PRIMARY MASTER OF MEDICINE (ANAESTHESIOLOGY) EXAMINATION

Transcription

1 Yong Loo Lin School of Medicine National University of Singapore SYLLABUS FOR PRIMARY MASTER OF MEDICINE (ANAESTHESIOLOGY) EXAMINATION First Edition July / 17

2 1. Introduction: a. This syllabus serves as a guide to study for candidates presenting for the Primary Master of Medicine (Anaesthesiology) Examination conducted by the, Yong Loo Lin School of Medicine, National University of Singapore. b. The Board of Examiners for the Primary Master of Medicine (Anaesthesiology) Examination does not restrict examiners in the choice of questions. c. This document should be regarded as a guide to study. It indicates a general scope of preparation necessary for the examination and is not intended to be all- inclusive. Reading of current literature is required. 2. The subjects for the examination are:- a. Physiology b. Physics, Principles of Measurement and Monitoring c. Pharmacology d. Statistics 3. Physiology a. Includes the knowledge of body functions in the normal state, the relation of structure to function and the disturbances of function, which may arise in clinical practice. b. Topics to cover include: i. Cellular Physiology ii. Respiratory Physiology iii. Cardiovascular Physiology iv. Renal Physiology v. Body Fluids and Electrolytes vi. Acid Base Physiology vii. Nervous System Physiology 2 / 17

3 viii. Muscle Physiology ix. Liver Physiology x. Haematology xi. Nutrition and Metabolism xii. Thermoregulation xiii. Immunology xiv. Endocrine Physiology xv. Maternal Physiology xvi. Fetal and Neonatal Physiology xvii. Gastrointestinal Physiology 4. Physics, Principles of Measurement and Monitoring: a. Knowledge of terminology, principles and concepts of physics and mathematics necessary for understanding of physiological functions and biochemical effects and their measurements in clinical practice. b. Knowledge of physical principles underlying the storage, utilization and hazards of the use of gases and fluids in clinical practice. c. Principles of monitoring in clinical practice including the basis, problems, calibration and the evaluation (of accuracy, reliability, convenience and hazards) of methods of monitoring 5. Pharmacology includes a. Principles of general pharmacology including pharmacokinetics, pharmacodynamics, molecular mechanism of actions of ligands, ions and drugs, causes of variability in drug response, antigen- antibody reaction, side effects, toxic effects, tolerance, interaction between drugs, drug evaluation and clinical trials b. Detailed knowledge of the pharmacology of drugs used in anaesthetic practice is required with particular attention paid to the principles involved in their uptake, distribution and clearance from the body c. Physiological pharmacology: a detailed knowledge of drugs that act on the autonomic nervous system. d. Non- anaesthetic drugs: general knowledge of the therapeutic agents, which may be used in patients presenting for anaesthesia or during post- operative treatment. e. General principles of management of poisoning. 3 / 17

4 6. Statistics: An appreciation of the statistical and mathematical methods commonly employed in clinical research is required 4 / 17

5 Physiology Outline of Topics: A. Cellular Physiology B. Respiratory Physiology C. Cardiovascular Physiology D. Renal Physiology E. Body Fluids and Electrolytes F. Acid Base Physiology G. Nervous System Physiology H. Muscle Physiology I. Liver Physiology J. Haematology K. Nutrition and Metabolism L. Thermoregulation M. Immunology N. Endocrine Physiology O. Maternal Physiology P. Fetal and Neonatal Physiology Q. Gastrointestinal Physiology A. Cellular Physiology: a. Cell membrane and its properties b. Functions of mitochondria, endoplasmic reticulum, and other organelles c. Mechanisms of transport across cell membranes; diffusion, facilitated diffusion, primary active transport and secondary active transport d. Membrane potentials and the Gibbs- Donnan Effect e. Role of Receptors, G- proteins and secondary messengers f. Sources of energy available to cells through metabolic processes g. Composition of intracellular fluid and its regulation including the role of the sodium- potassium pump B. Respiratory Physiology a. Structure and function of the respiratory system. b. Dead space: anatomical and physiological. c. Control of ventilation and changes in ventilation in abnormal physiological and common pathological conditions d. Respiratory reflexes e. Mechanics of breathing: pressure, flow, work, compliance, muscles, etc f. Humidification and heat exchange 5 / 17

