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INDIANA UNIVERSITY DEPARTMENT OF ANESTHESIOLOGY
Acute Perioperative Pain Management Rotation
Goals and Objectives
GOALS and OBJECTIVES:
The goal of the Acute Perioperative Pain Management Rotation at the Indiana University School
of Medicine is to train physicians to be competent and compassionate practitioners of
perioperative pain management. The Acute Perioperative Pain Management Rotation is
designed to enhance overall knowledge, understanding and application of pain management
principles in the perioperative period. This differs from the regional analgesia experience in pain
management rotation where emphasis is placed on the execution of specific regional blocks and
techniques of delivering local anesthetics to specific peripheral nerves / plexi to render a
specific region of the body analgesic in a safe and effective manor for perioperative pain
management.
Acute Perioperative Pain Management Resident Duties:
1. Preoperatively evaluate, understand concerns specific to the patient, and develop a
tailored anesthetic plan to be administered for acute perioperative pain management
2. Focus on intraoperative techniques that provide optimal outcome of perioperative pain
considerations
3. Post-operatively understand potential complications associated with the administration of
various drugs utilized to treat perioperative pain issues
4. Attend didactic conferences
5. Take night call on a rotating schedule
6. Respond to requests for anesthesia consults in a timely fashion
7. Maintain a personal program of self-study and professional growth
8. Complete medical records promptly
9. Document all duty hours
10. Document all procedures
11. Monitor self for fatigue
12. Dress appropriately
13. Act in a professional and ethical manner
14. Complete the appropriate evaluation instruments used by the department, including QA
forms
Educational Strategy:
The Acute Perioperative Pain Management Rotation is a one-month block. During the Acute
Perioperative Pain Management Rotation residents will be supervised by various members of the
anesthesia teaching faculty. The Director of Acute Perioperative Pain Management Rotation is
Dr. John Hasewinkel. In his absence Dr. James Mitchell is assigned to cover these
responsibilities. When rotating at an institution which is not the primary site of practice of the
above mentioned faculty, please contact the below listed individuals:
Dr. John Wolfe, or Dr. Yar Yeap—University
Dr. Ken Gwirtz—VA
During the rotation in Acute Perioperative Pain Management Rotation, residents are expected to
participate in journal club, and morbidity and mortality conferences (QA).
Core Competencies:
The six core competencies are used as a template to evaluate residents during all Anesthesia
rotations. The terms used to define these competencies are similar to those used for other
rotations. The Goals and Objectives that follow have been specifically modified to meet the
needs of the specific teaching rotation in which you are to participate. These Goals and
Objectives are not intended to be comprehensive but have been developed to help you acquire
the core competencies in the area of Clinical Anesthesia. These core rotations should serve as
the foundation upon which the subspecialty anesthesia rotations are based. We ask you as the
learner to consider how each of the subcategories within these six competencies might relate to
cognitive, motor and affective characteristics of your education and your professional behavior.
If while reading this document you discover an area that requires revision or improvement please
bring these issues to the attention of either the Course Director or the Program Director. We seek
changes that will improve your educational experience.
EDUCATIONAL OBJECTIVES
Medical Knowledge:
After completing this rotation, residents will have gained knowledge and practical experience in
the care of regional anesthesia patients. The ABA content outline is the basis of the Medical
Knowledge component of these goals and objectives. The below list of topics should serve as a
foundational basis for your study:
A. ANATOMY
1.
Topographical Anatomy as Landmarks
a) Neck: Cricothyroid Membrane, Internal and External Jugular Veins, Thoracic
Duct, Carotid and Vertebral Arteries, Stellate Ganglion, Cervical Spine
Landmarks (Vertebra Prominens, Chassaig nac’s Tubercle)
b) Chest: Pulmonary Lobes, Cardiac Landmarks, Subclavian Vein
c) Pelvis and Back: Vertebral Level of Topographical Landmarks, Caudal Space
d) Extremities: Relationship of Bones, Nerves, and Arteries
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2.
