Download Cardiothoracic

Cardiothoracic Anesthesiology Rotation
Curricular Milestones
Prepare Anesthesia Work Station
1. Performs appropriate and timely room set up, including standard ASA setup and
relevant invasive monitors
2. Prepare emergency drugs, vasoactive infusions, and appropriate drugs for
cardiothoracic cases
Basic Preoperative Assessment
1. Perform preoperative assessment for patients presenting for cardiac and thoracic
surgery.
2.Perform focused history and physical exam
3.Summarize and present key diagnostic data relevant to surgical procedure.
4.Correctly assign ASA classification for patients presenting for cardiac or thoracic
surgery.
Advanced Preoperative Assessment
1. Identifies any ethical issues which may interfere with standard perioperative care
(DNR, Jehovah’s Witness, etc)
2. Demonstrate compassion to the patient and family members presenting for major
surgery, while facilitating task completion of entire health care team (surgeon,
nursing etc) in a timely manner
3. Incorporates evidenced-based medicine into practice; cites peer reviewed articles
4. Communicates unusual circumstances or anesthetic concerns with surgical team
Preoperative Planning for Common Thoracic Surgeries
1. Identify and discuss key anesthetic and perioperative management
considerations for common thoracic surgeries including:
a) VATS
b) Esophagectomy
c) Pleurodesis
d) Thoracotomy
e) Mediastinoscopy
f) Bronchoscopy
Preoperative Planning for Less Common Thoracic Surgeries
1. Identify and discuss key anesthetic and perioperative management
considerations for less common thoracic surgeries including:
a) Tracheoplasty
b) Tracheal Resection
c) Pneumonectomy
d) Lung Transplant
Preoperative planning for major cardiac surgery (Standard Cardiac Operations):
1. Identify and present the key hemodynamic and perioperative management
concerns that must be considered for mitral valve pathology including:
a)Mitral Stenosis
b)Mitral Regurgitation
2. Identify and present the key hemodynamic and perioperative management
concerns that
must be considered for aortic valvepathology, including:
a)Aortic Stenosis
b)Aortic Insufficiency
3. Identify and present the key hemodynamic and perioperative
managementconcerns that must be considered for tricuspid and pulmonic valve
pathology including:
a) Tricuspid Regurgitation
b) Tricuspid Stenosis
c) Pulmonary Regurgitation
d) Pulmonary Stenosis
4. Identify and present the key anesthetic and perioperative management concerns
that must be considered for surgery in the setting of ischemic cardiac disease
including:
a) CABG
b) LV dysfunction
c) RV dysfunction
Preoperative planning for major cardiac surgery (Advanced Cardiac Operations):
1. Identify and discuss key anesthetic and perioperative management
considerations for
mechanical circulatory support including:
a) VAD
b) ECMO
c) Tandem Heart
d) Impella
e) IABP
2. Identify and discuss key anesthetic and perioperative management
considerations for
atypical cardiac surgical scenarios including:
a) Pulmonary Hypertension
b) LVOT obstruction
c) Ablation Procedures
d) ASD
e) VSD
f) TOF
g) Heart Transplant
3. Identify and discuss key anesthetic and perioperative management
considerations for
patients undergoing thoracic aortic surgery including:
a) Aortic Dissection- open replacement
b) Aortic Dissection- endovascular repair
c) Aortic Aneurysm- open replacement
d) Aortic Aneurysm- endovascular repair
Choice of Anesthesia
1. Identifies possible difficult mask ventilation and/or intubation
2. Has a plan and rationale for induction based upon the patient’s medical history
and planned procedure
3. Adjusts induction medications/ technique depending on patient’s co-morbidities
4. Appropriately manages hemodynamics during line placement.
Basic Procedures for Cardiac Operations
1. Understands the indications for the invasive monitors placed
2. Understands the contraindications for the invasive monitors placed
3. Places arterial lines, central lines and PAC in a timely fashion
4. Recognizes problems with and troubleshoots invasive monitoring
Advanced Procedures for Cardiac Operations
1. Manages epicardial pacing
2. Performs basic TEE assessments (wall motion, ventricular function ventricular
filling).
