Download GENERAL O

SURGICAL ANESTHESIOLOGY-VAMC
GOALS AND OBJECTIVES
CA 1 and CA 3 Level
DEFINITION
This is a 3 month rotation for CA-1 residents and a 1 month rotation for CA-3 residents, which
includes anesthesia for general and colorectal surgery, vascular surgery, urologic surgery,
orthopedic and plastic surgery, ENT surgery, cardiac surgery, neurosurgery, and minimally
invasive surgery.
CURRICULUM
Didactics include daily programs including monthly journal club, weekly Grand Rounds, clinical
case discussions, QA case discussions, and assigned anesthesia topic presentations by staff and
residents.
General and Colorectal Surgery: The resident will be assigned to cases involving abdominal,
perineal and other general surgery procedures. Monthly journal clubs will provide subspecialty
information.
Vascular Surgery: Assigned primarily to CA-3s. The resident will acquire the skills necessary to
manage the elderly, high risk vascular surgical patient peri- and intraoperatively in a safe and
logical manner. Since the vascular patient usually has multiple complex medical problems, the
scope of knowledge should include related diseases, including hypertension, diabetes,
cardiopulmonary, renal-vascular and cerebrovascular diseases. The degree of difficulty of the
cases is graded to provide increasingly challenging cases as the level of training and skill
progress.
ENT Surgery: The resident will manage anesthetic care for patients undergoing a variety of ENT
surgical procedures. Anesthetic care includes preoperative assessment of the patient, the
formation of an anesthetic plan, intra-operative application and management of the anesthetic
plan, patient monitoring, safe emergence and postoperative care. The surgical procedures include
airway laser cases, airway endoscopies, head and neck cancer procedures including
reconstructive facial surgery, nose and sinus surgery, laryngeal and tracheal reconstructive
surgery, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty, tracheotomy, and ear
surgery. While managing these anesthetics, the resident will have to work in close proximity
with the surgeon and learn to safely share one primary field, the airway, while having less access
to the patient.
Urologic Surgery: The resident will be assigned to provide anesthesia for cystoscopy, prostate
surgery, urologic oncology, kidney transplantation, procedures to ensure the continuity of the
urinary tract and reconstructive urologic procedures.
Orthopedic and Plastic Surgery: The resident will be assigned to major and minor procedures
involving elective, emergency and trauma surgery involving orthopedics and plastic surgery.
Minimally Invasive Surgery: This rotation will expose the resident to minimally invasive surgery
for general, colorectal, urologic, gynecologic, and spine procedures. Because of the emphasis on
short hospitalization, there will be an emphasis on rapid-emergence anesthetic techniques and
issues relevant to ambulatory surgery.
Neurosurgery: The resident will be assigned to spine and intracranial procedures. Anesthetic care
includes preoperative assessment and formulation of plan and intra-operative application of this
plan as required for the surgery anticipated. The residents will have to interact with surgeons and
with the neuromonitoring personnel as required for the surgery.
Cardiac surgery: Assigned primarily to CA-3s. The resident will acquire the skills necessary to
manage this high risk population and perform the specific procedures such as line placement,
TEE, pacemaker management, and cardiovascular medication manipulations that are required.
The resident will have to work closely with the surgeons and with the bypass machine techs.
MEDICAL KNOWLEDGE
General and Colorectal Surgery: The resident should be able to describe:
1.
appropriate ventilator settings for abdominal surgery in an adult patient.
2.
the physiological consequences of abdominal surgery.
3.
the anesthetic issues with thyroid and parathyroid procedures.
4.
procedures and risks with prone, lateral and lithotomy positions.
5.
fluid management for abdominal surgery.
6.
the indications for blood transfusion.
7.
the causes, prevention and treatment of hypothermia.
8.
the indications for rapid sequence induction of anesthesia.
9.
the indications for invasive monitoring.
10.
the complications of invasive monitoring.
11.
the impact of chronic steroid use in the perioperative period.
12.
neuromuscular blockage and neuromuscular blockade monitoring for abdominal
surgery.
13.
the anesthetic issues associated with total parenteral nutrition.
Vascular Surgery: The resident should understand:
1.
the anatomy and discuss the physiology of the cardiovascular system.
