Download Neuro Goals and Objectives

Goals and Objectives for first month
in Neuroanesthesia
GOALS AND PRIMARY AREA OF KNOWLEDGE:
This rotation will introduce and concentrate on the basic practices of neuroanesthesia for patients
with normal or abnormal intracranial, neuraxial, cerebrovascular, and peripheral nerve
conditions. The basic sciences of anatomy, physiology, and physics as they relate to the
preanesthetic assessment, intraoperative management, and postoperative care of the
neurosurgical patient will be emphasized. Patients with intracranial pathology represent a
significant proportion of the population requiring operative intervention. The physiology of
intracranial dynamics and the pharmacologic results of anesthetic intervention constitute a
specialty field of knowledge within that of general anesthesiology. Vascular malformations,
trauma, and tumors all require an understanding concerning their origin, natural clinical course
and potential for therapeutic intervention. Patients with chronic neurologic disorders represent a
patient subgroup who benefit from the applied pharmacologic understanding of the neuroanesthesiologist. The goal of this rotation is proficiency in the administration of anesthesia and
perioperative care of the patient undergoing a neurosurgical procedure. The resident should gain
an understanding of:
1.
2.
Preoperative assessment of the neurosurgical patient to include coexisting diseases
Intraoperative management, including:
a)
b)
c)
d)
e)
f)
Choice of anesthetic (general, regional, MAC)
Anesthetic agents as they apply to neurosurgical cases
The risks and benefits of the agents chosen
The effects of the anesthetics and adjuvant agents chosen on abnormal
neurophysiology
Understanding abnormal central nervous system physiology
Management of anesthesia for:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
Craniotomy for supratentorial masses
Posterior fossa craniotomy (including the sitting position)
Epilepsy surgery
Stereotactic surgery
CSF shunting procedures
Head trauma
Spinal column and spinal cord surgery (including injury)
Intracranial aneurysms and arteriovenous malformations
Anesthesia for radiologic procedures
Neuroendocrine Procedures
Postanesthesia recovery
CORE COMPETENCY PROFICIENCY
Patient Care
Residents must be able to provide patient care that is compassionate, appropriate, and effective
for the treatment of health problems and the promotion of health. Residents are expected to:
1.
2.
3.
4.
Perform an appropriate evaluation; including history, physical exam and laboratory
studies when needed
Interact effectively with patients and their families demonstrating respect and care for
individuals.
Formulate a plan based on the individual patients medical history, expectations and
expected course of their condition.
Work together with other members of the interdisciplinary health care team, to optimize
patient care and enhance quality of life.
Integrated Medical Knowledge
Residents must demonstrate knowledge about established and evolving biomedical, clinical, and
cognate sciences and the application of this knowledge to patient care. Residents are expected
to:
1.
2.
3.
4.
Apply relevant scientific knowledge and reasoning to the practice of neuroanesthesia.
Understand both normal and abnormal central nervous system physiology, neuroanatomy
relevant to neurosurgical procedures, cerebral and spinal cord blood volume and flow, the
anatomy of the blood brain barrier, the etiology of cerebral edema, the anatomy of
peripheral nerves and their innervation, physiology of the NMJ and muscle.
Understand neuro-physiological monitoring to include EEG, SSEPS, MEPS, BAEPS,
EMG and ICP.
Understand the anesthetic ramifications of increased ICP, intracranial masses, intracranial
vascular lesions, epilepsy, CSF shunting procedures, head and spine trauma, radiographic
procedures, pituitary surgery, peripheral nerve surgery, surgery on patients with muscle
disorders, and patients with disorders of muscle
Interpersonal/Communication Skills
Residents must be able to demonstrate interpersonal and communication skills that result in
effective information exchange and teaming with patients, their patients families, and
professional associates. Residents are expected to:
1.
2.
3.
4.
Discuss with patients and family members the utility and advantages, as well as potential
disadvantages, of the different anesthetic options.
Establish good rapport with patients and families, addressing patient and family concerns
and anxieties.
Create and sustain a therapeutic and ethically sound relationship with patients.
Use effective listening skills to elicit appropriate clinical information.
5.
6.
Work effectively with others in the interdisciplinary health care team.
Establish working relationships with operating room staff, surgeons, resident and
attending anesthesiologists.
Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to a diverse patient population. Residents are
expected to:
1.
2.
3.
4.
5.
6.
7.