Radiological Anatomy
a) Chest (Including CT and MRI)
b) Brain and Skull (Including CT and MRI)
c) Spine (Cervical, Thoracic, Lumbar), Including CT and MRI
d) Neck (Including Doppler Ultrasound for Central Venous Access)
e) Ultrasound Imaging (as it relates in identifying peripheral nerves/plexi)
B. PHARMACOLOGY
1. GeneralConcepts
a) Pharmacokinetics and Pharmacodynamics, Protein Binding; Partition
Coefficients; pka; Ionization; Tissue Uptake; Compartmentalization and
Exponential Models
1) pharmacokinetics of neuraxial drug administration: epidural and suba
rachnoid
2) tolerance and tachyphylaxis
b) Termination of Action
1) elimination; biotransformation; context-sensitive half-time
2) impact of renal disease
3) impact of hepatic disease
c) Drug Interactions: Enzyme Induction and Inhibition, Hepatic Blood Flow,
Drug-Drug Binding
1) alternative and herbal medicines: perioperative implications
d) Drug Reactions (Anaphylactoid, Ana phylaxis, Idiosyncratic)
e) Pharmacogenetics
1) malignant hyperthermia (including diagnosis and therapy)
2) butyrylcholinesterase (pseudocholinesterase) deficiency
3) prolonged QT syndrome
4) genetic factors in drug dose-response relationships
f) Addiction
1)
physiology and pharmacology
2) patient addiction: anesthetic implications
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Anesthetics-Intravenous (Opioid and Non-Opioid Induction and Anesthetic
Agents)
a) Opioids
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
(a) intravenous
(b) epidural and intrathecal
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
Benzodiazepines
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
f)
Ketamine
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
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8) indications and contraindications
C. ANESTHESTICS-LOCAL
a)
Uptake, Mechanism of Action
b)
Biotransformation and Excretion
c)
Comparison of Drugs and Chemical Groups
d)
Prolongation of Action
e)
Side Effects and Toxicity
1) CNS : seizures, cauda equina syndrome, transient neurological symptoms
2) cardiac
3) allergy
4) preservatives/additives
5) methemoglobinemia
Peripheral and Autonomic Nerve Blocks: Indications, Contraindications, Techniques,
Clinical Assessment, Complications, Use of Nerve Stimulators
1) head and neck
2) upper extremity/brachial plexus
3) trunk and perineum
4) lower extremity
C) REGIONAL
a) Pain Mechanisms and Pathways
1) nociceptors and nociceptive afferent neurons, wind-up phenomenon
2) dorsal horn transmission and modulation
3) spinal and supraspinal neurotransmission and modulation; opioid receptors
4) autonomic contributions to pain; visceral pain perception and transmission
5) social, vocational and psychological influences on pain perception
6) gender and age differences in pain perception
b) Autonomic Nervous System
1) sympathetic: receptors; transmitters, synthesis; storage; release; responses;
termination of action
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2) parasympathetic: receptors; transmitters; synthesis; release; responses;
termination of action
3) ganglionic transmission
4) reflexes: afferent and efferent limbs
c)
Regional Anesthesia; Main Nerve Blocks (includes techniques and
comparisons
of techniques)
1) autonomic: stellate, celiac, lumbar sympathetic
2) head and neck: retrobulbar/peribulbar, facial, trigeminal nerve and
branches, cervical plexus, glossopharyngeal, superior laryngeal,
transtracheal, occipital
3) extremities: brachial plexus (interscalene, supraclavicular, infraclavicular,
axillary), ulnar, radial, median, musculocutaneous, sciatic, femoral, lateral
femoral cutaneous, obturator, lumbar plexus (psoas block), popliteal fossa,
ankle block
4) trunk: intercostal, paravertebral somatic, ilio-inguinal, genito-femoral
5) spine: epidural (cervical, thoracic, lumbar, caudal, transforaminal), spinal
(suba rachnoid), combined spinal-epidural, facet
D. PAINFUL DISEASE STATES
1. Pathophysiology
a)
Acute Pain
b) Cancer-related Pain
c)
Chronic Pain States
1) acute and chronic neck and low back pain
2) neuropathic pain states
(a) complex regional pain syndrome, types I and II
(b) postherpetic neuralgia
(c) phantom limb, post-stroke
(d) peripheral neuropathies (e.g., diabetic neuropathy)
3) somatic pain conditions: myofascial pain, facet arthropathy, etc.
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2. Treatment
a)
Acute postoperative and posttraumatic pain
1) postoperative epidural analgesia
2) neuraxial opioids
3) peripheral nerve blockade and catheters
4) patient-controlled analgesia
5) other modalities, multimodal analgesia (nonsteroidal analgesics, electrical
stimulation, acupuncture, ketamine, etc.)
b) Cancer-related Pain
1) systemic medications, tolerance and addiction
2) continuous spinal and epidural analgesia
3) neurolytic and non-neurolytic blocks
4) World Health Organization analgesic ladder
c)
Chronic Pain (Non-Cancer-Related)
1) systemic medications: nonsteroidal anti-inflammatory drugs (NSAIDs),
opioid analgesics, anticonvulsants, antidepressants
2) spinal and epidural analgesia
3) peripheral nerve blocks
4) sympathetic nerve blocks
5) other techniques: TENS, spinal cord stimulation, neuroablation (surgical
and chemical neurolysis)
Patient Care:
Using the above medical knowledge the resident is expected to:
1. Evaluate regional patient and developing a treatment plan
2. Plan a comprehensive approach for appropriate periopeative pain management for their
patients
3. Access and evaluate medical literature related to the field of anesthesia via utilization of
systems based practice models
4. Demonstrate the ability to function as a consultant in perioperative pain management
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Interpersonal and Communication Skills:
After completing this rotation, residents will have gained experience and competence in:
1.
2.
3.
4.
Obtaining an accurate, useful patient history appropriate for ambulatory anesthesia
Completing an informative, legible medical record
Communicating skillfully with patients and family members
Communicating information about anesthetic procedures with other colleagues
including referring physicians, nurses, and workers on ancillary services
5. Effective counseling of patients and families regarding methods of ambulatory
anesthesia, alternatives, and risks and benefits of treatment options
6. Obtaining informed consent for ambulatory anesthesia procedures
7. Answering questions from the patient and/or family members regarding the ambulatory
anesthesia issues in a fashion that is readily understood
Professionalism:
After completing this rotation, residents will have gained experience and competence in:
1.
