Primary FCARCSI Syllabus

8/6/2019 Primary FCARCSI Syllabus

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COLLEGEOFANAESTHETISTS RCSI

SYLLABUS FOR THE PRIMARY FCARCSI EXAMINATION

EDUCATIONAL PROGRAMME FOR BASIC SPECIALIST TRAINEES INANAESTHESIA

Draft 27/01/02


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Diagnosis of death

323/9/02

-29/9/02

+

28/10/02-

17/11/02

BLOOD & IMMUNOLOGYRed blood cellsBlood groupsHaemoglobin & variantsHaemostasis & coagulationWhite blood cellsThe inflammatory responseImmunity & allergy

Drug isomerismProtein bindingOxidation & reduction

AnticoagulantsVitamins K, B12 & ThiamineNSAIDS

Surface anatomy:Landmarks for tracheostomy,cricothyrotomy, chest drain.

Abdominal wall and inguinalregionLandmarks for suprapubic urinaryand peritoneal lavage cayheters

Physics of gases & vapoursAbsolute & relative pressuresGas Laws; triple point, criticaltemperature & pressureDensity & viscosity of gasesVapour pressureSaturated vapour pressure

PRE-OPERATIVE ASSESSMENTKnowledge requiredImplications for anaesthesia of commoner electiveconditions requiring gynaecological, abdominal,orthopaedic, ENT, dental, urological and body surfacesurgery. Knowledge of sub-specialty practice andspecialised techniques is not required unless specifiedelsewhere.The relevance of trauma, intestinal obstruction and acuteabdominal emergencies.The ASA classification and other scoring systems such asGlasgow coma scale (GCS).The interpretation of relevant preoperative investigationsRestriction of food and fluid by mouth, cessation of

smoking, correction of dehydrationAssessment of difficulties in airway management and theimportance of the 'shared airway'.Implications for anaesthesia of common medical conditions(ischaemic heart disease, hypertension, diabetes, asthma,rheumatoid arthritis etc)

Anaesthetic implications of current drug therapy andwhether it should be continued, modified stopped orchanged peri-operatively.Need for and methods of perioperative antithrombotictreatment

The importance of an anaesthetic history and geneticdiseases in anaesthesia with respect to suxamethoniumapnoea, anaphylaxis and malignant hyperpyrexia

Assessment of post-operative analgesic needsAssessment of whether ICU or HDU care will be requiredpost-operativelyThe importance of consent and the issues surrounding itDangers of repeat anaesthesia

Experience to be gainedHISTORY TAKING

Anaesthetic history, personal and familial

Previous airway/intubation difficultiesMedication, current and past

Allergies and previous drug reactionsTobacco and alcohol consumptionPrevious anaesthetic exposure and surgeryRespiratory status and symptoms (especially COPD &asthma)Cardiovascular status and symptoms (especially IHD &hypertension)Neurological status and symptoms (especially epilepsy,CVA, level of consciousness and mental state)

GI problems (especially reflux, obstruction, possibledelayed gastric emptying)


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Arthropathies and other musculo-skeletal disorders(especially rheumatoid arthritis)Renal conditionsHepatic conditions (especially jaundice, cirrhosis)Endocrine conditions (especially steroid therapy, diabetes)Skin conditionsObstetric conditionsHereditary & Congenital disorders affecting anaesthesia

HaemoglobinopathiesCoagulopathiesNutritional abnormalities (obesity)Social problems and identification of groups who pose ahigh infection risk

PHYSICAL EXAMINATIONTeeth/ airway/ cervical spine/ intubation assessmentCardiovascular system (IHD, hypertension, LVF)Respiratory system (asthma, COPD)Nutritional state (obesity)

Neurological system (GCS: any acute or residual effects ofCVA)

Abdomen and GI tractAnaemiaJaundiceSequelae of diabetes and steroidsMusculo-skeletal problems (including relevance topositioning, neck stability, regionalblockade)

