Chair’s report Final exam 2019.

General Comments

This report summarises the areas examined in the most recent final examination. The report
has some updates which we believe will improve its utility for candidate preparation. It is
hoped that this document will be a useful tool for upcoming exam candidates, Supervisors of
Training and other senior colleagues who assist trainees with exam preparation.

Candidates should be aware that whilst the exam is not held at the absolute end of their
training, the standard expected across all aspects of the exam is that of someone ready to
commence independent specialist practice; functionally it is an exit exam.

As all aspects of the curriculum are examinable, trainees are advised their best chance of
success is to sit the exam when their clinical experience matches their theoretical knowledge.
All sections of the exam are referenced to the curriculum so candidates are advised to be
familiar with all aspects of the curriculum.

The assessment is inclusive of all four sections of the examination: multiple choice question
paper, short answer question paper, medical viva examination and anaesthetic viva
examination. In order to cover the breadth of the curriculum, content is spread over all
sections. In each examination sitting, it is variable what content is covered in each section of
the final examination. For this reason, all sections need to be undertaken in the same
examination sitting.

The mark allocation for the examination for this examination is shown below:

Section FANZCA Vivas only

MCQ 20
SAQ 20
Medical vivas 12 12 (20%)
Anaesthesia vivas 48 48 (80%)
TOTAL 100 60 (100%)

The pass rates for candidates presenting for the Final Fellowship in August/ October 2019 are
presented below:

Medical
Category MCQ SAQ Clinical VIVA Overall
ANZCA Trainees No. Sat 131 131 131 110 131
No.
Passed 102 54 103 81 80
Pass rate 77.9% 41.2% 78.6% 73.6% 61.1%
SIMG - No
Written No. Sat - - 22 22 22
No.
Passed - - 8 6 5
Pass rate - - 36.4% 27.3% 22.7%
No. Sat 131 131 153 132 153
No.
TOTAL Passed 102 54 111 87 85

Pass rate 77.9% 41.2% 72.5% 65.9% 55.6%

Medical Viva Examination - pass rate 72.5%

The medical viva tests the ability of a candidate to identify and assess the severity and
stability of a specified medical condition. It is NOT a pre-anaesthetic assessment.

Candidates are expected to asses a patient by taking a focused history, eliciting relevant
physical signs and from these, determine the functional status of the system to which they are
directed. Candidates are likely to have at least one cardiovascular or respiratory examination.
Candidates should familiarise themselves with other clinical examinations e.g.
gastrointestinal, neurological and musculoskeletal systems, and demonstrate competency in
these areas.

As part of the viva, candidates will be expected to interpret relevant investigations and
integrate them with their clinical findings in order to obtain a comprehensive functional
medical assessment. Candidates in this exam were asked to interpret on average three
different investigations. Examples of investigations asked in this exam include ECGs, CXRs,
pulmonary function tests, a variety of blood tests and relevant CT scans. Poor performance in
the interpretation and integration of investigations (particularly ECGs and CXRs) remains
problematic.

An understanding of the management of the medical condition is expected and candidates

should be able to discuss medical optimisation.

Criteria for assessment in the medical viva include:

- Professionalism and courtesy in dealing with patients.

- An appropriate history which explores risk factors, degree of severity and stability,
functional impact, progression, response to therapy and long-term management
(where appropriate) for a disease state.
- A physical examination that elicits key signs in an efficient, logical sequence.
- An organised presentation of findings which interprets and integrates the history
and clinical examination.
- Interpretation and integration of relevant investigations.

Candidates are encouraged to utilise the above criteria when reviewing patients during their
preparation for the medical viva.

It is important during the history-taking that candidates listen to the patient as part of the
process of assessment and to help guide their subsequent questions rather than relying on
checklists.

Candidates should be mindful they are interacting with patients. Difficulties may well arise in
the course of the exam and candidates need to demonstrate some flexibility in their approach
to the patient.

The following is a list of some of the medical conditions assessed in this exam:

Cardiovascular System

 atrial fibrillation
 ischaemic heart disease and cardiomyopathy
 complex congential congenital cyanotic heart disease
 hypertrophic obstructive cardiomyopathy
 aortic stenosis and ventricular septal defect
 mitral valve prolapse
 aortic regurgitation

Respiratory System

 sarcoidosis
 interstitial lung disease
  idiopathic pulmonary hypertension
 bronchiectasis
 chronic obstructive pulmonary disease
 Wegener’s granulomatosis
 bronchiectasis
 cystic fibrosis

Other systems

 cirrhosis
 motor neurone disease
 polycystic kidney disease
 renal/ pancreas transplant

Multiple Choice Question Examination - pass rate 77.9%

Each question is of the one best answer type. No marks are deducted for incorrect answers.