8.
demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients
and society that supersedes self-interest; accountability to patients, society, and the
profession; and a commitment to excellence and on-going professional development
demonstrate a commitment to performing duties as a physician and medical professional.
demonstrate a consistent work ethic.
demonstrate a consistent level of respect to patients, families, and operating room staff.
demonstrate a commitment to ethical principles pertaining to provision of clinical care,
confidentiality of patient information, informed consent, and business practices
demonstrate sensitivity and responsiveness to patients culture, age, gender and
disabilities.
demonstrate accountability to patients, colleagues and institution.
demonstrate the integrity of a medical professional and a commitment to excellence and
ongoing professional development.
Residents must be able to investigate and evaluate their patient care practices, appraise and
assimilate scientific evidence, and improve their patient care practices. Residents are expected
to:
1.
2.
3.
4.
locate, appraise, and assimilate evidence from scientific studies related to cardiac and
thoracic anesthesia. This includes, but is not limited to, the directed readings in the Core
Curriculum. In selected cases, it is appropriate to pursue additional scientific evidence in
a reference text or in an electronic online search.
be able to synthesize medical information from texts, lectures, and journal articles and
apply this information to the care of neuro-surgical patients.
apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness
use information technology to manage information, access on-line medical information;
and support their own education.
Systems-Based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system
of healthcare and the ability to effectively call on system resources to provide care that is of
optimal value. Residents are expected to:
1.
2.
3.
4.
5.
6.
7.
understand how their patient care and other professional practices affect other health care
professionals, the health care organization, and the larger society and how these elements
of the system affect their own practice
Understand the healthcare system as it relates to neurosurgery and neuro-anesthesiology.
The patient preoperative process, diagnosis by neurologists, neurosurgeons, radiologists,
through the post op course patients will experience, including ICU, floor care,
rehabilitation, and home care.
practice anesthesiology within the context of this health care institution and in
cooperation with other health care professionals.
practice cost-effective health care.
advocate for quality patient care and assist patients in dealing with system complexities
know how to partner with health care managers and health care providers to assess,
coordinate, and improve health care and know how these activities can affect system
performance
COGNITIVE OBJECTIVES:
1.
2.
3.
4.
Describe an appropriate anesthetic based on the clinical condition, goals of the procedure,
and anticipated intraoperative monitoring for surgeries listed above
Describe neuroanatomy relevant to a neurosurgical procedure
Understand and explain the physiology of cerebral metabolism, blood flow and blood
volume
Understand and explain the effects of anesthetic agents and adjuvant drugs on:
a)
b)
c)
d)
5.
Cerebral metabolism
Cerebral and spinal cord blood volume and blood flow
Blood brain barrier and cerebral edema
Cerebral protection, ischemia and resuscitation
Understand the application and the effects of anesthesia on:
a)
Neurophysiologic monitoring.
1.)
2.)
3.)
4.)
5.)
6.)
b)
6.
electroencephalography
somatosensory evoked responses
motor evoked responses
peripheral and cranial nerve monitor
BAERS
EMG
intracranial pressure monitoring.
Understand and describe the perioperative surgical and anesthetic considerations for fluid
management
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Recognize, understand the origins of, and treatment of intracranial hypertension
Interpret and respond to data from monitoring devices (etCO2, CBF, EEG, EMG, SSEP,
BAER, ICP)
List, and describe ways to avoid, the problems associated with emergence from
anesthesia
Understand CBF and factors affecting it, including CO2 and 02 response and
pharmacological changes in CBF.
Understand the use of fluids for neuro-surgical patients, including crystalloid, colloid,
blood products, mannitol and dextrose-containing solutions.
Understand patient positioning and its implications.
Understand the pathophysiology of acute and chronic spinal cord injury, including the
cardiovascular and pulmonary consequences (especially autonomic hyperreflexia).
Understand the consequences of using depolarizing muscle relaxants in these patients.
Understand the management of increase ICP for craniotomy and the use,
hyperventilation, barbiturate infusion, diuretics and CSF drainage.
Have knowledge of airway management and sedation requirements for patients
undergoing stereo tactic procedures under GA or local anesthesia.
SKILL OBJECTIVES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Demonstrate the basic skills of anesthesia to include airway management, starting IVs, Alines, long arm CVP’s, etc.
