Dr.

David Pappin (Sept 2006)

THE PRIMARY FRCA OSCE & VIVA

Recommend getting a copy of Physics, Pharmacology and Physiology for Anaesthetists: Key Concepts
for the FRCA by Cross & Plunkett

Pharmacology (Peck & Hill)

Definitions:- Drug,Receptor Graphs: - % ionisation vs. pH
- Weak acid, pKa - Dose-Response curves
- Graham’s Law, Fick’s Law - Log dose-Response curves
- Isomer - FA/FI vs. time (for different volatiles)
- Structural isomerism: Tautomerism - plasma concentration vs. time graphs
- Stereoisomerism: Geometric/Optical i.comparing different routes of admin.
- Chiral centres, Enantiomers ii. 1st order/zero order kinetics
- Racemic mixture iii. Semi-log plot for 1st order kinetics
- Blood Gas Partition Coefficient iv. Bi-exponential curve (t½α, t½β)
- Concentration effect - CSHT vs. duration of infusion
- Diffusional hypoxia (for thiopentone, propofol & opioids)
- MAC (MAC50 and Bar, Awake)
- Therapeutic index = LD50/ED50 Formulae: - Cl = VD x kel
- Meyer-Overton hypothesis - τ = 1/kel
- Elimination constant - t½ = ln2/kel etc.
- Half life, time constant
- Context Sensitive Half Time Structures: - Volatiles, Propofol, Thiopentone, Sux
- Volume of Distribution
- Clearance Physicochemical properties and effects of volatiles
st
- Zero & 1 Order pharmacokinetics Comparing properties of LA’s (pKa, PPB, solubility)
- Affinity, Efficacy, Potency Diagrams of drug-receptor mechanisms
- Agonist (full, partial, inverse)
- Antagonist (competitive/non-competitive, irreversible)
- Receptor Reserve (eg. rocuronium onset)
- Adverse Drug Reactions - Dose-related → side effects or excess effect
→ result of pharmacokinetics or interactions
- Idiosyncratic → Hypersensitivity reactions I-IV)

Drugs: - All of the drugs you commonly use everyday are fair game and should be known in detail
- For other drugs I just learnt how to classify them and their modes of action.

Describing a drug: - Class/structure, Indications, MOA

- Properties: Pharmaceutical (presentation, routes of administration/doses)
Pharmacokinetic (onset, duration, metabolism, excretion)
Pharmacodynamic (Effects/Side effects, Contraindications/Cautions)

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 Dr. David Pappin (Sept 2006)

Physics (try the A-Z; or Essentials of Anaesthetic Equipment by Baha Al-Shaikh; or Davis and Kenny’s)
Definitions:- Freezing/Boiling/Triple point
- What BTPS/STPD/LASER stand for?
- Specific Latent Heat of Vaporization
- SVP (Splitting Ratio) Classify or Die: - Ventilators & Breathing systems
- Tare weight/Filling ratio - Flowmeters
- Adiabatic change - Temperature measurement
- Absolute/Relative Humidity (ISB level) - Humidifiers (& nebulisers)
- Raoult’s Law - Hygrometers
- Osmolality/Osmolarity/Azeotropes - Pressure measurement
- Avogadro’s number - Scavenging systems
- Dalton’s Law of Partial Pressures - Gas & vapour measurement
- Gas Laws
- Henry’s Law Graphs: - Pressure vs. Flow (Laminar/Turbulent flow)
- Radiation/Convection/Evaporation - Pressure/Volume/Flow vs. Time graphs for
- Critical temperature/pressure constant flow vs. constant pressure ventilators
- Gas vs Vapour - Current vs. Time
- Pseudocritical temperature (for capacitors/inductors/defibrillators/diathermy)
- Absolute/Gauge pressure - Isotherms for N2O
- Resistance/Reactance/Impedence - Capnograph tracings
- Capacitors/Inductors - Absolute humidity: vapour pressure vs. Temp
- Transformer/Transistor/Transducer
- Differential amplifier
- Common Mode Rejection Diagrams: - of everything....helps to explain concepts
- Band width/Gain - keep it simple (need to be able to draw it fast)
- Doppler effect
- Electrocution/Macro-/Microshock (+ current thresholds at 50 Hz)
- Class I, II, III; Type B, C, BF/CF equipment (learn symbols)
- Bernoulli principle
- Venturi/Coanda effect
- Linearity/Drift/Hysteresis
- Static/Dynamic response
- Signal to Noise ratio
- Resonant (Natural) Frequency, Fourier’s Analysis
- Damping (optimal/critical)
- Allen’s test Equations: - Electrode reactions for fuel cell/Clark’s electrode
- Beer-Lambert’s Law - Soda Lime reaction
- Fick’s principle - Hagen-Pouseille formula & Reynold’s number
- Mass vs Weight - Latent Heat & Heat Sink equations
- SI units: Fundamental vs Derived - Capacitor equations: E = ½CV2; E = Q x Vmax
- Mole/Newton/Joule/Watt/Coulomb - Gas Laws etc. 2
- Volt/Ohm/Ampere
- Pressure: atm/bar/mmHg/Torr/kPa/cmH2O/p.s.i
- Sterilization/Disinfection/Decontamination
- Heat vs Temperature
- Stochiometric mixture