The table below outlines the number of questions in each of the core subject categories
(noting that an individual question may have more than one subject). The subject spread in
the MCQ paper varies from exam to exam, as it is partly determined by the content of the
short answer and viva sections of the exam.

Topic Number Of Percentage

Questions (%)
GG Breast 1 0.67
GG GI Surg 1 0.67
HN ECT 1 0.67
HN ENT 1 0.67
IC Sepsis 1 0.67
PM Acute Pain 1 0.67
PM Pain Pharmacology 1 0.67
PO Antibiotic Prophylaxis 1 0.67
PO Immunology 1 0.67
PO Infectious diseases 1 0.67
PO Substance abuse 1 0.67
RT Resp failure 1 0.67
SQ Safety 1 0.67
SQ Scientific Enquiry 1 0.67
VS Vascular Surgery 1 0.67
zcardiac physiology 1 0.67
AR ANZCA Roles in Practice 2 1.33
CS Interventional Cardiology 2 1.33
GS Physiology 2 1.33
GS Vascular Access 2 1.33
HN Dental/Faciomax 2 1.33
OP Eyes 2 1.33
PM Persistent Pain 2 1.33
PO Aspiration 2 1.33
RA Regional Pharmacology 2 1.33
RT Metabolic/Electrolyte 2 1.33
RT Trauma 2 1.33
SQ Equipment 2 1.33
SQ Prof Docs 2 1.33
TS Thoracics 2 1.33
 GS Fluid Therapy 3 2.00
GS Monitoring 3 2.00
NS Neuroradiology 3 2.00
PO Perioperative Investigation 3 2.00
PO Psychiatric disorders 3 2.00
RT Periop Crises 3 2.00
IC Organ Failure/Disorders 4 2.67
PB Burns 4 2.67
RA Regional Complications 4 2.67
RT Equipment/Environment Crisi 4 2.67
AM Airway Management 5 3.33
NS Neurosurgery 5 3.33
PO Respiratory disorders 5 3.33
RA Regional Anatomy 5 3.33
RT Arrest Resuscitation 5 3.33
CS Cardiac surgery 6 4.00
PO Neurological, Neuromuscular 6 4.00
PA Paediatrics 7 4.67
PO Metabolic & Endocrine 8 5.33
PO Haematol/ oncology, anticoa 9 6.00
OB Obstetrics 10 6.67
PO Cardiovascular disorders 13 8.67
GS Pharmacology 17 11.33

Short Answer Question Examination – pass rate 41.2%

The SAQ Examination is designed to challenge and test the candidate’s ability to apply their
knowledge to clinical or workplace situations in a systematic and prioritised way.

This report is primarily written to assist future candidates in their preparation for the SAQ
paper and therefore places emphasis on some of the recurrent themes and errors seen in
answers that do not attract sufficient marks to meet the minimum standard criteria to achieve
a pass mark.

Candidates are reminded to read the questions carefully during the reading time allocated at
the beginning of the examination and again when they commence answering each question.
Marks are only awarded for answering the question that has been asked. Time is wasted by
writing information that is not required and will not contribute to the overall mark.

Answers that contain correct information are marked down when the answer is poorly
structured, especially when information is poorly prioritised.

Answers containing information that is incorrect are marked down not withstanding they may
contain adequate correct information. It is therefore crucial to consider carefully what is
written in response to a question.
The failure by some candidates to act on key words in the question remains problematic. In
order to emphasise the importance of these words and to clarify their meanings, the following
is a list of key words with their generally accepted meanings.

COMPARE Look for similarities

CONTRAST Set in opposition
DEFINE Give the precise meaning of
DESCRIBE Give a detailed account of
DISCUSS Write about a topic in detail, taking into account different issues or
ideas
EVALUATE Make an appraisal of the worth of something
EXPLAIN Make plain, interpret, account for
ILLUSTRATE Make clear by concrete examples (or use a diagram to clarify)
JUSTIFY Show adequate grounds for decisions
LIST Catalogue by groups or classes with minimal explanation
OUTLINE Give the main features or general principles
RELATE Show how things are connected to and affect each other

Candidates are encouraged to read through previous examination reports and practise
answering past questions under examination conditions.

Question 1

Describe the rationale for the use of deep hypothermic circulatory arrest and outline the
pathophysiological consequences of this technique.

Pass rate 44.3%

Many candidates demonstrated that they had little or no knowledge of deep hypothermic
circulatory arrest (DHCA), often confusing it with cardioplegia, ECMO, passive cooling post
cardiac arrest or cardiopulmonary bypass.

To pass this question an answer was required to demonstrate an understanding that the
rationale for the use of deep hypothermic circulatory arrest is cerebral protection and that
there are pathophysiological consequences such as coagulopathy, arrhythmias and
neurological issues.

The examiners recognise that this technique may not have been seen by many candidates,
however the question could have been answered with the application of knowledge gained
from clinical experience in cardiac anaesthesia and Primary Examination physiology.

