D7.i · Inotropes & Vasopressors

This viva will examine sympathomimetic pharmacology. How does the activity and metabolism of metaraminol compare to adrenaline and why?

This viva is about adrenaline and basic pharmacology. An ampoule of adrenaline contains the active drug and excipients (additives). What is the role of the excipient?

This station will explore your knowledge of Catecholamines. This is adrenaline (epinephrine). What are the important STRUCTURAL components? (Image removed from report.)

This viva tested knowledge of cardiovascular physiology. It discussed cardiac output, stroke volume, sarcomere length myocardial contractility, the role of calcium and then related pharmacology of drugs that increase cardiac contractility including catecholamines and digoxin.

This viva tested knowledge of cardiovascular physiology and pharmacology, the Frank Starling mechanism, venous return and stroke volume. It went on to discuss cardiac output measurement and the pharmacology of milrinone, West’s zones of the lung and pulmonary vascular resistance.

This Viva tested knowledge on cardiovascular physiology and measurement. It explored understanding of cardiac pressure waves, alterations in these with vasopressor infusion and an understanding of invasive pressure measurement.

This Viva tested knowledge of the hypersensitivity reactions. It began by asking about different types of hypersensitivity reactions, sought examples for each and also covered aspects of histamine, histamine receptors and adrenaline. Overall most candidates performed well, with knowledge of histamine and histamine receptors being a consistent area of weakness.

This Viva explored knowledge of the control of the heart rate. It assessed knowledge of the origin of the heart rate, its regulation, and catecholamines. Most candidates performed well. Anatomical location of the SA node, ionic currents related to the action potential, structure-activity of catecholamines and dobutamine pharmacokinetics were areas of weakness.

The initial information given to the candidates was – An anaesthetist calls you to request an ICU bed for a patient suffering from spina bifida who has just suffered what is believed to be an adverse reaction shortly after induction of anaesthesia. Classify allergic reactions. In this viva candidates were asked to explain and classify allergic reactions, the pharmacological basis to their treatment (eg what are the mechanisms by which adrenaline is used for anaphylaxis) and to list common agents (latex was commonly overlooked) in ICU practice that are associated with allergic reactions.

The initial information given to the candidates was – This viva will test your knowledge about the use of diuretics, pharmacokinetics and dynamics. And Use of drugs during a cardiac arrest. Candidates were asked to explain mechanism of action of diuretics, in particular frusemide. Candidates were also tested upon the basis that various vasoactive drugs (eg adrenaline and vasopressin) are used in cardiac arrest, in particular their mechanism of action and routes of administration.

The initial information given to the candidates was - This station will explore your knowledge of the pharmacology and physiology of noradrenaline. Discuss the pharmacologic effects of noradrenaline on the human heart in-vivo. This viva explored the candidates’ knowledge in relation to the following points Pharmacology of noradrenaline Pressure-Volume Loop of the cardiac cycle Mark on the Pressure-Volume Loop the changes you would expect for an adult patient infused noradrenaline at 10 mcg/min. Explain the consequences of a noradrenaline infusion on myocardial oxygen consumption, work and efficiency. Dobutamine infusion of 5 mcg/kg/min and affect the Pressure-Volume Loop Examination feedback: This viva tested knowledge related to cardiac cycle, P-V loop, inotropes and most importantly a candidates ability to integrate those topics and then discuss them. Generally candidates knowledge in describing the basic P-V loop were sound, but were weaker in explaining how the P-V loop changed with changes in physiology and pharmacological intervention. Candidates were expected to generate discussions relating to the impact in changes to afterload, pre load and contractility as well as concept of potential energy as it elated to the P-V loop.

CH2 CH2 NH2 Candidates were expected to recognise ‘phenylethylamine’ and appreciate that it is the precursor molecule for the naturally occurring catecholamines. A brief overview of its structure activity relationships, particularly with respect to substitutions on the phenyl ring, β carbon and amine group (producing dopamine, adrenaline and noradrenaline) was expected. Questioning then progressed to discuss the pharmacology of noradrenaline in more detail. Changing questions, candidates were asked to provide a very brief overview of what the autonomic nervous system was before exploring the physiology of the valsalva manoeuvre in some detail. Syllabus: G3a2d, G3a2b and G3a1

Cardiogenic shock (BP 90/60, CI 1.8, SVR 1500). What drugs would you use to increase the blood pressure?