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Syllabus for the Primary FFA / FRCA Examination

Contents
Introduction Primary FRCA Syllabus
Anaesthesia and resuscitation
Preoperative assessment
Premedication
Anaesthesia in Special Circumstances
Regional Anaesthesia
Resuscitation and Trauma
Anatomy
Physiology and Biochemistry
Pharmacology
Physics and Clinical Measurement
Basic Statistics
Skills Directory
Data Interpretation
Communication
Technical Skills
Equipment

Introduction

The purpose of the examination is to assess trainees who have completed a minimum of 12 months of recognised training. It is expected, however, that most trainees will have completed 18 of months training before attempting the Primary FFA /FRCA examination. The topics outlined in the Primary FFA / FRCA examination syllabus indicate areas in which knowledge should be demonstrated.
It is accepted that a candidate’s depth of knowledge will vary from subject to subject depending upon its relevance to the basic science and clinical practice of anaesthesia undertaken in the first year or 18 months of training.

This examination is designed to test: 

• The candidates' understanding of the fundamentals of clinical anaesthetic practice including equipment and resuscitation.

• The candidates' knowledge of the fundamental principles of Anatomy, Physiology, Pharmacology, Physics, Clinical Measurement and Statistics as is appropriate for the discipline of anaesthesia.

• The candidates' clinical skills and attitudes appropriate to the above level of training

Anaesthesia and Resuscitation

Candidates should be able to demonstrate a good understanding of the fundamentals of clinical anaesthetic practice, with an ability to discern when more senior assistance will be required.

• Anaesthetic equipment and safety

• Physical principles underlying the function of the anaesthetic machine, pressure regulators, flowmeters, vaporizers, breathing systems. Absorption of carbon dioxide

• Principles of lung ventilators, disconnection monitors

• Manufacture and storage of oxygen, nitrous oxide, carbon dioxide, compressed air.

• Pipeline and suction systems, gas cylinders

• Humidification devices

• Minimum monitoring requirements

• Environmental control of the operating theatre including scavenging systems for waste

• anaesthetic gases and vapours

• Pre-use checks of anaesthetic machine, breathing systems and monitoring apparatus

• Anaesthetic records and critical incidents

• Function and use of related anaesthetic and resuscitation equipment including that used for regional anaesthesia. Airways, tracheal tubes, tracheostomy tubes, laryngeal masks, oxygen therapy equipment, self-inflating bags, spinal and epidural needles, intravenous cannulae and transfusion devices

• Sterilisation and cleaning of equipment

Preoperative assessment

• Implications for anaesthesia of commoner medical conditions. In particular, respiratory diseases (e.g. asthma, chronic obstructive airway disease), cardiac disease (e.g. angina pectoris, valvular disease, myocardial infarction, pacemakers, arrhythmias), vascular disease (e.g. hypertension), sickle cell disease and anaemias, rheumatoid arthritis, renal dysfunction and insufficiency, plasma electrolyte disturbance (e.g. hyper- and hypokalemia), diabetes mellitus, liver disease

• Implications for anaesthesia of commoner surgical conditions, trauma, intestinal obstruction and acute abdominal emergencies

• ASA classification and other pre-anaesthetic scoring systems such as Glasgow coma scale

• Interpretation of relevant preoperative investigations, plasma electrolytes, haematology, disturbances of acid/base status, ECG, X-rays, pulmonary function tests and clotting abnormalities

• Preoperative assessment of a patient of any age (excluding neonates) for elective or emergency surgery

• Restriction of food and fluid by mouth, cessation of smoking, correction of dehydration

• Assessment of difficulty of tracheal intubation

• Precautions in the management of the infective patient (e.g. hepatitis B positive or HIV positive)

• Anaesthetic implications of current drug therapy such as beta blockers, antihypertensive drugs, tricyclic antidepressant agents and monoamine-oxidase inhibitors, insulin, anti-diabetic drugs, anticoagulants, contraceptives

• Assessment of post-operative analgesic needs

Premedication and Perioperative Management

Preoperative Assessment

Rationale for premedicant drugs. Choice of drugs, advantages and disadvantages

Induction

• Intravenous and inhalational induction of anaesthesia; advantages and disadvantages,

• Recognition and management of anaphylactic and anaphylactoid reactions including follow up and patient information

• Indications for tracheal intubation.

