Final FRCA SAQ Critical Care - Frcaheadstart
Final FRCA SAQCritical CareTom KellyST6 ICM/Anaesthetics18th June 2019
Outline Top tips on general approach Chairman’s report & recurring advice Previous question practice, examiner feedbackand answers Structure of RCOA mark scheme Hot topics in critical care
Tips Read, plan and read the question again Is this detail or breadth that i’m being asked for Be mindful of weighting of marks 3 marks 2 minutes Succinct bullet points You don’t have to be able to define something to pass a question You don’t have to know aetiology/risk factors to pass a question Use surgical sieve to eke out marks (ABCDE/Hx-Ex-Ix/VITAMIN) If in doubt, write it down!
Chairman’s Report Along with past papers - September and Marchon the RCOA )
Chairman’s Report Recurring Advice; “Failing to answer the question asked” “Poor weighting of answers” “Giving general and superficial answers to specific questions” “Illegible handwriting” “Candidates encouraged to set out answers in “bullet point” or“table” format” “In preparation for this exam it might be prudent to arrange tastersessions”
Chairman’s Report Take a look at last fe papers in a group of two orthree. Quick way to cover important topics andshare knowledge Other resource for ca.org.uk/ We will cover previous FRCA SAQ examples in aQuestion, Feedback, Answer format
Sep 2018 Questiona) What is meant by the term ventilator associated pneumonia? (3marks)b) List the factors that increase the risk of the development ofventilator associated pneumonia? (10 marks)c) What measures may reduce the risk of development of ventilatorassociated pneumonia? (7 marks)
Sep 2018 Feedback Pass rate 38.6% Examiners were surprised at the lack of knowledge on this topicparticularly as it has been used in a recent paper. The conditionids topical, important and frequently seen so candidates reallyshould know it in more detail than was demonstrated here.Candidates lacked knowledge of definition, and listed just lungprotection strategies rather than protection against VAP. Thisquestion showed the closest correlation with overall performance.
Sep 2018 Answera) What is meant by the term ventilator associated pneumonia? (3marks)Diagnosis of VAP is based on a combination of clinical, radiological,and microbiological criteria;Invasively ventilated with radiological infiltrates and two from three of;FeverLeucocytosisPurulent secretions
Sep 2018 Answerb) List the factors that increase the risk of the development ofventilator associated pneumonia? (10 marks)Non-subglottic suction ETT, biofilm formation and microaspirationLow cuff pressuresTracheostomyIneffective coughing - NMBDs/No suctioningImmunosuppressionProlonged ventilation & reintubationsNursing patients supineEnteral feeding via a nasogastric tubeMales & Age 60Pre-existing lung diseaseHead TraumaUse of antacids/PPI/H2 anatagonistsAntibiotic useCircuit changes & aerosol treatment
Sep 2018 Answerc) What measures may reduce the risk of development of ventilatorassociated pneumonia? (7 marks)Care bundlesTT modification; Cuff pressure control - 20-30cm H2OSubglottic secretion drainageTT cuff design - ultra thinpolyurethaneTT coating - silver coatingNebulized gentamicinKinetic therapyCare of airway equipment - keep closed circuit, hand hygiene & limitcircuit/equipment changesIntubation-related events - Regular sedation holds, minimise reintubationsLimit PPI/H2 useFeeding ?postpyloric - debatable!?Probiotics
March 2018 Questiona) Define delirium. (2 marks)b) List the key clinical features that are used to diagnose delirium incritical care. (4 marks)c) In a delirious critical care patient what are the most commonpotentially treatable causes? (9 marks)d) When is pharmacological treatment indicated (2 marks), and whichclasses of drugs can be used? (3 marks)
March 2018 Feedback Pass rate 46.5% This was a new and very topical ITU question. Overall themanagement of delirium was described well but a lot of answerslacked detail. There was poor knowledge of the definition andfeatures of delirium. This probably reflects the fact that candidateshave dealt with many patients with delirium whilst working on ITU,but have not read around the subject.
