Fellowship of the Royal College of Anaesthetists (FRCA) Subspecialty Anaesthesia Syllabus

Subspecialty Anaesthesia syllabus — full chapter and topic list

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

1. 1

   Obstetric Anaesthesia

   6 topics

   • Physiological changes of pregnancy relevant to anaesthesia
   • Labour analgesia
     • Epidural and remifentanil PCA
   • Anaesthesia for caesarean section
     • Spinal, epidural top-up and general anaesthesia
   • Obstetric emergencies
     • Major obstetric haemorrhage and uterine atony
     • Pre-eclampsia, eclampsia and HELLP
   • Maternal collapse and resuscitation
   • Anaesthesia for the parturient with comorbidity
2. 2

   Paediatric Anaesthesia

   6 topics

   • Anatomical and physiological differences in children
   • Neonatal and infant anaesthesia
   • Paediatric airway management
     • Equipment sizing and the difficult paediatric airway
   • Fluid, glucose and temperature management
   • Paediatric pain and regional techniques
   • Common paediatric surgical and emergency presentations
3. 3

   Neuroanaesthesia

   5 topics

   • Intracranial pressure and cerebral protection
   • Anaesthesia for craniotomy
     • Tumour, aneurysm and awake craniotomy
   • Traumatic brain injury management
   • Spinal surgery anaesthesia
   • Anaesthesia for neuroradiology and seizure surgery
4. 4

   Cardiothoracic and Vascular Anaesthesia

   5 topics

   • Cardiopulmonary bypass principles
   • Anaesthesia for cardiac surgery
     • Valvular and ischaemic heart disease
   • Thoracic anaesthesia and one-lung ventilation
     • Lung isolation techniques and hypoxia management
   • Vascular anaesthesia
     • Aortic aneurysm and carotid endarterectomy
   • Transoesophageal echocardiography basics
5. 5

   Other Subspecialties

   7 topics

   • Ophthalmic, ENT and maxillofacial anaesthesia
     • Shared airway and laser surgery
   • Anaesthesia for day surgery
   • Anaesthesia in remote and non-theatre locations
   • Bariatric and obesity anaesthesia
   • Hepatobiliary, renal and transplant anaesthesia
   • Anaesthesia for the elderly and frail patient
   • Dental and sedation practice

Subspecialty Anaesthesia flashcards for Fellowship of the Royal College of Anaesthetists (FRCA)

24 of 51 cards from the Subspecialty Anaesthesia deck — real questions with worked answers.

1. List the key cardiovascular changes of pregnancy at term relative to non-pregnant values.

   Cardiac output $\uparrow$ by 40-50%, plasma volume $\uparrow$ ~45%, red cell mass $\uparrow$ ~20% (giving physiological dilutional anaemia), heart rate $\uparrow$ 15-25%, systemic vascular resistance $\downarrow$ ~21%, and a fall in both systolic and diastolic blood pressure that nadirs mid-pregnancy.

2. Why are pregnant women considered to have a 'full stomach', and from what gestation does aspiration prophylaxis become standard?

   Progesterone relaxes the lower oesophageal sphincter and the gravid uterus raises intragastric pressure, increasing reflux/aspiration risk. Pregnant patients are treated as having a full stomach (rapid sequence induction, antacid prophylaxis) from about 16-20 weeks' gestation.

3. Describe the respiratory changes of pregnancy relevant to anaesthesia.

   Minute ventilation $\uparrow$ ~50% (mainly tidal volume), producing a compensated respiratory alkalosis ($PaCO_2 \approx 4.0$ kPa). Functional residual capacity $\downarrow$ ~20% while oxygen consumption $\uparrow$ ~20%, causing rapid desaturation during apnoea. The airway is oedematous and friable, so a smaller tracheal tube is used.

4. What is aortocaval compression and how is it prevented during caesarean section?

   From ~20 weeks the gravid uterus compresses the inferior vena cava and aorta when supine, reducing venous return and uteroplacental perfusion (supine hypotension syndrome). It is prevented by left lateral tilt of at least 15$^\circ$ or manual left uterine displacement.

5. What dermatomal block height is required for caesarean section under regional anaesthesia, and how is it tested?

   A block to T4 (nipple line) is required to cover peritoneal traction. Adequacy is confirmed by loss of cold/light touch sensation up to T4 and assessing for absent sensation; light touch to T5 is often the most reliable predictor of patient comfort.

6. What is the first-line vasopressor for maintaining maternal blood pressure during spinal anaesthesia for caesarean section, and why?

   Phenylephrine, because it better maintains fetal acid-base status (less fetal acidosis) than ephedrine. It is given as a prophylactic infusion or boluses, accepting reflex bradycardia which may need atropine/glycopyrrolate.

7. Compare combined spinal-epidural (CSE) with single-shot spinal for caesarean section.

   Single-shot spinal: fast, dense, reliable block but fixed duration and no top-up ability. CSE: rapid spinal onset plus an epidural catheter for top-ups (prolonged surgery) and postoperative analgesia, but is technically more involved and the epidural component is untested initially.

8. How does a working epidural for labour analgesia differ from the block required for caesarean delivery, and how is it converted?

   Labour analgesia uses a low-concentration, segmental (T10-L1) block with dilute local anaesthetic plus opioid. For caesarean it is topped up to a dense T4 surgical block, typically with concentrated local anaesthetic (e.g. lidocaine with adrenaline, or levobupivacaine) plus opioid and bicarbonate to speed onset.