Question 2

Evaluate the options for managing a confirmed postdural puncture headache in an obstetric
patient.

Pass rate 78.6%

This question had a high pass rate with over half the candidates scoring well. This may reflect
a high volume of practice in obstetrics attained by candidates by the time of sitting the
examination.

It is of note that higher marks would have been awarded had candidates evaluated the
conservative and invasive management options rather than simply describing or listing
them (refer to the definitions above).

Question 3

Discuss how Marfan syndrome influences your anaesthetic management for a patient
requiring an urgent laparoscopic appendicectomy.

Pass rate 67.2%

This discussion required consideration of:

1. Cardiovascular pathology and specifically the requirement for perioperative blood
pressure control, for example during laryngoscopy, pneumoperitoneum and
extubation.
2. Airway issues surrounding endotracheal intubation
3. Lung pathology and how this determines the ventilation strategy to minimise risk of
pneumothorax.
The question was handled reasonably well by most candidates although a number of answers
contained a lack of detail or inaccuracies regarding the features and issues encountered in
Marfan syndrome.
Some answers exaggerated the likely difficulties and advocated extensive invasive
monitoring, cardiac supportive therapies and ICU care postoperatively.

Of note there were a significant number of answers that gave a ‘recipe’ type answer for
anaesthesia in an unfasted patient with sepsis, with no reference to Marfan syndrome. These
answers may reflect a lack of knowledge of Marfan syndrome or a failure to read and
understand the question correctly.

Question 4

Describe the requirements for establishing an anaesthetic service for a neurosurgical theatre
with a magnetic resonance imaging scanner.

Pass rate 67.2%

This question attracted a wide range of responses with some candidates scoring very well.

Answers scoring well included those giving consideration to the consultation and
development of a new anaesthetic service and the specifics of this service in a neurosurgical
theatre with an MRI scanner. This includes factors such as MR safe equipment, use of an
anaesthesia bay for induction and emergence, specific requirements before scanning in
theatre, staff safety training and emergency procedures.

Question 5

A patient dies soon after induction of anaesthesia. As a senior clinician you are asked to
arrange a debriefing.

Outline the considerations.

Pass rate 81.7%

This question had an excellent pass rate with over half the candidates scoring well.

The vast majority of candidates were familiar with the considerations of the purpose and
structure of a debriefing after a critical event such as an anaesthetic death.

The Welfare of Anaesthetists SIG document RD 05 (2016) is a useful resource to assist

anaesthetists in this situation.

Question 6

Discuss the advantages and disadvantages of non-invasive ventilation methods in the

intensive care unit.

Pass rate 22.9%

This question proved difficult for the candidates.

The examiners decided it was possible to interpret the question in two ways. It was therefore
marked according to how the candidate interpreted the question, either discussing the
advantages and disadvantages of non-invasive ventilation (NIV) methods in the intensive
care unit (ICU) or discussing the advantages and disadvantages of the different methods of
NIV in the ICU.

There is overlap in the answers required to the two questions both of which require
knowledge and some experience of managing patients on NIV in the ICU.
Advantages of NIV in the ICU
Avoid intubation and invasive ventilation with associated risks
Ease and simplicity of performing non-invasive ventilation
Particular benefits in certain patient groups ex. COPD, CCF, OSA, chest trauma

Disadvantages of NIV in the ICU

Patient cooperation required
No airway protection
Certain contraindications for example untreated pneumothorax, respiratory arrest,
life-threatening hypoxaemia

The advantages and disadvantages of the different methods of NIV include the factors above
and also relate to the equipment available, the patient’s condition, requirements and tolerance
of the technique and the type of ventilatory support offered or available. (volume ventilation,
pressure support, bilevel positive airway pressure (BiPAP), proportional-assist ventilation
(PAV), continuous positive airway pressure (CPAP)).

Question 7

Describe the anatomy relevant to siting an epidural catheter for postoperative analgesia
following open abdominal surgery. (50%)

Outline the limitations and complications of providing epidural analgesia for this type of
surgery. (50%)

Pass rate 70.2%

The anatomy of the epidural space and epidural analgesic techniques are topics regarded as
core knowledge for the Final Examination. A high level of detail was expected and required to
pass this question.

The importance of reading the question carefully is again emphasised. This question
specifically required candidates to consider open abdominal surgery yet there were a number
of generic answers to the second part of the question.

Question 8

Your patient is midway through a laparoscopic cholecystectomy. You smell smoke and can
see flames in the room adjacent to your theatre.

Describe your management of this situation.

Pass rate 39.7%

The majority of answers to this question fell short of the minimum standard required.

The question required an answer demonstrating a sensible approach to patient and staff
safety. This would include raising the alarm, evaluation of the immediate risk posed by the
fire, the ability of staff to fight and contain the fire and the assessment of the requirement for
patient and staff evacuation with consideration of the ongoing surgery.