30/9/02-27/10/02

EXAMINMATION BREAK

418/11/02

-15/12/02

EXCITABLE TISSUESOrigin of membrane potentialsFactors influencing membranepotentialPassive and active changes inmembrane potentialProperties of local potentialsProperties of action potentialsandvariations in different tissues

Nerves; Propagated and non-propagated changes in membranepotential, conduction of actionpotential, synaptic mechanismsFunctional subdivisions ofcompound nerves

MODE OF DRUG ACTIONDrug-receptor interaction dynamics

Agonists, antagonists, partialagonists, inverse agonists

Local a naesthetics Spin al nerves an d dermatome sBrachial plexus and nerves of thearm

Basic concepts of electricity &magnetismResistance, capacitance,inductance, impedance

Amplifiers; bandwidth, filters, A/D& D/A conversion

Amplification of biologicalpotentials; ECG, EMG, EEGSources of and methods of

reducing electrical interferenceMeasurement of neuromuscularblockade

PRE-OPERATIVE ASSESSMENTDATA INTERPRETATIONClinical:Respiratory function testsElectrocardiographsCentral venous pressure measurementSystolic, diastolic and mean arterial pressureExercise testsInterpreting fluid balance and other charts

Radiological (showing clear abnormalities) :Chest radiographsFilms showing long bone, skull, vertebral and rib fracturesSimple CAT and MRI scans of head demonstratingfractures/ haemorrhageNeck and thoracic inlet filmsFilms showing abdominal fluid levels/airLaboratory:Haematology (including coagulation and sickle tests)Urea and electrolytespH and blood gases

Liver function testsThyroid function


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SPECIAL GROUPSChildren (aged 5 years and over)The elderlyDay case patients

PLANNINGDeciding on an anaesthetic technique appropriate to the

findings.Ensuring the necessary resources are available for safepatient care

COMMUNICATIONConsent for:general anaesthesia (including a discussion of the risks)epidural/caudal/spinal/regional/local blocks ((including adiscussion of the risks)Explanation of need for preoperative routine andspecialised tests (including hepatitis

screening, HIV testing and sickle cell status)Explanation of pain management, side effects andcomplications of:oral/sublingual/rectal/subcutaneous/IM/IV/nasal/transdermaldrugsepidural/regional techniques/local blocksinhalational analgesiapatient controlled analgesiaDiscussion of preoperative medication choicesExplanation of postoperative expectations and careCommunication with other professionals

56 weeksduring

16/12/02-

9/2/03

EXCITABLE TISSUESMuscle types; skeletal, smooth,cardiacSkeletal neuromuscular junction &transmissionMuscle; propagated and non-propagated changes in membranepotentialSkeletal muscle microstructure andexcitation-contraction couplingSkeletal muscle contraction

Motor UnitsMechanisms of neuromusculartransmission and contraction insmooth muscles

MODE OF DRUG ACTIONEfficacy & potencyToleranceMetabolic pathways; enzymesDrug/enzyme interactionMichaelis Menten RelationshipEnzyme inducers and inhibitors

Neuromuscular blockersAnticholinesterases

Intercostal nervesNerves of the abdominal wallNerves of the leg and foot

Processing, storage and display ofphysiological mkeasurementsBridge circuitsPrinciples of pressure transducersResonance, damping andfrequency responseUnits of pressureDirect and indirect methods ofblood pressure measurement

PREMEDICATIONKnowledge RequiredRationale for use of premedicant drugs.Choice of drugs, advantages and disadvantagesRationale for antacid and prokinetic premedicationRationale for antithrombotic therapy.Understanding of causes of delayed gastric emptying.

