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

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.

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.

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).

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.

What are the four main types of acute respiratory failure by mechanism/blood gas?

Type 1: hypoxaemic ($PaO_2 < 8\ \text{kPa}$, normal/low $PaCO_2$) — V/Q mismatch, shunt. Type 2: hypercapnic ($PaCO_2 > 6.0\ \text{kPa}$ with hypoxaemia) — alveolar hypoventilation. Type 3: perioperative/atelectasis. Type 4: shock-related (hypoperfusion of respiratory muscles).

State the alveolar gas equation.

$$P_AO_2 = FiO_2(P_{atm} - P_{H_2O}) - \frac{P_aCO_2}{R}$$ where $R$ (respiratory quotient) $\approx 0.8$ and $P_{H_2O} = 6.3\ \text{kPa}$ at $37^\circ\text{C}$. At sea level on air: $P_AO_2 \approx 0.21(101 - 6.3) - \frac{5.3}{0.8} \approx 13\ \text{kPa}$.

What are the UK preconditions and exclusions before performing brainstem death testing?

Precondition: known, irreversible cause of catastrophic brain injury causing apnoeic coma. Exclusions: no sedative/neuromuscular blocking drug effect, no severe metabolic/endocrine derangement, normothermia (temp $>34^\circ\text{C}$), and acceptable physiological parameters. Two competent doctors perform two sets of tests.

List the brainstem reflexes tested in UK brainstem death testing.

Pupillary light reflex (fixed, unreactive pupils), corneal reflex, vestibulo-ocular reflex (cold caloric — no eye movement), no motor response within cranial nerve distribution to supraorbital pressure, gag and cough reflexes, and the apnoea test (no respiratory effort with $PaCO_2 > 6.65\ \text{kPa}$ and pH $<7.4$).

Outline the adult ALS shockable rhythm algorithm.

For VF/pulseless VT: deliver a shock, immediately resume CPR for 2 min. Reassess; if still shockable, second shock then CPR. After the 3rd shock give adrenaline $1\ \text{mg}$ IV and amiodarone $300\ \text{mg}$ IV, then adrenaline every 3–5 min (alternate cycles). Give a further amiodarone $150\ \text{mg}$ after the 5th shock.

How is adrenaline used differently between shockable and non-shockable cardiac arrest?

In non-shockable rhythms (PEA/asystole), give adrenaline $1\ \text{mg}$ IV as soon as access is obtained. In shockable rhythms (VF/pVT), give adrenaline $1\ \text{mg}$ only after the 3rd shock. Thereafter repeat every 3–5 minutes (every other 2-minute loop) in both.

List the reversible causes of cardiac arrest (4 Hs and 4 Ts).

4 Hs: Hypoxia, Hypovolaemia, Hyper/hypokalaemia (and metabolic), Hypothermia. 4 Ts: Thrombosis (coronary/pulmonary), Tension pneumothorax, Tamponade (cardiac), Toxins.

What are the key drug doses in paediatric advanced life support?

Adrenaline $10\ \mu\text{g kg}^{-1}$ ($0.1\ \text{mL kg}^{-1}$ of $1{:}10\,000$) IV/IO. Amiodarone $5\ \text{mg kg}^{-1}$ after the 3rd and 5th shocks in shockable rhythm. Defibrillation energy $4\ \text{J kg}^{-1}$. Fluid bolus $10\text{–}20\ \text{mL kg}^{-1}$.

Describe the initial steps of newborn life support at birth.

Dry, wrap and stimulate, start the clock, assess tone/breathing/heart rate. If gasping/not breathing, open airway and give 5 inflation breaths (sustained, $\sim 30\ \text{cmH}_2\text{O}$). Reassess; if HR $<60\ \text{min}^{-1}$ despite effective ventilation, start chest compressions at a 3:1 compression:ventilation ratio.

What ratio of fluid/blood and ventilation differs in neonatal versus adult resuscitation?

Neonatal resuscitation uses a compression:ventilation ratio of 3:1 (aiming ~120 events/min: 90 compressions + 30 breaths), reflecting the respiratory cause of most neonatal arrests. Adult single/two-rescuer CPR uses 30:2, and paediatric (with 2 rescuers) uses 15:2.

