The ‘thrombus/pLateLet’ diagram in Katzung page 544 iLLustrates in summary form the information and it was incLuded in some candidate answers.

There is aLways a risk of eLaborating on adverse effects probabLy more than the marks aLLocated at the expense of time spent on other agents. Medications whose unwanted side effects incLude pLateLet inhibition are not used therapeuticaLLy for that purpose thus not gaining marks. Comments on dextran and thrombin inhibitors gained credit.



QUESTION 8 What is meant by the term Randomised Controlled Trial (RCT)? What are the strengths and weaknesses of randomized control trial design?



79% of candidates passed this question, with 9% receiving a very Low mark.

A cLear expLanation of a Randomised ControLLed TriaL was required e.g. “a triaL in which patients are aLLocated by a form of randomisation between groups; and in which an intervention group is compared to a controL group, that may be active or inactive”. Thereafter a discussion of the strengths and weaknesses of such triaLs was required. Strengths were considered to be that RCT represents a high LeveL of evidence and can be incLuded in meta-anaLyses, minimisation of bias,
reduction of the effect of confounders by being evenLy distributed between groups, ease of bLinding, ease of appLying incLusion/excLusion criteria and providing a good basis to appLy statisticaL anaLysis. Weaknesses were considered to be that they are more expensive, may not refLect reaL Life situations, raise the possibLe ethicaL concern of recruiting patients to what may be considered a Less effective technique, difficuLty of meeting ethicaL requirements in obtaining informed consent from patients who may receive a Less beneficiaL treatment.

Many candidates appeared to confuse randomisation with bLinding and wrote entireLy on the advantages and disadvantages of bLinding. WhiLst bLinding is often added to an RCT, a discussion of the advantages conferred with bLinding was appropriate and attracted additionaL marks; however candidates who wrote soLeLy about bLinding with no acknowLedgement of what constitutes an RCT, received Low marks. Likewise the “controLLed” part of an RCT appLies to the use of a controL against which to compare the intervention group and does not mean that there is a “high degree of controL” of the study or that the researchers “tightLy controL aLL aspects of the triaL”.





PHARMACOLOGY - VIVA SECTION


PHARMACOLOGY TOPICS:


. Draw a dose - response cure.
. OutLine the drug treatment of anaphyLaxis.
. What is meant by the term “toLerance”?
. What are some members of the H2 antagonist group?
. Draw a concentration- time curve foLLowing an I.V. injection of propofoL.
. What are the potentiaL routes of administration of drugs?
. What are some probLems associated with giving drugs by the transdermaL route?
. How can drugs be given to controL post-operative pain?
. What drugs can be used by management of neuropathic pain?
. How do you cLassify corticosteroids ?
. What is meant by the word “addiction”?
. What sort of drug is neostigmine?
. What is the roLe of cytochrome P450 systems in drug metaboLism?
. What specific pharmaceutic probLems exist in the eLderLy popuLation?
. What sort of drugs can be given by the intrathecaL route?
. How do voLatiLe agents affect the pattern of ventiLation?
. What are the uses of beta bLocking drugs?
. How do you assess the extent of neuromuscuLar bLockade?
. What is meant by the term “depoLarising bLockade”?
. What is the mechanism of action of LocaL anaesthetics?
. What are the signs of LocaL anaesthetic toxicity?
. Describe the uses of antichoLinesterase agents.
. What is acetyLchoLine?
. Describe the phases of cLinicaL drug deveLopment.
. Describe the pharmacokinetics of fentanyL.
. What is the appropriate dose of paracetamoL?
. What is meant by the term “probabiLity”?
. What is meant by the term “power” in statistics?
. What is meant by the term sensitivity & specificity?
. How do you cLassify adverse effects of LocaL anaesthetics?
. What are the contents of an ampouLe of thiopentone?
. What is the cause of differences in speed of onset between fentanyL & aLfentaniL?
. What are the advantages and disadvantages in using nitrous oxide?
. What are the contents of a Hartmann’s soLution?
. How does the addition of nitrous oxide affect the uptake of sevofLurane?
. What drugs can be used in the management of ventricuLar fibriLLation?
. What is the Vaughn-WiLLiams cLassification of anti-arrhythmic drugs?
. What types of statisticaL data are there?
. What type of intravenous drugs can be usefuL to controL pain?
. Concentration time cure for aLfentaniL?
. What are some of the advantages of tramadoL as an anaLgesic?
. What agents can be used to reduce bLood pressure?
. What do you understand by the term intrinsic sympathetomimetic activity?
. What intravenous induction agents do you know of?
. The normaL distribution curve.
. What is syntocinin?
. What is ropivacaine?
. Side effects of suxamethonium.
. Wash in curve for isofLurane.
. How are inhaLed anaesthetic removed from the body?
. MetaboLism of the voLatiLe anaesthetic agents
. How do you cLassify anti-choLinesterase agents?
. What is ephedrine?
. How do you define MAC?
. What is protamine?
. What is heparin?
. What drugs cause histamine reLease?
PHYSIOLOGY - WRITTEN SECTION



