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

Describe the WHO analgesic ladder for acute and chronic pain management.

Step 1: non-opioid (paracetamol $\pm$ NSAID) $\pm$ adjuvant; Step 2: weak opioid (codeine, tramadol) + non-opioid $\pm$ adjuvant; Step 3: strong opioid (morphine) + non-opioid $\pm$ adjuvant. Acute pain is often managed in reverse, stepping down as pain settles.

What is multimodal analgesia and why is it preferred?

Combining analgesics with different mechanisms (e.g. paracetamol, NSAIDs, opioids, local anaesthetics, ketamine, gabapentinoids) to achieve additive/synergistic pain relief while minimising the dose and side effects (especially opioids) of any single drug.

State the equation for the alveolar partial pressure of oxygen (alveolar gas equation).

$$P_AO_2 = F_iO_2 \,(P_{atm} - P_{H_2O}) - \frac{P_aCO_2}{R}$$ where $P_{H_2O}\approx 6.3\,\text{kPa}$ at 37 °C and the respiratory quotient $R\approx 0.8$.

List the key elements of an Enhanced Recovery After Surgery (ERAS) pathway.

Preoperative counselling and optimisation, avoidance of prolonged fasting/carbohydrate loading, minimally invasive surgery, opioid-sparing multimodal analgesia, goal-directed fluid therapy, normothermia, early removal of drains/catheters, early mobilisation and early enteral feeding.

What are the components of the ABCDE approach to the deteriorating patient?

A: Airway (patency, protect); B: Breathing (rate, $SpO_2$, auscultation, give oxygen); C: Circulation (pulse, BP, capillary refill, IV access, fluids); D: Disability (AVPU/GCS, pupils, glucose); E: Exposure (full examination, temperature). Reassess after each intervention.

What is the National Early Warning Score 2 (NEWS2) and which parameters does it use?

An aggregate physiological scoring system using respiratory rate, $SpO_2$ (two scales), supplemental oxygen, systolic blood pressure, pulse rate, level of consciousness (ACVPU), and temperature. A score $\geq 7$ (or 3 in a single parameter) triggers urgent clinical review.

Compare spinal and epidural anaesthesia (site, dose, onset).

Spinal (subarachnoid): drug injected into CSF below L2 (typically L3/4), small dose (e.g. 2–3 mL bupivacaine), rapid dense block, single-shot. Epidural: drug into the epidural space at any level, large dose, slower onset, catheter allows continuous/titratable block; less dense ('differential') block.

What are the recognised contraindications to neuraxial (central) blockade?

Absolute: patient refusal, local infection at the site, raised intracranial pressure, uncorrected coagulopathy/therapeutic anticoagulation, severe hypovolaemia/uncorrected shock. Relative: systemic sepsis, fixed cardiac output states (severe aortic stenosis), certain neurological diseases, severe spinal deformity.

List the early signs and the immediate management of local anaesthetic systemic toxicity (LAST).

Early signs: perioral tingling, tinnitus, metallic taste, agitation, confusion, then seizures, and cardiovascular collapse/arrhythmias. Management: stop injection, ABC, 100% oxygen, control seizures (benzodiazepine), and give IV lipid emulsion (Intralipid 20%): bolus $1.5\,\text{mL}\,\text{kg}^{-1}$ then infusion $15\,\text{mL}\,\text{kg}^{-1}\,\text{h}^{-1}$.

State the maximum safe doses of lidocaine and bupivacaine (with and without adrenaline).

Lidocaine: $3\,\text{mg}\,\text{kg}^{-1}$ plain, $7\,\text{mg}\,\text{kg}^{-1}$ with adrenaline. Bupivacaine (and levobupivacaine): $2\,\text{mg}\,\text{kg}^{-1}$ (adrenaline does not significantly increase this). Always calculate based on lean/ideal body weight.

How do you convert a percentage concentration of a drug to $\text{mg}\,\text{mL}^{-1}$?

A 1% solution contains $10\,\text{mg}\,\text{mL}^{-1}$ (1 g per 100 mL). So bupivacaine 0.5% = $5\,\text{mg}\,\text{mL}^{-1}$; lidocaine 2% = $20\,\text{mg}\,\text{mL}^{-1}$; adrenaline 1:1000 = $1\,\text{mg}\,\text{mL}^{-1}$.