6 g. Lung volumes and capacities and the application of this knowledge to normal and diseased respiratory states h. Physics of gas flow, solution and diffusion. i. Laws of diffusion and their application to capillary exchange of oxygen and carbon dioxide in the lung j. Pulmonary circulation, pulmonary interstitial space and lymphatic function and their relevance in clinical practice k. Alveolar ventilation. l. Normal and abnormal matching of ventilation and perfusion, the mechanisms causing ventilation- perfusion inequality including effects of posture, respiratory and circulatory changes, and an appreciation of its clinical significance m. Principles involved in transport of oxygen and carbon dioxide in blood and their applications in clinical practice n. Blood- tissue gas exchange. o. Changes with exercise, anaesthesia, disease, posture, age p. Respiration at high and low barometric pressures: adaptation. q. Hypoxia and asphyxia. r. Hypoventilation and hyperventilation. s. Respiratory inadequacy and failure; principles of therapy. t. Artificial ventilation. u. Evaluation of respiratory function; lung volumes, gas flow, ventilation, blood flow, diffusion, compliance, resistance, gas transport, gas concentrations and pressures in ventilating gas mixtures and body fluids. v. Non- respiratory functions of lung. C. Cardiovascular Physiology: a. Functional anatomy of the heart, including properties of cardiac muscle, nodal and conductive tissue, and its relationship to cardiac function b. Mechanical and electrical changes during the cardiac cycle c. Factors that influences cardiac output and its control and the application of this knowledge to clinical practice d. Concept of cardiac and vascular compliance. e. Electrocardiogram and electrophysiological control of the heart. f. Physics of blood flow. g. Arrangements and special features of specific vascular beds, e.g. renal, cerebral, pulmonary, coronary, hepatic and splanchnic, muscle (skeletal), skin, utero- placental etc h. Distribution and regulation of circulation: overall and regional i. Myocardial oxygen balance. j. Physiology of embolism, ischaemia and infarction. k. Capillary circulation. l. Lymphatic circulation. m. Fluid exchange in tissues and control of blood volume in normal and 6 / 17

7 abnormal conditions n. Cardiovascular responses to physiological and common pathological changes; e.g. age, exercise, altitude changes, changes in posture, artificial ventilation, blood loss, shock, fluid loading and cardiac failure o. Measurement of cardiovascular function i. Arterial and venous blood pressure. ii. Cardiac output. iii. Regional flow. iv. Blood volume. D. Renal Physiology a. Functional anatomy of the kidneys including the physiology and regulation of renal blood flow b. Glomerular filtration and tubular function c. Counter- current mechanisms in the kidney d. Regulation of renal function e. Endocrine functions of the kidney f. Maintenance of acid- base, fluid osmolality and electrolyte balance g. Role of the kidney in the handling of glucose, nitrogenous products and drugs h. Measurement of glomerular filtration rate and renal blood flow i. Physiological effects and clinical assessment of renal dysfunction j. Renal responses to hypovolaemia k. Effects of general anaesthesia on renal function E. Body fluids and Electrolytes: a. Body water: distribution, movement and regulation b. Electrolyte composition of body fluids: distribution and regulation. c. Function, regulation and physiological importance of sodium, potassium, magnesium, calcium and phosphate ions d. Composition and functions of lymph e. Osmotic pressure, oncotic pressure and reflection coefficients f. Measurement of osmolality and the regulation of osmolality g. Disturbances of body fluids and electrolytes in pathological conditions such as dehydration, over- hydration, oedema and electrolyte changes. h. Evaluation and principles of therapy of such pathological conditions i. Measurements of body fluids and constituents: compartment volumes and electrolytes. F. Acid Base Physiology a. Chemistry and physiology of acid- base balance in the body and the application of this knowledge to clinical situations b. Henderson- Hasselbalch equation and its application in clinical situation. c. Chemistry of buffer mechanisms and their roles in the body d. Regulation of acid- base balance by the respiratory and renal system 7 / 17

