Malaysia Anesthesia Parallel Pathway
Dr Wong Yin Fatt (currently still of Hospital Melaka) and I are in the process of making a compilation of past questions for reference of other people to study.
If any of you have compilations that we’re not aware off, you may share them with either of us for inclusion.
Thanks!
The following experience sharing session on the Malaysian anesthesia parallel pathway training program was delivered by Dr Muhammad Amir Ayub (yours truly behind the YouTube channel) from Hospital Melaka for the MEDEX/MCAI Preparatory Course held by Hospital Ampang, Malaysia on July 31 2023.
As usual, don’t forget to subscribe and share!
Recording and editing (of himself): ANAKAYUB
I wasn’t really into this assessment/exam/other suitable synonym this time around. I passed, but at what cost of myself? I sat through 4 CAI-related exams since 2014-2019, and no fails. I guess I could be considered at fault for taking my time (and money) to prepare for each? I’ve sat for 5 6-monthly assessments since then. While doing clinical work which consists the majority of COVID work. While my wife and kids are a usual 3 hour drive away (with the old car); the R&R’s on the Plus Highway are my usual weekend home…Before I reach home. And other parallel-pathway stuff (that isn’t going my way), demotivating me. Along with “co-curricular stuff” like handling the MY sigRA YouTube stuff (which if you’d notice, we had a collaborative program the weekend before this “assessment”), few other “higher difficulty, more intensive” video projects (which are much more draining given the circumstances), and regularly taking housemen teachings. And being the general tech guy of the department, which luckily has no longer needed much of my input/work. And trying my best to keep myself “physically healthy” by going to the gym despite my “frailty” as I am currently. I’ve lost 8 kg, and my pants are loose because I no longer have any glutes. From a competition deadlift of 215 kg, today deadlifting 130 kg for 5 reps is “positive progress”. I’m just fucking exhausted. Or experiencing the depressive phase of bipolar disorder.
I barely made notes this time around, and the ones I did have not been uploaded to the site. They could whither and get destroyed before getting scanned. No listening of music while studying. Just going through the motions while I fall asleep either on the chair (got my sciatic nerve numb sometimes) or the bed.
When I heard I passed, there was anhedonia in general.
To keep myself sane, I’m gonna have to say no to any new commitments and hurt some feelings.
Anyways, for those interested in pursuing this pathway (which for now there are only few successor(s) coming from HKL unfortunately), here are the compilations of questions:
78 year old with dm/hpt/af/probably other stuff, oa for thr with cemented implant
Preop considerations
Frailty definition and classification
Differences vs aging
Preop optimization
Considerations on anesthesia technique
Identifying bcis, classification, pathophysiology, management
Intraop optimization as regards to frailty/pocd/po delirium
Types of deliruum
Management of po delirum
Triple low stuff
Some guy… probably with urosepsis
Did not know shit that there was a new SSC 2021 update…oops. Ironically right after the exam this was the department CME topic
Identifications, definitions of sepsis vs septic shock
Fluid management
Vasopressor management
Peripheral administration of vasopressors
Cultures
Antibiotics
Lactate
1 hr bundle
Role of imaging
Targets of feeding
Contraindications
Types of feeds
Adjustments of feeding in the obese patient
Some guy with hypertension and esrf with a UGIB needing laparotomy
Preop assessment - history/pe (including ngt)/bloods/cxr/usg
Preintubation considerations - includes lines, airway
Induction agents, paralytics
Inhalational considerations
Delayed awakening
Differentials/investigations - drugs/temp/abg/gluc/neuro/tof - whatever else
CABG for CAD, while on pump, hyperk and hyperglycemia
Causes of hyperk - includes hemolysis from roller pump
Management of hyperk on pump, including hemofiltration and frusemide (and it’s pharmacodynamics)
Dangers of hyperglycemia for cabg
Management of hyperglycemia on pump
Hypotension postop with high cvp, drains 100 ml/h x 4 already resuscitsted
Assessment including ecg/echo
Right heart failure - causes, pathophysiology of subsequent lv failure, usg findings
Diagnosis of tamponade
Pressure volume differences of acute effusion vs chronic
Pulsus paradoxus in spont vs ventilated, normal vs rv failure
Hemodynamic aims of tamponade pre reopen
Role of inotropes in tamponade
Patient was transfused with blood. Received call that the pack cell was not listed as cross matched for this patient. Transfusion error. What would you do?
