Click on the links above to view information about each
topic:
PREOPERATIVE ASSESSMENT
Implications for anaesthesia of commoner elective conditions requiring gynaecological, abdominal, orthopaedic, ENT, dental, urological and body surface surgery. Knowledge of sub-specialty practice and specialised techniques is not required unless specified elsewhere.
The relevance of trauma, intestinal obstruction and acute abdominal emergencies
The ASA classification and other scoring systems such as Glasgow coma scale (GCS)
The interpretation of relevant preoperative investigations
Restriction of food and fluid by mouth, cessation of smoking, correction of dehydration
Assessment of difficulties in airway management and the importance 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 and whether it should be continued, modified stopped or changed peri-operatively
Need for and methods of perioperative antithrombotic treatment
The importance of an anaesthetic history and genetic diseases in anaesthesia with respect to suxamethonium apnoea, anaphylaxis and malignant hyperpyrexia
Assessment of post-operative analgesic needs
Assessment of whether ICU or HDU care will be required post-operatively
The importance of consent and the issues surrounding it
Dangers of repeat anaesthesia
PREMEDICATION
Rationale for use of premedicant drugs
Choice of drugs, advantages and disadvantages
Rationale for antacid, and prokinetic premedication
Rationale for antithrombotic therapy
Understanding of causes of delayed gastric emptying
ANAESTHESIA, HDU AND ICU EQUIPMENT: MONITORING AND SAFETY
Physical principles underlying the function of the anaesthetic machine, pressure regulators, flowmeters, vaporizers, breathing systems
Chemistry of 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
Minimum monitoring requirements
Basis for pre-use checks of anaesthetic machine, breathing systems and monitoring apparatus
Function and use of resuscitation equipment, transfusion devices
Humidification devices
Environmental control of the operating theatre including temperature, humidity, air changes and scavenging systems for waste anaesthetic gases and vapours
Sterilisation and cleaning of equipment
Electrical safety
Characteristics of intravenous cannulae, spinal and epidural needles
INDUCTION OF GENERAL ANAESTHESIA
Intravenous and inhalational induction of anaesthesia; advantages and disadvantages of each technique
Indications for tracheal intubation
Selection of tube type (oral, nasal, armoured etc), diameter and length
Management of difficult intubation and failed intubation
Methods of confirming placement of the endotracheal tube; oesophageal and endobronchial intubation, complications
Insertion and use of oral airways, face masks and laryngeal mask airway
Causes of regurgitation and vomiting during induction, prevention and management of pulmonary aspiration
Cricoid pressure
Induction of anaesthesia in special circumstances, (head injury, full stomach, upper airway obstruction, shock)
Drugs: pharmacology and dosages of induction agents, relaxants, analgesics, and inhalational agents
Side effects of drugs used and their interactions
Monitoring during induction
Recognition and management of anaphylactic and anaphylactoid reactions including
follow up and patient information
Management of intra-arterial injection of harmful substances (e.g. antibiotics, thiopentone)
Management of asthma, COPD, hypertension, IHD, rheumatoid arthritis
Problems of the obese patient
INTRAOPERATIVE CARE (INCLUDING SEDATION)
Techniques of maintenance of general anaesthesia involving both spontaneous and controlled ventilation (except sub-specialty and highly specialised practice)
Definition of and methods of sedation
Management of the shared airway
Effects and hazards of the pneumoperitoneum induced for laparoscopic surgery
Drugs: Pharmacology, uses and dosages of induction agents used for IV maintenance, relaxants, analgesics, inhalational agents
Methods of producing muscle relaxation
Choice of spontaneous and controlled ventilation and methods of monitoring them
Minimum monitoring standards
Additional monitoring for sick patients (e.g. CVP, urine flow)
Detection and prevention of awareness
Management of important critical incidents occurring during anaesthesia (critical incidents)
Prevention, diagnosis and management of postoperative pulmonary atelectasis, deep vein thrombosis and pulmonary embolus
Criteria for discharge of day-stay patients
INTENSIVE AND HIGH DEPENDENCY CARE
SHO trainees in anaesthesia are required to spend a total of 3 months in intensive care training. The SHO knowledge, skills and attitudes lists below are compatible with the recommendations of the Intercollegiate Board for Training in Intensive Care Medicine (IBTICM)9 for SHO training in intensive care medicine. Because these are reproduced in full, there is obviously repetition of material that appears in other sections of this document. There is, in addition, guidance on assessment for ICM.