MULTIPLE CHOICE QUESTIONS:

83% of candidates achieved a pass in this section of the PhysioLogy Examination.



SHORT ANSWER QUESTIONS:


QUESTION 9 What is humidity and how can it be measured?

53% of candidates passed this question.

The minimum requirement for a pass mark was an adequate definition of humidity and a brief description of two methods of its measurement. Candidates were expected to be abLe to define absoLute and reLative humidity, extra marks were awarded for an expLanation of the infLuence of temperature on humidity and for the provision of the humidity of fuLLy saturated air at 20 and 37 degrees. A common error was the description of absoLute humidity as a pressure, rather than as mass of water vapour /voLume of air. SuccessfuL candidates couLd in generaL describe hair hygrometers, wet and dry buLb hygrometers and RegnauLt’s hygrometer. Extra marks were awarded for a description of the reLative merits of these techniques and for descriptions of other methods for measuring absoLute humidity (such as eLectricaL transducers / mass spectrometry). However, no marks were awarded for descriptions of humidifiers, or for discussion on the environmentaL or cLinicaL consequences of high or Low humidity.

QUESTION 10 Describe sepsis and describe the metabolic consequences of sepsis.

48% of candidates passed this question.

A basic definition of sepsis was expected. Recognition of the spectrum of severity encompassed by the term sepsis gained additionaL marks, as did a brief description of the mechanisms and mediators of sepsis.

Given the wording of this question equaL marks were given for the generaL (non-metaboLic) and metaboLic features of sepsis. The generaL features were best organised by a systems approach nameLy cardiovascuLar, respiratory, haematoLogicaL, endocrine and CNS. Of these the cardiovascuLar features required the most detaiL.

Important information to be incLuded in the metaboLic part of the answer incLuded the generaL cataboLic state, hypermetaboLism, fever, tissue hypoxia, metaboLic acidosis, insuLin resistance and the effect of sepsis on the metaboLism of carbohydrates, proteins and Lipids.

CLear writing and simpLe organisation invoLving underLined headings and common abbreviations aLLowed candidates to cover this broad question weLL. Those who faiLed this question simpLy did not provide enough content and detaiL. The most common mistake was to write at Length about metaboLic acidosis to the excLusion of a wider ranging answer. DetaiLed metaboLic pathways were not expected.
QUESTION 11 Write brief notes on the physiological changes associated with sleep.

39% of candidates passed this question.

A definition of sLeep, an indication of the components of sLeep and their duration foLLowed by a
brief notation of the physioLogicaL changes occurring in the neuroLogicaL, cardiovascuLar, respiratory and metaboLic systems was rewarded with a good pass. AdditionaL detaiL, particuLarLy in regard to the neuroLogicaL changes, was rewarded with additionaL marks.

SLeep is a NECESSARY REVERSIBLE reduction in the conscious state from which one can be easiLy AROUSED by sensory or other stimuLi. The most common reason for not passing this question was a poor definition (or no definition at aLL) and simpLy not notating an adequate number of physioLogicaL changes. The most common error was to correctLy state that parasympathetic tone predominates during sLeep onLy to then state that gut motiLity was reduced. Quite a few answers Lacked any structure what so ever.

Credit was not given for descriptions of physioLogicaL compensatory mechanisms, such as for reduced venous return or determinants of GFR.



QUESTION 12 Detail the protective and regulatory roles of the liver.


32% of candidates passed this question.

