Machine check : Carry out a check on a basic anaesthetic machine with the following faults: No marks for absent

pipelines Oxygen analyser had no battery Two empty vaporisers (isoflurane and enflurane) on back bar No interlock mechanism. "O" ring missing in enflurane vaporiser No marks for absent pipelines Oxygen analyser had no battery Two empty vaporisers (isoflurane and enflurane) on back bar No interlock mechanism. "O" ring missing in enflurane vaporise You are shown a photograph of an entonox inhalation unit. Answer the following questions: - What is the pseudocritical temperature? - What happens at this temperature? - What is the critical temperature? - Does the gauge pressure reflect the amount of entonox remaining? - Besides the doctors, who else is authorised to use entonox? - Describe the two-stage regulator Oxygen: Describe the use and mechanism of action of a paramagnetic oxygen analyser and a fuel cell oxygen analyser. a) You are shown a photograph of a pulse oximeter monitor. - What details can be obtained from this monitor? b) You are shown an oxygen dissociation curve, with two points, A and B, marked. - What does point A represent? - What does point B represent, and what are its uses? c) You are shown oxygen dissociation curves for myoglobin and haemoglobin and asked to identify them. d) You are shown a chart of the absorption characteristics of oxyhaemoglobion and deoxyhaemoglobin. - Identify the wavelengths used in the pulse oximeter. - Why are there two wavelengths? - Why is there only a pulsatile component? - What is the point marked at around 800 nm?

- What value do you obtain with light absorption at that point? e) You are shown the chart below: Where would you see this type of tracing commonly? f) What are the various sources of error associated with a pulse oximeter?

Carbon dioxide: You are presented with a patient in the prone position, whose capnograph trace is shown below. Answer the true/false questions that follow:

- Surgery should be stopped immediately. (T/F?) - There is a risk of cerebral hypoxia present. (T/F?) - The slope of the inspiration phase is dependent on the tidal volume. (T/F?) - D is the end-tidal point. (T/F?)

Breathing systems: You are asked to check a Bain circuit. - What will happen if the bag of the circuit falls off suddenly, while the patient is breathing spontaneously? Check a Bain circuit using the Venturi principle to check the inner tube. Carry out a Bain circuit check. - What is the volume of the expiratory limb? - What would be the fresh gas flow in a 100 kg man? - What would happen if the reservoir bag were to be removed? Assemble a Bain circuit. - Why is the capnograph tubing of narrow bore? - Why is it placed behind the filter? - You are shown some capnograph traces and asked to interpret them. What safety features are in place to avoid delivery of a hypoxic gas mixture?

Filters:

Temperature: You are shown a urinary bladder temperature probe. - How does it function? - Describe the Kelvin and Centigrade scales. - What factors affect heat loss by conduction? You are to identify a temperature probe. You are also asked about thermistors. Discuss their relationship using graphs. - You are asked about core temperature and sites for measurement. - Discuss radiation and the factors affecting it

Electricity: You are shown an oesophageal temperature probe and asked questions about temperature and thermistors, and given some graphs to interpret.

You are shown a photograph of a patient lying on the bed, connected to a central venous pressure monitor and other electronic monitors which are connected to earth. Answer the following questions: - What is the magnitude of the current required for microshock? - Assuming that all equipment is working correctly and that the patient is not touching any metal, why does electrocution not occur? - What do the symbols mean? - Is earth potential the same at all points on the equipment? - How can they be made to be equal? - What is the maximum allowed difference between earth potential and the mains voltage of 240 volts? - Select any two symbols from the card and explain what they represent. You are asked questions on diathermy devices and pacemakers, and asked to interpret some diathermy circuits showing a floating circuit. Flow: Describe the various types of flowmeters. You are shown a picture of flow meters and asked some questions about them: - What are their sources of error? - What are their principles of action? - How accurate are they? 3

Pressure: You are shown an arterial line and asked to point out errors. The errors are: Venflon catheter with side port, kinked 18G. Contains ordinary i.v. tubing instead of non-compliant tubing. Contains glucose instead of heparinised saline. Contains a non-pressurised bag. There is too much air in the tubing. - How would you zero the equipment? - What is high pressure zero? Describe the working principles of DINAMAP, hazards Describe the function of the Bourdon gauge.