The RACE protocol is a useful tool to assist in structuring an answer to this question.

Fire safety and evacuation procedures are mandatory staff training in hospitals and it is
expected that candidates are familiar with procedures that may be required in their daily
working environment, particularly if this type of emergency occurs mid-surgery.
Question 9

A 25-year-old male is scheduled for an elective inguinal hernia repair. He has a ventricular
septal defect and was recently diagnosed with Eisenmenger syndrome.

Discuss your preoperative assessment and how this affects your anaesthesia plan.

Pass rate 55.0%

There were some excellent answers to this question which demonstrated a clear
understanding of Eisenmenger syndrome, particularly of right to left shunt.

These answers went on to discuss the assessment of severity through functional status,
clinical signs, echocardiogram and catheter results.

Discussion followed of how the severity then affects anaesthesia management. This included
but was not limited to consideration of factors increasing pulmonary vascular resistance, pros
and cons of LA/Regional/GA techniques and possible delaying of surgery until after
transplant.

There were many extremely poor answers falling well below the standard expected of
candidates sitting the Final Examination. Some answers simply stated that they wouldn’t
anaesthetise the patient.

Question 10

Describe the role of the anaesthetist in minimising surgical site infection.

Pass rate 45.8%

The following points required consideration in an answer to achieve a pass mark:

1. Anaesthetists are leaders in observing policy/protocol on institutional infection control

2. Infection risk is broken down into patient/provider/environmental reservoirs
3. Appropriate choice and timing of antibiotic prophylaxis
4. Avoidance of patient hypothermia

It is of note that some candidates answered in relation to infection in general rather than
surgical site infection which may reflect not reading the question carefully.

Question 11

A patient on an organ transplantation waiting list is taking rivaroxaban for recurrent pulmonary
emboli.

Discuss your perioperative anticoagulation plan.

Pass rate 54.3%

This question was looking for the candidate’s ability to apply their knowledge of the
pharmacokinetics and pharmacodynamics of rivaroxaban to a clinical situation where
continued anticoagulation is required up to the time of surgery which is unpredictable in
timing.

A significant number of candidates demonstrated poor knowledge of the pharmacokinetics of

rivaroxaban and so could not answer the question to a satisfactory standard.

The high VTE risk and appreciation of surgery with a high risk of bleeding required
consideration. An appropriate choice of alternative agent for bridging and a plan in
consultation with other specialties was required.
The intention of this question was a discussion centred around the patient’s organ
transplantation which is in effect ‘elective’ until they are called in for transplant upon which
their surgery becomes ‘urgent’. Transplant surgery is clearly high risk for bleeding.

The majority of candidates answered the question in this way, however some answered in
relation to an upcoming surgery not related to their transplant. This approach required further
consideration of the type of surgery and bleeding risk.

On review of the question the examiners agreed that it was possible to interpret the question
in this way and these answers were marked accordingly.

Question 12

List the advantages and disadvantages of opioid-free approaches for laparoscopic sleeve
gastrectomy. (50%)

Justify your choice of opioid-free technique for this procedure. (50%)

Pass rate 62.6%

Overall the candidates handled this question to a satisfactory standard recognising the issues
in bariatric surgery and demonstrating a familiarity with the ideas behind the practice of opioid
free anaesthesia.

Some candidates answered the second part of the question by justifying choosing an opioid
free technique rather than justifying their choice of opioid free technique for this procedure.

On review of the question the examiners decided that it was possible to interpret the question
in this way and these answers were marked accordingly.

Question 13

List the risk factors for perioperative stroke. (50%)

Discuss the measures you use to minimise perioperative stroke in high-risk patients
undergoing major orthopaedic surgery. (50%)

Pass rate 48.9%

The first part of this question required a list of risk factors.

Higher marks were awarded to those candidates who demonstrated a prioritisation of risk
factors and also limited their list to known risk factors, separately identifying them as patient
and surgical risk factors.

Many candidates were able to identify some known risk factors but also listed incorrect
factors which resulted in lower marks being awarded.

In the second part of the question evaluation and optimisation of CVS and CNS disease
(including carotid artery disease), haemodynamic control, antiplatelet and anticoagulation
management, blood glucose control and postoperative neurological observation formed the
basis of the answer.

A common omission was the measure of delaying surgery if there had been a recent stroke,
even though this may have been identified as a risk factor by candidates.

Another common error was listing strategies to reduce the risk of DVT/PE rather than stroke
(although there is cross over with interventions to reduce the risk of stroke).
Question 14

Compare and contrast first-generation and second-generation laryngeal mask airways.

Pass rate 55.0%

This equipment question proved difficult for some candidates who did not demonstrate they
knew the difference between first-generation and second-generation laryngeal mask airways.

It is expected that a candidate sitting the Final Examination would be able to demonstrate a
complete understanding of these items of airway equipment.