Define major haemorrhage and outline the typical massive transfusion ratio.

Major haemorrhage is loss of one entire blood volume within 24 h, or 50% of blood volume in 3 h, or ongoing loss $>150\ \text{mL min}^{-1}$. Empirical resuscitation targets a balanced ratio of red cells : FFP : platelets approaching $1{:}1{:}1$. Give tranexamic acid $1\ \text{g}$ early (within 3 h).

What is the lethal triad (trauma triad of death) in major haemorrhage?

Hypothermia, acidosis, and coagulopathy. These three reinforce each other in a vicious cycle, worsening bleeding. Management emphasises damage control resuscitation: permissive hypotension, haemostatic resuscitation, and rapid surgical/haemorrhage control.

How is a regular narrow-complex tachycardia with adverse features managed in the peri-arrest setting?

If unstable (shock, syncope, myocardial ischaemia, heart failure): synchronised DC cardioversion (up to 3 attempts), then amiodarone $300\ \text{mg}$ IV if unsuccessful. If stable and regular narrow-complex: vagal manoeuvres, then adenosine $6\ \text{mg}$ rapid IV (then $12\ \text{mg}$, then $18\text{ mg}$).

How is bradycardia with adverse features or risk of asystole managed?

Give atropine $500\ \mu\text{g}$ IV, repeat to a maximum of $3\ \text{mg}$. If no response, use second-line measures: transcutaneous pacing, or isoprenaline/adrenaline infusion, or alternatives (aminophylline, glucagon for beta-blocker overdose). Seek expert help for transvenous pacing.

What are the key targets of post-resuscitation (post-cardiac arrest) care?

Maintain $SpO_2$ $94\text{–}98\%$ (avoid hyperoxia) and normocapnia, target MAP to achieve adequate urine output and normal/falling lactate, treat the cause (e.g. PCI for STEMI), control temperature (targeted temperature management, avoid fever $\geq 37.7^\circ\text{C}$ for $\geq 72$ h), control seizures, and maintain normoglycaemia.

Define post-cardiac arrest syndrome and its four components.

A pathophysiological state after ROSC comprising: (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischaemia/reperfusion response (sepsis-like), and (4) the persistent precipitating pathology.

Differentiate nociceptive, neuropathic and nociplastic pain.

Nociceptive: arises from actual/threatened tissue damage activating nociceptors (e.g. surgical, inflammatory). Neuropathic: caused by a lesion or disease of the somatosensory nervous system (e.g. burning, shooting, allodynia). Nociplastic: pain from altered nociception without clear tissue damage or nerve lesion (e.g. fibromyalgia).

Outline the WHO analgesic ladder.

Step 1: non-opioid $\pm$ adjuvant (paracetamol, NSAID). Step 2: weak opioid (codeine, tramadol) $\pm$ non-opioid $\pm$ adjuvant. Step 3: strong opioid (morphine) $\pm$ non-opioid $\pm$ adjuvant. Originally for cancer pain; analgesia given 'by mouth, by the clock, by the ladder'. A 4th interventional step is sometimes added.

What are the core roles of an acute pain service (APS)?

To manage and optimise post-operative and acute pain, supervise techniques such as PCA and epidural analgesia, provide staff education and protocols, audit pain outcomes and complications, manage opioid-tolerant/complex patients, and act as a multidisciplinary link improving safety and quality of pain relief.

What are typical settings for a morphine PCA in a postoperative adult?

Bolus dose $1\ \text{mg}$ IV with a lockout interval of 5 minutes, usually no background infusion in opioid-naive patients. The lockout prevents stacking; the patient self-titrates within safe limits, with monitoring of sedation and respiratory rate.

What is the mechanism and a key safety concern of epidural local anaesthetic/opioid analgesia?

Local anaesthetic blocks neuraxial sodium channels (segmental sensory/sympathetic block) and opioids act on dorsal horn opioid receptors. Key concerns: hypotension from sympathetic block, motor block, urinary retention, respiratory depression (especially with neuraxial opioids), and the rare but serious epidural haematoma or abscess.