• Management of difficult intubation and failed intubation

• Recognition of correct placement of tracheal tube, oesophageal and endobronchial intubation, complications

• Causes of regurgitation and vomiting during induction, prevention and management

• Technique of cricoid pressure. Pulmonary aspiration

• Induction of anaesthesia in special circumstances, head injury, full stomach, upper airway obstruction

Intraoperative

• Ability to deal with emergencies before, during and after anaesthesia and the ability to stabilise a patient's condition until senior assistance can be obtained.

• Techniques of maintenance of anaesthesia. To provide adequate analgesia usingopioids and other analgesic drugs. To prevent awareness. Management of appropriate intermittent positive pressure ventilation. Airway control. Intraoperative fluid therapy. Minimal monitoring

• Diagnosis and management of important critical incidents during anaesthesia including: cyanosis, hypertension, hypotension, cardiac arrhythmias, bronchospasm, respiratory obstruction, increased peak inspiratory pressure, hyper- and hypocarbia, failed intubation, failed reversal

• Management of massive haemorrhage, volume expansion, blood transfusion (hazards including incompatibility reaction), gas embolism, malignant hyperthermia

• Correct intraoperative positioning on theatre table - complications, prone position

• Diagnosis and treatment of pneumothorax

Postoperative

• Causes and treatment of failure to breathe at end of operation, suxamethonium apnoea- management

• Care of the unconscious patient

• Recovery room diagnosis and treatment of inadequate pulmonary ventilation, cyanosis, hypo- and hypertension, shivering, stridor. Oxygen therapy, indications and techniques

• Methods of pain management. Assessment of pain and analgesic techniques

• Prevention, diagnosis and treatment of postoperative pulmonary atelectasis, deep vein thrombosis and pulmonary embolus

• Postoperative fluid therapy

• Causes and treatment of postoperative nausea and vomiting

• Minor and major adverse sequelae to anaesthesia and their management

Anaesthesia in special circumstances

• Principles of obstetric anaesthesia

• Principles of the care of children (excluding neonates and infants) undergoing anaesthesia for straightforward surgical procedures, including ENT, eye and dental operations

• Principles of general anaesthesia for simple ophthalmic procedures and a penetrating eye injury

• Patients with a pacemaker

• Advantages and problems associated with day surgery, appropriate anaesthetic techniques

• Principles of neurosurgical anaesthesia as applied to the management of the head- injured patient

• Problems of anaesthesia in the obese patient

• Repeat anaesthesia - hepatic injury

• Implications for the anaesthetist of viral hepatitis and HIV infections

• Laparoscopic and minimally invasive procedures

• Management of patients requiring transfer

Regional anaesthesia

Indications, technique and management of the complications of spinal and epidural (including caudal approach) analgesia. Techniques including intravenous regional anaesthesia, brachial plexus block, femoral nerve block, inguinal field block, ankle block and dorsal nerve of the penis block

Local anaesthesia for awake tracheal intubation

Resuscitation and Trauma

Immediate care and resuscitation in patients of all ages. The guidelines promulgated by the European Resuscitation Council and the Resuscitation Council [UK] will be followed. The syllabus will include:

• Patient assessment

• The principles and practice of life support

• The principles and practice of recognition and management of life-threatening arrhythmias including defibrillation and drug therapy

• The techniques of venous access and the intraosseous route

• Management of the airway and ventilation in the emergency including care of cervical spine

• Specific problems in paediatric resuscitation

• Ethical aspects of resuscitation

Trauma

• Pathophysiology of trauma and hypovolaemia

• Assessment, immediate care and management of trauma patients of all ages

• Performance and interpretation of the primary and secondary survey

• Immediate specific treatment of life-threatening illness or injury, with special reference to thoracic and abdominal trauma

• Care of cervical spine injury

• Emergency airway management and oxygen therapy

• Cannulation of major vessels for resuscitation and monitoring

• Management of hypovolaemic shock

• Chest drain insertion and management

• Pain management in trauma victims

Anatomy

Candidates should be able to demonstrate a good understanding of human anatomy relevant to the practice of anaesthesia.