8 e. Blood gas and acid- base analysis including measurement of hydrogen ion activity, carbon dioxide in solution (direct and indirect) and bicarbonate f. Changes in disordered acid- base states: evaluation and principles of therapy G. Nervous system physiology a. Electro- physiology of neural tissue including resting membrane potential, conduction of nervous impulses, action potentials, excitatory and inhibitory post- synaptic potentials, and synaptic function b. Major sensory and motor pathways c. Autonomic nervous system and its role in controlling body function d. Integration of central nervous system activity via the cerebellum, hypothalamus, and limbic system e. Physiology of cerebrospinal fluid including formation, drainage, regulation and function f. Regulation of cerebral and spinal cord circulation g. Regulation of intra- cranial and intra ocular pressure h. Major neurotransmitters and their physiological role i. Principles of reflex activity j. Physiology of pain including i. Definition of pain, ii. Mechanisms of nociception, iii. Spinal cord modulation, iv. Role of chemical mediators, v. Central processing of the noxious impulse, vi. Inhibitory pathways and opioid receptors k. Physiology of sleep l. Basis of the electroencephalogram H. Muscle physiology a. Physiology and functional anatomy of skeletal, smooth, and cardiac muscle b. Muscle spindle and Golgi organ c. The neuromuscular junction and its receptors d. Mechanism of excitation- contraction coupling e. Types of skeletal muscle fibres (i.e. fast or slow) f. Concept of motor units g. Monosynaptic stretch reflex h. Single twitch, tetanus and Treppe effect, and their physiological basis i. Relationship between muscle length and tension I. Liver Physiology a. Storage, synthetic, metabolic and excretory functions of the liver and the physiological consequences of hepatic disease b. Clinical laboratory assessment of liver function and hepatic failure c. Handling of bilirubin in the body 8 / 17

9 d. Anatomical and physiological considerations in hepatic blood flow, and the changes that occur with anaesthesia e. Reticulo- endothelial functions of the liver f. Protective function of the liver between the gut and the body g. Portal circulation and its significance J. Haematology a. Production, function and breakdown of blood constituents including red blood cells, haemoglobin, and plasma proteins b. Origin and importance of blood groups c. Constituents and functions of plasma d. Platelets and their role in coagulation e. Intrinsic and extrinsic coagulation pathways f. Mechanisms of preventing thrombosis g. Fibrinolysis and its regulation h. Methods for assessing coagulation, platelet function and fibrinolysis i. Consequences of acute and chronic anaemia j. Constituents of blood products, their source, role and risks k. Changes during blood storage and the problems of massive blood transfusion and their management l. Abnormal haemoglobins and their clinical significance K. Nutrition and Metabolism a. Energy balance. b. Basal metabolic rate and its measurement c. Factors that influence metabolic rate d. Uptake, synthesis and metabolism of carbohydrates, fat and protein. e. Essential nutritional requirements, including the role of vitamins and trace elements f. Principles of parenteral nutrition and enteral nutrition. g. Common enzyme systems, evaluation of disturbances. h. Consequences of anaerobic metabolism i. Physiological consequences of starvation j. Metabolic consequences of sepsis, burns and trauma L. Thermoregulation a. Mechanisms for heat transfer between the body and its environment b. Mechanisms by which heat is produced by the body c. Mechanisms by which heat is lost and gained by the body d. Processes used for conserving as well as generating heat under situations of lowered environmental temperature, and the effects of anaesthesia on these processes e. Processes used for losing heat as well as increasing heat loss under situations of raised environmental temperature, and the effects of anaesthesia on these 9 / 17

10 processes f. Thermoneutral zone, and describe the energy requirements for maintaining normal body temperature g. Neonatal regulation of body temperature compared with the adult and to explain the physical and physiological reasons for these differences h. Temperature sensing devices and measurement M. Immunology a. Basic immunology including non- specific resistance mechanisms and specific immunity. b. Principles of tissue/organ transplantation and the mechanisms of rejection of allogeneic organs c. Auto- immunity d. Principles of tissue typing e. Mechanism and pathophysiological effects of hypersensitivity. f. Significance of route of drug administration with regards to drug reactions g. Principles of management strategies for anaphylactic/anaphylactoid reactions h. Effects of anaesthesia, surgery and critical illness on immune function i. Implications of depression of immune status. j. Assessment of immune reaction N. Endocrine Physiology a. Neural control of endocrine secretions b. Secretions of the pituitary, thyroid, parathyroid, adrenals, pancreas, kidney and the heart. c. Formation and control; metabolism and excretion, over- secretion and under- secretion; evaluation of function. d. Prostaglandins and other autocoids O. Maternal Physiology a. Cardiovascular and respiratory changes during pregnancy and parturition, their causes, and their consequences b. Consequences of the supine posture during pregnancy c. Functions of the placenta d. Transfer of gases between mother and fetus including the double Bohr and Haldane effects e. Endocrine changes that occur during pregnancy and their consequences f. Haematological changes with pregnancy P. Fetal and Neonatal Physiology a. Fetal circulation during development b. Circulatory and respiratory changes that occur at birth c. Pulmonary function; airway size, gas transfer, respiratory work, lung volume 10 / 17