Candidates are referred to the definitions at the beginning of this SAQ paper report when
structuring an answer to this type of question.

COMPARE Look for similarities

CONTRAST Set in opposition

Question 15

A 16-year-old girl has failed to wake from anaesthesia following posterior instrumentation for
severe idiopathic scoliosis.

Discuss the potential causes and management of her failure to wake.

Pass rate 61.8%

The examiners were looking for a systematic approach to the patient described in the
question. Those answers that did this and included the relevant and likely causes in a
prioritised fashion and then demonstrated a similar approach to correctly managing the
situation scored well.

Candidates are reminded to answer questions in the context of the given scenario not in
general terms. Answers containing factually correct information written out of context and not
directly answering the question will attract poor marks.

Anaesthesia Viva Examination - Pass Rate 65.9%

Viva examination formats provide a unique opportunity for both Candidates and Examiners. It
is the one place in the exam where several areas of specialist level practice can be tested in
eight complex and evolving scenarios. There are several key areas that are tested here:
1. Application of safe clinical practice,
2. Demonstration of sound clinical judgment
3. Plan and prioritise clinical actions
4. Demonstrate an ability to adapt to changing clinical scenarios, and
5. Be able to justify your clinical decisions.

As a final exit examination, candidates are expected to demonstrate consultant-level thinking

and communication. All vivas are thoroughly vetted and discussed within the Court of
Examiners over a two-month period prior to the viva examination. This allows the
determination of a consensus as to what constitutes a minimum level of competence
needed to pass each viva. This is consistent with what we would expect of an independent
specialist anaesthetist trained by ANZCA.

It is paramount that candidates demonstrate safe clinical practice. Some areas in the viva
scenarios are clearly situations designed to test a candidate’s ability to make appropriate
decisions in a safe manner. Decisions that are deemed unsafe practice are marked severely.
This also applies to what is considered to be core knowledge expected of a specialist
anaesthetist, e.g. ACLS algorithms, and candidates are expected to perform at an exceptional
level in such core areas.
Communication during the viva is another fundamental skill - not just communicating your
clinical decisions during the viva, but also moving through the viva at a pace which will allow
the candidate to maximise the full coverage of all areas of the viva. Whilst it is not critical to
have completed the whole of the available viva in order to pass, a candidate who is very slow
to move forward will have limited time available to achieve marks.

Clearly then, better performing candidates will give clear structured answers. Their answers
will be organised, even in the face of a complex problem, demonstrating their ability to
prioritise the main issues involved. They will also demonstrate consultant-level decision
making, which is based on sound clinical and evidentiary principles.

Below are the stems for the sixteen vivas. As well as providing the introductory stems, the key
points needed to pass each viva have also been included. It is hoped that this information will
provide guidance for future candidates in preparing to meet the not-insignificant challenge of
sitting the Final FANZCA Examination.

VIVA 1 - pass rate 58.6%

You are seeing a 50-year-old man in the pre-anaesthetic clinic.

He is scheduled for robotic-assisted laparoscopic radical prostatectomy in one week’s time.

He has type 2 diabetes mellitus and hypertension, and he smokes 10–15 cigarettes a day.

Current medications include:

Metformin
Empagliflozin
Ramipril

How would you prepare this patient for surgery?

Key Points:
Good preoperative assessment and planning.
Rational approach to SGLT2i management
Major component was response to loss of capnography trace during case.
Tube malposition with subsequent difficult airway. Candidates were expected to perform this
algorithm very well.
Differential and approach to the slow to emerge patient.
It is clear that robotic surgery is not commonly dealt with by trainees.
VIVA 2 - pass rate 72.9%

A six-year-old boy with cerebral palsy is on your morning eye list at a paediatric referral
hospital. He is listed for strabismus surgery.

You are reviewing his case notes when the admissions nurse comes over to tell you his
mother has requested that her son receives a different premed before surgery today.

You find previous anaesthetic charts relating to a series of upper and lower limb Botox
injections. On the most recent it is documented that oral midazolam 8 mg was administered
as premedication.

It is also noted that the child was very anxious on arrival in theatre and became distressed
and uncooperative during his inhalational induction.

His weight is 16 kg.

Current medication:

Omeprazole 20 mg daily
Baclofen 20 mg bd
Clonazepam 1.5 mg bd
Carbamazepine 100 mg qid
Diazepam 2.5 mg prn

How will you approach your anaesthetic assessment of this boy?

Key Points
Demonstrate adequate understanding of challenges of cerebral palsy and apply this to patient
and premedication.
A sensible approach to airway management during gaseous induction, with regurgitation and
proceeding to intubation.
Ability to troubleshoot PACU issues.

VIVA 3 – pass rate 78.6%

A 58-year-old male presents to the pre-anaesthetic clinic prior to a

functional endoscopic sinus surgery (FESS) procedure.

