Download Advanced Pediatric Goals and Objectives - IU Anesthesia

INDIANA UNIVERSITY DEPARTMENT OF ANESTHESIOLOGY
ADVANCED--Pediatric Anesthesia
Goals and Objectives
GOALS and OBJECTIVES:
This advanced rotation is meant to provide you with the opportunity to further develop the
competencies in the area of pediatric anesthesia required to meet the expectations for a
Board Certified (Consultant) Anesthesiologist.
The goal of the Advanced Pediatric Anesthesia Rotation at the Indiana University School of
Medicine is to train anesthesia residents to extend their areas of knowledge and competency in
their practice of Pediatric Anesthesia. We expect the residents to be able to more readily evaluate
and develop treatment plans regarding patient care issues than during their previous rotations in
the Core Pediatric Anesthesia rotation. This rotation, like the core rotation in Pediatric
Anesthesia, is designed to enhance your overall knowledge, understanding and application of
pediatric anesthesia principles. However, given the advanced nature of this rotation, emphasis
will be placed upon enhancing your skill in the areas of analysis, synthesis and evaluation of the
patient. The rotation will build upon the Basic Pediatric Anesthesia Rotation to include the care
of the patient undergoing more complex surgical procedures, the care of medically more
complex patients, and enhancing levels of clinical performance. We would again reemphasize
that this rotation is meant to provide you with the opportunity to develop the competencies
required to meet the expectations of a Board Certified (Consultant) Anesthesiologist.
Basic Pediatric Anesthesia Resident Duties:
1. Perform preoperative evaluations of infants and children presenting for inpatient and
ambulatory surgery and report findings to the attending staff
2. Obtain informed consent for sedation, general, and regional anesthesia
3. Develop an intra-operative anesthetic plan for each patient and discuss this with
attending staff
4. Provide appropriate anesthetic management for a variety of surgical cases including
but not limited to: neurosurgery, plastic and reconstructive surgery, orthopedic,
genitourinary, gastroenterology, pediatric general surgery and radiologic procedures.
5. Attendance at didactic conferences
6. Taking night call on a rotating schedule
7. Develop 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 (ADVANCED Pediatric Anesthesia):
The ADVANCED Pediatric Anesthesia Rotations occur in one-month (4 week) blocks. During
their time on Pediatric Anesthesia residents will be will be supervised by various members of the
anesthesia teaching faculty. The Director of Pediatric Anesthesia is Dr. Scott Walker. A packet
of materials (the “Riley Anesthesia Manual”) has been compiled by Dr. Thomas Wolfe and is
provided as a means of enhancing their educational experience.
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 (ADVANCED Pediatric Anesthesia):
Medical Knowledge:
The ADVANCED Pediatric Anesthesia rotation is meant to sharpen the resident’s knowledge
base to the degree expected of a consultant in Pediatric anesthesia. We believe that the below
ABA content outline provides the benchmark upon which these expectations are founded.
Pediatric Anesthesia
a. Apparatus: Breathing Circuits (Advantages/Disadvantages, Dead Space, Etc.), Humidity,
Thermal Control
1) Endotracheal Tube Selection (Cuffed vs. Uncuffed) and Sizing
2) Warming Devices: Types, Efficacy, Complications
b. Premedication: Drugs; Dosage; Routes; Vehicles, Including Topical Anesthetics; Parental
Presence
c. Agents and Techniques
1) Induction Techniques
2) Anesthetics: Actions Different From Adults
a) Drug Toxicities Preferentially Occurring in Children: e.g., Propofol
b) Opioid Dosing and Sensitivity
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c) Neuromuscular Blockers (Sensitivity, Congenital Diseases, Complications of
Succinylcholine, Age-Related and Drug-Related Pharmacodynamics and
Pharmacokinetics)
d) Regional Anesthesia
d. Fluid Therapy and Blood Replacement, Physiologic Anemia, Glucose Requirements
e. Problems in Intubation and Extubation (Full Stomach, Diaphragmatic Hernia, Tracheo
Esophageal (T-E) Fistula, Pierre-Robin, Treacher-Collins, Crouzon’s, Goldenhar’s, Hurler’s,
Awake/Fiberoptic Intubation, Dentition, Laryngospasm, Stridor)
f. Neonatal Physiology
1) Respiratory
a) Development, Anatomy, Surfactant
b) Pulmonary Oxygen Toxicity
c) Pulmonary Function
d) Lung Volumes vs. Adult
e) Airway Differences, Infant vs. Adult
2) Cardiovascular
a) Transition, Fetal to Adult
b) Persistent Fetal Circulation
3) Retinopathy of Prematurity: Anesthetic Implications
4) Metabolism, Fluid Distribution and Renal Function
5) Thermal Regulation (Neutral Temperature, Nonshivering Thermogenesis)
6) Fetal Hemoglobin
7) Prematurity, Apnea of Prematurity
8) Bronchopulmonary Dysplasia
g. Congenital Heart and Major Vascular Disease
1) Cyanotic Defects
2) Acyanotic Defects
3) Primary Pulmonary Hypertension
4) Major Vascular Malformations: Coarctation, Persistent Patent Ductus Arteriosus,
Vascular Rings.