Experience to be gainedAssessment of level of anxiety and addressing patient'sconcerns

Recognition of situations leading to delayed gastricemptyingChecking a patient prior to premedication and on arrival inthe anaesthetic room/theatre

SPECIAL GROUPSChildren (aged 5 years and over)The elderlyDay case patientsPregnancyThe acutely ill

COMMUNICATION


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Recovery room equipmentPrevention, diagnosis and management of postoperativepulmonary atelectasis, deep vein thrombosis andpulmonary embolusCriteria for discharge of day-stay patients

1125/8/03

-21/9/03

RESPIRATIONPulmonary ventilation; spirometery,

volumes, flows, dead spaceMechanics of ventilationVentilation perfusion relationship;normal physiologic variationthroughout lungs and V/Qabnormalities, shunt.

PHARMACOKINETICS &PHARMACODYNAMICS

Distribution to organs and tissues;body compartmentsInfluence of specialised membranes;tissue binding and solubilityDistribution in CSF and extraduralspace

AntidepressantsAnticonvulsants

PleuraMediastinum and its contents

Lungs and lobes; grossMicrostructure of lungsDiaphragm and other muscles ofrespiration, including innervation

Physical principles underlyinganaesthetic machine function;

pressure regulators, flowmeters,vaporisers, breathing systemsDetection and prevention ofdelivery of low PO2 gas mixtureDetection of gas supply failure

POSTOPERATIVE AND RECOVERY CAREExperience to be gained

Recovery from anaesthesia in patients with elective andurgent conditions requiring gynaecological, abdominal,orthopaedic, ENT, dental, urological and body surfacesurgery. Knowledge of sub-specialty practice andspecialised techniques is not required unlessspecified elsewhere.Clear instructions during handover of patient to recoverystaff

Assessment of full return of protective reflexesAssessment of adequacy of ventilation/reversalRecognition of residual relaxant action

Use of nerve stimulator.Extubation and airway protection in presence of potentiallyfull stomachPrescription of postoperative fluids

Assessment of fluid balance and need for urethralcatheterisationEvaluation and management of post-operative confusion

Assessment of postoperative painPrescription of postoperative pain regimenTreatment of nausea and vomitingStabilisation before discharge from RecoveryContinuation of care until discharge from Recovery, andbeyond as appropriateCriteria for discharge of patients to wardCriteria for discharge of day-stay patients

COMMUNICATIONClear communicationResponding rapidly to calls for helpFollow up of sick patients on the ward before going home


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INTENSIVE & HIGH DEPENDENCY CAREKnowledge required

An understanding of the potential benefits of highdependency and intensive careCommon causes of admission to high dependency andintensive careMethod of examination of the unconscious patientThe principles of brain stem death diagnosis

An understanding of sepsis and the basic patterns of failureof the major organsThe common causes of cardiac and respiratory arrestThe anatomy of the oropharynx, larynx, trachea & bronchialtreeBasic anatomy of neck, upper thorax, arms, wrists, inguinalregion and foot relevant to securing venous and arterialaccessMethod of inserting a chest drain and relief of tensionpneumothoraxUnderstanding of the pharmacology and choice of

intravenous fluids appropriate for use in major fluid lossThe recognition of basic cardiac dysrrhythmias and thecurrent therapies (physical (carotid sinus massage),electrical (defibrillation & countershock), electrolytic (Mg++,

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-28/9/03

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27/10/03-

16/11/03

RESPIRATIONControl of breathing

Acute and chronic ventilatory failure,including effect of oxygen therapyEffect of IPPV on the lungsNon-respiratory function of the lungs

PHARMACOKINETICS &PHARMACODYNAMICSModes of drug elimination; directexcretion, metabolism in organs ofexcretion (phase I and IImechanisms), renal excretion andurinary pH, non-organ drugbreakdown

Anaesthetic gases and vapours Thoracic inlet and 1st ribInterpretation of normal chest X-ray

Chemistry of CO2 absorptioncompoundsPrinciples of lung ventilatorsDisconnection monitors

