Tips on How to Answer an Essay Question by Doaa Kamal

Tips on How to Answer an Essay Question

Examples from Previous Exams
By Doaa Kamal
Revised and corrected by Prof.Dr.Raafat Abdel Azim
General / Rules:
1) Categorize / divide your answer into major headlines.
2) Dont miss any major headlines relevant to the question.
3) Write a few sentences under each headline.
4) Stick to the point and avoid elaboration on irrelevant & routine information.
5) You must be aware of your time limit: for a Q that is worth 10 marks your time
limit is 15 minutes. For a Q worth 20 marks your time limit is 25-30 minutes.
N.B. The following model answers are written in consideration to the time limit.

Example # 1
Anesthetic management for a patient with mitral stenosis undergoing
Cesarean section.
Answer:
Physiological changes with pregnancy:
CVS: tachycardia, hypervolemia, systemic vascular resistance,
hyperdynamic circulation, pregnancy may precipitate heart failure in pts with
cardiac disease (NYHA I, II III, IV).
o Aorto-caval compression 20 weeks gestation compression of IVC
venous return hypotension, oliguria, fetal distress.
o After delivery autotransfusion of 500 ml blood from the placental to
the central circulation may precipitate acute congestion, pulmonary
edema, heart failure.
CNS: sedation, MAC (by progesterone).
Respiratory: FRC (rapid hypoxemia with intubation), higher incidence of
difficult airway management, higher incidence of aspiration pneumonitis.
GIT: full stomach aspiration, delayed gastric emptying (due to:
progesterone, labour pains, mechanical compression by the fetus).
Blood: hypervolemia, physiological anemia with pregnancy, hypercoagulable
state.
Preoperative assessment:
History:
$ of low COP: dyspnea, syncopal attacks, oliguria, cold extremities.
$ of pulmonary venous congestion: orthopnea, PND, pulmonary edema, pink
frothy sputum.
$ of Rt-sided failure: epigastric pain, lower limb edema.
Palpitations: (AF).
Previous surgery: valvotomy or valve replacement.
Medications: prophylaxis against IEC, digoxin, warfarin, diuretics.
Examination:
BP, pulse (HR), auscultation of lung bases (pulmonary congestion).
Investigations:
CBC: Hb (physiological anemia of pregnancy).

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Tips on How to Answer an Essay Question by Doaa Kamal

Coagulation profile: PT, INR for warfarin.

Serum level for digoxin.
ECG: for AF.
Echo: EF%, FS%, mitral valve area (<1.2 = severe MS), pressure gradient
across mitral valve (10 mmHg = severe MS), regurge, other valves,
pulmonary hypertension (25-25 mmHg = mild, 35-50= moderate 50=
severe).
CXR: pulmonary congestion.
Assessment for fetal well being.
Preoperative preparation:
NPO, fasting at least 6 hours.
Stop warfarin 3 days before elective CS and shift to heparin (stopped 6 hr
preop) or clexane (stopped 12 hr preop). If emergency CS correct INR by FFP
& vitamin K.
Cardiologic consultation.
HRC.
Postop ICU bed for severe MS or mod-severe pulmonary HTN.
Premedications:
Aspiration prophylaxis.
Prophylaxis against IEC: 2g amoxicillin + 80 mg gentamycin 1 hr preop. (in
case of penicillin hypersensitivity: vancomycin).
Avoid anticholinergics.
Avoid sedation (fetus).
Choice of anesthesia:
Regional: 1- Contraindicated in mod-severe MS due to low fixed COP.
2- Contraindicated if anticoagulated INR 1.4.
3- Avoided in mod-severe pulmonary HTN.
GA: preferred due to more hemodynamic stability.
Monitoring:
Standard: ECG (lead II for AF), SpO2, BP (invasive preferred), capnography.
CVP: to guide IV fluid therapy and RV function.
PAP: if pulmonary hypertension is present.
UOP.
CNS: BIS (awareness).
Fetal monitoring.
Frequent auscultation of lung bases.
Induction:
Preoxygenate for 5 minutes.
Lt lateral position: wedge pillow under Rt side (to avoid aortocaval
compression by fetal head).
Modified rapid sequence crash induction with cricoid pressure using:
o Fentanyl: 50-100 ug before induction in presence of naloxone at hand and
neonatologist informed.
o Lidocaine: 1 mg/kg to diminish stress response to intubation.
o Ideally induction agent: etomidate.
o Thiopental minimal sleeping dose (3 mg/kg) slowly. (slow arm to brain
circulation time due to low COP).

