Consultant Anesthesiology oral assessment prep

Knowledge: The combination of bronchospasm with a raised airway pressure, profound hypotension, tachycardia and cutaneous flush within minutes of a beta-lactam antibiotic is grade 3 anaphylaxis until proven otherwise, and antibiotics are now the commonest trigger of perioperative anaphylaxis in the NAP6 data, ahead of neuromuscular blocking agents and chlorhexidine.

Management: I would declare an emergency, call for help and the anaesthetic emergency manual, stop the cefazolin and any other potential trigger including latex and chlorhexidine, give 100 per cent oxygen, and tell the surgeon to stop and not to start. I would give intravenous adrenaline in 50 microgram boluses titrated to effect, repeated every one to two minutes, and start an adrenaline infusion if two or three boluses are needed, alongside rapid crystalloid boluses of 20 ml per kg and more as required.

Ethics and communication: She consented to a routine day-case operation and will wake in intensive care after a life-threatening event, so I would see her personally, explain clearly and without jargon what happened, apologise for the distress even though no error occurred, and answer her questions. Duty of candour applies to serious harm regardless of fault, and in this case honesty is also clinically necessary because she must understand the allergy risk for the rest of her life.

Reference: Royal College of Anaesthetists NAP6 report, Perioperative Anaphylaxis, 2018; Association of Anaesthetists Quick Reference Handbook, guideline 3-1 Anaphylaxis, updated 2023.

Knowledge: The picture of an unexplained rising end-tidal carbon dioxide resistant to increased ventilation, unexplained tachycardia, masseter spasm after succinylcholine and a late rise in core temperature is malignant hyperthermia until proved otherwise. The rising carbon dioxide is the earliest and most sensitive sign; temperature rise is late, and waiting for it is a classic reason for delayed treatment.

Management: I would declare a malignant hyperthermia crisis, call for help and the MH box and cognitive aid, tell the surgeon to stop or finish as fast as safely possible, and turn off the vaporiser while giving 100 per cent oxygen at high fresh gas flow. I would convert to a total intravenous technique with propofol and a non-depolarising relaxant, hyperventilate to two to three times normal minute ventilation, and either change to a vapour-free machine or insert activated charcoal filters, and I would not waste time changing the circle absorber.

Ethics and communication: I would speak to his parents early and in person, in their own language where needed, explaining that a rare inherited reaction to anaesthetic drugs occurred, that it is being treated, and that this is not anyone's fault, while being explicit that we do not yet know the outcome.

Reference: Hopkins PM et al. Association of Anaesthetists guidelines on Malignant Hyperthermia 2020, Anaesthesia 2021; Malignant Hyperthermia Association of the United States treatment protocol, current edition.

Knowledge: Hypoxaemia on one-lung ventilation is primarily a shunt problem, since perfusion continues through the non-ventilated right lung despite hypoxic pulmonary vasoconstriction, and it typically occurs in the first twenty to thirty minutes before hypoxic pulmonary vasoconstriction is fully established. My differential is grouped into equipment and tube problems, patient physiology, and surgical causes.

Management: First I would increase the inspired oxygen fraction to 1.0, inform the surgeon and ask them to pause, and check the patient: look at the capnograph and airway pressure trace, hand-ventilate to assess compliance, and check the tube position and connections. I would perform fibreoptic bronchoscopy through the tracheal lumen to confirm the bronchial cuff is just below the carina in the left main bronchus and that the right upper lobe is not being occluded, and suction both lumens for secretions or blood.

Ethics and communication: Effective communication with the surgeon is the professional core of this case: I would state the problem clearly, ask for a pause and for the specific help I need, such as tolerating CPAP or a period of reinflation, rather than silently struggling, and I would avoid the culture of not interrupting a senior surgeon that contributes to preventable harm in the operating theatre.

Reference: Slinger P and Campos JH, Anesthesia for Thoracic Surgery, in Miller's Anesthesia, 9th edition, 2020; Slinger P, Principles and Practice of Anesthesia for Thoracic Surgery, 2nd edition, 2019.

Knowledge: My overriding duty is to patients, and the General Medical Council and every GCC licensing authority state explicitly that a doctor must act if patient safety is or may be compromised by a colleague's health, conduct or performance, and that personal loyalty is not a defence.

Management: I would speak to him immediately, privately and calmly, tell him directly what I have observed and that I am not prepared to let him start the list, and offer to take over or reorganise it. I would not allow him to see patients or to leave and drive home unsupervised, and I would arrange transport.

Ethics and communication: The professional obligation to act overrides collegial loyalty, cultural reluctance to shame a senior colleague, and my own discomfort, and I would be honest with the panel that this is uncomfortable but not optional. Confidentiality is owed to him as far as possible: I would disclose only to those with a legitimate need to know, would not discuss the matter with theatre staff or in the coffee room, and would correct rumour if it spread.

Reference: General Medical Council, Good Medical Practice, 2024, domains on acting when patient safety may be compromised; Association of Anaesthetists, Fatigue and Anaesthetists, 2014, and Substance Use Disorder in the Anaesthetist, Anaesthesia 2011.