Critical incident report
Root cause analysis -principles
Audit after implementation
After checking however it was fortunate that the wrong blood product was still compatible and patient did not suffer harm.
Would you inform the patient?
Ethical principles, autonomy, beneficence, non maleficence, justice
How would you inform?
Involve consultants, medico legal unit
Documentation
Why is it important for the patient-doctor relationship?
Patient critically ill in shock with multiorgan failure, unstable for cvvh
How to inform family
Breaking bad news steps
How to counsel for withdrawal
How withdrawal is done, off vasopressors/ reduce vent settings/ terminal extubation
Visitation for family
What if patient’s family cannot accept
Will you continue with cvvh and vasopressors
Neuro surgery. Frontal tumour. Mayfield clamp and conduct. Venous air embolism. Brain herniation type.
Amniotic fluid embolism. Collapse and Resuscitation. Perimortem caesarean.
Abdominal aortic aneurysm. Management in ED n intraop.
Downs coming for intussuception. Resuscitation especially fluids.
G3p2 38 weeks 2 previous scar plan for ellscs. bmi 31 ht 160cm
What premed u want to give?
Tell me what drug will you give in sab.
What are the layers of spinal anaesthesia
What are the factors affecting spread?
What is the level of anaesthesia required for lscs.
Why reduced dose in obstetric patient?
Now patient complain of slight sob but bp 120/90 pr 90. What will you do?
What symptoms do you want to look out for?
Now BP 60/40 pr 110, what is likely happening?
How would you prevent?
What vasopressors will you use? Ephedrine or phenylephrine? Why? What are the advantages and disadvantages of each?
How does ephedrine cause fetal acidosis?
Now bp 60 40 bradycardia, what would you do?
What is definition of high spinal block?
What are the modifications of resusitation you know of in obstetic patients?
A pregnant patient collapse in ward, what would you do?
Any change in cpr method? Uterine manual displacement, branula upper limb, perimortem cser
60 yo planned for Whipple procedure with Ivi tracium
Which lead to monitor intra op
Why?
If to detect ischaemia which one? Cm5, why
Art line, zero and leveling
Whats connected to transducer
Art line discrepancy - leveling and damping
EtAG- disequilebrium of gases
Flow time curve - air trapping
Capno re breathing - change soda lime
Peripheral nerve monitoring
Considerations to build a remote Anaes facility
What are the remote areas
Ect Indications
Ect complications
How to Induce ect pt
Prolonged seizure, how to manage
24 yo with head injury, intraab and facial Fracture
Anaesthetic concern
How to intubate such patient
Picture of CT Brain - cerebral edema
How to prepare ot for intra ab
Haemodynamic aims
How to assess fluid status
45 years old, lady, presented with right eye Penetrating injury, BMI 45, full meal before onset, mallampati 3 Underlying epilepsy, mental retardation.
What's your anaesthetic concern?
How does epilepsy affect GA?
How would you induce this case?
Would you insert the NG for this patient?
What other investigation you want to do
Surgeon complaint the eyes is moving, what do you want to do?
Surgeon want to do retrobulbar with Monitored sedation, how would you proceed.
Noted bradycardia, what do you do? How would you treat?
Afferent and efferent pathway of the occulocardiac
45 years old, Nkmi
Acute abdomen with signs of sepsis. Temperature 38, spo2 95
CXR showed? Widened mediastinum
Your anaesthetic concern
Differential of widened mediastinum
How do you induce this patient?
How do you assess the airway?
What are the factor of difficult BVM and difficult larygoscope
How to plan the extubation
45, female, breast cancer stage 3b, planned for MAC
What's multimodal analgesia?
Define multimodal analgesia
Step ladder analgesia
How to treat pain?
What regional you want to offer?
Why is regional is recommended for breast ca patient (PROSPECT)
Patient have immediate post op pain, how to manage the pain?
Nerve innervation of chest wall, lateral wall and axillary wall.
Risk factor for post op chronic pain
16 years old, Trauma. Right 3 to 6th rib fracture and left hand wound.
How do you want to anaesthetize this patient?
What do you think supra clavicular, infraclavicular and axillary nerve block?
What are the adjunct for safe block?
How do you use nerve stimulator
What you want to explain to patient
Tourniquet, which additional nerve you want to block and how?
What post op u want to give?
Patient presented two days later, unable to flex and lateral arm numbness.
What investigation you want to do?
If CT scan, what do you expect?
Nerve conduction test, when do you order it?