Ca++), and pharmacological (adrenaline, atropine,lignocaine and 2nd line drugs)Pharmacology of the common inotropes, major a nalgesics,muscle relaxants and sedative and anaesthetic inductionagents used in the critically ill, including their common sideeffects and contraindicationsThromboprophylaxis in intensive and high dependencypatientsChoice of antibioticsUse of diuretics for cardiac and respiratory failure and tomaintain urine outputBasic cardiac physiologyBasic physiology of respiration and the consequences ofpositive pressure ventilation

An understanding of common blood gas abnormalitiesAn understanding of mechanical lung ventilation in use incritically ill patients, with a knowledge ofthe vocabulary

An understanding of the uses and limitations of monitoring

equipmentThe content of an ICU record

An insight into likely outcome based upon severity scoringThe grief response

29/9/03-

26/10/03

EXAMINATION BREAK


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Prescription of continuous epidural infusionsUse of epidural techniques for post-operative painmanagementChecking epidural/spinal packsTechnique of intravenous regional anaesthesia (IVRA)Performance of some simple peripheral nerve blocksUse of drugs to provide sedationCombined general and regional anaesthesia

COMMUNICATIONSafety firstConsidering views of patient and surgeonManagement of theatre environment with awake patientPlanning list to allow block to take effectCommunication and reassuranceConsent for regional blockade

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THE LIVERFunctional anatomy and blood

supplyMetabolic functionsBile FormationOther functions

THE DIGESTIVE SYSTEMGastric function; secretion, nauseaand vomitingGut motility, sphincters and reflexesDigestive functions


Pharmacokinetic analysis contd;Pharmacokinetic variation, influenceof body size, sex, age, disease,anaesthesia, trauma, surgery,smoking, alcohol and other drugs

AntacidsDrugs influencing gastric secretion

and motilityAntiemetics

Interpretation of x-yays, CT scansand MRI scans of head and neck,

both normal and showing grossabnormality eg fracture,haemorrhage

Airways, laryngeal masks, trachealtubes, tracheostomy tubes,

emergency airwaysFixed and variable performanceoxygen therapy equipmentSelf-inflating bags

TRAUMA MANAGEMENT, STABILISATION &TRANSFER

Knowledge requiredPerformance and interpretation of the primary andsecondary surveyEmergency airway management

Anatomy and technique ofcricothyrotomy/tracheostomy/mini-tracheotomyEstablishing IV access: interosseous cannulationImmediate specific treatment of life-threatening illness orinjury, with special reference to thoracic and abdominaltraumaRecognition and management of hypovolaemic shockEffects of trauma on gastric emptyingCentral venous access: anatomy and techniquesCentral venous pressure monitoring

Arterial pressure monitoringPleural drain insertionPeritoneal lavagePrinciples of the management of head injuryMechanisms and effects of raised intra-cranial pressure:coup and contra-coup injuriesMethods of preventing the 'second insult' to the brainPrinciples of anaesthesia in the presence of a recent headinjury

Management of cervical spine injuriesPrinciples of the safe transfer of patientsUnderstanding portable monitoring systemsRecognition and management of dilutional coagulopathyFactors affecting intraocular pressure

Experience to be gainedAssessment and immediate management of trauma patient:primary and secondary surveyGlasgow coma scaleRecognition of need for appropriate investigations (Hb,

cross-match, chest X-ray etc)Assessment and management of circulatory shock


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Emergency airway management, oxygen therapy andventilationChest drain insertion and management: emergency relief oftension pneumothoraxCannulation of major vessels for resuscitation andmonitoringCare and immobilisation of cervical spineTransfers within and between hospitals of adults who do not

have life threatening conditions or a severe head injuryAnalgesia for trauma victimUrinary catheterisation in traumatised patientEstablishing central venous pressure monitoring:interpretation of readingsEstablishing arterial pressure monitoring: interpretation ofreadings

Anaesthesia in the presence of a recent head injury (whichitself does not require surgery)

Anaesthesia for a penetrating eye injuryAbility to deal with emergencies before, during and after

anaesthesia and the ability to stabilise a patient's conditionuntil senior assistance arrives