11 and role of surfactant d. Body fluids and electrolyte composition e. Blood volume and haemoglobin changes, f. Temperature regulation in the neonate and how this differs from the adult g. Physiological differences in organ function, including liver and kidney, between the neonate and the adult h. Control of body fluids in the neonate and how the control and composition differ from the adult Q. Gastrointestinal Physiology a. Secretory function: salivary glands, stomach, small intestine, pancreas (external secretion) bile, volumes and composition, regulation. b. Digestion and absorption of carbohydrate, fat and protein. c. Swallowing d. Vomiting e. Control of gastric motility and emptying f. Splanchnic circulation and its regulation. g. Gastro- intestinal fluid losses: effects and principles of treatment. h. Factors preventing reflux of gastric contents into the oesophagus 11 / 17

12 Physics, Principles of Measurement and Monitoring Outline of Topics: A. Physics and Principles of Measurement B. Clinical Monitoring A. Physics and Principles of Measurement: a. Mathematical concepts such as exponential functions, integration, differentiation, time constants and half life b. Electrical concepts such as current, potential difference, resistance, impedance, inductance and capacitance as they relate to biomedical apparatus c. SI system of units d. Conversion between the different units of pressure measurement e. Laws governing the behaviour of gases, liquids and vapours. f. Principles of the measurement and mathematical derivation of respiratory dead space, gas laws, compliance, and ventilation- perfusion relationships, g. Physical principles of heat transfer. h. Principles of measurement employed by apparatus in clinical use, including transducers, and to describe their calibration i. Physico- chemical basis of the measurement of hydrostatic pressure and osmotic forces j. Basic physics of ultrasound and the Doppler principle B. Clinical Monitoring a. Electrocardiogram including calibration, sources of errors and limitations b. Methods of measuring pressure including invasive and non- invasive arterial blood pressure, central venous pressure and pulmonary wedge pressure c. Measurement of organ blood flow and cardiac output,, d. Measurement of temperature, e. Measurement of humidity f. Monitoring of depth of sedation and anaesthesia, g. Principles of pulse oximetry including calibration, sources of errors and limitations h. Principles of gas analysis using ultraviolet or infra- red absorption, paramagnetic analysis, gas chromatography, mass spectrometry and Raman scattering i. Principles of capnography including calibration, sources of errors and limitations j. Methods of measuring gas flow 12 / 17

13 Pharmacology Outline of Topics: General Pharmacology A. Pharmacodynamics B. Pharmacokinetics C. Variability in drug actions D. Pharmaceutical Aspects and Drug development Pharmacology of Specific Drugs E. Detailed knowledge of the pharmacology of drugs used in anaesthetic practice F. Detailed knowledge of drugs that act on the autonomic nervous system G. General knowledge of non- anaesthetic drugs H. General principles of the management of poisoning General Pharmacology A. Pharmacodynamics a. Knowledge of the biochemistry, physical chemistry of cellular membranes and intracellular elements for understanding drug actions and metabolism b. Modes of drug action such as receptor theory, enzyme interactions and physico- chemical interactions c. Detailed knowledge of receptor theory including, ionic fluxes, second messenger, G proteins, nucleic acid synthesis, regulation of receptor number and activity and evidence for presence of receptors. d. Detailed knowledge of dose- effect relationships of drugs with reference to: graded and quantal response, therapeutic index, potency and efficacy, competitive and non- competitive antagonists, partial agonists, mixed agonist- antagonists and inverse agonists e. Law of Mass Action, Affinity and dissociation constants f. Theories of mechanism of action of general anaesthetic agents B. Pharmacokinetics a. Concept of single and multiple compartment models b. Concept of and the mathematics required to apply the concept of half- life, clearance, zero and first order kinetics, volume of distribution, bio- availability, area under the plasma concentration time curve, extraction ratio, loading and maintenance dosage regimens c. Absorption of drug at clinically utilized sites of administration and factors that will influence it d. Factors influencing the distribution of drugs (e.g. protein binding, lipid 13 / 17