What is the recommended ultrasound needle approach in regional anaesthesia and its main advantage?

The 'in-plane' approach, where the whole needle shaft and tip are visualised along the long axis of the ultrasound beam, allowing real-time tracking of needle tip relative to nerve and vessels, reducing the risk of vascular puncture and intraneural injection.

Summarise the recommended timing of neuraxial procedures relative to LMWH.

Prophylactic LMWH: wait at least 12 h after the last dose before neuraxial puncture/catheter removal; therapeutic (treatment) LMWH: wait at least 24 h. After the procedure or catheter removal, wait at least 4 h before the next LMWH dose (regional anaesthesia/anticoagulation guidelines).

What dynamic parameters guide goal-directed fluid therapy and what threshold suggests fluid responsiveness?

Stroke volume variation (SVV) and pulse pressure variation (PPV) in ventilated patients; SVV or PPV >13% suggests the patient is on the steep part of the Frank–Starling curve and likely to be fluid-responsive. A stroke-volume rise >10% after a fluid bolus confirms responsiveness.

Define perioperative inadvertent hypothermia and list its main consequences.

Core temperature <36.0 °C. Consequences: increased surgical-site infection, coagulopathy and bleeding, increased transfusion, prolonged drug action, shivering (raising oxygen demand), myocardial events, and delayed recovery. NICE recommends warming and maintaining temperature $\geq 36.5$ °C before induction.

What are the patient blood management 'three pillars'?

1) Optimise the patient's own red cell mass (treat preoperative anaemia, e.g. iron); 2) minimise blood loss and bleeding (surgical haemostasis, antifibrinolytics like tranexamic acid, cell salvage); 3) optimise tolerance of anaemia (restrictive transfusion threshold, typically transfuse if Hb <70 g/L, or <80 g/L in cardiac disease).

List the steps of the immediate management of suspected anaphylaxis under anaesthesia.

Stop the trigger, call for help, ABC, give 100% oxygen, lay flat and raise legs. Adrenaline IM $0.5\,\text{mg}$ (or IV $50\,\mu\text{g}$ boluses by an anaesthetist), rapid IV crystalloid bolus, then adjuncts: chlorphenamine, hydrocortisone, and a bronchodilator. Take mast cell tryptase samples and refer for investigation.

What triad classically suggests malignant hyperthermia, and what is the definitive treatment?

Triggered by volatile agents/suxamethonium: unexplained rising end-tidal $CO_2$, tachycardia, masseter/generalised muscle rigidity, then hyperthermia, hyperkalaemia and metabolic acidosis. Treatment: stop trigger, hyperventilate with 100% $O_2$, and give dantrolene $2.5\,\text{mg}\,\text{kg}^{-1}$ IV repeated to a max of $10\,\text{mg}\,\text{kg}^{-1}$, plus active cooling and treat hyperkalaemia/arrhythmias.

What is accidental awareness under general anaesthesia (AAGA) and how is it monitored/prevented?

AAGA is consciousness/recall during intended general anaesthesia. Risk factors: RSI, obstetric/cardiac surgery, neuromuscular blockade, TIVA, light anaesthesia. Prevention: adequate anaesthetic depth, end-tidal agent monitoring (volatile), processed EEG/BIS monitoring for TIVA, and minimum-alveolar-concentration vigilance. (NAP5 reported incidence ≈1 in 19,000.)

Outline a standard pharmacological VTE prophylaxis strategy and the alternative when contraindicated.

Risk-assess all surgical patients; for those at risk give low-molecular-weight heparin (e.g. enoxaparin) once the bleeding risk is acceptable. When pharmacological prophylaxis is contraindicated, use mechanical methods: anti-embolism (graduated compression) stockings and/or intermittent pneumatic compression devices. Early mobilisation and hydration are also key.

What is meant by 'human factors' / non-technical skills in anaesthesia, and name a recognised framework.