COMMUNICATIONImportance of speed of response and proper resuscitationTry to offer the best chance of survival.Focus on the golden hour.Communication with appropriate specialists

Ability to take control when either appropriate or necessaryInsist on stabilisation before transferPretransfer checking of kit and personnelCommunication with relatives

1/3/04-

28/3/04

EXAMINATION BREAK

165 4 04

-2 5 04

METABOLISMNutrition; carbohydrates, proteins,fats, vitamins, minerals and traceelementsMetabolic pathways and enzymesfor energy productionMetabolic rate

Hormonal control of metabolismRegulation of plasma glucoseResponse to traumaThe Stress ResponsePhysiological alterations instarvation, obesity and exerciseThermoregulation

PHARMACOKINETICS &PHARMACODYNAMICSEffects of acute organ failure ondrug eliminationPharmacodynamics;concentration-effect relationships,

hysterisis

Anti-diabetic agentsCorticosteroids

The eye and orbit

STATISTICSTypes of data and their handlingMeasures of central tendency anddispersionThe Normal distribution

Probability theory and confidencelintervals

Function and use of resuscitationequipmentTransfusion devicesHumidification devices

OBSTETRIC ANAESTHESIA & ANALGESIAPhysiological changes associated with a normal pregnancyFunctions of the placenta: placental transfer: foeto-maternalcirculationThe foetus: foetal circulation: changes at birthPain pathways relevant to labourMethods of analgesia during labour: indications and

contraindicationsEffect of pregnancy on the technique of general andregional anaesthesiaPrinciples of anaesthesia for incidental surgery duringpregnancyPreoperative assessment of pregnant patient

Anaesthesia for retained products of conceptionAnalgesia for labourManagement of APH and PPHManagement of dilutional coagulopathyIntubation problems in the full-term mother

Anaesthesia/analgesia for instrumental deliveryAnaesthesia for retained placenta


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Anaesthesia for caesarean section

COMMUNICATIONAttempt by conscientious care to recognise problems earlySeek senior help earlyGood communication with mother, partner and other familymembersCalmness under pressure

Timely assistance and prompt response to requests foranalgesia and helpReassurance to the motherCompassion and kindness when the outcome of labour hasbeen poor

173 5 04

-30 5 04

ENDOCRINE SYSTEMMechanisms of hormonal action;effect on membrane andintracellular receptors, feedbackmechanisms

Hypothalamic and pituitary functionsAdrenocortical hormonesAdrenal medullary hormonesInsulin, glucagon and exocrinepancreatic functionThyroid and parathyroid hormonesand calcium homeostasis

PHARMACOKINETICS &PHARMACODYNAMICSPharmacogenetics; familial variationin drug response

Adverse reactions to drugs;

hypersensitivity, allergy,anaphylaxis, anaphylactoid reactions

Other hormone preparations STATISTICSNull hypothesisSimple parametric and nonparametric testsChoice of appropriate test

Type I and type II errors

Aspects of study designDefinition of outcome: methodsand uncertainty of measurementBasic concepts of evidence basedmedicine and meta-analysis

Environmental control in theoperating theatre; temperature,humidity, air changes, scavengingsystems

Measurement of pain

PAEDIATRIC ANAESTHESIAAnatomical differences in the airway, head, and spinal cordfrom the adultDeciduous and permanent dentitionPhysiological differences from the adult

Haematological and biochemical changes with ageEstimation of blood volume, replacement of fluid lossModification of drug dosages

Analgesia for childrenPremedication, including local anaesthesia forvenepunctureCalculation of tube sizes, selection of masks and airwaysChoice of breathing systemUpper respiratory tract infections and when to canceloperationsPsychological aspects of sick childrenPreoperative assessment of the previously fit child

Anaesthesia in fit children for elective and urgent general,ENT, and ophthalmic surgery, minor trauma and other non-specialist procedures.Venous access (including local a naesthesia premedication)

