Fellowship of the Royal College of Anaesthetists (FRCA) Intensive Care, Pain Medicine and Resuscitation Syllabus

Intensive Care, Pain Medicine and Resuscitation syllabus — full chapter and topic list

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

1. 1

   Critical Care Fundamentals

   5 topics

   • Admission, triage and levels of care
   • Shock states and haemodynamic support
     • Septic, cardiogenic, hypovolaemic and distributive shock
   • Sepsis recognition and management
     • Sepsis Six and source control
   • Multi-organ dysfunction syndrome
   • Scoring systems and outcome prediction
2. 2

   Organ Support

   5 topics

   • Mechanical ventilation
     • Modes of ventilation and lung-protective strategies
     • ARDS management
   • Renal replacement therapy
   • Cardiovascular support and mechanical assist devices
   • Nutrition in critical illness
   • Sedation, analgesia and delirium management
3. 3

   Specific Critical Illness

   5 topics

   • Acute respiratory failure
   • Acute kidney injury
   • Neurological emergencies
     • Status epilepticus and raised intracranial pressure
   • Poisoning and overdose
   • Brainstem death and organ donation
4. 4

   Resuscitation and Emergencies

   5 topics

   • Adult advanced life support
     • Shockable and non-shockable rhythms
   • Paediatric and neonatal resuscitation
   • Trauma and major haemorrhage management
   • Peri-arrest arrhythmias
   • Post-resuscitation care
5. 5

   Pain Medicine

   6 topics

   • Assessment and classification of pain
   • Acute pain services and management
   • Chronic pain management
     • Neuropathic pain and pharmacological ladder
   • Cancer pain and palliative care
   • Interventional pain techniques
   • Psychological and multidisciplinary approaches

Intensive Care, Pain Medicine and Resuscitation flashcards for Fellowship of the Royal College of Anaesthetists (FRCA)

24 of 55 cards from the Intensive Care, Pain Medicine and Resuscitation deck — real questions with worked answers.

1. What are the UK Intensive Care Society levels of care, from Level 0 to Level 3?

   Level 0: normal ward care. Level 1: ward care with additional monitoring/support or recently stepped down from higher levels. Level 2: HDU — single organ support (excluding advanced respiratory) and more detailed observation, e.g. 1:2 nursing. Level 3: ICU — advanced respiratory support alone, or support of $\geq 2$ organ systems, typically 1:1 nursing.

2. Define shock and list the four broad physiological categories.

   Shock is inadequate tissue oxygen delivery/perfusion to meet metabolic demand, causing cellular hypoxia. Categories: hypovolaemic, cardiogenic, obstructive, and distributive (e.g. septic, anaphylactic, neurogenic).

3. Give the formula for oxygen delivery ($DO_2$) and a normal value.

   $$DO_2 = CO \times CaO_2 = CO \times (1.34 \times Hb \times SaO_2 + 0.003 \times PaO_2)$$ Normal $DO_2 \approx 1000\ \text{mL min}^{-1}$ (or $\approx 500\text{–}550\ \text{mL min}^{-1}\,\text{m}^{-2}$ indexed).

4. What is the Surviving Sepsis Campaign 'Hour-1' bundle?

   Measure lactate (re-measure if $>2$); obtain blood cultures before antibiotics; give broad-spectrum antibiotics; begin rapid crystalloid $30\ \text{mL kg}^{-1}$ for hypotension or lactate $\geq 4\ \text{mmol L}^{-1}$; start vasopressors if hypotensive during/after fluids to maintain MAP $\geq 65\ \text{mmHg}$.

5. State the Sepsis-3 definitions of sepsis and septic shock.

   Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection, identified as an acute rise in SOFA score $\geq 2$ points. Septic shock: sepsis with vasopressor requirement to maintain MAP $\geq 65\ \text{mmHg}$ AND lactate $>2\ \text{mmol L}^{-1}$ despite adequate fluid resuscitation.

6. What is the qSOFA score and what defines a positive screen?

   qSOFA (quick SOFA) is a bedside screen: respiratory rate $\geq 22\ \text{min}^{-1}$, altered mentation (GCS $<15$), systolic BP $\leq 100\ \text{mmHg}$ — 1 point each. A score $\geq 2$ identifies patients at higher risk of poor outcome.

7. What is the first-line vasopressor in septic shock, and what is added if MAP targets are not met?

   Noradrenaline is first-line. If MAP remains inadequate, add vasopressin (up to $0.03\ \text{units min}^{-1}$); add adrenaline as third-line. Hydrocortisone is considered in refractory shock requiring ongoing vasopressors.

8. Define Multi-Organ Dysfunction Syndrome (MODS).

   MODS is the presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. It typically involves progressive, potentially reversible dysfunction of $\geq 2$ organ systems following an insult such as sepsis, trauma, or major surgery.

9. In the SOFA score, which six organ systems are assessed?

   Respiratory ($PaO_2/FiO_2$ ratio), coagulation (platelets), liver (bilirubin), cardiovascular (MAP/vasopressor dose), central nervous system (GCS), and renal (creatinine/urine output). Each scored 0–4.

10. What are the components of the original APACHE II score?

    Acute Physiology score (12 physiological variables including temperature, MAP, heart rate, respiratory rate, oxygenation, arterial pH, sodium, potassium, creatinine, haematocrit, WCC, GCS) plus age points and chronic health points. Maximum 71; higher scores predict higher hospital mortality.

