Fellowship of the Royal College of Surgeons (FRCS) Generic Surgical Sciences and Critical Care Syllabus

Generic Surgical Sciences and Critical Care syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Generic Surgical Sciences and Critical Care in Fellowship of the Royal College of Surgeons (FRCS), not a summary of it.

1. 1

   Applied Surgical Physiology and Homeostasis

   5 topics

   • Fluid, electrolyte and acid-base balance
     • Body fluid compartments and daily requirements
     • Disorders of sodium and potassium
     • Interpretation of arterial blood gases
     • Metabolic and respiratory acidosis/alkalosis
   • The metabolic response to injury
     • Ebb and flow phases
     • Neuroendocrine and cytokine mediators
     • Nutritional consequences of catabolism
   • Shock and tissue perfusion
     • Classification of shock (hypovolaemic, septic, cardiogenic, neurogenic)
     • Compensatory mechanisms
     • Goal-directed resuscitation
   • Haemostasis and coagulation
     • Coagulation cascade and platelet function
     • Anticoagulant and antiplatelet pharmacology
     • Management of the bleeding patient and reversal agents
   • Wound healing and scar formation
     • Phases of healing
     • Factors impairing healing
     • Hypertrophic and keloid scarring
2. 2

   Perioperative Care and Critical Illness

   6 topics

   • Preoperative assessment and risk stratification
     • ASA grading and cardiopulmonary exercise testing
     • Risk prediction tools (P-POSSUM, NELA)
     • Optimisation of comorbidities
   • Sepsis and the systemic inflammatory response
     • Sepsis-6 and surviving sepsis bundles
     • Source control principles
     • Multi-organ dysfunction syndrome
   • Organ support in the surgical ICU
     • Mechanical ventilation and ARDS
     • Renal replacement therapy
     • Vasoactive and inotropic support
   • Nutrition in the surgical patient
     • Enteral versus parenteral nutrition
     • Refeeding syndrome
   • Venous thromboembolism prophylaxis
   • Postoperative pain management and enhanced recovery
3. 3

   Microbiology, Infection and Antimicrobial Stewardship

   6 topics

   • Surgical site infection prevention
     • Risk factors and wound classification
     • Antibiotic prophylaxis timing
     • Skin preparation and theatre discipline
   • Healthcare-associated infections
     • MRSA and Clostridioides difficile
     • Catheter-related bloodstream infection
   • Principles of antimicrobial therapy and stewardship
   • Necrotising soft tissue infections
   • Sterilisation and decontamination of instruments
   • Bloodborne viruses and occupational exposure
4. 4

   Surgical Oncology and Pathology Principles

   6 topics

   • Cancer biology and carcinogenesis
     • Hallmarks of cancer
     • Tumour grading and staging (TNM)
     • Metastatic pathways
   • Principles of surgical resection and margins
   • Adjuvant and neoadjuvant therapy concepts
     • Chemotherapy principles
     • Radiotherapy and its surgical implications
   • Multidisciplinary team working in oncology
   • Screening programmes and early detection
   • Palliative surgery and end-of-life care
5. 5

   Imaging, Diagnostics and Technology

   4 topics

   • Principles of cross-sectional imaging
     • CT and contrast considerations
     • MRI indications and contraindications
     • Ultrasound in surgical practice
   • Interventional radiology in surgery
     • Embolisation and angioplasty
     • Image-guided drainage
   • Energy devices and surgical instrumentation
     • Diathermy principles and hazards
     • Laser and ultrasonic dissection
   • Principles of minimal access and robotic surgery

Generic Surgical Sciences and Critical Care flashcards for Fellowship of the Royal College of Surgeons (FRCS)

19 of 67 cards from the Generic Surgical Sciences and Critical Care deck — real questions with worked answers.

1. What are the approximate daily maintenance requirements for water, sodium and potassium in an adult surgical patient (per NICE/GIFTASUP guidance)?

   Water $25\text{--}30\ \text{mL/kg/day}$, sodium $1\ \text{mmol/kg/day}$, and potassium $1\ \text{mmol/kg/day}$ (sodium and potassium roughly $1\ \text{mmol/kg/day}$, glucose $50\text{--}100\ \text{g/day}$ to limit ketosis).

2. State the Henderson–Hasselbalch equation used to assess acid–base status.

   $$\text{pH} = 6.1 + \log_{10}\!\left(\frac{[\ce{HCO3-}]}{0.03 \times P_{\ce{CO2}}}\right)$$

3. How is the anion gap calculated, and what is the normal range?

   $\text{Anion gap} = ([\ce{Na+}] + [\ce{K+}]) - ([\ce{Cl-}] + [\ce{HCO3-}])$, normal $\approx 8\text{--}16\ \text{mmol/L}$ (or $4\text{--}12$ if potassium is omitted).

4. Give two causes each of a raised anion gap and a normal anion gap metabolic acidosis.

   Raised anion gap: lactic acidosis, ketoacidosis, renal failure (urate/phosphate), toxins (methanol, ethylene glycol, salicylates). Normal (hyperchloraemic) anion gap: diarrhoea (\ce{HCO3-} loss), renal tubular acidosis, large-volume $0.9\%$ saline infusion.

