Fellowship of the Royal College of Anaesthetists (FRCA) General and Clinical Anaesthesia Syllabus

General and Clinical Anaesthesia syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for General and Clinical Anaesthesia in Fellowship of the Royal College of Anaesthetists (FRCA), not a summary of it.

1. 1

   Preoperative Assessment and Optimisation

   6 topics

   • History, examination and risk stratification
     • ASA classification and functional capacity
     • Cardiopulmonary exercise testing
   • Investigations and preoperative testing
   • Assessment of the airway
     • Predictors of difficult intubation and ventilation
   • Comorbidity optimisation
     • Cardiac, respiratory and diabetic patients
   • Fasting, premedication and aspiration prophylaxis
   • Consent, capacity and shared decision-making
2. 2

   Conduct of Anaesthesia

   6 topics

   • Induction techniques
     • Intravenous, inhalational and rapid sequence induction
   • Maintenance and monitoring standards
     • AAGBI minimum monitoring standards
   • Airway management
     • Supraglottic devices and tracheal intubation
     • Difficult Airway Society guidelines and rescue techniques
   • Intravenous access and fluid therapy
   • Emergence and extubation
   • Positioning and prevention of injury
3. 3

   Postoperative and Recovery Care

   6 topics

   • The recovery room and discharge criteria
   • Postoperative nausea and vomiting
     • Risk scoring and multimodal prophylaxis
   • Acute pain management
     • Multimodal analgesia and patient-controlled analgesia
   • Postoperative oxygen therapy and respiratory care
   • Enhanced recovery after surgery pathways
   • Recognition and management of the deteriorating patient
4. 4

   Regional Anaesthesia

   5 topics

   • Neuraxial anaesthesia
     • Spinal anaesthesia technique and physiology
     • Epidural and combined spinal-epidural techniques
     • Complications and neurological injury
   • Peripheral nerve blocks
     • Upper and lower limb blockade
     • Truncal and fascial plane blocks
   • Ultrasound guidance in regional anaesthesia
   • Local anaesthetic systemic toxicity management
   • Anticoagulation and regional techniques
5. 5

   Perioperative Medicine and Complications

   6 topics

   • Fluid balance and goal-directed therapy
   • Perioperative temperature management
   • Blood transfusion and patient blood management
     • Major haemorrhage protocols
   • Anaesthetic emergencies
     • Anaphylaxis, malignant hyperthermia and laryngospasm
     • Cardiac arrest and resuscitation in theatre
   • Awareness under anaesthesia
   • Venous thromboembolism prophylaxis
6. 6

   Patient Safety, Ethics and Professionalism

   6 topics

   • Human factors and non-technical skills
   • Critical incident reporting and learning
   • Consent, confidentiality and medical law
   • End-of-life care and DNACPR decisions
   • Infection prevention and control
   • Checklists and the WHO surgical safety checklist

General and Clinical Anaesthesia flashcards for Fellowship of the Royal College of Anaesthetists (FRCA)

20 of 51 cards from the General and Clinical Anaesthesia deck — real questions with worked answers.

1. What does the ASA Physical Status Classification grade I through VI represent?

   I: normal healthy patient; II: mild systemic disease; III: severe systemic disease (not incapacitating); IV: severe systemic disease that is a constant threat to life; V: moribund, not expected to survive 24 h without operation; VI: brain-dead organ donor. An 'E' suffix denotes emergency surgery.

2. What is a Metabolic Equivalent (MET) and what value indicates adequate functional capacity for surgery?

   1 MET = resting oxygen consumption of about $3.5\,\text{mL}\,\text{kg}^{-1}\,\text{min}^{-1}$. The ability to achieve $\geq 4$ METs (e.g. climbing two flights of stairs) suggests adequate cardiopulmonary reserve and a lower perioperative risk.

3. List the components of the Mallampati classification and what each class predicts.

   Assessed with mouth open, tongue out, no phonation. Class I: soft palate, uvula, fauces, pillars visible; II: soft palate, uvula, fauces; III: soft palate and base of uvula; IV: hard palate only. Classes III–IV predict potentially difficult laryngoscopy/intubation.

4. What bedside airway measurements suggest a difficult intubation (the LEMON / 3-3-2 rule)?

   3-3-2 rule: <3 finger-breadths mouth opening (inter-incisor distance), <3 finger-breadths from chin to hyoid (thyromental approximation), <2 finger-breadths from hyoid to thyroid notch. Also: thyromental distance <6.5 cm, restricted neck movement, and prominent incisors predict difficulty.

5. Define the Cormack–Lehane grading of the laryngeal view at direct laryngoscopy.

   Grade 1: full glottis visible; Grade 2a: partial glottis, 2b: only arytenoids/posterior cords; Grade 3: epiglottis only; Grade 4: neither glottis nor epiglottis visible. Grades 3–4 indicate a difficult view.

6. What are the standard preoperative fasting guidelines (the '6-4-2 rule')?

   6 hours for solid food and non-human milk; 4 hours for breast milk; 2 hours for clear fluids. Clear fluids may be encouraged up to 2 hours before induction in elective patients without aspiration risk.