An understanding of the potential benefits of high dependency and intensive care
Common causes of admission to high dependency and intensive care
Method of examination of the unconscious patient
The principles of brain stem death diagnosis
An understanding of sepsis and the basic patterns of failure of the major organs
The common causes of cardiac and respiratory arrest
The anatomy of the oropharynx, larynx, trachea & bronchial tree
Basic anatomy of neck, upper thorax, arms, wrists, inguinal region and foot relevant to insertion of venous and arterial access
Method of inserting a chest drain and relief of tension pneumothorax
Understanding of the choice of intravenous fluids appropriate for use in major fluid loss, and their pharmacology
The recognition of basic cardiac dysrrhythmias and the current therapies (physical (carotid sinus massage), electrical (defibrillation & countershock), electrolytic (Mg++, Ca++), and pharmacological (adrenaline (epinephrine), atropine, lignocaine and 2nd line drugs)
Pharmacology of the common inotropic agents used in the critically ill (adrenaline (epinephrine), nor-adrenaline (nor-epinephrine))
Pharmacology of major analgesics used as respiratory depressants (morphine, fentanyl series), and common side effects and contra-indications
Pharmacology of common muscle relaxants (depolarising and non-depolarising) and common side effects and contra-indications
Pharmacology of intravenous sedative and anaesthetic induction agents used in the critical care unit
Thromboprophylaxis in intensive and high dependency patients
Choice of antibiotics
Use of diuretics for cardiac and respiratory failure and to maintain urine output
The basic cardiac and respiratory physiology
The basic physiology of respiration and the consequences of positive pressure ventilation
An understanding of common blood gas abnormalities
An understanding of the use of ventilation in use on critically ill patients, with a knowledge of the vocabulary
An understanding of the uses and limitations of monitoring equipment
The content of an ICU record
An insight into likely outcome based upon severity scoring
The grief response
Regional Anaesthesia
Pharmacology of local anaesthetics & spinal opioids
Anatomy of spine, nerve roots, cauda equina, intercostal nerves, brachial plexus, femoral nerve, inguinal canal, nerves at wrist and ankle, nerve supply of larynx
Dermatomes and levels for common operations (e.g. inguinal hernia, haemorrhoids)
Technique of spinal and epidural (including caudal) anaesthesia: single shot and catheter techniques
Management of the complications of spinal and epidural (including caudal) analgesia (associated hypotension, shivering, nausea & anxiety)
Management of accidental total spinal blockade
Management of dural tap
Techniques and complications of intravenous regional anaesthesia (IVRA),
Toxicity of local anaesthetic agents and its management
Management of failed/ deteriorating regional block
Methods of sedation
Absolute and relative contraindications to regional blockade
MANAGEMENT OF TRAUMA, STABILISATION AND TRANSFER OF PATIENTS
Performance and interpretation of the primary and secondary survey
Emergency airway management
Anatomy and technique of cricothyrotomy/tracheostomy/mini-tracheotomy
Establishing IV access: interosseous cannulation
Immediate specific treatment of life-threatening illness or injury, with special reference to thoracic and abdominal trauma
Recognition and management of hypovolaemic shock
Effects of trauma on gastric emptying
Central venous access: anatomy and techniques
Central venous pressure monitoring
Arterial pressure monitoring
Pleural drain insertion
Peritoneal lavage
Principles of the management of head injury
Mechanisms and effects of raised intra-cranial pressure: coup and contra-coup injuries
Methods of preventing the 'second insult' to the brain
Principles of anaesthesia in the presence of a recent head injury
Management of cervical spine injuries
Principles of the safe transfer of patients
Understanding portable monitoring systems
Recognition and management of dilutional coagulopathy
Factors affecting intraocular pressure
OBSTETRIC ANAESTHESIA AND ANALGESIA
Physiological changes associated with a normal pregnancy
Functions of the placenta: placental transfer: feto-maternal circulation
The fetus: fetal circulation: changes at birth
Pain pathways relevant to labour
Methods of analgesia during labour: indications and contraindications
Effect of pregnancy on the technique of general and regional anaesthesia
Principles of anaesthesia for incidental surgery during pregnancy
PAEDIATRIC ANAESTHESIA
(infants and children)
Anatomical differences in the airway, head, and spinal cord from the adult
Deciduous and permanent dentition
Physiological differences from the adult
Haematological and biochemical changes with age
Estimation of blood volume, replacement of fluid loss
Modification of drug dosages
Analgesia for children
Premedication, including local anaesthesia for venepuncture
Calculation of tube sizes, selection of masks and airways
Choice of breathing system
Upper respiratory tract infections and when to cancel operations
Psychological aspects of sick children
ANAESTHESIA AND THE ELDERLY
Physiological changes with age
Altered pharmacological response
Erosion of physiological reserve
Frequent co-morbidities
Positioning difficulties
Communication difficulties (eyesight, hearing, CVAs)
Mental clarity, memory loss
Causes of post-operative confusion
Importance of social circumstances
INFECTION CONTROL
Universal precautions and good working practices (hand washing, gloves etc)
Cross infection: modes and common agents
Emergence of resistant strains: antibiotic policies in a hospital
Common surgical infections: antibiotic choice and prophylaxis
Infections from contaminated blood
Hepatitis and HIV infections: modes of infection: natural history: at risk groups
Immunisation policy
Sterilisation of equipment
Strategy if contaminated
CRITICAL INCIDENTS
Common causes of critical incidents
Principles of the causes, detection and management of:
Cardiac and / or respiratory arrest
Unexpected Hypoxia with or without cyanosis
Unexpected increase in peak airway pressure
Progressive fall in minute volume during spontaneous respiration or IPPV
Transfusion of miss-matched blood or blood products
Malignant hyperpyrexia
Inadvertent intra-arterial injection of irritant fluids
High spinal block
Local Anaesthetic toxicity
Failed intubation
Difficulty with IPPV and sudden or progressive loss of minute volume
MANAGEMENT OF RESPIRATORY AND CARDIAC ARREST
This section should be read in conjunction with Section 2.1 and Appendix 1. Trainees can be regarded as achieving the necessary competencies if they have successfully completed an ALS course in the last 12 months.