Respiratory System

• Mouth, nose, pharynx, larynx, trachea, main bronchi, segmental bronchi, structure of

• bronchial tree

• Pleura, mediastinum

• Lungs, lobes, bronchopulmonary segments. Structure of lungs

• Innervation of respiratory tract, blood supply and lymphatic drainage

• Diaphragm, muscles of respiration, innervation

Cardiovascular system

• Heart, chambers, conducting system, blood and nerve supply. Pericardium

• Great vessels, main peripheral arteries and veins

• Fetal circulation

Nervous system

• Brain and spinal cord, structure of spinal cord, age variation, spinal meninges, subdural and extradural space, contents of extradural space, CSF

• Spinal nerves, dermatomes

• Cervical plexus, brachial plexus, nerves of arm

• Intercostal nerves

• Lumbar plexus, nerves of abdominal wall

• Sacral and coccygeal plexuses, nerves of leg

• Autonomic nervous system, sympathetic innervation, sympathetic chain, ganglia and plexuses

• Stellate ganglion

• Parasympathetic innervation. Coeliac plexus

• Cranial nerves. Trigeminal ganglion

Vertebral column

• Cervical, thoracic and lumbar vertebrae

• Sacrum, sacral hiatus

• Ligaments of vertebral column

Areas of special interest

• Base of skull

• The thoracic inlet and 1st rib

• Intercostal spaces including paravertebral space

• Abdominal wall (including the inguinal region)

• Antecubital fossa

• Large veins of neck

• Large veins of leg

• Diaphragm

• Anatomy of tracheostomy, cricothyrotomy

• Eye and orbit

• Axilla

PHYSIOLOGY AND BIOCHEMISTRY

Candidates should have a good general understanding of human physiology, and recognise the need to apply physiological principles and knowledge to the clinical practice of anaesthesia.

General

• Organisation of the human body and control of internal environment

• Differences between neonates, infants, children, adults and the elderly

• Function of cells; genes and their expression

• Cell membrane characteristics; receptors

• Protective mechanisms of the body

Biochemistry

• Acid base balance and buffers

• Ions e.g. Na⁺, K⁺, Ca⁺⁺, Cl^-, HCO₃^-

• Body fluids and their functions and constituents

• Capillary dynamics and interstitial fluid

• Osmolarity: osmolality, partition of fluids across membranes

• Lymphatic system

• Special fluids especially cerebrospinal fluid and ocular fluids. Also pleural, pericardial and peritoneal fluids

Haematology and Immunology

• Red blood cells: haemoglobin and its variants. Blood groups

• Haemostasis and coagulation

• White blood cells

• The inflammatory response

• Immunity and allergy

Muscle

• Action potential generation and its transmission

• Neuromuscular junction and transmission

• Muscle types

• Skeletal muscle contraction

• Smooth muscle contraction

• Motor unit

Heart / Circulation

• Cardiac muscle contraction

• The cardiac cycle: pressure and volume relationships

• Regulation of cardiac function; general and cellularControl of cardiac output

• Rhythmicity of the heart

• Electrocardiogram and arrhythmias

• Neurological and humoral control of systemic blood pressures, blood volume and blood flow (at rest and during physiological disturbances e.g. exercise, haemorrhage and Valsalva manoeuvre)

• Peripheral circulation: capillaries, vascular endothelium and arteriolar smooth muscle, tissue

• Characteristics of special circulations including: pulmonary, coronary, cerebral, renal, portal and fetal

Renal tract

• Blood flow and glomerular filtration and plasma clearance

• Tubular function and urine formation

• Regulation of fluid and electrolyte balance

• Regulation of acid-base balance

• Micturition

Respiration

• Gaseous exchange: O₂ and CO₂ transport, hypoxia and hyper- and hypocapnia, hyper- and hypobaric pressures

• Pulmonary ventilation: volumes, flows, dead space. Effect of IPPV on lungs

• Mechanics of respiration: ventilation/perfusion abnormalities

• Regulation of respiration

• Non-respiratory functions of the lungs

Nervous System

• Functions of nerve cells and synaptic mechanisms

• The brain: functional divisions - cortex, midbrain, medulla, limbic system, brain stem

• and cerebellum

• Intracranial pressure: cerebrospinous fluid, blood flow

• Maintenance of posture

• Autonomic nervous system

• Neurological reflexes

• Motor function: spinal and peripheral

• Senses: receptors, nociception, special senses

• Pain: afferent nociceptive pathways, dorsal horn, peripheral and central mechanisms, neuromodulatory systems, supraspinal mechanisms, visceral pain, neuropathic