The cognitive, social and personal-resource skills that complement technical ability and reduce error: situation awareness, decision-making, communication, teamwork, leadership and task management. The Anaesthetists' Non-Technical Skills (ANTS) framework formally categorises these four domains.

What is a 'never event' and why are critical incidents reported?

A never event is a serious, largely preventable patient-safety incident that should not occur if national safety guidance is implemented (e.g. wrong-site block, retained instrument, wrong-route drug administration). Incidents are reported (e.g. via the NRLS/local systems) to enable a culture of learning, root-cause analysis and system improvement rather than individual blame.

Distinguish capacity, consent and confidentiality in medical law, and when confidentiality may be breached.

Capacity: ability to make a specific decision; Consent: voluntary, informed authorisation by a person with capacity; Confidentiality: duty to protect patient information. Confidentiality may be breached with consent, when required by law (e.g. notifiable diseases, court order), or in the public interest (risk of serious harm to the patient or others).

What is a DNACPR decision and does it limit other treatments?

A 'Do Not Attempt Cardiopulmonary Resuscitation' decision means CPR will not be attempted if the patient suffers cardiac/respiratory arrest. It applies ONLY to CPR and does not restrict any other treatment (oxygen, antibiotics, fluids, surgery, etc.). It should involve discussion with the patient (or those close to them if they lack capacity) — established by the Tracey judgment.

List the WHO 'Five Moments for Hand Hygiene'.

1) Before touching a patient, 2) before a clean/aseptic procedure, 3) after body-fluid exposure risk, 4) after touching a patient, 5) after touching patient surroundings.

Name the three phases (and a key check from each) of the WHO Surgical Safety Checklist.

1) Sign In (before induction): confirm identity, site, procedure, consent, allergies, airway/aspiration risk; 2) Time Out (before skin incision): team introductions, confirm patient/site/procedure, antibiotic prophylaxis, anticipated critical events, imaging; 3) Sign Out (before patient leaves theatre): confirm procedure recorded, instrument/swab/needle counts correct, specimen labelling, equipment issues, recovery plan.

What is the train-of-four (TOF) ratio and what value confirms adequate recovery from neuromuscular block?

TOF delivers four supramaximal stimuli at 2 Hz; the TOF ratio is the amplitude of the 4th twitch divided by the 1st (T4/T1). A TOF ratio $\geq 0.9$ indicates adequate recovery and is the threshold for safe extubation. Fade indicates residual non-depolarising block.

How does sugammadex reverse rocuronium/vecuronium, and what is the suxamethonium/neostigmine alternative?

Sugammadex is a modified $\gamma$-cyclodextrin that encapsulates aminosteroid relaxants (rocuronium, vecuronium), rapidly reducing free drug; dose 2–16 $\text{mg}\,\text{kg}^{-1}$ depending on block depth. Neostigmine (an anticholinesterase, given with glycopyrronium/atropine) reverses non-depolarising block by increasing acetylcholine but is ineffective against deep block. Suxamethonium (depolarising) is not reversed — it is metabolised by plasma cholinesterase.

What is the difference between Type 1 and Type 2 respiratory failure by blood gas?

Type 1 (hypoxaemic): $P_aO_2 < 8\,\text{kPa}$ with normal or low $P_aCO_2$ — a problem of oxygenation/V-Q mismatch. Type 2 (hypercapnic): $P_aO_2 < 8\,\text{kPa}$ with $P_aCO_2 > 6\,\text{kPa}$ — a problem of alveolar ventilation/'pump' failure.

State target oxygen saturation ranges for postoperative oxygen therapy in different patient groups.

For most patients, target $SpO_2$ of 94–98%. For patients at risk of type 2 (hypercapnic) respiratory failure, e.g. COPD, target a controlled 88–92% to avoid loss of hypoxic drive and worsening hypercapnia.

What is goal-directed therapy's physiological basis on the Frank–Starling curve?

The Frank–Starling relationship links preload (end-diastolic volume) to stroke volume. On the steep (ascending) portion, fluid boluses raise stroke volume; on the flat (plateau) portion, further fluid yields little gain and risks overload. Goal-directed therapy titrates fluid boluses to keep the patient at the optimal point of the curve, using stroke volume response (>10% rise) to guide each bolus.