14 solubility, ph, pka) and variation in different physiological and pathological conditions e. Mechanisms of drug clearance and variation in different physiological and pathological conditions f. Hepatic and non- hepatic metabolism of drugs, Phase 1 and Phase 2 reactions, hepatic extraction ratio and its significance, first pass effect, enzyme induction and inhibition g. Concepts related to intravenous and infusion kinetics; context sensitive half time, effect- site and effect- site equilibration time and their clinical applications. h. Pharmacokinetics of drugs administered in the epidural and subarachnoid space i. Clinical drug monitoring C. Variability in drug actions a. Tolerance, tachyphylaxis, dependence, addiction, and idiosyncrasy b. Mechanisms of tolerance c. Alterations to drug response due to different physiological conditions: neonates, the elderly and pregnancy d. Alterations to drug response due to different pathological conditions: cardiac, respiratory, renal and hepatic disease e. Adverse drug effects f. Anaphylaxis and anaphylactoid reaction g. Mechanisms of drug interaction h. Pathophysiology of drug abuse with particular reference to the perioperative period and potential drug interactions (specific drugs to consider include alcohol, nicotine, benzodiazepines, opioids, cannabinoids, cocaine, amphetamines and ecstasy) i. Pharmacogenetic disorders such as malignant hyperpyrexia, porphyria, atypical cholinesterase and variation of cytochrome function j. Management of malignant hyperthermia with reference to the pharmacology of dantrolene D. Pharmaceutical Aspects and Drug development a. Shelf- life, changes drug potency during storage and methods of preserving shelf- life of drugs. b. Drug additives including buffers, anti- oxidants, anti- microbial and solubilizing agents c. Isomerism d. Processes by which new drugs are evaluated and approved for research and clinical use including the phases of human drug trials (phase I- IV) Pharmacology of Specific Drugs 14 / 17

15 E. Pharmacology of drugs used in anaesthetic practice *Detailed knowledge of the following drugs is required: a. Inhalational Anaesthetic Agents b. Intravenous sedative and hypnotic Agents c. Local Anaesthetics d. Opioid Agonists and Antagonists e. Paracetamol and Non- steroidal anti- inflammatory drugs f. Neuromuscular blocking drugs g. Anti- emetics h. Adjuvant medications for management of pain F. Drugs that act on the autonomic nervous system a. A detailed knowledge* of the following drugs is required: b. Anti- hypertensives drugs c. Drugs used in cardiovascular support including sympathomimetics d. Adrenoceptor blocking agents e. Anti- arrhythmic agents f. Anticholinergic agents g. Anti- cholinesterases h. Drugs used for treatment of asthma *Detailed knowledge includes knowledge of: Chemical nature and source Preparation, purity and stability Site/s and mechanisms of action Structure activity relationships Routes of administration Absorption, distribution, metabolism and excretion Variation in drug effects Effects on other systems Considerations in pregnancy and lactation. Unwanted, adverse effects and toxic effects Dosage, strengths of solution, inhaled concentrations Indications and contraindications G. Non- anaesthetic drugs **General knowledge of the following drugs is required. a. Psychotherapeutic drugs. b. Anticonvulsant drugs. c. Therapy of cardiac arrest, ischemia and failure d. Drugs that affects the coagulation pathway, platelet function and fibrinolyic pathway. 15 / 17

16 e. Autocoids. f. Drugs that affects the hypothalamic- pituitary- adrenal axis and steroids. g. Drugs used in the treatment of diabetes mellitus. h. Drugs used in the treatment of thyrotoxicosis and hypothyroidism i. Hormonal drugs j. Drugs acting on the gastrointestinal system k. Drugs acting on the uterus. l. Cytotoxic drugs. m. Antimicrobial drugs. n. Intravenous fluids o. Blood products **General knowledge includes: General idea of preparations, strength and dosages Site/s and nature of action Routes of administration Absorption, distribution, metabolism and excretion Modification of action Effects on other systems Adverse effects Indications and contraindications H. General principles of the management of poisoning a. Physiological effects of and management of the overdose of agents such as paracetamol, aspirin, tricyclic anti- depressants, sedatives, cyanide, digoxin and organophosphates b. General knowledge of methods to decrease absorption and enhance drug elimination using modalities such as charcoal, emetic agents, gastric lavage, haemodialysis and charcoal haemoperfusion etc 16 / 17

17 Statistics Topics: A. General knowledge of the stages involved in the design of a clinical trial. a. Considerations of a good study design including: b. Types of errors and techniques to minimize errors c. Sampling d. Bias and confounders e. Optimal power of the study B. Concepts in statistic analysis including: a. Types of data b. Descriptive statistics to measure central tendency and distribution of data c. Parametric and non- parametric tests in statistical inference d. Linear regression analysis and correlation e. Sensitivity, specificity, positive and negative predictive value of diagnostic tests f. Risks and estimation of Risk g. Calculation of power of a study C. General knowledge of evidence- based medicine including: a. Levels of evidence b. Systemic review c. Meta- analysis - END - 17 / 17