March 2018 Answera) Define delirium. (2 marks)-Delirium is defined as a disturbance of consciousness and a changein cognition that-Develops over a short period of time-Hypoactive/Hyperactive/Mixedb) List the key clinical features that are used to diagnose delirium incritical care. (4 marks)All of the following must be present (CAM ICU assessment)1. Acute change or fluctuating course of mental status2. Inattention3. Altered level of consciousness (RASS other than zero)4. Disordered thinking
March 2018 Answer
March 2018 Answerc) In a delirious critical care patient what are the most commonpotentially treatable causes? (9 marks) Failure to provide adequate pain relief Hypoxaemia Acidosis Sepsis/Dever Immobilisation Frustration Patient-ventilator desynchrony Metabolic and haemodynamic instability Cerebral illnesses (eg Alzheimer’s, dementia,stroke, abscesses, seizures, tumours) Drug interactions Withdrawal of drugs Pre-existing alcohol/substance abuse Drug side effects (principally excess antimuscarinic and dopaminergic activity.) Anaemia Sleep disturbance/deprivation, Depression Smoking Vision/hearing impairment Hepatic Failured) When is pharmacological treatment indicated (2 marks), and whichclasses of drugs can be used? (3 marksIf all preventative measures fail and no organic cause can be identified and treated,active delirium treatment should be instigated. Drug classes;Butyrophenone antipsychotics (Haloperidol), Atypical anti-psychotics (olanzapine,quetiapine), Benzodiazepines (Debatable), Alpha 2 agonists, ?Night Sedatives(Zopiclone, Trazadone)
September 2017 Questiona) What are the indications for renal replacement therapy (RRT) in theintensive care setting? (8 marks)b) List the types of RRT available in intensive care. (6 marks)c) Outline the principle mechanisms of solute and water removal byfiltration (3 marks) and dialysis (3 marks) during RRT.
September 2017 Feedback Pass rate 84.9% This question had the highest pass rate in the paper. The topic isrelevant to everyday practice in intensive care so it was reassuringto see that knowledge of it was generally excellent. However, anumber of candidates still gave incomplete accounts of thedifferences between dialysis and filtration.
September 2017 Answera) What are the indications for renal replacement therapy (RRT) in theintensive care setting? (8 marks)Renal Failure/AKI, metabolic acidosis, Sepsis, Diuretic resistant pulmonary oedema,hyperkalemia, uremic complications (pericarditis, encephalopathy, bleeding), dialyzableintoxications (eg, lithium, toxic alcohols, and salicylates)b) List the types of RRT available in intensive care. (6 marks)?Peritoneal dialysis (PD)Intermittent hemodialysis (IHD)Continuous renal replacement therapies (CRRT) - CVVH/CVVHD/CVVHDFc) Outline the principle mechanisms of solute and water removal byfiltration (3 marks) and dialysis (3 marks) during RRT.Haemofiltration a convection process whereby a hydrostatic pressure gradient is used tofilter plasma, water, and solute across a membraneIn haemodialysis, solute clearance is achieved by diffusion across the membrane.
March 2017 QuestionYou are asked to review a 27-year-old male who is a known epilepticin convulsive status epilepticus.a) Define convulsive status epilepticus. (1 mark)b) Outline your initial management of this patient including the use ofemergency antiepileptic drug therapy. (7 marks)c) 60 minutes after your initial management the patient continues instatus epilepticus. What would be your further management? (5marks)d) What are the complications associated with refractory convulsivestatus epilepticus? (7 marks)
March 2017 Feedback Pass rate 47.1%This question was judged to be easy and is relevantto everyday practice as anaesthetists may encountersuch patients in multiple areas including ITU,neurosurgery and the emergency department. Veryfew candidates were aware of the up to datedefinition of status epilepticus. In part b somecandidates failed to give details of drug managementdespite this being specifically asked for in thequestion.
March 2017 AnswerDirectly from the college.
March 2017 AnswerDirectly from the college.