His past medical history includes:

Obstructive sleep apnoea

Poorly controlled gastro-oesophageal reflux
Ischaemic heart disease with coronary stenting ten years ago
Ex-smoker (ceased ten years ago)

Weight 145 kg, body mass index 45 kg/m 2

Current medications:

Metoprolol
Ramipril
Aspirin
Ranitidine prn

Please describe key areas of concern in your pre-anaesthetic management plan.

Key Points
Good preoperative assessment and planning for anaesthesia was needed. Use of a
supraglottic airway was unacceptable in this scenario.
Candidates needed to approach the ST changes during use of vasoconstrictors rationally. Not
unexpectedly, this patient was a challenge to extubate, with high airway pressures and
hypoxia. Candidates were expected to manage this sensibly.

VIVA 4 – pass rate 64.3%

You are the anaesthetist for a gynaecology list at a major metropolitan hospital. You are
reviewing the next patient on the list in the anaesthetic room. She is a 36-year-old woman for
removal of an intrauterine device (IUD) +/- laparoscopy.

The surgeon’s booking notes state:

Removal of hormone-releasing IUD (Mirena) –possible extrauterine migration requiring

laparoscopy
Tetraplegia (15 years)
Obese

Current medications:

Amitriptyline
Baclofen
Cranberry capsules

What additional specific information do you require in order to formulate your

anaesthetic plan?

Key Points
Candidates were expected to be clear on the use or not of suxamethonium in this patient.
The recognition and management of autonomic dysreflexia, was also required to be
approached rationally. Hydralazine as an agent to manage this situation was considered a
poor choice.
Overall, the pathophysiology of AD was poorly handled by candidates.

Viva 5 - pass rate 51.4%

A 34-year-old patient presents at your pre-admission clinic. She is booked on your list for a
diagnostic laparoscopy for infertility. She has a BMI of 45kg/m2 and a past history of severe
asthma. A respiratory physician is managing her for her asthma. The patient says that her
asthma has improved and a letter from the physician states that her current FEV1 ranges
from 50-64% of predicted and this has improved from 40-50% of predicted in the preceding 3
months.

Her current medications include:

Symbicort
Ventolin

Discuss the key issues in your pre-op assessment of this patient.

Key Points
Thorough assessment of the patient’s obesity and asthma. This would lead to an appropriate
management plan for theatre.
The patient suffers an intraoperative hypotensive crisis that requires a systematic approach
and response from the candidates. Overall, this was not handled well. A large proportion of
candidates needed direction from the examiners to make the diagnosis of CO2 embolus.
A small section of dealing with the patient who in a crisis situation has developed a painful
hand, post operatively, from an intrarterial cannulation, used during the crisis.
VIVA 6 - pass rate 64.3%

Your first patient on the next day’s neurosurgical list is a 55-year-old female inpatient for
excision of a meningioma. Prior to her admission with this problem she had been fit and well.

She is to undergo a stereotactically-guided retrosigmoid craniotomy.

Current medications:

Levetiracetam 500 mg PO bd
Dexamethasone 4 mg IV tds
Ondansetron 4 mg IV tds

Please describe the main focus of your preoperative assessment in this case.

Key Points
Candidates were expected to systematically assess the patient and plan for the operation. It
was important for them to recognise the implications of major posterior fossa surgery.
Intraoperatively a rapidly evolving crisis occurs that involves, severe hypotension, hypocarbia
and new RBBB. This progresses to a PEA arrest. Candidates needed to work through their
ACLS in what is a difficult situation. Both venous air embolus should have been implicated
and a recognition that blood loss had also contributed. This crisis needed an organised and
rapid approach.
Subsequently in ICU, the patient develops polyuria. A sensible approach to diagnosis of the
cause and management was required.
VIVA 7- pass rate 71.4%

A 56-year-old man presents to the emergency department after a motor vehicle accident
involving a fatality in the other vehicle. You have been asked to escort this patient for a
computed tomography scan.

He complains of bilateral upper limb paraesthesia.

His past medical history includes mechanical aortic valve replacement.

Medications include:

Warfarin 3 mg daily

He appears oriented with a blood pressure of 90/40 mmHg and a heart rate of 50 /minute.

What are your concerns?

Key Points
On the whole, this viva was handled quite well by candidates.
An organised and rational approach was needed, including assessment of acute spinal cord
injury and then assessment for intubation and management of this. The patient’s
anticoagulation needed to be appropriately managed. An episode of intraoperative
hypotension required a systematic approach including working through possible differentials.

VIVA 8 - pass rate 71.4%

A 52-year-old woman with end-stage kidney disease (ESKD) presents to your pre-admission
clinic prior to an iliac artery aneurysm repair. The procedure is being performed to enable a
live-donor kidney transplant to be undertaken in three months’ time.