7. Name the three pharmacological strategies for aspiration prophylaxis and an example of each.

   1) Raise gastric pH: H2 antagonist (ranitidine) or proton-pump inhibitor (omeprazole); 2) Neutralise existing acid: non-particulate antacid (sodium citrate $0.3\,\text{M}$); 3) Promote gastric emptying / increase lower oesophageal sphincter tone: prokinetic (metoclopramide).

8. What are the three core elements required for valid consent?

   The patient must have capacity, the consent must be given voluntarily (free from coercion), and it must be informed (material risks, benefits, and reasonable alternatives disclosed) — the standard set by Montgomery v Lanarkshire (2015).

9. State the four components of the test for mental capacity under the Mental Capacity Act 2005.

   The person must be able to: 1) understand the relevant information, 2) retain it (long enough to decide), 3) use or weigh it as part of the decision, and 4) communicate the decision. Failure of any one component (due to impairment of mind/brain) means they lack capacity for that decision.

10. What is rapid sequence induction (RSI) and its classical components?

    A technique to secure the airway quickly in patients at aspiration risk: preoxygenation, a predetermined induction dose with a rapid-onset muscle relaxant (suxamethonium $1{-}1.5\,\text{mg}\,\text{kg}^{-1}$ or rocuronium $1.2\,\text{mg}\,\text{kg}^{-1}$), application of cricoid pressure, avoidance of bag-mask ventilation, and prompt cuffed-tube intubation.

11. What are the AAGBI minimum monitoring standards required from before induction of anaesthesia?

    Pulse oximetry ($SpO_2$), non-invasive blood pressure, ECG, capnography (end-tidal $CO_2$), and inspired/expired oxygen and anaesthetic agent concentration. For paralysed patients, a peripheral nerve stimulator; temperature monitoring for procedures >30 min.

12. Define MAC (minimum alveolar concentration) and give approximate MAC values for sevoflurane, isoflurane and desflurane.

    MAC is the alveolar concentration of a volatile agent (at 1 atm) that prevents movement to a surgical stimulus in 50% of patients. Sevoflurane ≈ 2.0%, isoflurane ≈ 1.15%, desflurane ≈ 6.0% (in $O_2$).

13. List factors that increase and decrease MAC.

    Increase MAC: youth (infants), hyperthermia, hyperthyroidism, chronic alcohol use, acute amphetamine/cocaine, hypernatraemia. Decrease MAC: old age, hypothermia, pregnancy, opioids/sedatives, acute alcohol, hyponatraemia, lithium, $\alpha_2$ agonists, severe hypoxia/hypotension.

14. Describe the steps of the difficult airway 'can't intubate, can't oxygenate' (CICO) emergency pathway.

    Declare CICO, give 100% oxygen, ensure full neuromuscular blockade, and proceed to emergency front-of-neck access (eFONA) — a scalpel-bougie-tube cricothyroidotomy through the cricothyroid membrane (DAS guidance).

15. State the formula for daily maintenance fluid requirement using the 4-2-1 rule.

    Hourly maintenance: $4\,\text{mL}\,\text{kg}^{-1}\,\text{h}^{-1}$ for the first 10 kg, $+2\,\text{mL}\,\text{kg}^{-1}\,\text{h}^{-1}$ for the next 10 kg, $+1\,\text{mL}\,\text{kg}^{-1}\,\text{h}^{-1}$ for each kg above 20 kg. E.g. a 70 kg adult: $40+20+50 = 110\,\text{mL}\,\text{h}^{-1}$.

16. What are the criteria for safe extubation and the difference between awake and deep extubation?

    Safe extubation requires reversal of neuromuscular block (train-of-four ratio >0.9), adequate spontaneous ventilation, protective airway reflexes, haemodynamic stability and oxygenation. Awake extubation: patient obeys commands, lower aspiration risk; deep extubation: performed under anaesthesia to avoid coughing/straining but with higher airway-obstruction/aspiration risk.

17. Which nerves are at risk from improper positioning, and how are they protected?

    Ulnar nerve (avoid elbow compression/pronation), common peroneal nerve (pad fibular head in lithotomy/lateral), brachial plexus (avoid arm abduction >90° and external rotation), and the saphenous/sciatic nerves. Use padding, neutral joint positioning, and avoid prolonged pressure.

18. List the standard discharge criteria from the post-anaesthesia care unit (recovery).

    Often using a modified Aldrete score: stable airway/respiration with adequate oxygenation, stable cardiovascular signs, full consciousness/orientation, controlled pain and nausea, normothermia, no active bleeding, and adequate motor recovery (e.g. resolving regional block).

19. What are the four main risk factors in the Apfel score for postoperative nausea and vomiting (PONV)?

    1) Female sex, 2) non-smoker, 3) history of PONV or motion sickness, 4) postoperative opioid use. With 0,1,2,3,4 factors the approximate PONV risk is 10%, 20%, 40%, 60%, 80%.

20. Match common antiemetics to their receptor targets used in PONV prophylaxis.

    Ondansetron: 5-HT$_3$ receptor antagonist; dexamethasone: glucocorticoid (mechanism uncertain); cyclizine: H$_1$ antihistamine; prochlorperazine/droperidol: dopamine D$_2$ antagonists; aprepitant: NK$_1$ receptor antagonist; hyoscine: muscarinic antagonist.

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