Humidity: Humidity - Define relative humidity. - What is absolute humidity? - What are the units of absolute humidity? - What is the value of absolute humidity in the trachea? - Give two reasons why humidity is important - You are shown three charts; which chart is taken from a hair hygrometer? - Explain the principle of Regnault's hygrometer. - You are given a chart showing relative humidity lines (100%, 50% etc), with the Y axis denoting water vapour (in g/m3) and the X axis denoting temperature; if the dew point is at 30 degrees C, what is the absolute humidity? Nerve stimulator: Demonstrate the use of a peripheral nerve stimulator. - Identify the patterns obtained and describe the patterns of stimulation. - What happens during a depolarising and a non-depolarising block? Filters: You are shown various filters and asked the following questions on them: - Identify an epidural filter and describe its use. - Identify a blood filter; how often should it be changed? - Identify a breathing circuit bacterial filter (answer a question on dead space). - You are shown a big flat white filter attached to an i.v. set and asked to identify it.

- What virus is transmitted by white blood cells? - Arrange the following in increasing order of size: platelet, red blood cell, coccus. You are shown a selection of filters: epidural filters, heat and moisture exchanging filters, a filter in a standard blood-giving set. - What are the pore sizes of each? - Discuss other features of these filters.

Biological potentials Discuss differential amplifiers, CM5 placement, monitoring mode and diagnostic mode - Discuss the protocol for management of atrial fibrillation. pH You are shown a diagram of pH electrode and asked to identify the components. Vaporisers You are shown a picture of a TEC5 plenum vaporiser. - How is it different to a draw-over vaporiser? - Discuss the use of vaporisers inside the circle versus vaporisers out of the circle. - What is the latent heat of vaporisation? - What is temperature compensation? - How is the concentration and partial pressure of the volatile affected by altitude? Vaporisers: - How do they work? - How are they affected by high altitude? What are the differences between vaporisers inside and outside the circle system? - Why should a plenum vaporiser not be used inside the system? - What are the characteristics of a desflurane vaporiser? Miscelanneous You are shown a precordial stethoscope. - What are its uses? - How would you identify and treat an air embolism?

Anaesthetic machine check . You are shown some diagrams of a diathermy machine and asked questions relating to it. You are asked a series of questions about all types of earthing systems. You are shown a picture of a CO2 electrode and asked questions about i You are shown a photograph of some rotameters and asked the following questions: - Where do you read the value from? - What shape are the rotameters? - What is the purpose of the dot? - What are the sources of error? - Describe the different types of flow. - What is the equation for flow? You are shown a phrenic nerve stimulator and asked to identify it. - You are then shown a manikin arm with neuromuscular monitoring leads. Demonstrate the method for monitoring the ulnar nerve. - Which muscle is stimulated? - Why is a supramaximal current used? - You are given a laminated sheet with all the four neuromuscular TOF patterns. Name them. - What is the difference between depolarising and non-depolarising patterns? - Discuss the frequency and duration of each. - When can tetanus / train-of-four be repeated?

- When should you use post-titanic count? - Discuss double-burst stimulation frequency, duration and purpose. (a) You are shown three endotracheal tubes: a low pressure high volume disposable tube, an uncuffed tube and a Ring-Adair-Elwyn (RAE). - Describe each of them (b) You are shown a laser tube. - Describe it. - Why does it have a double cuff? - Why is saline used? - What does LASER stand for? - How is a laser beam produced? - Describe the different types of laser. - What are the properties of lasers? - What precautions should be taken during their use? You are shown three diagrams: (a) A paramagnetic O2 analyser - Describe the differences between paramagnetic and diamagnetic analysers. Give examples of each. - Why is O2 paramagnetic? - What is the dumbbell filled with, and why? - Describe the principle of action of the instrument. (b) A Clark electrode - Label the components - Describe the uses. (c) A fuel cell - Label the components. - Why is a battery needed? - What is its lifespan? You are to identify a temperature probe. You are also asked about thermistors. Discuss their relationship using graphs. - You are asked about core temperature and sites for measurement. - Discuss radiation and the factors affecting it You are asked about the CardioQ monitor and how it works. - How should the probe be placed?. - You are shown three traces and asked to interpret them. 10. Equipment Describe the different types of lasers and their uses. - What does the acronym Laser mean? - Discuss laser safety (give three factors). - Discuss endotracheal tubes (metal vs normal) and their specific characteristics. 7