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 Dr. David Pappin (Sept 2006)

Physiology (recommend getting a copy of The Physiology Viva book by Brandis)

Respiratory: - Oxygen cascade (Pi02 = FiO2 x (PB - SVPwater))
- Alveolar gas equation & O2 content equation (Huffner’s constant)
- Ventilation/Perfusion differences (West’s Zones)
- Oxyhaemoglobin dissociation curve: i. Positive co-operativity, p50
ii. Causes of right or left shift (Bohr effect)
iii. MetHb, COHb & Hyperbaric O2 Therapy
iv. Types of hypoxia
v. Pre-oxygenation, Exercise, Altitude
- CO2 carriage (diagram of corpuscle), Haldane effect
- A-a gradient (causes of ): i. Shunt Equation (diagram & basic derivation)
ii. V/Q mismatch
iii. Diffusion (DLCO)
iv. Venous admixture
- Fowler’s method for Anatomical Dead Space (graph)
- Physiological dead space (Bohr’s Equation simple derivation)
- Central & Peripheral chemoreceptors (Ventilation response graphs to pCO2 & pO2)
- Lung volumes (definitions & graph)
- FRC & Closing capacity (definitions, factors affecting them & measurement)
- Compliance Curves (static & dynamic)
- Airway Resistance (Volume-Time curve for FEV1/FVC & Flow-Volume loops)
- Dynamic Compression
- Non-respiratory functions of the lung

Cardiovascular - Cardiac action potential graphs

- CVP waveform
- Cardiac cycle (pressures, volumes, coronary blood flow, heart sounds, ECG)
- Pulmonary artery catheter insertion waveforms
- Starling’s Law, Preload, Afterload
- Contractility - effect of preload & heart rate (Bowditch staircase)
- Pressure-Volume loops (elastance curve)
- Valsalva Manoeuvre
- BP control (Haemorrhage, Standing, Vasovagal episode)
- What happens on … transfusion of 1litre blood/saline/5% dextrose or drinking water?
- distribution of cardiac output to organs (% and ml/min/100g) %CO ml/min/100g %O2
- % O2 consumption of each organ Brain 15 50 20
- distribution of blood volume in various blood vessels Heart 5 70 11
Kidney 25 400 7
Liver 25 100 20
Muscle* 15 4 20
Skin 5 (*Skeletal) 5
Nervous System - Epi/Peri/Endoneurium, Fasciculus, Saltatory, Myelin Lung 2 Rough numbers only
- AP graph, RMP (Pump-Leak hypothesis, Donnan Effect), propagation (current sink)
- Nerve classification → compare susceptibilities to LA’s, pressure, hypoxia
- Compound nerve AP (at supramaximal stimulus)
- Reflexes (monosynaptic, polysynaptic diagrams)
- Factors affecting Cerebral Blood Flow graphs (autoregulation, pO2, pCO2)
- Monroe-Kellie doctrine (ICP vs intracranial volume)
- Distribution of ANS, neurotransmitters, receptors and actions
- Pain pathways: peripheral/central sensitization (wind-up),
gate theory (diagram), descending inhibition, hyperalgesia, allodynia

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 Dr. David Pappin (Sept 2006)

Renal- GFR measurement

- Factors affecting Renal Blood Flow and measurement (autoregulation graph)
- Counter-exchange mechanism/multiplier
- How nephron handles H2O, Na and Acid/Base balance (diagrams & action of diuretics)
- Henderson-Hasselbach equation (basic derivation), and Anion Gap
- distribution of total body water (measurement of different compartment volumes)
- constituents of different iv fluids
- microcirculation (diffusion vs filtration)
- Starling’s equation & forces (normal capillaries vs renal vs pulmonary capillaries)
- Donnan effect, Nernst equation vs Goldman equation

Gastroenterology - Swallowing reflex

- Vomiting reflex (probably as part of antiemetics talk in pharmacology,
or maybe biochemistry of pyloric stenosis)
- Factors affecting gastric acid production
- Factors affecting motility & lower oesophageal sphincter
- Iron absorption and distribution