2.
invasive hemodynamic monitoring and make treatment decisions based upon the
findings or derangements to maintain hemodynamic stability.
3.
medical problems frequently associated with vascular disease as outlined above.
4.
ischemic cardiac episodes intraoperatively and effectively treat and manage them.
5.
the anesthetic implications for management of the patient with vascular disease.
6.
preoperative anesthesia assessment for vascular patients, present the assessment to
the staff anesthesiologist in a logical and organized manner and develop a
reasonable and safe anesthetic plan which takes into account those implications
peculiar to this group of sick and elderly patients.
7.
regional as well as general anesthetic options for a given vascular surgical
procedure and discuss the risks and benefits.
8.
frequently used vasoactive drugs, their pharmacology, pharmacokinetics and
appropriate usage.
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11.
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a “routine” anesthetic plan for a given vascular surgical procedure.
a postoperative pain control plan for the vascular surgical patient.
blood gas analysis results and institute appropriate therapy.
issues related to anticoagulation.
the anesthetic issues with endovascular aortic surgery.
ENT Surgery – Laser Airway Procedures: The resident should be able to:
1.
define Laser principles.
2.
classify the various kinds of lasers used in ENT procedures.
3.
review the risks of laser use in the airway.
4.
apply safety principles to airway laser procedures.
5.
appraise the available endotracheal tubes for laser procedures and select the
appropriate one.
6.
formulate a safe anesthetic plan for airway laser surgery.
7.
summarize a plan of action to deal with airway fires.
8.
explain the principles of venturi jet ventilation when used during laser procedures
on the larynx or trachea via a rigid bronchoscope or laryngoscope.
9.
evaluate Propofol and narcotic mixtures for these procedures and compare with an
inhalation technique.
Endoscopies: The resident should be able to:
1.
describe the sequence of events during a pan-endoscopy.
2.
plan an anesthetic including patient monitoring, for fiberoptic or rigid
bronchoscopy.
3.
summarize the possible complications of pan-endoscopy.
4.
explain the rationale for eliminating nitrous oxide from the anesthetic mixture
during apneic periods.
5.
discuss apneic oxygenation and the speed of rise of PaCO2 during its use.
6.
review neuromuscular monitoring for depolarizing and non depolarizing block,
including the diagnosis of phase II block.
7.
rank the various techniques available for control of the hemodynamic response to
rigid laryngoscopy and bronchoscopy.
Major Head and Neck Cancer Procedures: The resident should be able to:
1.
summarize the common co-existing problems in head and neck cancer patients.
2.
evaluate the monitoring modalities available and the rationale for avoiding the use
of neck veins for central monitoring.
3.
describe the rationale for use of intracardiac EKG tracing during antecubial
central line placement.
4.
discuss intraoperative fluid management of these cases.
5.
plan a general anesthetic for a patient undergoing a glossectomy or
mandibulectomy with free flap reconstruction.
6.
prescribe and administer pain medication to insure a comfortable and smooth
emergence for the patient at the end of the procedure.
7.
critique the methods available for prevention of hypothermic and their utility in
head and neck cases.
8.
describe the rationale for the use of a neuromuscular stimulator or nerve
conduction monitor by the surgeons and its influence on the planned anesthetic.
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describe the end result of various laryngeal surgical resections such as
hemilaryngectomy, supraglottic and total laryngectomy.
Nose and Sinus Surgery: The resident should be able to:
1.
review the interaction of catecholamines and inhalation anesthetic agents.
2.
critique the use of cocaine and epinephrine as mucosal vasoconstrictors by ENT
surgeons.
3.
describe possible contraindications to the use of cocaine.
4.
discuss the management of inadvertent intravascular injection of epinephrine.
5.
plan emergence and extubation in the presence of pharyngeal blood.
6.
review anesthetic management for patients with asthma and nasal polyps.
Laryngeal Reconstructive Surgery/T-tube Insertion: The resident should be able to:
1.
reconstruct the natural history of laryngeal and tracheal injury and stenosis.
2.
review the clinical picture and differential diagnosis of tracheal stenosis.
3.
review the presentation and clinical management of acute laryngeal trauma.
4.
describe the Montgomery T-tube and its use as a stent in reconstructive surgery.