Successfully manage complex neurosurgical cases
Utilize multiple anesthetic methods (topicalization, nerve blocks, nebulized local
anesthesia) in the preparation of a patient for awake intubations
Perform awake fiberoptic intubation and awake positioning with the ability to assess
neurologic function as needed
Insert, properly interpret, and respond to invasive hemodynamic monitors
Perform and properly maintain hypotensive anesthesia when indicated
Be able to give a case presentation, including medical problems, pre-anesthesia concerns,
airway management, lines, anesthetic medications, and extubation plans in a
neurosurgical patient.
Be able to review the medical history and physical exam to define the type and severity
of the neurosurgical problem, as well as other medical problems the patient may have.
Recognize patients with spinal cord pathology and be able to determine which ones may
require special techniques (awake intubation) and positioning.
Recognize which patients would be appropriate for early extubation (in OR or PACU)
considering their CNS, neuromuscular, and other medical conditions.
Manage an elective craniotomy and understand the choice for the anesthetic agents.
Be able to evaluate CT/MRI images for obvious abnormalities such as epidural and
subdural hematomas, large strokes and masses.
Manage spine surgery, including cases with potential for massive blood losses.
Manage cases in the sitting position.
a)
b)
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Pre-cordial Doppler placement - Recognize air entrapment
Long-arm CVP placement and management
Manage craniotomy for neuroendocrine tumors.
Plan an anesthetic to allow for rapid reversal of anesthetic effects to assess neurological
function after craniotomy.
Be able to place a right atrial catheter for diagnosis and management of air embolism.
Perform awake laryngoscopy, fiber optic laryngoscopy, fast-track LMA or in-line
traction. Understand their use in patients with spinal cord injury.
Be able to set up, organize, and execute the planning of a complicated case.
Perform preoperative patient assessment and choose an anesthetic plan specific for that
neurosurgical patient.
Provide the basic skills and experience necessary to care for patients undergoing surgery
for intra-cranial masses, intra-cranial vascular surgery, epilepsy, stereo-tactic surgery,
CSF shunting procedures, head trauma, radiographic procedures, pituitary surgery,
peripheral nerve surgery, surgery on patients with muscle disorders, and anesthesia for
patients with disorders of the neuro-muscular junction.
Provide appropriate treatment for increased intra-cranial pressure
Provide proper fluid management in neurosurgery patients
Manage patients with neurologic disease undergoing non-neurosurgery procedures
Perform fiber optic intubations, start IV’s, arterial lines, and obtain central venous access
Provide initial postoperative care in the ICU/PACU
REQUIRED READING:
In order to facilitate a coordination of reading topics and discussion between residents and
assigned staff the following chapters in Newfield will be assigned on a daily and weekly basis.
Not every rotation will start on a Monday. Thus, the reading assignments will begin on the first
day of the first week of the rotation according to the in the following table. For example if your
rotation starts on a Thursday you will be responsible for Chapter 4 Cerebral Protection. The
other chapters will be covered in the fourth week of the rotation.
Mongan Chapter
1 (Brain Metabolism and CBF)
2 (Anesthesia effects on CBF)
3 (Fluid Management)
4 (Routine Craniotomy)
5 (Emergency Craniotomy)
6 (Posterior Fossa)
8 (Pituitary Gland)
9 (Intracranial aneurysms)
10 (AVMs)
12 (Spinal cord injury)
13 (Intramedullary Spinal Cord Tumors)
14 (Functional Neurosurgery)
23 (Stroke and Brain Protection)
26 (Electrophysiology)
27 (ICP)
29 (TBI)
Week
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
Day
Monday
Tuesday
Wednesday
Thursday
Monday
Tuesday
Wednesday
Thursday
Monday
Tuesday
Wednesday
Thursday
Monday
Tuesday
Wednesday
Thursday
RECOMMENDED READING:
Week 1.
Cerebral Physiology, Ch 13 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2009
Week 2.
Neurological Monitoring, Ch 46 Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2009
Week 3/4.
Neurosurgical Anesthesia, Ch 63 Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2009
EVALUATION:
Final evaluation will be based upon clinical performance with a written evaluation
Goals and Objectives for the second month
in Neuroanesthesia
GOALS AND PRIMARY AREA OF KNOWLEDGE:
As part of the consolidation of neuroanesthesia subspecialty concepts, the resident in the second
month will have become familiar with the basic elements of neuroanesthesia management during
the first month. Advanced Training in Neuroanesthesia in the second month will include steady
advancement to more difficult and complex anesthetic problems, including care of seriously ill
neurosurgical patients. At this level, neuroanesthesia will include an enhanced experience in an
understanding of the anatomy, pharmacology, physiology, pathophysiology, and specialized
issues related to the administration of anesthetics to neurosurgical patients.