5) Altered Uptake/Distribution of IV and Inhalation Anesthetics
6) Anesthetic Considerations
a) Cardiac Surgery; Corrective and Palliative
b) Noncardiac Surgery
c) Chronic Congenital Heart Disease, Corrected, Uncorrected, and Palliated
(1) In Childhood Beyond the Newborn and Infant Periods
(2) In Adulthood
h. Emergencies in the Newborn
1) Diaphragmatic Hernia
2) Tracheoesophageal Fistula and Esophageal Atresia
3) Neonatal Lobar Emphysema
4) Pyloric Stenosis
5) Necrotizing Enterocolitis
6) Omphalocele/Gastroschisis
7) Respiratory Distress Syndrome: Etiology, Management, Ventilation Techniques
8) Myelomeningocele
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i. Pediatric Medical Problems with Anesthetic Implications
1) Respiratory: Upper Respiratory Infections (Colds, Epiglottitis,
Laryngotracheobronchitis), Bronchopulmonary Dysplasia, Cystic Fibrosis
2) Musculoskeletal: Muscular Dystrophies, Myotonias, Etc.
3) Developmental Delay, Cerebral Palsy, Autism
4) Childhood Obesity
5) Endocrine Diseases: Childhood Diabetes, Congenital Adrenal Hyperplasia, Etc.
6) Skeletal Abnormalities with Or without Systemic Implications : Klippel-Feil,
Achondroplasia, Marfan’s, Morquio’s, Osteogenesis Imperfect
7) Trisomy 21 and Other Chromosomal Abnormalities
8) Juvenile Rheumatoid Arthritis
9) Anemias: Congenital and Acquired: Iron Deficiency, Physiologic Anemia, Sickle Cell,
Thalassemia, Etc.
10) Malignant Hyperthermia in Children; Susceptibility, Associated Diseases, Anesthetic
Management of MH Susceptibility, Intraoperative Diagnosis, Treatment
j. Anesthetic Implications for Common Non-Neonatal Pediatric Subspecialty Surgery
1) Otolaryngology: Cleft Lip and Palate, Tonsillectomy and Adenoidectomy, Common
Ear Procedures, Peritonsillar Abscess, Flexible and Rigid Bronchoscopy, Diagnostic and
Therapeutic Laryngoscopy Techniques (Jet Ventilation, Laser Implications), Airway
Foreign Bodies
2) Neurosurgery: Craniotomies for Tumor Or Vascular Malformations, Hydrocephalus,
Ventriculoperitoneal Shunts, Craniofacial Procedures, Tethered Spinal Cord, Halo
Placement Implications
3) Thoracic Surgery: Anterior Mediastinal Mass, Lung Isolation Techniques, Pectus
Excavatum and Carinatum
4) General and Urologic Surgery: Laparotomy vs Laparoscopy, Bowel Surgery, Urologic
Surgery (Wilms Tumor, Ureteral Reimplantation, Bladder and Urethral Malformations,
Neuroblastoma)
5) Orthopedic Surgery: Fractures and Dislocations, Congenital Hip Dysplasia, Foot and
Hand Malformations; Scoliosis Implications and Repair
6) Ophthalmologic: Strabismus, Cataract, Glaucoma Procedures, Etc.