The ESKD is secondary to long-standing type 2 diabetes. In addition the patient has an
autonomic neuropathy secondary to diabetes and hypertension.

Medications:

Candesartan 16 mg daily
Dapagliflozin 10 mg daily
Long-acting insulin 16U nocte
Gabapentin 200 mg bd

Relevant investigations: haemoglobin 90 g/l; creatinine 585 µmol/l.

The patient describes a history of anaphylaxis during a prior anaesthetic. She has been to an
allergy clinic and had skin testing. The patient has a letter stating she is allergic to oxycodone.
The patient is concerned about having another anaphylactic reaction during the upcoming
procedure and whether this would impact upon her ability to have a kidney transplant.

What would you tell the patient?

Key Points
Correct interpretation of the allergy testing provided. Better candidates were able to make
comments on the sensitivity and specificity of skin prick versus intradermal testing. On the
whole candidates were unfamiliar with these tests.
Progressive hypotension develops after induction that becomes clear is an anaphylaxis
episode. Differentials were expected. There needed to be a recognition that despite the
patient’s ESRF, fluid was needed in the management of the episode. There needed to be a
rational approach to this in order to pass the viva.
VIVA 9 - pass rate 58.1%

You are asked to help with the management of a 28-year-old male intravenous drug user,
who is on methadone 200 mg daily, and has presented to the emergency department in
severe pain with a wound to his neck sustained in a knife fight.
On entering the emergency department you can hear the patient shouting at the nurse that he
needs more fentanyl.
The emergency department registrar has given 200 micrograms of fentanyl and is worried
about giving more.

How do you approach this situation?

Key Points
Management of a distressed patient in the Emergency Department. Candidates needed to
recognise the significance of a subglottic airway injury. There needed to be a rational
approach to the management of the airway, with cogent backup planning.
A recognition of polymorphic VT as distinct from simple VT and its management.

VIVA 10 - pass rate 71%

You have been called to the emergency department to assess a 12-year-old boy who has
been booked for an urgent scrotal exploration for suspected testicular torsion.

On arrival you notice the child has Down syndrome, is obese and has a cough. His mother
tells you that shortly after having his breakfast he suddenly started crying inconsolably,
placing his hands over his genital area. She also tells you she is quite worried about him
having surgery as a cold has exacerbated his asthma.

You see the following information on his chart:

Height: 140 cm
Estimated body weight: 63 kg

Medications:

Budesonide 200 µg daily

Salmeterol 50 µg bd

How will you assess this situation?

Key Points
An organised and thorough assessment highlighting the major issues was required. This
would have led to formulating an appropriate plan for conduct of anaesthesia. Intraoperative
bronchospasm was generally handled well. Recognition of pneumothorax later in the viva was
required.
VIVA 11- pass rate 75.8%

An 80-year-old man sustained right-sided rib fractures after a fall and was admitted to the
surgical ward of your regional hospital last night. His only other injury is a fractured right
clavicle. You are asked to review his pain management.

His past medical history includes:

Hypertension
Dyslipidaemia
Chronic obstructive pulmonary disease
Chronic moderate renal impairment
Type 2 diabetes mellitus
Prostate cancer

Regular medications:

Atorvastatin 40 mg daily
Budesonide-formoterol (50 µg/3 µg) inhaler bd
Irbesartan 75 mg daily
Metformin 500 mg daily
Salbutamol inhaler prn

Despite his medical issues, he is still active, and cares for his wife in their home.

Currently, his pain management is tramadol by intravenous infusion at 20 mg per hour, and
oral paracetamol 1 g qid.

You attend to assess him and notice that he is disorientated and confused, although
cooperative.

Why may he have become confused?

Key Points
This is a standard ICU scenario, with an elderly patient with chest trauma and inadequate
analgesia. A thorough assessment needed to be performed, ruling out the obvious
differentials. Ultimately this was respiratory failure secondary to sputum retention.
A multimodal analgesia plan was needed including a regional technique. Despite this the
patient continued to deteriorate. Safe intubation and management of a patient in imminent
danger of haemodynamic collapse was required
VIVA 12 - pass rate 58.1%

A 40-year-old obese woman (body mass index 32 kg/m 2, 95 kg) with myasthenia gravis is
listed for a laparoscopic total hysterectomy and bilateral salpingectomy.

Medications:

Pyridostigmine 240 mg tds

Prednisolone 25 mg daily
Buprenorphine patch 10 µg/hour
Oxycodone 5–10 mg prn
Tramadol IR prn
Oral contraceptive pill

Allergies:

Sugammadex

How will you assess the severity of her myasthenia gravis in order to formulate a
perioperative plan?