Uvulopalotopharygoplasty (UPP): The resident should be able to:
1.
interpret a polysomnogram report to stage sleep apnea patients.
2.
evaluate the degree of airway compromise in patients scheduled for UPP.
3.
review the pathophysiology of sleep apnea.
4.
plan a general anesthetic and airway management plan for a patient with sleep
apnea.
Tracheotomies: The resident should be able to:
1.
describe the anatomy and placement of a tracheotomy.
2.
review the possible complications of tracheotomy.
3.
contrast the anesthetic management for a tracheotomy performed for long term
ventilation to that performed acute for airway obstruction.
4.
predict the special setup required for transporting patients with severe ARDS
from the ICU to the operating room.
5.
compare the tracheotomy tubes and airway stents to the usual endotracheal tubes.
Vocal Cord Injections and Arytenoid Medialization: The resident should be able to:
1.
review the anatomy of the larynx.
2.
draw the appearance of the vocal cords in various nerve injuries.
3.
discuss the rationale behind vocal cord medialization procedures.
4.
review the major causes for vocal cord paralysis.
Tonsillectomy and Adenoidectomy (T&A): The resident should be able to:
1.
draw the lymphatic structures in the head and neck area.
2.
review the complications of T&A.
3.
design a safe anesthetic technique for T&A, including premedication and
postoperative pain control.
4.
compare various methods for managing a bleeding tonsil.
Ear Surgery: The resident should be able to:
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1.
2.
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review the anatomy of the middle and inner ear and the course of the facial nerve
in relation to the ear structure.
discuss the causes of high incidence of post operative nausea and vomiting in ear
surgery.
summarize the effect of N2O diffusion on the middle ear.
describe the fluid and ventilation management for intracranial ear procedures.
classify the paragangliomas of the head and neck.
Difficult Airway Management: The resident should be able to:
1.
review the innervation of the upper airway, larynx and trachea.
2.
describe topical anesthesia of the airway for awake intubation.
3.
summarize the ASA Difficult Airway Management Algorithm.
4.
plan an induction technique for a difficult airway and an alternative plan for
managing a “cannot ventilate-cannot intubate” scenario.
5.
review the anatomy of the cricothyroid membrane.
6.
describe needle cricothyrotomy.
7.
compare the pressure required for transtracheal ventilation in adults and children
using the Sander’s injector.
8.
describe the possible complications of transtracheal ventilation.
9.
diagram emergency cricothyrotomy.
10.
summarize the principles of fiberoptics and name the various parts of the
fiberoptic scope.
Urologic Surgery – The resident should understand:
1.
the indications for urologic surgery.
2.
the perioperative implications of renal failure.
3.
the physiologic consequence of endoscopic prostate surgery.
4.
positioning issues for nephrectomy.
5.
the perioperative implications of renal malignancy with extension into the interior
vena cava.
6.
regional anesthesia for major urologic procedures.
7.
anesthetic implications of lithotripsy.
8.
TURP syndrome.
Orthopedic and Plastic Surgery – The resident should be able to:
1.
identify common preoperative issues in reconstructive surgery patients and
explain how they impact on an anesthetic plan.
2.
create a reasonable anesthesia plan for most common, reconstructive surgical
procedures.
3.
identify and manage the common problems in trauma.
4.
plan and select equipment and local anesthetic agents for most regional anesthetic
procedures. Select and defend these local anesthetic choices for surgical
procedures, depending on duration, location and severity of illness of the patient.
5.
describe the basic pharmacology of a local anesthetic including the characteristics
which determine onset, duration, potency and toxicity.
6.
discuss the unique topics within anesthesia for orthopedic and plastic surgery,
including pneumatic tourniquets, fat embolism, hemodynamic implications of
methylmethacrylate and etiology of deep venous thrombosis.
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describe the preoperative implications of co-existing diseases in reconstructive
surgery patients, including hypertension, coronary artery disease, rheumatoid
arthritis, diabetes mellitus, and ankylosing spondylitis.
explain and contrast postoperative pain control strategies including patient
controlled analgesia (PCA) with various opiates, subarachnoid opiates, epidural
analgesia, continuous peripheral nerve catheters, intra-articular local anesthetic
and opiate, and non-steroidal anti-inflammatory drugs.
describe the techniques of autologous blood programs, cell salvage, hemodilution
and perioperative blood conservation.