March 2017 Questiona) List criteria for a diagnosis of acute respiratory distress syndrome(ARDS)? (3 marks)b) Which clinical indices are used to quantify oxygenation in ARDS. (3marks)c) What tidal volume would you select for a patient that meets thecriteria for ARDS, using the ARDSNet protocol? (2 marks)d) What are the ventilatory (6 marks) and non-ventilatory, (6 marks)measures that can be taken to improve oxygenation or preventfurther deterioration in a patient with ARDS.
March 2017 Feedback Pass rate 57.3% ARDS is a clinical condition which is seen commonlyon ITU and of which candidates should have athorough understanding. Whilst the definition waswell known, the majority of candidates did not knowthe clinical indices used to assess oxygenation. Partd was on the whole well answered but thosecandidates who lost marks tended to write aboutgeneral ITU care rather than the specifics of care forpatients with ARDS.
March 2017 Answera) List criteria for a diagnosis of acute respiratory distress syndrome (ARDS)? (3 marks)Berlin criteria - Acute( 1 week), bilateral opacities consistent with p oedema(CXR or CT), PF ratio 300mmHg min PEEP 5, not fully explained by cardiacfailure or overload.b) Which clinical indices are used to quantify oxygenation in ARDS. (3 marks)Pa02, Fi02, PF ratio, satsc) What tidal volume would you select for a patient that meets the criteria for ARDS, usingthe ARDSNet protcol? (2 marks)6ml/kg PBW. Strictly 8ml/kg PBW, reducing by 1ml/kg 2hrly until 6ml/kg PBWd) What are the ventilatory (6 marks) and non-ventilatory, (6 marks) measures that can betaken to improve oxygenation or prevent further deterioration in a patient with ARDSVentilatory - Monitor plateau pressure with inspiratory pause (30mmHg),optimise PEEP, insp exp, permissive hypercapnia, consider spontaneousbreathing trial ? Non ventilatory - Paralysis, Nitric oxide, proning, diuretic00
September 2016 QuestionA 20-year-old patient who satisfies the criteria for brainstemdeath has been accepted as an organ donor.a) List the main adverse cardiovascular changes associatedwith brainstem death. (5 marks)b) What are the physiological goals (with values) required toensure optimisation of this donor? (7 marks)c) Outline the measures and drugs that may be used toachieve these goals. (8 marks)
September 2016 Feedback Pass rate 68.8% Examiners anticipated that candidates would find thisquestion difficult but gratifyingly most achieved enoughmarks to pass and demonstrated good knowledge of thisimportant topic.
September 2016 AnswerFrom the college.
September 2016 AnswerFrom the college.
March 2016 Question a) List 3 common causes of acute pancreatitis in theUnited Kingdom. (3 marks) b) How is acute pancreatitis diagnosed? (3 marks) c) Describe the classification of severity of acutepancreatitis. (3 marks) d) What are the specific principles of managing severeacute pancreatitis in a critical care environment? (11marks)
March 2016 Feedback Pass rate 53.6% This is a condition seen commonly in intensive care. Manycandidates did not mention alcohol as a cause in part (a).Few candidates could describe the classification ofseverity of acute pancreatitis as asked for in part (b). Alsosome candidates tended to give a generic answer to part(d) describing the management of sepsis, rather than thespecific management of acute pancreatitis as asked. Thisresulted in them losing marks in this section.
March 2016 Answera) List 3 common causes of acute pancreatitis in the UnitedKingdom. (3 marks) GETSMASHED. Gall stone, ETOH, ERCPb) How is acute pancreatitis diagnosed? (3 marks)History, examination, blood tests - amylase and lipase (typically 3xthe normal limit)c) Describe the classification of severity of acute pancreatitis. (3marks)Imrie and Ranson criteria. Combination of blood test results andclinical measurements. Score of or 3 suggests increasedlikelihood of being severe. Not full proof ! Only valid after 48 hrs.APACHE scoring has also been used.