• pain, influence of therapy on nociceptive mechanisms

• Spinal cord: anatomy and blood supply, effects of spinal cord section

Liver

• Functional anatomy and blood supply

• Metabolic functions

Gastrointestinal

• Gastric function; secretions, nausea and vomiting

• Gut motility, sphincters and reflex control

• Digestive functions

Metabolism

• Nutrients: carbohydrates, fats, proteins, vitamins and minerals

• Metabolic pathways, energy production and enzymes; metabolic rate

• Hormonal control of metabolism: regulation of plasma glucose, response to trauma

• Physiological alterations in starvation, obesity, exercise and the stress response

• Body temperature and its regulation

Endocrinology

• Mechanisms of hormonal control: feedback mechanisms, effect on membrane and intracellular receptors

• Hypothalamic and pituitary function

• Adrenocortical hormones

• Adrenal medulla

• Pancreas

• Thyroid and parathyroid hormones and calcium homeostasis

Pregnancy

• Physiological changes associated with normal pregnancy

• Functions of the placenta: dynamics of placental transfer

• Fetus: changes at birth

PHARMACOLOGY

Candidates should have a good understanding of general pharmacological principles, together with knowledge of drugs likely to be encountered in (a) basic anaesthetic practice and (b) current treatment of patients presenting for anaesthesia.

GENERAL PHARMACOLOGY

• Applied chemistry

• Types of intermolecular bonds

• Laws of diffusion. Diffusion of molecules through membranes

• Solubility and partition coefficients

• Ionization of drugs

• Drug isomerism

• Protein binding

• Mode of action of drugs

Receptors:

• Dynamics of drug:receptor interaction. Graphical representations of receptor binding. Agonists, antagonists, agonist/antagonists, partial agonists, inverse agonists. Efficacy and potency. Receptor function and regulation. Tolerance

Metabolic pathways; enzymes; drug:enzyme interactions; Michaelis Menten equation

Ion channels:

• Types of ion channels. Relation to receptors. Gating mechanisms. Types of drug action

Signal transduction: cell membrane/receptors/ion channels to intracellular molecular targets, second messengers

Membranes: Action of gases and vapours

Other mechanisms: Osmotic effects. pH effects. Adsorption and chelation. Oxidation and reduction

Mechanisms of drug interactions:

• Inhibition and promotion of drug uptake. Competitive protein binding. Receptor interactions. Enzyme inducers and inhibitors. Addition, subtraction and synergism

• Effects of metabolites and other degradation products.

Methodology of clinical trials

Pharmacokinetics

• Drug uptake from the gastrointestinal tract

• Presystemic metabolism: bioavailability

• Drug uptake from the skin. Transdermal administration systems

• Drug uptake by tissues:

• Muscle, subcutaneous, CSF, extradural space. Factors determining the distribution of drugs: perfusion, molecular size, solubility, protein binding. Significance of drug uptake by the lung

• The influence of drug formulation on disposition

• Body compartments

• Distribution of drugs to organs and tissues:

• Influence of specialised membranes. Tissue binding and solubility. Materno-fetal distribution. Distribution in CSF and extradural spaceModes of drug elimination:

• Direct excretion

• Metabolism in organs of excretion: phase I & II

• Non-organ breakdown of drugs

Pharmacokinetic analysis:

• Concept of a pharmacokinetic compartment

• Apparent volume of distribution

• Clearance. Clearance concepts applied to whole body and individual organs

Relation to the Fick principle

• Simple compartmental models

• Physiological models based on perfusion and partition coefficients

Pharmacokinetic variation: influence of body size, sex, age, disease, pregnancy, anaesthesia, trauma, surgery, smoking, alcohol and other drugs

Pharmacodynamics: concentration-effect relationships. Hysteresis

Pharmacogenetics. Familial variation in drug response

Adverse reactions to drugs: hypersensitivity, allergy, anaphylaxis, anaphylactoid reactions