This question required a description of the Liver as the interface between the gut and the body, and as a resuLt of this, its roLe in protection from organisms and toxins and reguLation of nutrient LeveLs.

The protective roLe is primariLy reLated to the removaL of bacteria, endotoxins, and protein denaturation. This is primariLy undertaken by the Kupffer CeLLs which are in the hepatic sinusoids. The action of these macrophages is an exampLe of innate immunity. FoLLowing their activation a series of events foLLows incLuding phagocytosis, compLetment activation, and recruitment of other ceLLs.

The primary reguLatory roLe of the Liver is as a gLucostat i.e. responding to both high and Low bLood gLucose LeveLs being presented to it by the portaL circuLation. DetaiL on how the Liver achieves this baLance was needed. Some candidates were confused about the action of insuLin and gLucacon in these processes.

Bonus marks were aLso awarded for the foLLowing as exampLes of protection: toxin/drug modification, production of acute phase proteins, compLement and urea, action as a bLood reservoir, and of reguLation production of aLbumen in reguLating oncotic pressure, biLe in reguLating fat and fat soLubLe vitamin absorption, biLirubin metaboLism, hormone inactivation and production of both coaguLation and anticoaguLation proteins.

Listing aLL Liver functions did not address the question, which asked for detaiL on a Limited area of Liver function. Some candidates focussed on minor detaiLs whiLe missing the big picture such as faiLing to mention bLood gLucose reguLation or any protective roLes.
QUESTION 13 Explain the concept of time constants and relate these to “fast”
and “slow” alveoli

40% of candidates passed this question. The answer shouLd incLude:
. An objective (mathematicaLLy-based) definition of a time constant,
. In reLation to Lung units, the time constant is often defined as the product of compLiance and resistance.
. Some factors that infLuence time constants (physioLogicaL and pathoLogicaL causes of aLterations in compLiance and resistance)
. The effects of heterogeneity in time constants (static vs. dynamic compLiance and respiratory rate)

AdditionaL marks were awarded for ways of measuring the effects of heterogeneity of time constants. The capnogram and the peak vs. pLateau pressures. Many candidates spent a Lot of time expLaining various other formuLas pertaining to compLiance, surfactant, and aLveoLar coLLapse that were not directLy reLevant to the question. Many candidates thought that increased compLiance causes fast time constants.



QUESTION 14 Explain in physiologic terms the effect of severe aortic stenosis on myocardial supply and demand.

45% of candidates passed this question.

This was an appLied physioLogy question. The first part of an answer was a description of aortic stenosis, with additionaL marks for giving measure(s) of severity. The main part of the answer concerned the interreLated effects of a severeLy stenosed aortic vaLve that may produce both increased myocardiaL work (described using LapLace’s Law) and compromised coronary bLood fLow. AdditionaL marks were awarded for answers that discussed the varying effects of Left ventricuLar hypertrophy on both suppLy and demand. Marks were aLso awarded for discussing how increased heart rate may both increase demand and reduce suppLy. Errors incLuded: confusing the effects of aLtered pressure with aLtered fLow; faiLing to indicate that severe aortic stenosis is a chronic condition; and incLuding, often at Length, the effects of anaesthesia or the symptoms and signs of aortic stenosis.



QUESTION 15 Describe the changes that occur with ageing that can affect oxygen delivery to the tissues during moderate exercise.

14% of candidates passed this question.

Oxygen deLivery is the product of cardiac output and arteriaL oxygen content. Oxygen deLivery during exercise is increased by raising cardiac output gLobaLLy and LocaLLy, and increasing oxygen extraction. Linking these changes to aging is the key to answering this question.
Cardiac output and respiratory changes with aging both needed discussion to gain a pass mark. Key points:
. Cardiac output - contractiLity., heart rate responsiveness., stroke voLume., ventricuLar compLiance., and cardiac workt with aging. These factors reduce the abiLity to increase cardiac output to match exercising tissue demand.
. Respiratory - PaO2., work of breathingt with a . in chest waLL compLiance, cLosing capacity encroaches on FRC, and diffusion capacity. from taLveoLar membrane thickness and . functionaL surface area. The tV/Q mismatch that resuLts reduces the abiLity to oxygenate bLood when extraction increases.
AdditionaL marks were awarded for mentioning bLood fLow. with atheroscLerosis, tpuLmonary resistance and heart strain, anaemia .O2 content, moderate exercise is beLow anaerobic threshoLd, and vaLvuLar defects can affect cardiac output.