Minimally Invasive Surgery – The resident should understand:
1.
the indications for minimally-invasive surgery.
2.
the physiologic consequences of pneumoperitoneum.
3.
the consequences of patient positioning in the lateral, prone and lithotomy
positions.
4.
the causes for the increased incidence of nausea after CO2 insufflation for surgery.
5.
common PACU issues for MIS patients.
6.
pneumomediastinum, subcutaneous emphysema and barotrauma.
PATIENT CARE
General and Colorectal Surgery – The resident should be able to:
1.
prepare an operating room completely for a major case in a timely manner.
2.
assemble the equipment for invasive monitoring.
3.
assemble the equipment for blood transfusion.
4.
place large-bore intravenous catheters (14-16 gauge)
5.
perform induction of general anesthesia with minimal assistance for ASA I-II
patients.
6.
perform a rapid sequence induction under supervision for ASA I-II patients.
7.
safely position anesthetized patients in the lateral lithotomy and prone positions.
8.
correctly position the patient for internal CVP line insertion.
9.
demonstrate skill at internal jugular catheterization. Complete the procedure in
some (35%) cases with minimal assistance.
10.
demonstrate skill in arterial line placement, succeeding in the majority (>75%) of
cases.
11.
perform neuromuscular blockade, monitoring and reversal with minimal
assistance.
Vascular Surgery – The resident should be able to:
1.
effectively communicate preoperative concerns or problems regarding preparation
of the vascular patient for surgery.
2.
set up equipment expeditiously for a major vascular surgery case.
3.
execute simple vascular cannulations such as IV’s and arterial lines in the
majority (>75%) of cases.
4.
perform central venous and pulmonary artery catheter insertions with guidance.
5.
perform spinal and epidural regional anesthetics with minimal assistance in the
majority (>75%) of cases.
6.
manage anesthesia for a routine vascular case fairly independently.
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manage pulmonary artery catheters, pacemakers, defibrillators, TEG equipment,
and continuous infusion of vasoactive drugs.
recognize and treat intraoperative hemodynamic derangements and complications.
ENT Surgery – The resident should be able to:
1.
administer anesthesia for the procedures mentioned under Medical Knowledge.
2.
evaluate an abnormal airway using clinical skills, radiological studies and
consultation with the surgeon and patient’s record.
3.
select, modify and prepare the appropriate endotracheal tubes for laser
procedures.
4.
modify the anesthetic mixture to minimize the risk of fire in airway laser
procedures.
5.
practice safety precautions for the patient and operating room staff during laser
procedures.
6.
perform jet ventilation using the Sander’s injector for laser cases performed with
no endotracheal tube in place.
7.
administer anesthesia for rigid and flexible airway endoscopy
8.
control the thermodynamic changes caused by rigid airway manipulation.
9.
treat the cardiovascular changes caused by the use of epinephrine and cocaine in
nasal surgery.
10.
insert an antecubital central line.
11.
manage anesthesia for major head and neck cancer procedures, including patient
monitoring, fluid management and postoperative pain control.
12.
evaluate the various specialty endotracheal tubes available and utilize them in the
appropriate situations.
13.
perform elective fiberoptic intubation on patients with normal airways under
general anesthesia.
14.
perform topical anesthesia of the airway including transcricoid membrane
injection of local anesthesia.
15.
administer Propofol for general anesthesia and for awake sedation.
16.
practice cricothyrotomy, needle cricothyrotomy and jet ventilation on the training
model.
17.
support the airway by utilizing positive airway pressure in situations of partial or
potential upper airway obstruction.
18.
prevent or modify postoperative nausea and vomiting by using appropriate doses
of antiemetics.
Urologic Surgery – The resident should be able to:
1.
manage an airway of normal to moderate difficulty utilizing a bag, mask,
laryngeal mask airways, oral airways, and endotracheal tubes.
2.
assemble anesthesia equipment for patients managed in this rotation including
those with renal failure.
3.
applying appropriate monitoring devices and describe the risk/benefit ratio of
utilizing invasive monitoring.
