Membership of the Royal College of Surgeons (MRCS) Perioperative Care and Critical Care Syllabus

Perioperative Care 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 Perioperative Care and Critical Care in Membership of the Royal College of Surgeons (MRCS), not a summary of it.

1. 1

   Preoperative Assessment and Optimisation

   3 topics

   • Risk assessment and fitness for surgery
     • ASA grading and cardiopulmonary exercise testing
     • Frailty and comorbidity assessment
   • Management of comorbidities
     • Diabetes, cardiac and respiratory disease
     • Anticoagulation and steroid management
   • Consent and preparation
     • Informed consent and capacity
     • Fasting, prophylaxis and the WHO checklist
2. 2

   Anaesthesia and Pain Management

   3 topics

   • Principles of anaesthesia
     • General, regional and local techniques
     • Airway management
   • Acute pain management
     • Multimodal analgesia
     • Patient-controlled and epidural analgesia
   • Anaesthetic complications
     • Malignant hyperthermia and anaphylaxis
     • Postoperative nausea and vomiting
3. 3

   Postoperative Care and Complications

   4 topics

   • Monitoring and recovery
     • Early warning scores and escalation
     • Enhanced recovery after surgery (ERAS)
   • Common postoperative complications
     • Haemorrhage, ileus and wound complications
     • Atelectasis, DVT and PE
   • Fluid and nutritional management
     • Perioperative fluid therapy
     • Enteral and parenteral nutrition
   • Surgical drains, tubes and stomas
     • Drain types and indications
     • Stoma care and complications
4. 4

   Critical Care and the Deteriorating Patient

   3 topics

   • Recognition and management of shock
     • Hypovolaemic, septic, cardiogenic and obstructive shock
     • Resuscitation and goal-directed therapy
   • Organ support
     • Ventilation and respiratory support
     • Renal replacement and cardiovascular support
   • Multi-organ dysfunction
     • SIRS, sepsis and ARDS
     • Scoring systems and prognosis
5. 5

   Blood, Transfusion and Haemostasis Management

   3 topics

   • Perioperative bleeding management
     • Major haemorrhage protocols
     • Cell salvage and blood conservation
   • Transfusion practice
     • Indications and consent
     • Component therapy
   • Venous thromboembolism prophylaxis
     • Risk stratification
     • Mechanical and pharmacological prophylaxis

Perioperative Care and Critical Care flashcards for Membership of the Royal College of Surgeons (MRCS)

20 of 50 cards from the Perioperative Care and Critical Care deck — real questions with worked answers.

1. What does the ASA Physical Status Classification grade ASA III represent?

   A patient with severe systemic disease that is a substantive functional limitation (e.g. poorly controlled diabetes/hypertension, COPD, morbid obesity with $BMI \geq 40$, active hepatitis). It is not incapacitating (ASA IV) and the disease is not immediately life-threatening.

2. List the components of the Revised Cardiac Risk Index (RCRI / Lee Index) used to estimate perioperative cardiac risk.

   1) High-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular), 2) Ischaemic heart disease, 3) History of congestive heart failure, 4) History of cerebrovascular disease, 5) Insulin-dependent diabetes, 6) Preoperative creatinine $>177\ \mu mol/L$ ($>2\ mg/dL$). Risk rises with the number of factors present.

3. How is a MET (metabolic equivalent) used in fitness for surgery, and what threshold indicates adequate functional capacity?

   $1\ \text{MET} = 3.5\ \text{mL O}_2/\text{kg/min}$ (resting oxygen consumption). The ability to achieve $\geq 4$ METs (e.g. climbing two flights of stairs, brisk walking) indicates adequate functional capacity and a lower perioperative cardiac risk.

4. In cardiopulmonary exercise testing (CPET), what anaerobic threshold value is associated with significantly increased perioperative risk?

   An anaerobic threshold below $11\ \text{mL O}_2/\text{kg/min}$ is associated with markedly increased perioperative morbidity and mortality. A $\dot{V}O_2$ peak above $15\ \text{mL/kg/min}$ is generally reassuring.

5. What perioperative management is advised for metformin and SGLT2 inhibitors in a patient undergoing surgery?

   Metformin is usually continued but withheld if there is significant renal impairment or risk of contrast/lactic acidosis. SGLT2 inhibitors (gliflozins) should be stopped at least 3 days before surgery (day of surgery and 2 days prior) because of the risk of euglycaemic diabetic ketoacidosis.

6. What are the recognised target ranges for perioperative blood glucose control?

   Aim to keep perioperative glucose between $6$ and $10\ \text{mmol/L}$ (acceptable range $4$–$12\ \text{mmol/L}$). A variable-rate intravenous insulin infusion (VRIII) is used when control is poor or for prolonged fasting/major surgery.

7. How should warfarin be managed before elective surgery, and what INR is generally acceptable?

   Stop warfarin about 5 days before surgery, aiming for an $INR \leq 1.5$ at operation. Bridge with therapeutic LMWH only if high thromboembolic risk (e.g. mechanical mitral valve, recent VTE, AF with prior stroke), stopping LMWH 24 hours preoperatively.