11. State the Berlin definition criteria for ARDS, including severity bands.

    Acute onset within 1 week, bilateral infiltrates on imaging not fully explained by effusions/collapse, respiratory failure not fully explained by cardiac failure/fluid overload, with PEEP $\geq 5\ \text{cmH}_2\text{O}$. Severity by $PaO_2/FiO_2$: mild $201\text{–}300$, moderate $101\text{–}200$, severe $\leq 100\ \text{mmHg}$.

12. Summarise the key lung-protective ventilation strategy for ARDS.

    Tidal volume $6\ \text{mL kg}^{-1}$ predicted body weight, plateau pressure $\leq 30\ \text{cmH}_2\text{O}$, driving pressure ideally $<15\ \text{cmH}_2\text{O}$, adequate PEEP, permissive hypercapnia, and prone positioning ($\geq 16$ h/day) for $PaO_2/FiO_2 < 150$.

13. What is compliance of the respiratory system and how is static compliance calculated?

    Compliance is change in volume per unit change in pressure. $$C_{static} = \frac{V_T}{P_{plateau} - PEEP}$$ Normal static compliance is approximately $50\text{–}100\ \text{mL cmH}_2\text{O}^{-1}$.

14. Define driving pressure and its significance in mechanical ventilation.

    Driving pressure $\Delta P = P_{plateau} - PEEP$ (equals $V_T/C_{rs}$). It reflects cyclic lung strain; values $>15\ \text{cmH}_2\text{O}$ are associated with increased mortality in ARDS, so it is targeted to be kept low.

15. What are the KDIGO stages of Acute Kidney Injury?

    Stage 1: creatinine $1.5\text{–}1.9\times$ baseline or rise $\geq 26.5\ \mu\text{mol L}^{-1}$, or urine output $<0.5\ \text{mL kg}^{-1}\text{h}^{-1}$ for 6–12 h. Stage 2: creatinine $2.0\text{–}2.9\times$, or UO $<0.5$ for $\geq 12$ h. Stage 3: creatinine $\geq 3\times$ or $\geq 353.6\ \mu\text{mol L}^{-1}$ or RRT initiated, or UO $<0.3$ for $\geq 24$ h or anuria $\geq 12$ h.

16. List the urgent (AEIOU) indications for renal replacement therapy in AKI.

    Acidosis (severe metabolic, pH $<7.1$), Electrolyte disturbance (refractory hyperkalaemia $>6.5\ \text{mmol L}^{-1}$), Intoxication (dialysable toxins e.g. lithium, salicylate, metformin, ethylene glycol), Overload (refractory fluid/pulmonary oedema), Uraemia (encephalopathy, pericarditis, bleeding).

17. Compare CVVH and CVVHD modes of continuous renal replacement therapy.

    CVVH (continuous veno-venous haemofiltration) clears solutes by convection (solvent drag across membrane with replacement fluid), favouring middle molecules. CVVHD (haemodialysis) clears by diffusion down a concentration gradient using countercurrent dialysate, favouring small solutes. CVVHDF combines both.

18. Give the formula for cardiac output and a normal value.

    $$CO = HR \times SV$$ Normal cardiac output is approximately $4\text{–}8\ \text{L min}^{-1}$; cardiac index (CO/BSA) is $2.5\text{–}4.0\ \text{L min}^{-1}\,\text{m}^{-2}$.

19. How does an intra-aortic balloon pump (IABP) work and what are its haemodynamic effects?

    A balloon in the descending aorta inflates during diastole and deflates just before systole (counterpulsation). Diastolic inflation augments coronary perfusion; presystolic deflation reduces afterload, decreasing myocardial oxygen demand and improving cardiac output. Timed to the ECG/arterial waveform.

20. What is the difference between VA-ECMO and VV-ECMO?

    VA (veno-arterial) ECMO provides both cardiac and respiratory support by draining venous blood and returning oxygenated blood into the arterial system, bypassing heart and lungs — used in cardiogenic shock/cardiac arrest. VV (veno-venous) ECMO provides respiratory support only, returning oxygenated blood to the venous side; the native heart maintains circulation — used in severe respiratory failure.

21. What are the calorie and protein targets in critical illness nutrition?

    Energy target approximately $25\text{–}30\ \text{kcal kg}^{-1}\text{day}^{-1}$ and protein $1.2\text{–}2.0\ \text{g kg}^{-1}\text{day}^{-1}$, ideally introduced gradually. Enteral nutrition is preferred over parenteral; underfeeding is common early and full targets are typically reached by day 3–7.

22. What is refeeding syndrome and which electrolyte change is the hallmark?

    A potentially fatal shift in fluids and electrolytes when nutrition is reintroduced to a malnourished/starved patient, driven by an insulin surge. The hallmark is hypophosphataemia; hypokalaemia, hypomagnesaemia and thiamine deficiency also occur. Manage by slow refeeding and electrolyte/thiamine replacement.

23. What scoring tools are recommended for ICU sedation and delirium assessment?

    Sedation: Richmond Agitation–Sedation Scale (RASS, $-5$ to $+4$) with a target around $0$ to $-2$. Delirium: CAM-ICU (Confusion Assessment Method for the ICU) or ICDSC (Intensive Care Delirium Screening Checklist).

24. What is the ABCDEF bundle for ICU liberation and delirium prevention?

    A — Assess/manage pain; B — Both spontaneous awakening and breathing trials; C — Choice of analgesia and sedation; D — Delirium assess, prevent, manage; E — Early mobility/exercise; F — Family engagement and empowerment.

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