Airway management, selection of correct sized tubes andmasks etcIV and gaseous induction of general anaesthesiaSpontaneous and ventilated maintenance of anaesthesiaCaudal and other simple blocksManagement and stabilisation of the injured child (excludingneonates and infants) until senior help arrives

Principles of paediatric resuscitation

COMMUNICATIONCommunication with the child and parentsReassurance for the child and parentsIssues of consentManagement of the environment during induction ofanaesthesia

ANAESTHESIA FOR THE ELDERLYPhysiological changes with age

Altered pharmacological responseErosion of physiological reserve


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Frequent co-morbiditiesPositioning difficultiesCommunication difficulties (eyesight, hearing, CVAs)Mental clarity, memory lossCauses of post-operative confusionImportance of social circumstancesModifications necessary when anaesthetising the elderlyManagement of post-operative confusion

COMMUNICATIONSpecial efforts to communicate clearly (N.B. deafness andblindness)Old people have feelings tooRespect for the social norms of older peopleProblems of consent in mental infirmityRecognising the limitations of therapyEthics of 'do not resuscitate' orders

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PREGNANCYPhysiologic changes in normal

pregnancyMaterno-foetal, foetal and neonatalcirculationsChanges in the foetus at birth


Effect of pregnancy on maternalpharmacokinetics and materno-foetal distribution

New drugs and drugs indevelopment, of relevance to

Anaesthesia, Intensive Care andPain Medicine.

Foetal and materno-foetalcirculation

Maternal anatomic changesduring pregnancy

Characteristics of IV cannulae,central lines, pulmonary artery

catheters, arterial cannulae andsetting up associated monitoringconnectionsCharacteristics of spinal andepidural needles

The content of the anaestheticrecord

PAIN MANAGEMENTAfferent nocioceptive pathways, dorsal horn, peripheral and

central mechanisms, neuromodulatory systems, supraspinalmechanismsNocioceptive pain, visceral pain, neuropathic painInfluence of therapy on nocioceptive mechanismsThe analgesic ladderMeasurement of pain

Assessment and management of postoperative pain andnauseaMonitoring acute pain and pain relieving methodsNon-steroidal anti-inflammatory agents: drugs andmechanismsUse of simple analgesics: paracetamol: NSAIDs

Opioids: drugs and mechanismsOpioids: intramuscular, intravenous infusion, intravenousPCA, subcutaneous PCA, epidural, intrathecalRegional local anaesthetic techniques: lumbar epidural,caudal epidural, simple peripheral nerve blocksLocal anaesthetic agents: drugs and mechanismsInhalational analgesiaSpecific clinical groups: children, elderly, impairedconsciousness, intensive careOrganisation and objectives of an acute pain serviceContributing to an acute pain service

COMMUNICATIONCommunication with patients, relatives, staffRapid response to unrelieved painManagement tempered by awareness of potentialcomplications and side effects

Awareness of limitations in pain managementMaking efforts to follow patients up on the wardsRecognition of need for team approach and partnerships ina pain team

INFECTION CONTROLUniversal precautions and good working practices (hand


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washing, gloves etc)Cross infection: modes and common agentsEmergence of resistant strains: antibiotic policies in ahospitalCommon surgical infections: antibiotic choice andprophylaxisInfections from contaminated bloodHepatitis and HIV infections: modes of infection: natural

history: at risk groupsImmunisation policySterilisation of equipmentStrategy if contaminatedPreoperative assessment: awareness of at risk groupsRecognition of the immunocompromised patient

Administration of IV antibiotics: risk of allergy andanaphylaxis

Aseptic techniquesUse of disposable filters and breathing systemsUse of protective clothing/gloves/masks etc

COMMUNICATIONEvery patient entitled to the best care availablePrevention of self-infectionPrevention of cross infection

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Primary FCARCSI Syllabus