Key Points
Good assessment and planning for a patient with myaestheniagravis was required. Early in
the procedure the patient developed high airway pressures and high CO2. Surgical
emphysema was noted.
Candidates who did not deflate the pneumoperitoneum to work through the problem were
marked severely. A CXR and ABG were available for comment. These confirmed exogenous
CO2 insufflation probably through an inadequately placed port.
In PACU the patient develops signs consistent with a myasthenic crisis which needed an
organised response with intubation and management leading on to ICU.
VIVA 13 - pass rate 66.1%

You are in the pre-admission clinic reviewing a 48-year-old woman booked for laparoscopic
total hysterectomy (excision of fibroids) on your list tomorrow.

Her past medical history is of type 1 diabetes mellitus, for which she is on insulin
administered via a subcutaneous pump.

Her electrocardiogram is below. What does it show and what will you do?

Key Points
The ECG needed to be interpreted and clinical significance recognised. There also needed to
be a rational approach to managing a patient with an insulin pump. An intraoperative
bradyarrhythmia developed requiring useof an ACLS algorithm leading to external pacing.
This was expected to be performed at an exceptional level. Surprisingly many candidates
were quite poor at managing external pacing.

VIVA 14 - pass rate 66.1%

At the beginning of your day shift, a 54-year-old woman presents to the emergency
department of your large tertiary referral hospital with an initial Glasgow Coma Scale (GCS)
score of 12 (E3, M5, V4).
A computed tomography scan demonstrates a subarachnoid haemorrhage.
You have been asked to review the patient in preparation for planned coiling of her ruptured
aneurysm in the interventional radiology suite.
When you arrive in the emergency department her GCS is now 9. Her blood pressure is
280/160 mmHg.

What will you do when you arrive in the emergency department?

Key Points
This is a neurosurgical emergency. Rapid assessment and emergent treatment of the
malignant hypertension and raised ICP needed to be managed. The appropriate destination
for this patient was theatre to undergo EVD insertion and temporary clipping. Candidates
were expected to manage this complex problem in an organised and well prioritised fashion.
During this period the management was a balance of cerebral perfusion versus ongoing
hamorrhageso careful maintenance of appropriate BP targets throughout was paramount. An
ECG taken shows catecholamine-induced ischaemic changes. Recognition of the significance
of this was required.
Hypoxia developed after clipping and an organised approach was needed working through
the differentials and recognising neurogenic pulmonary oedema.
VIVA 15 - pass rate 69.4%

A 48-year-old man was admitted to a burn centre 24 hours ago with self-inflicted flame burns
to 65% of his body, particularly affecting the upper body including the head and neck region.

Initial fibreoptic bronchoscopic examination revealed severe inhalational injury. He is currently

intubated in the intensive care unit on an FiO2 of 0.4, and is on haemofiltration to treat
hyperkalaemia.

His current blood results are as shown below:

Reference range

Na+ 143 mmol/l 135–145 mmol/l

K+ 5.3 mmol/l 3.5–5.5 mmol/l
Urea 25.2 mmol/l 3.5–9.5 mmol/l
Creatinine 285 µmol/l 60–115 µmol/l
White cell count 18.4 x 109 /l 4.0–11.0 x 109/l
Haemoglobin 180 g/l 128–173 g/l
Platelets 480 x 109/l 150–400 x 109/l
Prothrombin time 21 s 10–14 s
International Normalized Ratio 1.6
Activated partial thromboplastin
time 38 s 24–34 s
pH 7.38 7.36–7.44
PaCO2 42 mmHg 35–45 mmHg
5.6 kPa 4.7–6.0 kPa
PaO2 140 mmHg 80–100 mmHg
18.6 kPa 10.6–13.3 kPa
Base excess -3.0 mmol/l -2 to +2 mmol/l
HCO3⁻ 24 mmol/l 22–26 mmol/l

The surgeon would like to perform debridement of burns on the emergency list within the next
two hours.

What are the main areas of concern?

Key Points
This was a complex case needing the candidate to fully assess the patient’s haemodynamic
status. Expected fluid losses coupled with previous resuscitation should have been
considered. Major blood loss should have been planned for and the significance of the
hyperkalaemia also noted.
Rational approach to intraoperative hypoxia and then hyperkalemia as the case progressed.
VIVA 16 - pass rate 66.1%

You are asked to review a 35-year-old woman who presents for revision of a left forearm
arteriovenous fistula. Her comorbidities include end-stage renal failure due to nephrotic
syndrome, for which she requires haemodialysis; morbid obesity; and known pulmonary
hypertension.

Current medications:

Prednisolone 15 mg daily
Cyclosporine 150 mg bd
Amlodipine 5 mg daily
Aspirin 150 mg daily

How will you assess the severity of her pulmonary hypertension?

Key Points
A thorough assessment of pulmonary hypertension was needed, as well as considering the
patients other comorbidities. Options for anaesthesia needed to be justified. We expected that
candidates could explain an appropriate brachial plexus block in this setting. The patient then
develops a pulmonary hypertensive crisis that required a safe approach to management.