Patient assessment: diagnosis of causes of cardio-respiratory arrest
Causes of cardio-respiratory arrest during induction, maintenance and recovery from anaesthesia
Importance of considering non-cardiac causes of cardio-respiratory arrest
Methods of airway management (mouth-mouth/nose, bag-mask, LMA, intubation)
Recognition and management of life-threatening arrhythmias including defibrillation and drug therapy
Recognition and management of non-cardiac causes of cardio-respiratory arrest
Knowledge of specific problems of paediatric resuscitation
Ethical aspects of resuscitation
ANATOMY
Trainees should be able to demonstrate a good understanding of human anatomy relevant to the practice of anaesthesia at SHO level and to support progress to SpR 1/2 training
Respiratory System
Mouth, nose, pharynx, larynx, trachea, main bronchi, segmental bronchi, structure of bronchial tree: differences in the child
Airway and respiratory tract, blood supply, innervation and lymphatic drainage
Pleura, mediastinum and its contents
Lungs, lobes, microstructure of lungs
Diaphragm, other muscles of respiration, innervation
The thoracic inlet and 1st rib
Interpretation of a normal chest x-ray
Cardiovascular system
Heart, chambers, conducting system, blood and nerve supply.
Pericardium
Great vessels, main peripheral arteries and veins
Fetal and materno - fetal circulation
Nervous system
Brain and its subdivisions
Spinal cord, structure of spinal cord, major ascending and descending pathways
Spinal meninges, subarachnoid and extradural space, contents of extradural space
CSF and its circulation
Spinal nerves, dermatomes
Brachial plexus, nerves of arm
Intercostal nerves
Nerves of abdominal wall
Nerves of leg and foot
Autonomic nervous system
Sympathetic innervation, sympathetic chain, ganglia and plexuses
Parasympathetic innervation
Stellate ganglion
Cranial nerves: base of skull: trigeminal ganglion
Innervation of the larynx
Eye and orbit
Vertebral column
Cervical, thoracic, and lumbar vertebrae
Sacrum, sacral hiatus
Ligaments of vertebral column
Surface anatomy of vertebral spaces, length of cord in child and adult
Surface anatomy
Structures in antecubital fossa
Structures in axilla: identifying the brachial plexus
Large veins and anterior triangle of neck
Large veins of leg and femoral triangle
Arteries of arm and leg
Landmarks for tracheostomy, cricothyrotomy
Abdominal wall (including the inguinal region): landmarks for suprapubic urinary and peritoneal lavage catheters
PHYSIOLOGY AND BIOCHEMISTRY
Trainees should have a good general understanding of human physiology, be able to apply physiological principles and knowledge to clinical practice at SHO and have sufficient knowledge to support progress to SpR 1/2 training.