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o Avoid ketamine tachycardia, HTN.

o Rocuronium: 0.5-0.9 mg/kg for rapid intubation.
Maintenance:
Avoid N2O if pulmonary HTN.
Volatiles: < 0.5 MAC isoflurane (less myocardial depression, less
arrythmogenic), or sevoflurane. AVOID: halothane (myocardial depression,
arrythmogenic).
NDMR: rocuronium, vecuronium, cisatracurium provide hemodynamic
stability. Atracurium may cause histamine release & hypotension. AVOID:
pancuronium (vagolytic tachycardia).
Controlled mechanical ventilation.
After Delivery:
Supplementary opioids for GOOD analgesia: fentanyl 2-3 ug/kg.
Midazolam for awareness.
< 0.5 MAC volatile agent to avoid uterine atony.
Avoid oxytocin tachycardia.
Methergine 200 ug IM.
Furosemide 20-40 mg: for 500 ml autotransfusion after delivery to avoid
circulatory overload.
Care of neonate.
Target hemodynamics and fluid therapy:
IV volume:
o Amount: minimal, slowly, according to a strict fluid chart, guided by
CVP and frequent auscultation of lung bases.
o Type: crystalloids (physiological salt solution eg. ringer acetate). Avoid
colloids.
o Blood: if blood loss 1500 ml give packed RBCs.
SVR: maintain SVR avoid .
HR: maintain between 60-90. (< 60 give anticholinergics, 90 give esmolol or
propranolol).
BP: 120/80 140/90 mmHg. Hypotension is treated by direct vasopressors
(eg. phenylephrine) rather than IV volume.
Caution for Digoxin toxicity:
C/P: CNS: headache, flashes of light, yellow vision. GIT: nausea, vomiting.
CVS: arrhythmias (rapid AF, sinus bradycardia, heart block, sick sinus
syndrome, VT, VF).
Avoid hypokalemia & alkalosis.
Treatment: ttt of hypokalemia and alkalosis, digoxin binding antibodies, ttt of
arrthymias according to the type, ventricular arrythmias ttt by phenytoin
(avoid DC shock).
Pulmonary edema:
Stop IV fluids.
100% O2.
Semi-sitting position.
Diuretics: furosemide 40-80 mg.
Morphine: 5 mg IV.
Positive pressure ventilation + PEEP.
Recovery:

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Reversal of muscle relaxant.

Fully awake extubation after fulfilment of the criteria of extubation.
Or pt may be transferred to ICU intubated, mechanically ventilated if opioid-
based ansesthesia was used.
Postoperative management:
In ICU.
Semi-sitting position.
Supplementary O2.
Good analgesia.
Continue digoxin.
Once surgical hemostasis is achieved (clear drains) continue warfarin under
umbrella of heparin until INR = 2.5-3 then stop heparin.
Avoid anemia.

Example # 2
Anesthetic management for a 70 year old male patient with chronic
renal failure on dialysis, for total hip replacement. (Nov 2010)
Answer:
Def of ESRD: creatinine clearance (GFR) < 10 ml/min.
Preoperative assessment:
(A) For CRF:
History:
Dialysis: frequency, last session.
HTN.
Medications: anti-HTN, vit D, Ca.
Urine output: oliguric, anuric.
Site of the AV shunt.
DVT prohpylaxis (for fracture hip).
Examination:
BP measured from the arm opposite AV shunt.
Auscultation of lungs (pleural effusion), lung bases for pulm venous
congestion.
Investigations:
Renal function tests: BUN, Cr.
S.Electrolytes: Na ( 2ry hyperaldosteronism), K (), Ca ( vit D
deficiency), Ph ( due to Ca).
ABG: metabolic acidosis.
Liver function tests: s.albumin, HBV, HCV, HIV markers (hemodialysis
machine).
CBC: anemia of CRF, plt count within normal but poor plt function
(assessed by bleeding time).
Coagulation profile: PTT may be prolonged from heparin (from
hemodialysis).
(B) For geriatric pt: assess for comorbidities:
CVS: HTN, atherosclerosis, IHD, AF.
CNS: stroke, senile dementia.

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Tips on How to Answer an Essay Question by Doaa Kamal

Respiratory: COPD, emphysema.