5. What is the ECG progression of hyperkalaemia and its emergency drug management?

   ECG: tall tented T waves, then flattened P waves, widened QRS, sine-wave pattern, asystole. Treatment: IV calcium gluconate (cardiac membrane stabilisation), then insulin/dextrose and salbutamol to shift \ce{K+} intracellularly; definitive removal via dialysis or cation-exchange resins.

6. Describe the ebb and flow phases of the metabolic response to injury (Cuthbertson).

   Ebb phase (first $\sim$24--48 h): hypovolaemia, reduced metabolic rate, decreased cardiac output, vasoconstriction to preserve circulating volume. Flow phase: hypermetabolism, increased cardiac output, catabolism (proteolysis, lipolysis, gluconeogenesis), negative nitrogen balance, followed by an anabolic recovery phase.

7. Which counter-regulatory (catabolic) hormones rise during the metabolic response to injury?

   Cortisol, catecholamines (adrenaline/noradrenaline), glucagon and growth hormone; antidiuretic hormone and aldosterone rise to conserve salt and water, while insulin action is impaired (insulin resistance) producing hyperglycaemia.

8. List the four classes of haemorrhagic shock (ATLS) by blood loss and key signs.

   Class I: $<15\%$ ($<750$ mL), normal vitals. Class II: $15\text{--}30\%$ (750--1500 mL), tachycardia, raised pulse pressure narrowing. Class III: $30\text{--}40\%$ (1500--2000 mL), hypotension, tachycardia, confusion. Class IV: $>40\%$ ($>2000$ mL), marked hypotension, lethargy, negligible urine output.

9. Define shock and name the major physiological categories.

   Shock is inadequate tissue perfusion and oxygen delivery relative to demand. Categories: hypovolaemic, cardiogenic, obstructive (e.g. tamponade, tension pneumothorax, PE), and distributive (septic, anaphylactic, neurogenic).

10. Give the formula for oxygen delivery ($DO_2$) and its key determinants.

    $$DO_2 = CO \times CaO_2 = CO \times (1.34 \times \text{Hb} \times SaO_2 + 0.003 \times PaO_2)$$ Determined by cardiac output, haemoglobin concentration and arterial oxygen saturation.

11. Distinguish neurogenic shock from spinal shock.

    Neurogenic shock is a haemodynamic state of hypotension with bradycardia from loss of sympathetic tone after a high spinal cord injury. Spinal shock is the transient loss of all reflexes/flaccidity below the injury level (a neurological, not circulatory, phenomenon).

12. Outline the cell-based model: which factors make up the intrinsic, extrinsic and common coagulation pathways?

    Intrinsic: factors XII, XI, IX, VIII (measured by APTT). Extrinsic: tissue factor + factor VII (measured by PT/INR). Common: factors X, V, II (prothrombin), I (fibrinogen). Final step: thrombin converts fibrinogen to fibrin, stabilised by factor XIII.

13. Which clotting factors are vitamin K-dependent, and how does warfarin act?

    Factors II, VII, IX, X plus proteins C and S. Warfarin inhibits vitamin K epoxide reductase (VKORC1), preventing $\gamma$-carboxylation of these factors; effect is monitored by the INR.

14. Compare the mechanism and reversal of heparin, LMWH and warfarin.

    Unfractionated heparin potentiates antithrombin (inhibits IIa and Xa), monitored by APTT, reversed by protamine. LMWH mainly inhibits factor Xa, reversed partially by protamine. Warfarin inhibits vitamin K-dependent factors, monitored by INR, reversed by vitamin K and prothrombin complex concentrate (or FFP).

15. List the four phases of wound healing in order with their approximate timing.

    1. Haemostasis (immediate: vasoconstriction, platelet plug, fibrin clot). 2. Inflammation (days 1--5: neutrophils then macrophages). 3. Proliferation (days 5--21: fibroblasts, angiogenesis, granulation tissue, epithelialisation). 4. Remodelling/maturation (weeks to $\sim$1 year: type III collagen replaced by type I).

16. What is the difference between a hypertrophic scar and a keloid scar?

    Hypertrophic scars are raised but remain within the original wound boundaries and often regress over time. Keloids extend beyond the wound margins, do not regress, and have a high recurrence rate after excision; both involve excess collagen deposition.

17. What is the maximum tensile strength a healed wound achieves and when?

    A healed wound reaches only about $80\%$ of original skin tensile strength, achieved at roughly 3 months and never fully returning to $100\%$.

18. Distinguish healing by primary, secondary and tertiary (delayed primary) intention.

    Primary: clean wound edges apposed directly (e.g. sutured), minimal scarring. Secondary: wound left open to granulate, contract and epithelialise from the base (e.g. abscess cavity). Tertiary: wound initially left open (e.g. for contamination) then closed surgically after a few days.

19. Outline the ASA physical status classification (I--V).

    ASA I: normal healthy patient. II: mild systemic disease. III: severe systemic disease (functional limitation). IV: severe systemic disease that is a constant threat to life. V: moribund, not expected to survive without operation. ('E' suffix denotes emergency.)

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