Liver & Metabolism - Functions of liver

- Diagram of lobule (zone functions)
- Basal Metabolic Rate (value, definition & measurement)
- Anaerobic/Aerobic metabolism equations
- Krebs cycle diagram (simplify it as much as possible)
- Changes in exercise, starvation and the stress response
- Nutrition (assessment of status, -ve nitrogen balance, parenteral vs enteral)
- Temperature homeostasis

Endocrinology- Define hormone & classification, methods of assessment

- Hypothalamo-pituitary axis → ACTH/Cortisol, TSH
- Adrenaline (structure/synthetic pathway, effects)
- Insulin & Glucagon (with reference to metabolism, starvation etc)
- Thyroid
- Calcium homeostasis

Haematology- Anaemia and management (esp. Sickle cell)

- Coagulation Cascade & Fibrinolytic system (and associated pharmacology)

Pregnancy & Foetal Physiology - cardiovascular and respiratory changes

Anatomy (again try A-Z or Concise Anatomy for Anaesthetists by Erdman)

Neuroanatomy- CNS arterial supply diagram, spinal cord diagram, epidural, caudal
- ANS, stellate ganglion, coeliac plexus, vagus nerve
Head & Neck - skull from all angles, facial fractures (& intubation), trigeminal nerve, orbit
- surface anatomy of neck, CVP line insertion, cross section at C4
Thorax - Coronary circulation
- Larynx, bronchial tree, diaphragm, intercostals blocks
Upper limb - brachial plexus, cubital fossa, wrist blocks (& arterial supply to hand → A-lines)
Lower limb - Lumbar plexus, sciatic, femoral (& inguinal) blocks
- Popliteal fossa, Ankle blocks
Make sure you know your dermatomes.

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 Dr. David Pappin (Sept 2006)

Statistics
Definitions - parametric/non-parametric data
- central tendency (mean, median, mode)
- measures of dispersion (interquartile range, variance, SD)
- (non-)normal distribution, skewing (correction measures).
- inferential stats: SEM, confidence intervals
Null hypothesis
Type I/α error (Bonferoni correction)
Type II/β error
Power, Variance of variability
- Types of data: qualitative/categorical (nominal, ordinal)
Quantitative (discrete, continuous, interval, ratio)
- Tests: Sensitivity/Specificity
+ve/-ve predictive value
Student’s T-test, ANOVA
Rank-Sum (or the Mann-Whitney U test)
Chi-squared test, 2x2 contingency tables, degrees of freedom
Fisher’s Exact test
- Measures of association: correlation vs regression
Bland-Altman Plot (for measurement error)
For vivas (if you are that unlucky – good luck!) →The Anaesthesia Science Viva Book by Bricker
- Study design (Phases I-IV, Declaration of Helsinki, stages of trial design)
- Meta-analysis (advantages and disadvantages)
- Evidence Based Medicine (Levels of evidence I-V, recommendations A-D)

Clinical
Considerations in the - Obese, Diabetic, Rheumatoid Arthritic, Thyroid, COPD or IHD patient
- Paediatric trauma, burns (equations, assessment of shock, fluid admin)
Critical Incidents - know all current ALS guidelines & failed intubation drill
- ST changes on ECG
- intravenous bupivacaine, intra-arterial thiopentone
- cyanosis, respiratory obstruction in theatre/recovery (ASPIRATION)
- sudden hypocarbia/hypercarbia (MALIGNANT HYPERTHERMIA) - testing
- hypertension in recovery
- hypotension (+ bronchospasm/high peak inspiratory pressures = ANAPHYLAXIS)
(+ tracheal shift/high inspiratory pressures = TENSION PNEUMO)
- Gas/Fat embolism
- Failure of muscle relaxant reversal – SUX APNOEA (Dibucaine no.)
- Massive Perioperative Hamaemorrhage – Blood transfusion Reaction
- High/Total Spinal

ALSO FOR OSCE…

Be able to check the anaesthetic machine, put together a Bain’s circuit
Physical examination (CVS, Respiratory, Neurological → cranial nerves, CNS, PNS)
Know all equipment (from Tuohy needles, Huber points and Lee’s lines to different filter pore sizes)
Be able to interpret blood results, ABG’s, X-rays, CTs, ECGs.
Be able to explain how you would do an RSI, change a tracheostomy tube etc.
Be kind, sympathetic and understanding in the communication station (Touchy-Feely)
Remember there is NO negative marking in the OSCE multiple choice questions.