DM.
Skeletal: osteoporosis, rheumatoid arthritis.
Preoperative preparation:
Dialysis on the night of operation followed by RFTs (BUN, Cr),
s.electrolytes (Na, K), ABG.
N.B indications of dialysis:
o BUN 100 mg/dl.
o Cr 10 mg/dl.
o pH < 7.2.
o HCO3 < 12 mmol/L.
o s.K 7 mlEq/dl.
o CVP 15 or pulmonary venous congestion.
o Uremic encephalopathy.
o Uremic pericarditis.
Correction of hyperkalemia.
Continue anti-HTN ttt until morning of surgery.
Blood & FFP.
HRC.
Postop ICU bed.
DVT prohpylaxis: stop heparin 6 hr preop or clexane 12 hr preop.
Premedications:
Aspiration prophylaxis.
Antibiotic prophylaxis (pt immunocompromised & for THR complete
asepsis) dose adjusted to cr.clearance. Avoid nephrotoxic antibiotics.
Avoid sedation.
Avoid cannulating the arm with AV shunt damage.
Choice of Anesthesia:
(A) Regional neuroaxial (spinal/epidural):
Avoid volume preload.
Hypotension ttt by vasopressors rather than IV volume.
Care for coagulation profile & plt function.
Preferred to detect cement implantation syndrome.
(B) PNB: sciatic N + femoral N + wound infiltration.
Max safe dose of local anesthetics due to hypoalbuminemia free
active part of the drug.
(C) GA: N.B. geriatric pt may have difficult mask ventilation (due to loss of
buccal fat & facial hair & joint stiffness: TMJ & limited neck extension).
Lateral position: complications & precautions
CVS: postural hypotension.
Respiratory: V/Q mismatching (upper lung better ventilated, lower lung
better perfused).
Neurological: eye compression. Compression of dependent arm congestion
& ischemia & brachial plexus compression. Upper arm: traction on brachial
plexus, compression of ulnar N in elbow, compression of median N in wrist
or traction on radial N.
Monitoring:

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Tips on How to Answer an Essay Question by Doaa Kamal

Standard: ECG, SpO2, BP (invasive preferred) away from the AV shunt

damage the shunt & inaccurate readings, capnography.
CVP: to guide fluid therapy.
ABG, s.electrolytes.
UOP: if pt is oliguric not anuric.
Choice of anesthetic drugs:
BDZ: midazolam can be used. Avoid: diazepam (active metabolites
renally extcreted prolonged action).
Opioids: fentanyl, alfentanyl, sufentanyl, remifentanyl can be used. Avoid:
morphine active metabolites prolonged action, pethidine
accumulation of norpethidine convulsions.
Induction agents: thiopental, propofol can be used. Avoid: ketamine (active
metabolites prolonged action).
Muscle relaxants:
o Avoid succinyl hyperkalemia.
o Avoid: pancuronium & pipecuronium mainly renal excretion.
o Atracurium, cisatracurium (Hoffman degradation), vecuronium &
rocuronium (mainly hepatobiliary excretion) can be used.
Volatile agents: avoid: methoxyflurane (nephrotoxic metabolites),
sevoflurane with low flow anesthesia for prolonged time ( compound A
nephrotoxic).
N.B. all doses for geriatric pts.
Avoid adjuvant nephrotoxic drugs: eg. NSAIDS.
Fluid therapy:
Amount: minimal amount, according to strict fluid chart, guided by CVP &
frequent auscultation of lung bases.
Type: normal saline. Avoid K-containing solutions.
Blood: packed RBCs. Transfusion point: Hct < 25% (correct Hb to 8 mg/dl).
If pulmonary edema (fluid overload) occurs hemodialysis is mandatory & is
the only solution.
Considerations for THR:
1) Pulmonary embolism: thromboembolism: DVT.
2) Fat embolism syndrome:
C/P: (3 forms: incomplete, classic, fulminant type). Fever, CNS:
disturbed LOC, convulsions, coma. Pulmonary: hypoxemia, cyanosis,
respiratory distress. CVS: tachycardia, hypotension & shock. Systemic
embolic manifestations.
Ttt: supportive & resuscitative measures. O2, intubation, mechanical
ventilation, circulatory support, anti-convulsants. Steroids & heparin
may have a role in ttt.
3) Cement implantation syndrome:
C/P: hypotension, hypoxemia, disturbed level of consciousness (if
regional anesthesia was used), cardiac arrest.
Ttt: immediately stop cement implantation. Vent the bone cavity.
Steroids. Supportive treatment: intubation, mechanical ventilation,
support the circulation by inotropes & vasopressors.
4) Controlled hypotensive anesthesia may be required: to minimize blood
loss. Methods used: 1-regional anesthesia. 2-direct vasodilators:

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nitroglycerin, (avoid nitroprusside in renal impairment cyanide toxicity).