Name three drug classes used for neuropathic pain and an example of each.

Tricyclic antidepressants (amitriptyline), gabapentinoids (gabapentin, pregabalin), and SNRIs (duloxetine). NICE first-line options for neuropathic pain are amitriptyline, duloxetine, gabapentin or pregabalin; topical capsaicin or lidocaine for localised pain.

What principles guide cancer pain management and opioid dosing for breakthrough pain?

Use regular background analgesia (often modified-release strong opioid) titrated to a 24-hour requirement, with immediate-release opioid for breakthrough pain at approximately $\frac{1}{6}$ ($\frac{1}{10}\text{–}\frac{1}{6}$) of the total daily dose. Add adjuvants for specific pain types and treat opioid side effects (e.g. prophylactic laxatives).

How do you convert oral morphine to subcutaneous morphine and to oral oxycodone?

Oral morphine to subcutaneous morphine: divide by 2. Oral morphine to subcutaneous diamorphine: divide by 3. Oral morphine to oral oxycodone: divide by approximately 1.5–2. Always reduce the calculated dose when switching opioids to account for incomplete cross-tolerance.

Give examples of interventional pain techniques and a typical indication for each.

Epidural/transforaminal steroid injection (radicular leg pain), medial branch block/radiofrequency denervation (facet joint pain), coeliac plexus block (upper abdominal/pancreatic cancer pain), stellate ganglion block (CRPS of the arm), and spinal cord stimulation (failed back surgery syndrome, refractory neuropathic pain).

What is the biopsychosocial model and why is a multidisciplinary approach used in chronic pain?

The biopsychosocial model views pain as the product of interacting biological, psychological (mood, beliefs, catastrophising) and social (work, relationships) factors. Because chronic pain is multifactorial, a multidisciplinary team (physicians, physiotherapists, psychologists, nurses) addresses physical function, psychological coping (e.g. CBT, acceptance and commitment therapy) and social reintegration rather than pain intensity alone.

Name common pain assessment tools, including one for non-verbal/critically ill patients.

Unidimensional: Visual Analogue Scale (VAS), Numerical Rating Scale (NRS 0–10), Verbal Rating Scale. Multidimensional: McGill Pain Questionnaire, Brief Pain Inventory. Neuropathic screening: DN4, painDETECT, LANSS. For non-verbal/ventilated ICU patients: Behavioural Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT).

What general approach is used in the assessment of an acutely poisoned patient?

Resuscitate using ABCDE first (airway protection, support breathing/circulation), correct hypoglycaemia, then take a focused toxicological history and identify toxidromes. Use supportive care as the mainstay; consider decontamination (activated charcoal if within ~1 h), specific antidotes, and enhanced elimination. Consult TOXBASE/National Poisons Information Service.

Match these poisons to their specific antidotes: paracetamol, opioids, benzodiazepines, organophosphates, and beta-blockers.

Paracetamol — N-acetylcysteine; opioids — naloxone; benzodiazepines — flumazenil (used cautiously); organophosphates — atropine (plus pralidoxime); beta-blockers — glucagon (plus high-dose insulin euglycaemia therapy). Other notables: digoxin — Fab fragments; iron — desferrioxamine; cyanide — hydroxocobalamin.

How is the conscious level of a neurological emergency graded, and what GCS threshold mandates airway protection?

The Glasgow Coma Scale (GCS, score 3–15) grades eye (4), verbal (5) and motor (6) responses. A GCS $\leq 8$ indicates coma and typically mandates definitive airway protection (intubation) because of the loss of protective airway reflexes and risk of aspiration.

What physiological targets are used in the management of raised intracranial pressure / acute brain injury?

Maintain cerebral perfusion pressure $CPP = MAP - ICP$, targeting CPP $\geq 60\text{–}70\ \text{mmHg}$ and ICP $<22\ \text{mmHg}$. Strategies: head-up $30^\circ$, normocapnia ($PaCO_2$ ~$4.5\text{–}5.0\ \text{kPa}$), adequate oxygenation, normothermia, avoid hyponatraemia, osmotherapy (mannitol or hypertonic saline), and treat seizures.