March 2016 Answerd) What are the specific principles of managing severe acutepancreatitis in a critical care environment? (11 marks) Organ support Nutritional support Treating complications Adequate analgesia Fluid and electrolyte replacement/fluid balance Inotropic support Ventilatory support
March 2016 Question A 20-year-old man is brought to the emergency department havingbeen pulled from a river where he got into difficulties whilstswimming. a) Describe the relevant history (5 marks) and investigations (8marks) for this patient who has suffered near-drowning. b) He has a Glasgow Coma Score of 13 but is found to have anarterial oxygen partial pressure of 6kPa (45mmHg) breathing 4L ofoxygen via a variable performance mask. Outline your initialmanagement of this patient. (7 marks)
March 2016 Feedback Pass rate 57.9% Candidates who scored well in part (a) of this questionpresented well organized answers. Examiners markingthis question felt that candidates who scored poorly inpart (b) did so because they tended to focus solely onairway management and did not mention otherimportant measures in the resuscitation such asrewarming and fluid management. This part of thequestion asked for initial management, not just airwaymanagement.
March 2016 Answera) Describe the relevant history (5 marks) and investigations (8 marks) for this patientwho has suffered near-drowning.History - Submersion, Time in water, water type?, trauma. other medical historyand allergies, recent events, ? taken anything DSHInvestigations - Sats, BP, ECG, Temperature, Blood gas CXR, C spine ?b) He has a Glasgow Coma Score of 13 but is found to have an arterial oxygenpartial pressure of 6kPa (45mmHg) breathing 4L of oxygen via a variableperformance mask. Outline your initial management of this patient. (7 marks)Resus bay if not already and call for assistance, Airway - assess, Increased oxygen15 l non rebreathe, establish full monitoring (re assess need for escalation andintubation), Breathing - Auscultate chest and consider CXR if not alreadyperformed, look for signs of trauma, Cardiovascular - BP, gain IV access, sendbloods - FBC, U E, renal function, clotting (Risk of MOF), provide IV fluids (warm), DRepeat GCS and look for localising signs/focal neurology DEFG BSL given GCSlow. Expose patient to look for other injuries. Measure temperature and consideractive/passive rewarming. Continuous cardiac monitoring.
March 2016 QuestionA 45-year-old man has a major haemorrhage following significanttrauma and is admitted to your emergency department. He does nothave a head injury.a) Give one definition of major haemorrhage. (1 mark)b) What are the principles of management of major haemorrhage inthis patient? (11 marks)c) What complications might follow a massive blood transfusion? (8marks)
March 2016 Feedback Pass rate 85.3% This is an important topic and was generally wellanswered. It is reassuring that candidates have soundknowledge of the management of major haemorrhage,and of the complications of massive transfusion.
March 2016 AnswerFrom the college.
March 2016 AnswerFrom the college.
March 2015 Questiona) Define critical illness weakness (CIW, 1 mark) and list thetypes that may occur. (3 marks) b) List the risk factors for thedevelopment of weakness on the ICU. (6 marks)c) What are the clinical features of CIW? (4 marks)d) How may nerve conduction studies determine the type ofCIW? (4 marks)e) What are the options for the management of CIW? (2 marks)
March 2015 Feedback Pass Rate 30.4%, 46.6% of candidates received a poor fail This question was anticipated to be difficult for the candidates and thepass and poor fail rates reflect this expectation. The subject matter istopical and an important consideration in the management of criticallyill patients. Many candidates had no idea that the definition excludedpre-existing pathology, and that the weakness was symmetrical withcranial nerves sparing. Few candidates had knowledge of the use ofnerve conduction studies and even fewer mentioned the MRC scale ofscoring muscle power. The importance of preparing detailed notes onmandatory units of training when revising for the Final FRCA isexemplified by this question.