General
Organisation of the human body and control of internal environment
Variations with age
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
Cellular metabolism
Enzymes
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: also pleural, pericardial
and peritoneal fluids
Haematology and Immunology
Red blood cells: haemoglobin and its variants
Blood groups
Haemostasis and coagulation
White blood cells
Immunity and allergy
Muscle
Action potential generation and its transmission
Neuromuscular junction and transmission
Muscle types
Skeletal muscle contraction
Smooth muscle contraction: sphincters
Motor unit
Heart/Circulation
Cardiac muscle contraction
The cardiac cycle: pressure and volume relationships
Rhythmicity of the heart
Regulation of cardiac function; general and cellular
Control of cardiac output (including the Starling relationship)
Fluid challenge and heart failure
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
Characteristics of special circulations including: pulmonary, coronary, cerebral, renal, portal and foetal
Renal tract
Blood flow and glomerular filtration and plasma clearance
Tubular function and urine formation
Assessment of renal function
Regulation of fluid and electrolyte balance
Regulation of acid-base balance
Micturition
Pathophysiology of acute renal failure
Respiration
Gaseous exchange: O2 and CO2 transport, hypoxia and hyper- and hypocapnia, hyperand hypobaric pressures
Functions of haemoglobin in oxygen carriage and acid-base equilibrium
Pulmonary ventilation: volumes, flows, dead space
Effect of IPPV on lungs
Mechanics of ventilation: ventilation/perfusion abnormalities
Control of breathing, acute and chronic ventilatory failure, effect of oxygen therapy
Non-respiratory functions of the lungs
Nervous System
Functions of nerve cells: action potentials, conduction and synaptic mechanisms
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: adrenaline (epinephrine) and noradrenaline (norepinephrine)
Pancreas: insulin, glucagon and exocrine function
Thyroid and parathyroid hormones and calcium homeostasis
Pregnancy
Physiological changes associated with normal pregnancy
Materno-fetal, fetal and neonatal circulation
Functions of the placenta: placental transfer
Fetus: changes at birth
PHARMACOLOGY
Trainees should have a good understanding of general pharmacological principles, together with knowledge of drugs likely to be encountered in (a) anaesthetic practice and (b) current treatment of patients presenting for anaesthesia. The level of knowledge should be sufficient to enable clinical practice at SHO level and able to support progress to SpR 1/2 training.
Applied chemistry
Types of intermolecular bonds
Laws of diffusion. Diffusion of molecules through membranes
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
Simple analgesics
Opioids and other analgesics; and opioid antagonists
Non-steroidal anti-inflammatory drugs
Neuromuscular blocking agents (depolarising & non-depolarising), and anticholinesterases
Drugs acting on the autonomic nervous system: cholinergic and adrenergic agonists and antagonists
Drugs acting on the heart & cardiovascular system (including inotropes, vasodilators, vasoconstrictors, antiarrhythmics, diuretics)
Drugs acting on the respiratory system (including respiratory stimulants & bronchodilators)
Antihypertensives
Anticonvulsants
Anti-diabetic agents
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
Vitamin K, B12 and thiamine
PHYSICS AND CLINICAL MEASUREMENT
Candidates should have a good understanding of the principles of physics and clinical measurement with an emphasis on the function of monitoring equipment safety and measurement techniques.
Mathematical concepts: relationships and graphs
Concepts only of exponential functions and logarithms: wash-in, wash-out and tear away
Other systems of units where relevant to anaesthesia (e.g. mmHg, bar, atmospheres)
Simple mechanics: mass, force, work and power
Heat: freezing point, melting point, latent heat
Conduction, convection, radiation
Mechanical equivalent of heat: laws of thermodynamics
Measurement of temperature and humidity
Colligative properties: osmometry
Physics of gases and vapours
Absolute and relative pressure
The gas laws; triple point; critical temperature and pressure
Density and viscosity of gases
Laminar and turbulent flow; Poiseuille's equation, the Bernoulli principle
Vapour pressure: saturated vapour pressure
Measurement of volume and flow in gases and liquids
The pneumotachograph and other respirometers
Principles of surface tension
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 and safety of lasers
Basic principles of ultrasound and the Doppler effect
Principles of cardiac pacemakers and defibrillators
Electrical hazards: causes and prevention
Electrocution, fires and explosions
Diathermy and its safe use
Principles of pressure transducers
Resonance and damping, frequency response
Measurement and units of pressure
Direct and indirect methods of blood pressure measurement
Principles of pulmonary artery and wedge pressure measurement
Cardiac output: Fick principle, thermodilution
Measurement of gas and vapour concentrations, (oxygen, carbon dioxide, nitrous oxide, and volatile anaesthetic agents) using infra-red, paramagnetic, fuel cell, oxygen electrode and mass spectrometry methods
Measurement of pH, pCO2 , pO2
Measurement CO2 production/ oxygen consumption/ respiratory quotient
Simple tests of pulmonary function e.g. peak flow measurement, spirometry
Capnography
Pulse oximetry
Measurement of neuromuscular blockade
Measurement of pain
STATISTICAL METHODS
Trainees 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.
Data Collection
Simple aspects of study design
Defining the outcome measures and the uncertainty of measuring them
The basic concept of meta-analysis and evidence based medicine
Descriptive statistics
Types of data and their representation
The normal distribution as an example of parametric distribution
Indices of central tendency and variability
Deductive and inferential statistics
Simple probability theory and the relation to confidence intervals
The null hypothesis
Choice of simple statistical tests for different data types
Type I and type II errors
123Doc Education Davina House
137-149 Goswell Road
London EC1V 7ET