Describe the use and function of the oesophageal stethoscope. You are shown an entonox cylinder and asked questions on critical and pseudocritical temperature. - What would happen if you used it below -7 degrees C? - What are twostage valves? - How does the tubing help? You are asked about end-tidal gas monitoring. What would happen if you switched from isoflurane to sevoflurane? Describe the various types of flowmeters You are asked to check the anaesthetic machine and identify any faults (no pipeline supply, an empty O2 cylinder, no seal under the vaporiser). Check Arterial line set-up - Assess faults: (findings: no pressure on bag, 5% dextrose in bag, unable to flush transducer, venous cannula attached, inappropriate tubing) Urinary catheter with transducer attached for measuring core temperature - Methods of measuring temperature, difference between thermistor + thermocouple - Which metals are used in a thermocouple? - Shown four different graphs of resistance v potential difference: identify graphs for thermistor and thermocouple Machine check - Check circle only - Assess faults (findings: not attached to fresh gas flow, expiratory valve stuck in open position? What would this cause?) Correctly connect an HME filter and sidearm CO2 analyser to a Bain circuit - Describe the points of interest on a normal capnograph trace - Identify a trace showing disconnection and re-breathing - Why does the sidearm sampler tubing have to have a small diameter? Statistics - What is the difference between nominal, ordinal and categorical data? (Type 1 and 2 errors) - What can you do to reduce type 2 error? Temperature measurement You are shown photographs of a nasal probe and an axillary probe. - What are these? - How do they work? 8

- Describe resistance temperature curves for each device - What reference temperature does a thermocouple use? - What is the triple temperature of H2O? - What is the core temperature and how do you measure it? Electrical hazards - What current magnitude can cause microshock? - What techniques are used to safeguard from this common earth? - Identify four electrical symbols 14. Machine check In this case, there are no volatile gases; remember to connect the O2 analyser to the circuit, as well as calibrating it. . Statistics You are shown a negatively skewed distribution: - Is it normally distributed? - Label the mode, median and mean - Would the Mann Whitney U test be suitable for these data ? - Are the data parametric? - If these vaues were to be squared, would this produce a a normal distribution? - Would plotting the log of these values give a normal distribution? Diathermy - Which is the earth electrode? - paediatric suitable for 40 yo? - Should unipolar or bipolar electrodes be used? - You are shown a selection of sine waves: are they for cutting or coagulation? - What are the associated risks? - What is current density? - What is frequency for cutting? - Why does this not cause ventricular fibrillation? - You are shown two circuits, with circuit A isolated: which is safer for i) the patient? ii) staff? 8. Bain circuit check - What happens if it is disconnected at the patient/bag/at fresh gas flow (FGF)? - What is the volume of the outer tubing? - What FGF is needed for normocapnoea in a 100 kg patient (spontaneous ventilation & intermittent positive pressure ventilation)? - What is the effect of shortening the tubing? - What is the effect of lengthening the tubing? 9. You are shown a vitalograph trace - Is it calibrated for body temperature, pressure and saturation (BTPS)? - FEV1 greater than 200 - FVC greater than 250 - Normal FEV1/FVC ratio - Obstructive pattern - No risk associated with spinal