3- Bs: esmolol, propranolol. 4-- blockers: labetalol. Avoid mean ABP <
60mmHg for cerebral perfusion pressure. Avoid diastolic BP < 50mmHg
for coronary perfusion pressure. Hypotensive anesthesia is contraindicated
if: stroke, IHD, uncontrolled HTN.
5) Lateral position.
Recovery:
Dose of neostigmine (renal excretion).
Postoperative management:
ICU.
Semi-sitting position.
O2 supplementation.
Complications:
1) Postoperative delirium & cognitive dysfunction.
2) Pulmonary edema.
3) Hyperkalemia: ttt: glucose-insulin infusion, NaHCO3, salbutamol
nebulization, dialysis.

Example # 3
Anesthetic management of a male patient with acromegally
presenting for trans-sphenoidal pituitary adenoidectomy. (Nov 2011)

Answer:
Preoperative assessment:
History:
DM (GH is an anti-insulin hormone).
HTN (medications).
Polyneuropathy.
Other system survey.
Examination:
BP.
*Airway assessment: (acromegally difficult airway mangement).
Malampati score, thyromental distance, neck mobility (atlantoaxial joint
sublaxation), jaw mobility (mouth opening), large tongue, loose teeth.
Investigations:
CBC (Hct: bloody surgery).
X-ray of cervical spines for atlanto-axial instability.
RBS, ketone bodies in urine.
Complete hormonal profile: thyroid profile, ACTH (pituitary adenoma may be
associated with other hormonal disturbances).
Preoperative preparation:
Control of BP.
Control of blood sugar:
If pt is well controlled on oral medication, shift to short-acting oral
hypoglycaemic & avoid morning dose.
If the pt is well controlled on insulin: shift to crystalline insulin & avoid
morning dose.

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Tips on How to Answer an Essay Question by Doaa Kamal

If the pt is not controlled postpone until properly controlled as this is an

elective surgery.
Management of complications of hypoglycaemia: ketacidosis,
hypoglycaemia, diabetic non-ketotic coma.
Prepare cross-matched blood.
High risk consent.
Postop ICU bed.
Premedications:
AB prophylaxis.
Anti-cholinergics: may be difficult intubation.
Aspiration prophylaxis: for possibility of difficult intubation.
Sedation & anxiolysis to minimize the stress response.
Monitoring:
ECG: lead II: esp. for adrenaline injection.
BP: invasive preferred for hypotensive anesthesia.
SpO2.
Capnography.
UOP.
Hct (bloody surgery).
RBS.
Nerve stimulator (for profound muscle relaxation: coughing ICP & may
cause injury to intracranial structures).
Visual evoked potentials for optic N injury.
Difficult airway management:
Awake fibre optic intubation.
If pt refused or non-cooperative inhalational induction or IV induction with
short acting muscle relaxant (succinylcholine).
All facilities for difficult airway management must be prepared and available:
suction unit, various laryngoscope blades, various ETT sizes, boujie, stylet,
macgill forceps, oropharyngeal airways, nasopharyngeal aiways & LMA,
cricothyrotomy set.
Choice of ETT: armoured or oral RAE.
Positioning:
30o head up to aid venous drainage and hypotensive anesthesia.
N.B. neck extension may displace ETT outwards inadvertent extubation
(slipped ETT).
Eye protection: oil-based ointment, proper taping of the eyes shut (corneal
abrasions, chemical injury from sterilizing agent).
Oral Pack: complications: 1- sore throat, 2- missed oral pack.
Adrenaline injection: precautions
Concentration: 1:200,000 (5 g/ml).
Surgeon must notify before injecting.
Aspiration before injection.
Close observation of HR & ECG trace.
If IV escape occurs: stop injection immediately, discontinue volatile anesthetic
(added arrhymogenic effect), ventricular arrhythmias ttt by lidocaine 1-1.5
mg/kg, HTN best ttt by direct VD as: nitroglycerin or nitroprusside. (Avoid

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using beta-blockers propranolol alone unopposed -action severe

hypertension).
Controlled hypotensive anesthesia: to minimize blood loss & for a clear surgical
field. Agents used: 1-volatile anesthesia. 2-direct vasodilators: nitroglycerin,
nitroprusside. 3- Bs: esmolol, propranolol. 4-- blockers: labetalol. Avoid mean
ABP < 60mmHg for cerebral perfusion pressure. Avoid diastolic BP < 50mmHg for
coronary perfusion pressure.
Precautions for bloody surgery: minimize blood loss by hypotensive anesthesia &
prepare 2 units of type-specific cross matched blood.
Recovery:
V.Imp: removal of oral pack.
If pt was difficult intubation fully awake extubation.
Postoperative management:
In ICU.
Semi-sitting position.
Complications:
1. Missed oral pack.
2. Diabetes insipidus.
3. CSF rhinorrhea.
4. Optic nerve injury.
5. Complications of DM: hypoglycaemia, ketoacidosis, diabetic non-ketotic
coma, infections.