March 2015 Answera) Define critical illness weakness (CIW, 1 mark) and list the types that mayoccur. (3 marks)ICU-acquired weakness (ICUAW) is clinically detected weakness in critically illpatients in whom there is no plausible aetiology other than critical illnessPatients with ICUAW are then classified into those with critical illnesspolyneuropathy (CIP), critical illness myopathy (CIM), or critical illnessneuromyopathy (CINM). Those with CIM are further subclassified(histologically) into cachectic myopathy, thick filament myopathy, andnecrotizing myopathy.b) List the risk factors for the development of weakness on the ICU. (6 marks)Sepsis, MOF, prolonged mech vent/bed rest, hyperglycaemia, steroids,neuromuscular blockers, Age, hypoalbuminaemia. List is pretty extensive!
March 2015 Answerc) What are the clinical features of CIW? (4 marks)Onset is after acute presentationClinical context includes acute, severe illness, requiring either prolonged vent, orsepsis and multigrain supportNot due to sedation or neuromuscular blockerNormal cognition/flaccid paralysis/symmetrical. CN sparingMRC sum score 48/60e) What are the options for the management of CIW? (2 marks)Reducing risk, by minimising sedation, neuromuscular blockers and steroids
March 2015 QuestionA 54 year-old patient is admitted to the EmergencyDepartment following a traumatic brain injury. A CTscan reveals only cerebral oedema.a) What is secondary brain injury and when is it likely tooccur? (2 marks)b) Outline the main physiological and cellular changesassociated with secondary brain injury. (7 marks)c) How can secondary brain injury be minimised in thispatient? (11 marks)
March 2015 Feedback Pass Rate 8.3%, 59.2% of candidates received a poor fail The pass and poor fail rates for this question are disturbing, and thisquestion had only moderate discriminatory power as the candidatecohort performed so poorly. Management of head injury not requiringneurosurgery is common to most intensive care units. Many candidateswere unable to define secondary injury or give an appropriate timeframe. Most were unaware of the pathophysiological cellularmechanisms and focused solely on the Monroe-Kelly doctrine.Treatment options were too narrow in scope although the informationgiven was usually sensible. Examiners were left with the overallimpression that many candidates have little theoretical knowledge orpractical experience of care of the brain injured patient.
March 2015 Answera) What is secondary brain injury and when is it likely to occur? (2 marks)Insults that occur during the post injury phase after the primary brain injury.Secondary brain injury may occur during initial resuscitation, transport of patient,during anaesthesia and surgery and in the ICU. Likely to begin immediately afterprimary insult.b) Outline the main physiological and cellular changes associated with secondarybrain injury. (7 marks)Hypoxia, Hypotension, hypocapnia, hypercapnia, hyperthermia, hypoglycaemia,hyperglycaemia, hyponatraemia, hypernatraemia, decreased CPP, loss of autoregulation, metabolic dysfunction - neuronal ischaemia and neuronal deathExcitotoxic cel
intensive care setting? (8 marks) b) List the types of RRT available in intensive care. (6 marks) c) Outline the principle mechanisms of solute and water removal by filtration (3 marks) and dialysis (3 marks) during RRT.
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Specific speed and agility training program (SAQ). SAQ Continuum Flexibility Mechanics Innervation Accumulation of potential Explosion Expression of potential Cool down Total Week 1 Intensity (%) 50% 60% 100% 30% 70% Volume (min) 30 40 40 0 0 10 120 Top Cont % 25 .
Further Help 25 Introduction In order to make a valid application to the University of Cambridge, applicants are asked to complete an online Supplementary Application Questionnaire (SAQ) shortly after submitting their UCAS application. The purpose of the SAQ is to ensure that we have complete and consistent information about all applicants.
Service Provider Eligibility Criteria for Self-Assessment Questionnaire D Self-Assessment Questionnaire (SAQ) D for Service Providers applies to all service providers defined by a payment brand as being eligible to complete a self-assessment questionnaire. This SAQ is the ONLY SAQ option for service providers.
Alan R Aitkenhead [1-81] BSc MD FRCA Alan Aitkenhead was a research fellow in Oxford in 1978-79 and then became senior lecturer in Leicester. He remained there until 1988 when he was appointed profe
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