k. Outpatient Pediatric Anesthesia
1) Indications and Contraindications
2) Anesthetic Considerations: Premedication, Induction, Maintenance, Monitoring
3) Postoperative Considerations: Recovery Period, Discharge Criteria, Post-Discharge
Monitoring/Follow-Up
l. Postoperative Analgesia
1) Systemic Medications and Routes of Administration, Multimodal Therapy
2) Regional Techniques: Caudal, Epidural, Nerve Blocks
m. Postoperative Nausea and Vomiting: Risk Factors, Prophylaxis, Treatment
n. Pediatric Sedation: Guidelines, Pharmacology, Credentialing, Indications, Monitoring,
Complications
o. Pediatric Anesthesia Outside the Operating Rooms: Diagnostic and Interventional
Radiologic Procedures, Gastroenterology Laboratory, MRIs, Radiation Therapy
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Patient Care:
Using the above medical knowledge the resident is expected to:
1. Demonstrate capability of obtaining an informed consent
2. Practice proper technique in the management of normal and abnormal airways,
providing mechanical ventilation, and temperature regulation
3. Demonstrate proper technique in the placement of venous and arterial catheters
4. Exhibit appropriate technique when performing regional anesthesia for inpatient and
ambulatory patients
5. Administer crystalloid and colloid solutions and blood products appropriately
6. Exhibit reliability and dependability in patient care
Interpersonal and Communication Skills:
After completing this rotation, residents will have gained experience and competence in:
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Obtaining an accurate useful patient history appropriate for pediatric 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 pediatric
anesthesia, alternatives, and risks and benefits of treatment options
6. Obtaining informed consent for pediatric anesthesia procedures
7. Answering questions from the patient and or family members regarding pediatric
anesthesia issues in a fashion that is readily understood
Professionalism:
After completing this rotation, residents will have gained experience and competence in:
1. Acting in a professional manner while providing patient care
2. Demonstrating reliability and dependability
3. Exemplifying compassionate and appropriate patient care
4. 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:
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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. Working towards developing team building skills
Practice Based Learning and Improvement:
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 pediatric
anesthesia
3. Reviewing the medical literature related to the field of pediatric 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 pediatric anesthesia
5. Transferring knowledge about pediatric anesthesia to other members of the healthcare
team (medical students, other residents, 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 pediatric 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 provide them real-time feedback concerning their performance in
the delivery of anesthesia services. Informal discussions with the pediatric 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.
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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:
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3.
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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
Demonstrates respect for the dignity of patients and colleagues
Has no restriction, condition, limitation or revocation of license to practice
medicine
Understands anatomical, physiological, and pathophysiological concepts of organ
disease that culminates in the need for solid organ transplant
Collects and uses clinical data
Recognizes the psychological factors modifying pain experience
Communicates/works effectively with patients/colleagues
Demonstrates appropriate concern for patients
Demonstrates commitment to life long learning
Adapts and is flexible
Is careful and thorough
Generates complete, legible, and accurate medical record
Possesses business skills for effective practice management
Uses information technology to optimize patient care
Is an advocate for quality care
Recognizes gaps in knowledge and expertise
Demonstrates continuous practice improvement
Uses appropriate technical skills in diagnostic and therapeutic procedures
Completes study of management of acute pain, cancer pain, and chronic pain
Suggested Readings:
Suggested reading assignments to expand knowledge and patient care for this rotation include
but are not limited to the most recent editions of the following textbooks:
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A Practice of Anesthesia for Infants and Children - Cote’ et al
Pediatric Anesthesia – Gregory
Pediatric Anesthesia - Bissonette and Dalens
Pediatric Cardiac Anesthesia - Lake
Heart Disease in Infants, Children, and Adolescents – Moss and Adams
Anesthesia for Congenital Heart Disease - Andropoulos, Stayer, Russell
Clinical Anesthesia - Barash
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Anesthesia and Co-existing Disease – Stoelting and Dierdorf
Pharmacology and Physiology in Anesthetic Practice-Stoelting and Hillier
Syndromes – Rapid Recognition and Perioperative Implications – Bissonnette et
al.
Anesthesia for Genetic, Metabolic, and Dysmorphic Syndromes of Children –
Baum and O’Flaherty
Annual Refresher Course Lectures and Basic Science Reviews of the ASA
(published annually)
For guidance regarding regional analgesia for thoracic surgery the most recent editions of the
following textbooks are recommended:
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Atlas of Regional Anesthesia – Brown
Neural Blockade – Cousins
Peripheral Nerve Blocks: Principles and Practice—Hadzic and Vloka
Regional Block – Moore
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