SYSTEMATIC PHARMACOLOGY

• Anaesthetic gases and vapours

• Hypnotics, sedatives and intravenous anaesthetic agents

• Opioids and other analgesics

• Non steroidal anti-inflammatory drugs

• Neuromuscular blocking agents

• Drugs acting on the autonomic nervous system: cholinergic and adrenergic agonists and antagonists

• Drugs acting on the heart

• Antihypertensives

• Anticonvulsants

• Diuretics

• Antibiotics

• Corticosteroids and other hormone preparations

• Antacids. Drugs influencing gastric secretion and motility

• Antiemetic agents

• Local anaesthetic agents

• Plasma volume expanders

• Antihistamines

• Antidepressants

• Anticoagulants

PHYSICS AND CLINICAL MEASUREMENT

Trainees should understand the physical principles upon which methods of clinical measurement are based. Knowledge of clinical measurement techniques should be limited to principles and basic method.

• Mathematical concepts: sinusoids, exponentials and parabolas. Exponential functions and logarithms

• Basic measurement concepts: linearity, drift, hysteresis, signal:noise ratio, dynamic response

• SI units. Fundamental and derived units

• 
  Simple mechanics: Mass, Force, Work and Power

• 
  Heat: simple calorimetry. Conduction, convection, radiation. Mechanical equivalent of heat: laws of thermodynamics

Physics of gases. 

• Absolute and relative pressure. The gas laws. Triple point: critical temperature. Density and viscosity of gases. Laminar and turbulent flow. The Bernoulli principle

• Freezing point, melting point. Latent heat. Vapour pressure. Colligative properties;

• osmometry

Basic concepts of electricity and magnetism. Capacitance, inductance and impedance Amplifiers. Band width, filters. Amplification of biological potentials: ECG, EMG, EEG. Sources of electrical interference

Processing, storage and display of physiological measurements. Bridge circuits

• Basic principles of lasers

• Principles of cardiac pacemakers and defibrillators

• Electrical hazards: causes and prevention. Electrocution, fires and explosions. Diathermy and its safe use

Clinical Measurement

• Principles of pressure transducers.

• Resonance and damping, frequency response

• Measurement of pressure. Direct and indirect methods of blood pressure measurement. Pulmonary artery pressure

• Measurement of volume and flow in gases and liquids. The pneumotachograph and other respirometers. Peak flow measurement. Spirometry. Cardiac output

• Measurement of temperature and humidity

• Measurement of gas concentrations, especially oxygen, carbon dioxide, nitrogen, nitrous oxide, volatile anaesthetic agents

• Measurement of pH, pCO₂, pO₂

• Simple tests of pulmonary function

• Capnography

• Pulse oximetry

• Measurement of neuromuscular blockade

• Measurement of pain

BASIC STATISTICS

Candidates will be required to demonstrate understanding of basic statistical concepts, but will not be expected to have practical experience of statistical methods. Emphasis will be placed on methods by which data may be summarised and presented, and on the selection of statistical measures for different data types. Candidates will be expected to understand the statistical background to measurement error and statistical uncertainty.

• Descriptive statistics

• Categories of data. Statistical distributions (Gaussian, c², binomial) and their parameters. Non-parametric measures of location and variability. Graphical presentation of data

• Deductive and inferential statistics

• Simple probability theory. Confidence intervals. Linear regression. Linear correlation

• The null hypothesis. Type I and type II errors. Probability of error occurrence, and the power of a test to detect a significant difference, Bland-Altman plot. Choice of simple statistical tests for different data types

SKILLS DIRECTORY

Clinical Assessment

History:

• Respiratory symptoms

• Cardiovascular symptoms

• Airway/ intubation difficulties

• Relevant neurological history:

• head injury

• headache

• raised intracranial pressure

• space-occupying lesion

• "fits and faints"

Assessment and management of acute pain

Musculo-skeletal problems

Mental state:

• apprehension

• depression

• psychosis

• mania

• mental handicap

Gastro-intestinal problems

Obstetric considerations

Renal problems

Hepatic problems

Endocrine problems:

• thyroid

• pituitary

• adrenal

• diabetes mellitus

Skin problems

Congenital disorders

Hereditary disorders

• Haemoglobinopathies

• Coagulopathies

Anaesthetic history:

• personal

• familial

Medication:

• current

• past

Allergies

• Drug reactions

• Drug interactions

Social history:

• smoking

• alcohol

• recreational drugs

• "high risk" groups

• domestic/social circumstances

Physical Examination:

Nutritional state:

• obesity

• cachexia

• dehydration

Skin

Respiratory system:

• cyanosis/clubbing

• dyspnoea/orthopnoea

• chest deformities

• chest movement

• operation scars

• chest observation/palpation/percussion/auscultation

Cardiovascular system:

• cyanosis/oedema

• pulse

• anatomy of veins and arteries

• jugular venous pressure

• arterial blood pressure

• heart size/sounds/murmurs

Teeth/airway/intubation assessment:

• dental problems

• jaw opening/thyro-mental distance

• Mallampati criteria/Wilson risk factors

• mobility of cervical spine

• neck masses

Neurological signs:

• coma/charts/scores

• raised intracranial pressure/papilloedema

• cranial nerves

• wasting/muscle power

• reflexes

• loss of mobility

• sensory testing

• pain scores

Anaemia / Jaundice

Abdomen:

• masses

• bowel sounds

• free fluid

Musculo-skeletal problems (relevant to positioning)

Vascular access - suitability of sites

Other Aspects

• Cricoid pressure

• Cricothyrotomy/tracheostomy anatomy

• Pleural drain sites

• Epidurals/spinals/caudals

• Local nerve blocks for brachial plexus, femoral nerve and dorsal nerve of penis

Data Interpretation

Clinical:

• Respiratory function:

• peak flow, vital capacity, vitalograph and spirometry

• measurements

• Exercise tolerance

• Electrocardiographs

• Interpreting charts

• Fluid balance

• Central venous pressure measurement

Radiological:

• Chest radiographs

• Neck and thoracic inlet films

• Abdominal fluid levels/air/masses

• Skull films

• Other imaging investigations (simple data only)

Laboratory tests:

• Haematology

• Coagulation

• Haemoglobin electrophoresis

• Thyroid function

• Urea and electrolytes

• pH and blood gases

• Renal function

• Liver function

• Adrenal function

Communication

Consent for:

• general anaesthesia (discuss risks)

• epidural/caudal/spinal/regional/local blocks (discuss risks)

Explanation of need for preoperative:

• hepatitis screening

• HIV testing

• sickle cell status

Explanation of analgesic methods:

• oral/sublingual/rectal/subcutaneous/IM/IV/nasal/transdermal drugs

• inhalational analgesia

• patient controlled analgesia

• epidural/regional techniques/local blocks

• possible side effects and complications

Discussion of preoperative medication choices

Explanation of postoperative expectations and care

Instructions to nurses:

• preoperative preparation

• premedication

• postoperative care

• postoperative analgesia

Checking patient into anaesthetic room/operating theatre

Instructions for supervision of anaesthetic recovery/discharge from recovery area

Explanation to patients/ relatives of problems/complications:

• suxamethonium apnoea/difficult intubation

• anaphylaxis/malignant hyperthermia

• post-spinal headache

Technical Skills

Clinical:

Resuscitation:

• basic life support

• mouth to mouth/nose ventilation

• intubation and pulmonary ventilation

• cricothyrotomy/mini-tracheotomy

• external chest compression

• arrhythmia recognition and management (drugs/defibrillators/ pacemakers)

• vascular access

• fluid balance assessment/management

• Venous access

Central venous pressure monitoring

Arterial pressure monitoring

Pleural drain insertion

Emergency pericardiocentesis

Lumbar puncture/spinal anaesthesia

Epidural anatomy and cannulation:

Management of associated hypotension

Caudal block

Nerve blocks

Intravenous regional analgesia

Equipment

• Anaesthetic machine checks

• Checking pipelines

• Changing and checking cylinders

• Connecting up breathing systems

• Breathing system checks

• Setting up/checking/monitoring lung ventilators

• Setting up/checking alarm limits for monitoring equipment

• Data collection from monitors

• Checking resuscitation equipment

• Connecting up resuscitation equipment

• Defibrillator settings

• Recovery room equipment

• What is missing?

• What is misconnected?

• What is wrongly set up?

• What hazards are there?

Composing equipment checklists:

• resuscitation equipment

• epidural/spinal packs

• paediatric intubation set

• difficult intubation kit

• failed intubation management

• CVP monitoring

• arterial pressure monitoring

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