- Would the patient be suitable for upper airway surgery? - What might be the cause of this type of lung disease? Equipment - What are the safety features of lasers? - How do they work? - Describe the characteristics of different types of laser - Which types of endotracheal tubes are appropriate to use? Equipment You are shown a photograph of a Bourdon gauge on an N2O cylinder and asked questions on pressure, critical temperature and the physical properties of nitrous oxide. You are asked to assemble a Bain circuit with a heat and moisture exchanger. - Three different sizes of tubing are available for sampling - which would you choose? - You are then shown three capnography tracings and asked questions on rebreathing, disconnection, end tidal carbon dioxide and where inspiration and expiration start. Measuring equipment You are shown graphs,and asked to identify thermistor and resistance thermometer traces. - What is absolute zero? - Compare the Kelvin and Celsius scales. - You are asked to identify a nasal temperature probe what type of thermometer is this? - Explain how a thermocouple works. Which metals are used? Statistics You are shown a graph representing data from 10 children, with age plotted on the x-axis and weight on the y-axis. Answer the following true/false questions relating to correlationregression analysis: - This is a regression analysis - XX is the regression factor - The correlation coefficient can be 0.7 - The correlation coefficient can be 1.3 - The correlation coefficient of 0.7 is statistically significant Metal endotracheal tube for laser surgery: - What is it used for? - Why is it used in laser surgery? - What is a laser? - What are the hazards of laser? - What precautions would you take if laser is used? You are shown some glass goggles which are labelled: "only for CO2" - Why is this only used for CO2? - What is the wavelength of CO2? - What laser types do you know of? - What is the wavelength range of lasers? Machine check Check the breathing system attached to the anaesthetic machine and state whether you 10

would use this breathing system (circle absorber). Possible faults include: - fresh gas flow was not connected - inspiratory unidirectional valve not working - soda lime not filled properly (not full) You are asked questions about soda lime: - What is it? - What colour change occurs? - Would you use the circle system with the soda lime off? - What flow rates would you use? - What gas is expired out of this? . Equipment station You are asked about a nitrous oxide cylinder pressure gauge: - What makes this specifically a nitrous oxide gauge? - Can this be used for oxygen? Why? - What happens during usage? Why does it not fall? - What state is the nitrous oxide in? - What is the critical temperature? - What is gas and vapour? - Where is it used? what is entonox? You are shown a photograph of a cylinder: - Identify entonox. - What is its composition? - What precautions should be taken in regard to its storage? - What is pseudocritical temperature? - Why is it important? - What are the hazards of using it below the critical temperature? - Who can prescribe it? Machine check Basic anaesthetic machine with the following faults: - No marks for absent pipelines - Oxygen analyser: no battery - Two empty vaporisers on back bar - isoflurane and enflurane vaporisers - No interlock mechanism. O ring missing from the enflurane vaporiser - Could not pressurise the system with enflurane vaporiser turned on. You are shown a photograph of a pulse oximeter monitor - What details can be obtained from this monitor? (pulse rate, SpO2, waveform and signal strength) You are shown a picture of an oxygen dissociation curve, with marked points A and B - What is point A? (90% saturation = 60 mmHg) - What is point B? - What is P50? What are its uses? (to identify various Hb, position of ODC) 11

You are shown another chart containing two curves - You are asked to identify them (ODCs of Myoglobin and hemoglobin) You are shown a chart of absorption characteristics of oxy- and deoxyhaemoglobin - Identify the wavelengths used in the pulse oximeter - Why are there two wavelengths? Why is ther only a pulsatile component? - What are the points marked at around 800 nm? (isobestic point) - What do you obtain with light absorption at that point? (total haemoglobin) You are shown another chart - Where do you see this type of trace commonly? (blood pressure cuff going up on the same side, probe dislodged and corrected) - What are the various sources of error in pulse oximeter?

You are asked about the monaural stethoscope. - What are its uses? - What are the signs of venous air embolism? - Describe the risk factors and treatment. 12. Blood pressure measurement - Take the blood pressure from the model and answer questions: - What is the blood pressure? - Which phase is systolic blood pressure concerned with? - Which phase is diastolic blood pressure concerned with? - What is the formula for mean arterial pressure? - Why is this formula used? - What changes occur in elderly patients? - What differences you expect between men and women? - Is the difference the same throughout life? - What is the size of the blood pressure cuff? - What is the problem of using a small sized cuff? 13. Anaesthetic hazards You are shown a photo of a patient lying on the bed connected to a central venous pressure monitor and other electronic monitors which are connected to earth. There are electrical symbols displayed here and there. - What is the magnitude of current required for microshock? - Are all items of equipment working correctly? - Is the patient not touching any metal? - Why does electrocution not occur? - What do the symbols mean? (isolated circuit, earth potential) 12