2.
3.
4.
Acting in a professional manner while providing patient care
Demonstrating reliability and dependability
Exemplifying compassionate and appropriate patient care
Acquiring teaching skills essential for creating a positive learning environment,
including involvement in the education of medical students
5. Showing respect for patients
6. Providing for the emotional needs of patients
Systems-Based Practice
After completing this rotation, residents will have gained experience and competence in:
1. Understanding their role as a patient care advocate
2. Becoming familiar with the costs associated with the delivery of anesthesia care
3. Incorporating the concepts of cost-benefit analysis when considering therapeutic
options
4. Interpreting the constraints associated with management of the operating room and be
able to integrate this understanding into best patient care practices
5. Emphasizing safety for the patient as well as operating room personal
6. Obtaining a better understanding of the tools that are being utilized to assess best
practices in anesthesia by organizations such as Magnet and Leapfrog
7. Working towards developing team building skills
Practice Based Learning and Improvement:
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After completing this rotation, residents will have gained experience and competence in:
1. Self-directed learning
2. Becoming more efficient at locating medical information associated with Ambulatory
Anesthesia
3. Reviewing the medical literature related to the field of Ambulatory Anesthesia and
integrating this information with the care of the patient
4. Learning to better utilize information technology to access on-line medical
information pertaining to innovative diagnostic and therapeutic modalities in the area
of Ambulatory Anesthesia
5. Transferring knowledge about Ambulatory Anesthesia to other members of the
healthcare team (medical students, ancillary care personal and nursing staff)
Trainee Evaluations:
The Clinical Competency Committee (CCC) meets every other month to evaluate the progress of
the trainees. Specifically addressed are the six basic competencies and the ambulatory anesthesia
specific competencies outlined above. The instruments used to assess their progress include an
evaluation form which utilizes a scaled five point Likert scoring system which assesses each of
the six competencies. In house testing is also performed twice yearly to insure that the trainees
are acquiring the knowledge associated with the provision of a safe anesthetic. Residents are
expected to take the in-training examination administered by the American Society of
Anesthesiologists/American Board of Anesthesiology (ASA/ABA).
On a more informal (and potentially more important) level, members of the teaching faculty
evaluate our trainees daily and are provide them real-time feedback concerning their
performance in the delivery of anesthesia services. Informal discussions with the ambulatory
anesthesia residents address any deficiencies in patient care or knowledge base. Additionally,
we try to know our trainees personally to better understand and/or address underlying stressors or
personal issues that may interfere with learning and performance.
Every six months, the American Board of Anesthesiology requires that the Clinical Competency
Committee submit a Resident Training and Evaluation Report. In addition to the basic
competencies, we submit our evaluation of a trainee’s progress in the following areas:
1.
2.
3.
4.
5.
6.
Demonstrates ethical/moral behavior
Is reliable, conscientious, responsible and honest
Learns from experience; knows limits
Reacts to stressful situations appropriately
Has no documented abuse of alcohol or illegal use of drugs during this report period
Has no cognitive, physical, sensory or motor impairment that precludes individual
responsibility for any aspect of anesthetic management
7. Demonstrates respect for the dignity of patients and colleagues
8. Has no restriction, condition, limitation or revocation of license to practice medicine
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9. Understands anatomical, physiological, and pathophysiological concepts of organ
disease that culminates in the need for solid organ transplant
10. Collects and uses clinical data
11. Recognizes the psychological factors modifying pain experience
12. Communicates/works effectively with patients/colleagues
13. Demonstrates appropriate concern for patients
14. Demonstrates commitment to life long learning
15. Adapts and is flexible
16. Is careful and thorough
17. Generates complete, legible, and accurate medical record
18. Possesses business skills for effective practice management
19. Uses information technology to optimize patient care
20. Is an advocate for quality care
21. Recognizes gaps in knowledge and expertise
22. Demonstrates continuous practice improvement
23. Uses appropriate technical skills in diagnostic and therapeutic procedures
24. Completes study of management of acute pain, cancer pain, and chronic pain
Suggested Readings:
For guidance in the area of regional anesthesia, the most recent editions for the following
textbooks are recommended:







Atlas of Regional Anesthesia – Brown
Neural Blockade – Cousins
Peripheral Nerve Blocks: Principles and Practice—Hadzic and Vloka
Regional Block – Moore
Chapter on Opiods in Basics of Anesthesia—Stoelting, Miller
Chapter on Pain Management in Clinical Anesthesiology—Morgan, Mikhail and
Murray
Ultrasound Imaging for Regional Anesthesia. A Practical Guide Booklet,2nd
Edition—Vincent Chan
Online Resources:
www.nysora.com
www.anesth.uiowa.edu/rasci/movies.html
www.usra.ca
www.neuraxiom.com
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