Clinical subjects appropriate for a specialist anaesthesiologist
Domain 2 converts that science into bedside decisions: airway strategy, coexisting disease, obstetric, paediatric and trauma anaesthesia, resuscitation, intensive care and postoperative management. Part I presents a vignette with one best answer; Part II asks you to defend the choice and to state what you would do next.
Anchor answers in physiology and an algorithm
- Airway. Predict difficulty, position and preoxygenate (high-flow nasal oxygen prolongs safe apnoea), and use rapid-sequence induction when aspiration risk is real. For "cannot intubate, cannot oxygenate", move to front-of-neck access without delay; for an anticipated difficult airway, awake tracheal intubation.
- Coexisting disease. Aortic stenosis has a fixed stroke volume: preserve sinus rhythm, preload and afterload, avoid tachycardia, and choose phenylephrine over vasodilators. In pulmonary hypertension avoid hypoxia, hypercapnia and acidosis. Myasthenia gravis gives marked sensitivity to non-depolarising agents.
- Crises. Anaphylaxis under anaesthesia: stop the trigger, 100% oxygen, rapid crystalloid, 50 microgram IV adrenaline boluses. Malignant hyperthermia: stop volatile and suxamethonium, dantrolene 2.5 mg/kg, hyperventilate, cool, treat hyperkalaemia. Local anaesthetic toxicity: lipid emulsion.
- Intensive care. ARDS: 6 mL/kg predicted body weight, plateau ≤30 cmH2O, titrated PEEP, prone for ≥16 h if P/F <150. Sepsis: antibiotics within 1 h, 30 mL/kg crystalloid, noradrenaline to MAP ≥65 mmHg.
Worked example
A 70 kg patient has seizures then ventricular arrhythmia after 30 mL of 0.5% bupivacaine for a fascia iliaca block. That is 30 × 5 mg/mL = 150 mg, or 2.1 mg/kg - above the 2 mg/kg ceiling. Give 100% oxygen, control seizures with a benzodiazepine, and start 20% lipid emulsion at 1.5 mL/kg = 105 mL as a bolus, followed by 0.25 mL/kg/min ≈ 17.5 mL/min; repeat the bolus if the circulation stays unstable and continue for at least 15 min after stability.
Traps that cost marks
Never give more local anaesthetic to "settle" early toxicity. In LAST avoid vasopressin, calcium-channel blockers, beta-blockers, propofol boluses and large adrenaline doses; small boluses (<1 microgram/kg) are acceptable. Toxicity often begins with agitation or perioral tingling, not arrhythmia. In ARDS set tidal volume on predicted body weight - 50 + 0.91(height cm − 152.4) for men, 45.5 + 0.91(height cm − 152.4) for women - and watch plateau, not peak, pressure.