9. State the management priorities for a major obstetric haemorrhage.

   Call for help, ABC with high-flow oxygen, large-bore IV access, activate massive haemorrhage protocol, treat the cause (4 Ts: Tone, Trauma, Tissue, Thrombin), give uterotonics (oxytocin, ergometrine, carboprost, misoprostol), warmed fluids/blood with a balanced transfusion ratio, tranexamic acid, and correct coagulopathy guided by point-of-care testing.

10. What is the recommended dose of magnesium sulphate for severe pre-eclampsia/eclampsia and what is monitored?

    A loading dose of 4 g IV over 5-10 minutes followed by an infusion of 1 g/hour. Monitor for toxicity by checking patellar reflexes (lost first), respiratory rate, and urine output; treat severe toxicity with IV calcium gluconate.

11. List the clinical features that distinguish amniotic fluid embolism.

    Sudden cardiovascular collapse, profound hypoxaemia and dyspnoea, and disseminated intravascular coagulation, typically during labour or immediately postpartum. It is a diagnosis of exclusion; management is supportive with aggressive resuscitation, correction of coagulopathy and treatment of right heart failure.

12. State the key modifications to adult resuscitation in maternal cardiac arrest.

    Manual left uterine displacement (or left tilt), hand position slightly higher on the sternum, early airway management anticipating difficulty, and perform a resuscitative hysterotomy (perimortem caesarean) within 4 minutes if no return of spontaneous circulation, aiming for delivery by 5 minutes, to relieve aortocaval compression.

13. Why is the aim to deliver the baby within 5 minutes during a maternal arrest beyond 20 weeks' gestation?

    Emptying the uterus relieves aortocaval compression, dramatically improving venous return, the efficacy of chest compressions and maternal survival; it is performed for maternal, not primarily fetal, benefit.

14. What anaesthetic considerations apply to the parturient with cardiac disease (e.g. mitral stenosis)?

    Avoid tachycardia (reduces diastolic filling time), maintain preload and afterload, avoid aortocaval compression, and use a carefully titrated incremental epidural rather than single-shot spinal to prevent abrupt falls in systemic vascular resistance. Multidisciplinary planning and invasive monitoring are usual.

15. Give the formula for estimating the correct uncuffed tracheal tube internal diameter and length in a child over 1 year.

    Internal diameter $\text{(mm)} = \dfrac{\text{age}}{4} + 4$; oral length $\text{(cm)} = \dfrac{\text{age}}{2} + 12$ (or $\dfrac{\text{age}}{2}+15$ for nasal). For cuffed tubes subtract 0.5 mm from the diameter.

16. List the anatomical features of the paediatric airway that differ from the adult and their implications.

    Large head and occiput (neutral position needed), large tongue, high anterior larynx (at C3-4), long floppy U-shaped epiglottis (straight blade often preferred), and the narrowest point at the cricoid ring in the young child. These predispose to obstruction and favour specific equipment choices.

17. State a weight estimation formula for a child aged 1-5 years and the maintenance fluid rule.

    Weight $\text{(kg)} \approx (2 \times \text{age}) + 8$. Maintenance fluid by the 4-2-1 rule: 4 mL/kg/h for the first 10 kg, 2 mL/kg/h for the next 10 kg, and 1 mL/kg/h for each kg above 20 kg.

18. Why are neonates and infants prone to hypothermia and what measures counter it?

    High surface-area-to-volume ratio, thin skin, little subcutaneous fat, and non-shivering thermogenesis (brown fat) make them lose heat rapidly. Counter with a warm theatre (~26$^\circ$C), forced-air warmers, warmed fluids, heat-moisture exchangers, and minimising exposure.

19. What glucose management applies to neonatal anaesthesia and why?

    Neonates have limited glycogen stores and risk hypoglycaemia, so glucose is monitored and a glucose-containing maintenance fluid (e.g. dextrose) may be needed, while excessive glucose boluses are avoided to prevent hyperglycaemia. At-risk neonates have blood glucose checked perioperatively.

20. Define apnoea of prematurity risk and the threshold for overnight monitoring after anaesthesia.

    Ex-premature infants are at risk of postoperative apnoea, particularly if post-conceptual age is below ~60 weeks. They require overnight apnoea monitoring after general anaesthesia and ideally avoidance of day-case surgery; caffeine may be given.

21. Give the paediatric formula for maximum allowable blood loss (MABL).

    $$\text{MABL} = \frac{\text{EBV} \times (Hct_{start} - Hct_{min})}{Hct_{start}}$$ where estimated blood volume (EBV) is approximately 90 mL/kg in neonates, 80 mL/kg in infants and 70 mL/kg in older children.

22. Describe a caudal epidural block in children: indication, landmark and a common dosing guide.

    Used for sub-umbilical surgery analgesia. The needle enters the sacral hiatus through the sacrococcygeal membrane between the sacral cornua. Armitage regimen: 0.5 mL/kg for sacral, 1 mL/kg for lumbar/lower thoracic, and 1.25 mL/kg for upper abdominal spread, using 0.25% (or 0.125%) levobupivacaine.

23. Outline the anaesthetic priorities for pyloric stenosis repair.

    It is a medical, not surgical, emergency: first correct the hypochloraemic, hypokalaemic metabolic alkalosis and dehydration with fluid resuscitation before theatre. Then perform rapid sequence induction (full stomach), empty the stomach via NG tube, and anticipate postoperative apnoea due to CSF alkalosis.

24. List the components of the Monro-Kellie doctrine and its clinical consequence.

    The skull is a fixed volume containing brain (~80%), blood (~10%) and CSF (~10%). An increase in any component, or a mass lesion, must be compensated by a decrease in another; once compensation is exhausted, intracranial pressure rises steeply for small volume increases.

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