8. State the three key elements required for valid surgical consent.

   1) Capacity (the patient can understand, retain, weigh and communicate the decision), 2) Voluntariness (free from coercion), and 3) Sufficient information (material risks, benefits and reasonable alternatives) — the disclosure standard set by Montgomery v Lanarkshire (2015) based on what a reasonable patient would want to know.

9. What are the ASA/RCoA recommended preoperative fasting times for elective surgery (the '6-4-2 rule')?

   6 hours for solid food and non-clear/non-human milk, 4 hours for breast milk, and 2 hours for clear fluids before anaesthesia.

10. Describe the components of the classic triad of general anaesthesia.

    Hypnosis (unconsciousness), analgesia (pain relief), and muscle relaxation (areflexia/immobility). Modern balanced anaesthesia uses separate agents to achieve each component.

11. Compare depolarising and non-depolarising neuromuscular blockers with an example of each.

    Depolarising (e.g. suxamethonium): agonist at the nicotinic ACh receptor causing fasciculations then block; rapid onset/offset, not reversed by neostigmine, risk of hyperkalaemia and malignant hyperthermia. Non-depolarising (e.g. rocuronium, atracurium): competitive antagonists; slower onset, reversed by neostigmine or sugammadex (for aminosteroids).

12. What is the mechanism and key danger of suxamethonium-induced malignant hyperthermia, and what is its treatment?

    An inherited (autosomal dominant, RYR1 ryanodine receptor) hypermetabolic crisis triggered by suxamethonium or volatile anaesthetics, causing uncontrolled $\ce{Ca^2+}$ release, rising $\text{EtCO}_2$, hyperthermia, rigidity and rhabdomyolysis. Treatment: stop trigger, 100% oxygen, active cooling, and IV dantrolene $2.5\ \text{mg/kg}$ repeated as needed.

13. How is Maximum local anaesthetic dose calculated, and what is the max dose of lidocaine with and without adrenaline?

    Plain lidocaine maximum is $3\ \text{mg/kg}$; with adrenaline it is $7\ \text{mg/kg}$. Note $1\%$ solution $= 10\ \text{mg/mL}$. Example: a $70\ \text{kg}$ adult tolerates up to $210\ \text{mg}$ plain lidocaine ($21\ \text{mL}$ of $1\%$).

14. Describe the management of local anaesthetic systemic toxicity (LAST).

    Stop injection, ABC support, 100% oxygen, control seizures (benzodiazepine), and give IV lipid emulsion 20% (Intralipid): bolus $1.5\ \text{mL/kg}$ over 1 min then infusion $15\ \text{mL/kg/h}$, repeating boluses for cardiovascular collapse. Avoid vasopressin, calcium channel blockers and prolonged lidocaine for arrhythmias.

15. Outline the WHO analgesic ladder as applied to acute surgical pain.

    Step 1: non-opioids (paracetamol, NSAIDs); Step 2: weak opioids (codeine, tramadol) plus non-opioids; Step 3: strong opioids (morphine, oxycodone) plus non-opioids. For acute postoperative pain it is often used in reverse (step down), combined with adjuvants and regional techniques (multimodal analgesia).

16. What is the equianalgesic relationship between oral and IV morphine, and oral codeine to morphine?

    Oral morphine to IV morphine is approximately $2{:}1$ (oral $10\ \text{mg} \approx$ IV $5\ \text{mg}$ due to ~50% oral bioavailability). Oral codeine to oral morphine is approximately $10{:}1$ (codeine $60\ \text{mg} \approx$ morphine $6\ \text{mg}$).

17. What are the cardinal signs of opioid overdose and its antidote with dosing?

    Respiratory depression ($RR < 8$), pinpoint pupils and reduced consciousness. Antidote is naloxone $400\ \mu g$ IV (titrate in $100$–$200\ \mu g$ increments); note its short half-life (~30–60 min) means repeated doses or an infusion may be required.

18. What is the most common cause of postoperative airway obstruction in the recovery room, and how is it managed?

    Loss of pharyngeal muscle tone (the tongue falling back) in a sedated patient. Managed with head tilt/chin lift or jaw thrust, airway adjuncts (oropharyngeal/nasopharyngeal), oxygen, and assessment for laryngospasm or residual neuromuscular blockade.

19. List common risk factors for postoperative nausea and vomiting (PONV) in the Apfel score.

    Four factors each scoring 1 point: female sex, non-smoker, history of PONV or motion sickness, and use of postoperative opioids. Risk rises ~20% per factor (approximately 10/20/40/60/80% for 0–4 points).

20. Define the three classic phases/signs of a haemolytic transfusion reaction and differentiate acute from delayed.

    Acute haemolytic reaction (usually ABO incompatibility) occurs within minutes: fever, loin/back pain, hypotension, haemoglobinuria, DIC — a medical emergency requiring stopping the transfusion. Delayed haemolytic reaction occurs 5–10 days later from anamnestic antibody response (often Kidd/Rhesus), causing falling Hb, jaundice and a positive direct antiglobulin (Coombs) test.

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