Common errors incLuded focusing on either cardiac or respiratory changes; Listing aging and
exercise physioLogicaL changes without Linking the important factors of the two together; describing anaerobic metaboLism of tissues; stating that FRC reduces with increasing age; not differentiating between the .chest waLL compLiance and tLung compLiance that happens with aging.



QUESTION 16 Outline the mechanisms by which the kidney maintains potassium homeostasis

51% of candidates passed this question.

It was pLeasing to see some weLL structured answers covering aLL the main points. The main points expected to achieve a pass incLuded:
. NormaL intraceLLuLar and extraceLLuLar potassium concentrations and the need for “tight”
controL.
. A baLance between intake and excretion of potassium.
. The transit of potassium through the nephron in the kidney, excretion = fiLtered- reabsorption + secretion, with the major controLLed variabLe being secretion, and the pLaces within the nephron that these events occurred.
. The controL of the variabLe secretion in the distaL convoLuted tubuLe and coLLecting duct dependent on potassium concentration, tubuLar fLow rate and aLdosterone. Secretion of aLdosterone from the adrenaL gLand being under a feedback Loop with pLasma concentration of potassium.

Extra credit was given for mechanism of action of any of the steps above, in particuLar a cLear expLanation of how aLdosterone achieves further secretion was rewarded. The exchange of potassium for hydrogen ions within the renaL tubuLe was aLso rewarded if expLained correctLy. No credit was given for information of drug actions on the renaL tubuLe.





PHYSIOLOGY - VIVA SECTION


PHYSIOLOGY TOPICS:

CVS
. RegionaL bLood fLow
. Wiggers’ diagram
. Lead II ECG
. Frank-StarLing mechanism
. ContractiLity: definition & measurement
. CVP waveform
. AfterLoad: definition & measurement
. Oxygen fLux
. Venous return / atriaL pressure curve
. Anemia; causes, consequences
. Sino-atriaL node action potentiaL
. LV pressure-voLume Loop
. Changes in mean ateriaL waveform with propagation
. CerebraL bLood fLow determinants
Measurement
. CaLibration of pressure transducer
. Comparison of invasive & non-invasive bLood pressure measurement
. PA catheter waveform changes with insertion
. CO measurement
. Wheatstone bridge
. Fick principLe
. CO2 measurement
. ELectricaL circuits
. PuLse oximetry

Fluid & electrolytes
. Contents of one Litre bag of NormaL SaLine

Muscle
. Excitation-contraction coupLing

Renal
. HandLing of water
. GFR: definition, determinants
. CLearance
. RBF; response to hypovoLemia
. MetaboLic acid; handLing by kidney

Pain
. Response to skin incision
. Response to thermaL injury

Respiratory
. BLood gas interpretation
. ALveoLar gas equation
. Oxygen cascade
. Effect of pneumothorax on gas exchange
. ControL of ventiLation
. Surfactant
. Oxygen stores in the body
. Differences between base and apex of the Lung
. FRC
. CompLiance
. Dead space
. Shunt
. Work of breathing
. CLosing capacity
. ALtitude physioLogy
. Oxygen-haemogLobin dissociation curve
. CO2 carriage
. PuLmonary circuLation
. Airway resistance

Haematology
. Red ceLL metaboLism
. Processing of bLood donations
. PLateLets; structure and function
Metabolism
. GLucose: aerobic & anaerobic metaboLism
. FueL sources
. Effect of an eight hour fast

Endocrine
. ProstagLandins
. Thyroid hormones
. Pituitary hormones
. InsuLin

Pregnancy
. Respiratory changes in pregnancy
. CardiovascuLar changes in pregnancy

Materno-fetal
. Oxygen transfer across pLacenta

Nervous
. Sympathetic nervous system
. NMDA receptors
. Resting membrane potentiaL
. Nernst equation
. GoLdman-FieLd equation

Allergy/Immune system
. CLassification of immunoLogicaL reactions
. Defences against infection

Gastro-intestinal
. Lower oesophageaL sphincter
. Gastric emptying




Dr. C Noonan
Chairman, Primary Examination Sub Committee