- Is earth potential the same at all the places? - How can you make them equal? - What is the maximum allowed difference between earth potential and mains voltage of 240 V? - Select any two symbols from the card and explain what they represent Humidity - Define relative humidity - What is absolute humidity? - What are the units of absolute humidity? - What is the value of absolute humidity in the trachea? - Why is humidity important (give two reasons)? You are shown three charts: Regnault's, wet and dry bulb thermometer, hair hygrometer - Which is the hair hygrometer? - What is the principle of Regnaults hygrometer? You are shown chart with relative humidity lines (100%, 50% etc) Y axis is water vapour g/m3 and X axis shows temperature. - What is the absolute humidity if the dew point is at 30 degrees C Equipment You are shown a picture of Dinamap - What are its operating principles? - You are shown a trace of pressure oscillations within the system; explain how you would derive the systolic blood pressure, diastolic blood pressure and mean arterial pressure from this. - What is the correct size for the blood pressure cuff? Machine check You are asked to check a Bain circuit. There is a big hole in the outer tubing, in the undersurface, where it will attach with the adjustable pressure-limiting (APL) valve (not easily visible) - answer questions on fresh gas flow, minute volume etc. - what will happen if the bag of the circuit fell off suddenly when the patient is breathing spontaneously? 13. Statistics Answer 10 true/false questions (no negative marking): (Regarding different categories of data). 14. Entonox You are shown a photograph of entonox - what is the pseudocritical temperature? - what happens at this temperature? - what is the critical temperature? - does the gauge press reflect the amount left? 13

- who else is authorised to use entonox other than doctors? - describe the 2-stage regulator 15. Anaesthesia hazards You are shown various filters, then asked questions, including: - identify an epidural filter; what is its use? - identify a blood filter; how often it should be changed? - identify a bacterial filter in an anaesthetic breathing circuit; answer questions on dead space - identify a white blood cell (WBC) filter) - what virus is transmitted by WBC? - arrange the following in order of size, starting with the smallest: platelets, red blood cells and coccus 16. Check the arterial line set-up, which might contain the following faults: - venflon cannula with side port, kinked 18G - ordinary iv tubing instead of non-compliant - glucose instead of Hepsal - non-pressurised bag - lots of air in the tubing - how would you zero? - what is high pressure zero? Anaesthetic machine check You are asked to identify the following faults: - no spare O2 cylinder - half empty cylinder - no blanking plug in CO2 cylinder - vaporiser empty - no O ring Equipment - Diathermy: you are shown two plates (one for a child, one for an adult); discuss the current density and frequency used. - Discuss pacemakers in detail; what codes are used (e.g. VVI or DDD etc)? Equipment Humidity: you are shown a photograph of a piece of equipment: - What is it? - Define relative humidity and absolute humidity (you are required to give a very precise definition - remember to mention and define pressure/temperature) You are shown drawings (taken from Parbrook): - Which of these drawings is the hair hygrometer? - Which of these drawings is the Regnaults hygrometer? - Which of these drawings is the wet/dry bulb hygrometer? - How does the latter equipment work? - Define the latent heat of evaporation - How would you relate the readings on the thermometers to the humidity?

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You have two gas samples, one at 20 degrees C, one at 37 degrees C; both have a relative humidity of 50%: - which one has the highest absolute humidity? Equipment You are given a blood giving set: - What is filtered by this? - What is this filter used for? - What is this type of filter called? You are shown a white blood cell (WBC) filter: - What common infectious agent is carried in WBCs? - What percentage of the population have cytomegalovirus? You are given an epidural filter: - What is this used for? - What does it filter? - What is the pore size? - How does it filter viruses? You are shown a heat-moisture exchanger: - What is this used for? - Would it be appropriate for use in a 10 kg child breathing spontaneously? You are asked to examine a microscope slide of a blood film, and see a red blood cell, a platelet and a staphylococcus aureus. - Which is biggest? - Which is smallest? 11. Machine check You are asked to carry out an equipment check on an old machine with no pipelines, two Tec-5 vaporisers. Possible faults include: - O2 analyser not working - CO2 missing, no blanking plug - Both vaporisers had one O ring missing - O2 failure alarm not working Electrical hazard You are shown a picture of a man lying on a surgical table connected to a central venous pressure transducer with current leaking. He is also connected to an ECG monitor: - How much current is needed to produce a microshock? - Why is the microshock current not being transmitted to the ECG? - In an isolated floating circuit, how is the patient protected from electric shock? - What happens if a 1 amp current is delivered to you? - How is the earth potential made uniform? - What do the electrical symbols represent?