ACGME CORE COMPETENCIES:
Demonstrate mastery of all core competencies outlined for the first month.
COGNITIVE OBJECTIVES:
1.
Demonstrate mastery of knowledge of all cognitive objectives expected of a first month
with little or no staff assistance
2.
Demonstrate mastery of knowledge of normal brain physiology; functional and special
monitoring
3.
Demonstrate mastery of knowledge of cerebral and spinal cord blood flow
4.
Demonstrate mastery of knowledge of brain oxygen consumption, metabolism, and
cerebral ischemia
5.
Demonstrate mastery of knowledge of regional ischemia and global ischemia
6.
Demonstrate mastery of knowledge cerebrospinal fluid mechanics
7.
Demonstrate mastery of knowledge of the Anesthetic effects on CSF physiology and
intracranial pressure
8.
Demonstrate mastery of knowledge of ICP monitoring and interpretation of intracranial
compliance, elastance, relationships
9.
Demonstrate mastery of knowledge relating to severe neurologic injury to include:
a)
b)
c)
d)
e)
f)
g)
Primary and secondary injury
Edema formation
Vasospasm and delayed neuronal necrosis
Multi-system effects of head injury
Spinal cord injury - acute and chronic changes
Altered consciousness and coma
Brain protection, preservation and resuscitation
SKILL OBJECTIVES:
1.
Demonstrate all the “skill objectives” expected of the first month trainee
2.
Induce cerebral “protective” measures and manipulate hemodynamics based on
neurophysiological monitoring
3.
Balance the anesthetic technique to accommodate neurophysiological monitoring
4.
Demonstrate the ability to manage neuroanesthetic complications, prepare anesthetic
plans for complex neurosurgical patients including those involving sophisticated,
neurological monitoring or techniques such as deep hypothermic arrest for aneurysm
clipping
5.
Manage the anesthetic care of the complex and difficult neurosurgical patient which may
range from an infant with a brain tumor to complex AV malformation
6.
Manage anesthesia for neuroradiologic procedures in remote location anesthetic
7.
Manage anesthesia for supratentorial lesions to include rationale and positioning
8.
Demonstrate appropriate management for severe head injury to include interpretation and
therapy for ICP monitoring techniques
9.
Demonstrate appropriate management for posterior fossa procedures in the prone and
sitting position
10.
Demonstrate the ability to use:
a)
b)
11.
precordial doppler monitoring
right heart catheter (air aspiration)
Demonstrate anesthesia management for neurovascular procedures (neuroradiology,
aneurysm and endarterectomy)
12
Demonstrate appropriate implementation and interpretation of neurophysiologic
monitoring: EEG, SSEP, BAER, MEP
REQUIRED READING:
In order to facilitate a coordination of reading topics and discussion between residents and
assigned staff the following chapters in Newfield will be assigned on a daily and weekly basis.
Not every rotation will start on a Monday. Thus, the reading assignments will begin on the first
day of the first week of the rotation according to the in the following table. For example if your
rotation starts on a Thursday you will be responsible for Chapter 4 Cerebral Protection. The
other chapters will be covered in the fourth week of the rotation.
Mongan Chapter
1 (Brain Metabolism and CBF)
2 (Anesthesia effects on CBF)
3 (Fluid Management)
4 (Routine Craniotomy)
5 (Emergency Craniotomy)
6 (Posterior Fossa)
8 (Pituitary Gland)
9 (Intracranial aneurysms)
10 (AVMs)
12 (Spinal cord injury)
13 (Intramedullary Spinal Cord Tumors)
14 (Functional Neurosurgery)
23 (Stroke and Brain Protection)
26 (Electrophysiology)
27 (ICP)
29 (TBI)
Week
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
Day
Monday
Tuesday
Wednesday
Thursday
Monday
Tuesday
Wednesday
Thursday
Monday
Tuesday
Wednesday
Thursday
Monday
Tuesday
Wednesday
Thursday
RECOMMENDED READING:
Week 1.
Cerebral Physiology, Ch 13 Anesthesia, 7th edition, Ronald Miller Ed. Churchill
Livingston, 2009
Week 2.
Neurological Monitoring, Ch 46 Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2009
Week 3/4.
Neurosurgical Anesthesia, Ch 63 Anesthesia, 7th edition, Ronald Miller Ed.
Churchill Livingston, 2009
EVALUATION:
Final evaluation will be based upon clinical performance with a written evaluation