4.
provide and maintain venous access.
5.
induce and maintain general anesthesia in ASA I-II patients with moderate staff
direction, and in ASA III-IV patients with staff involvement as needed.
6.
induce and manage spinal anesthesia with limited staff involvement.
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7.
interpret a blood gas, and define the most common acid-base abnormalities,
including metabolic acidosis and alkalosis and define a treatment plan for
abnormality.
Orthopedic and Plastic Surgery – The resident should be able to:
1.
perform a spinal anesthetic with the correct equipment and agent and manage the
patient intraoperatively with minimal staff intervention.
2.
conduct a similar case with an epidural anesthetic.
3.
perform an axillary block, with correct selection of equipment and agents.
4.
perform an interscalene or a supraclavicular block for shoulder surgery, with
correct equipment and agents.
5.
perform a femoral, sciatic, and popliteal block for lower extremity surgery.
6.
provide appropriate, safe anesthesia for:
a.
total hip arthroplasty
b.
revision total hip arthroplasty
c.
total knee arthroplasty
d.
treatment of fractured hip
e.
anterior cruciate ligament repair.
f.
elective lumbar spine procedure (disc or spinal stenosis)
g.
ORIF of major long bone fracture.
h.
hand surgery.
i.
major skeletal tumor resection
j.
posterior spinal fusion
k.
flap procedures
l.
abdominoplasty
m.
breast reduction
n.
skin grafting
Minimally Invasive Surgery – The resident should be able to:
1.
set up for any minimally-invasive procedure.
2.
induce anesthesia for health (ASA I-II) patient under staff supervision with
minimum assistance.
3.
conduct rapid sequence induction with staff assistance.
4.
manage ventilation of a patient during pneumoperitoneum.
5.
participate in airway management for the morbidly obese patient.
6.
treat nausea/vomiting in PACU.
7.
treat shoulder pain secondary to CO2 in the peritoneum in the PACU patient.
INTERPERSONAL AND COMMUNICATION SKILLS
The resident will:
1.
2.
3.
define the correct acute plan by consultation with the surgical team.
confirm correct plans for antibiotic use by reviewing chart and conferring with the
surgical team.
determine the correct strategy for blood transfusion in non-emergent situations by
consultation with surgical service.
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accurately report changes in patient condition to the anesthesiology staff, surgical
team and any consultants.
transfer all relevant information during admission to intensive care units.
be able to perform consultative services for vascular surgery patients.
define airway management in advance with surgical team for airway sharing
cases.
define the best location for elective tracheostomy (O.R. vs. ICU)
identify laser hazards to the O.R. team.
define airway priorities to PACU.
determine discharge plans.
coordinate correct choices for postoperative analgesia.
communicate patient status to PACU for expected difficult management (i.e.,
TURP).
learn to establish a joint anesthesia-surgical plan for procedures prior to entering
the O.R.
identify needs to the O.R. team to support anesthetic procedures, such as regional
anesthesia and invasive monitoring.
ensure adequate personnel for patient positioning and bed transfer.
identify antibiotic needs of the patient from the surgical team.
verify blood availability.
notify the surgeon of tourniquet times.
correctly determine admission and discharge planning.
identify complications of CO2 insufflation when they occur to the surgical team.
PROFESSIONALISM
The resident must:
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facilitate room turnover in high volume surgical schedules.
problem-solve to prevent surgical delay and cancellation.
demonstrate skill at fully controlling the O.R. environment.
facilitate turnover for patients requiring considerable preparation.
accurately identify information that must be transmitted to staff, surgeons and
consultants, and do so in a timely manner.
ensure complete preparation for anticipated difficult airway management.
demonstrate respect for the use and proper care for fiberoptic bronchoscopies.
develop a sustained interest in learning the skills of airway management.
identify and respect the dignity of patients for urologic procedures.
identify the surgical plan.
facilitate the surgical procedure.
identify any patient issues to the surgeon.
facilitate individualized PACU care.
ensure optimum postop analgesia.
understand minimally invasive surgery (MIS) technology.
correctly identify low, moderate and complex MIS procedures.
participate in decisions to change from MIS to open procedures.
recognize complications of MIS in PACU.
Rev. 7/2009
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