1. Explain how cardiac output is measured using a thermodilution technique.

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2. Describe how the partial pressure of oxygen in a blood sample is measured using a Clark electrode. 3. Differentiate between the terms heat and temperature. 4. Briefly explain the principles of a mercury thermometer, indicating its advantages and disadvantages. 5. How does a fall in temperature influence blood gas solubility and acid-base values? 6. Explain the physical principles of ultrasound imaging. 7. Briefly explain the principles of Doppler ultrasound, used to measure cardiac output by echocardiography. 8. Briefly describe the differences between laminar and turbulent flow. 9. List the factors that increase the probability of turbulent flow. 10. Briefly describe the measurement of blood pressure using an automated oscillometric non-invasive blood pressure monitor. 11. Briefly outline the problems associated with this kind of monitor. 12. Briefly explain the causes of the differences between measured end tidal and arterial partial pressures of carbon dioxide. 13. Briefly explain the principles of the thermistor, indicating its advantages and disadvantages. 14. Outline the principles of the pneumotachograph. 15. What factors affect the accuracy of this device? 16. Compare two methods for measuring humidity. 17. Briefly discuss the factors which influence the measurement of oxygen saturation using a pulse oximeter. ArticleDate:20040907 SiteSection: Article Comparison of two laryngoscope blades You are asked to identify two laryngoscope blades (Macintosh and Robertshaw). Give four uses for Magill forceps Equipment You are shown an oesophageal stethoscope (what are its uses?) and a urethral catheter with a thermocouple attached to it for bladder temperature monitoring. - Answer questions on temperature - What is the SI unit for temperature? - Calibration scales? - Describe the use of a thermocouple? - Can you see the beck effect? - What is the triple-point of water?

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An actor poses as a patient; apply peripheral nerve stimulation (PNS) electrodes to his wrist and describe their operation. You are shown pictures of train-of-four (TOF) and double-burst stimulation (DBS), showing various types of block: discuss the use and specifications of nerve stimulators. 9. Safety Answer questions on diathermy plates. 10. Equipment check You are shown a metal Miller blade and a plastic fibreoptic Macintosh blade - Discuss the differences and uses of the two pieces of equipment - What is the pressor response to intubation? - List four uses of Magills forceps Filters Discuss depth, screen, leucocyte, and epidural What is each type used for? What might each one filter out? What problems are associated with paediatric heat and moisture exchanging filters? Rank the following, from largest to smallest: red blood cells, platelets, cocci Oxygen measurement You are shown a picture of a fuel cell. What is it used for? You are then shown a circuit diagram for a fuel cell. What is solution is contained in a fuel cell? What is the anode made of? What sort of reaction occurs at the anode? Does a fuel cell need replacing after use? Why? How is a fuel cell calibrated? What is the other circuit called? polarographic electrode 12. Circle check Faults with this included: not being connected to the fresh gas flow, a stuck expiratory valve, soda lime not full. What comes out of the apl valve? Can the circle be used without a CO2 absorber? What colour are the indicators? 13. Pulse oximetry

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You are shown a picture of a pulse oximeter. What two pieces of information does this equipment provide? what are the values of p50 and p90? Why is the p50 value useful? You are shown graph for myoglobin: what does this represent? How does a pulse oximeter work? How does pulse oximetry differentiate between arterial, venous and tissue oxygen absorption? What is the difference between pulse oximeters and oximeters found in laboratories?

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