3. Understands conditions that can complicate TEE; places TEE atraumatically
Procedures for Thoracic Operations
1. Can correctly place a double lumen endotracheal tube
2. Can discuss, or discuss placement of, a bronchial blocker
3. Can perform basic fiber-optic bronchoscopy, including identification of major
anatomic landmarks
4. Recognizes indications and contraindications, advantages and disadvantages of
thoracic epidurals
5. Places thoracic epidurals
Management of the Pre-Cardiopulmonary Bypass Phase
1. Anticipates the operative phase from skin incision to the initiation of
cardiopulmonary bypass
2. Executes the specific tasks required from the anesthesia team immediately preincision through the initiation of cardiopulmonary bypass
3. Describes the cannulation strategy for the case
Management of Cardiopulmonary Bypass
1. Describes anticoagulation during cardiopulmonary bypass and can alter plan
when traditional dosing fails (e.g. AT3 deficiency management)
2. Can formulate a plan for a patient with HIT/HITT who requires cardiopulmonary
bypass
3. Appropriately manages hypotension during cardiopulmonary bypass
4. Manages circulatory arrest
5. Understands the physiologic complications of circulatory arrest at various
temperatures
6. Prepares the patient for separation for from CPB
Management of Separation from Cardiopulmonary Bypass
1. Gives protamine appropriately and recognizes complications of protamine
administration
2. Can give a differential diagnosis of hypotension upon separation from CPB
3. Can discuss how to manipulate the variables contributing to blood pressure and
oxygen delivery
4. Understands the different pharmacologic agents used to manage hemodynamics
in the setting of cardiac surgery and utilizes invasive monitors to guide decision
making for use
Management of the Post Bypass Phase
1. Appropriately plans post-operative analgesia
2. Accurately charts in the anesthetic record
3. Identifies patients that are appropriate for extubation
4.Maintains appropriate contact with supervising staff
Maintenance of Cardiac Cases Without Cardiopulmonary Bypass
1. Appropriately estimates fluid requirements and administers appropriate fluid
type
2. Accurately estimates allowable blood loss and the need for transfusion
3. Manages massive hemorrhage
4. Treats hemodynamic changes in timely and appropriate fashion
5. Appropriately plans post-operative analgesia
6. Maintains accurate anesthestic patient record
7. Maintains appropriate contact with supervising staff
General Management of Thoracic Cases
1. Appropriately estimates fluid requirements and administers appropriate fluid
type
2. Understands absolute and relative indications for one lung ventilation
3.Uses appropriate tidal volumes during one lung ventilation
4.Can mathematically show minimum necessary saturation for a patient to maintain
adequate oxygen delivery
5.Can discuss differential lung perfusion
6. Accurately charts in the anesthetic record
7. Maintains appropriate contact with supervising staff
Management of Common Issues During Thoracic Cases
1. Manages hypoxemia during one lung ventilation
2.Recognizes dysfunction/ malposition of bronchial blocker/ DLT and intervenes to
resolve the problem.
3. Appropriately identifies when blood transfusion would be beneficial
4. Appropriately treats bronchospasm
5. Manages ventilation in obstructive lung disease
6. Appropriately manages patients with pulmonary hypertension
7. Appropriately plans post-operative analgesia
Coordination within operating room environment
1.Perform timely room turnover between cases
2.Utilize anesthesia technicians and pharmacy staff as appropriate
3.Maintain accurate record of controlled substances
4.Arrange transfer of patient to and from the intensive care unit
5.Communicates effectively with the surgical team and operating room
Management of Unanticipated Intraoperative Events &Peri-anesthetic complications
1.Identifies, formulates a differential diagnosis and manages unexpected or
emergent intraoperative scenarios
2.Understands how to apply ACLS guidelines to the operating room environment
3. Accurately charts in the anesthetic record
4.Maintains appropriate contact with supervising staff
5. With supervision, discusses adverse events with patients and family.
Emergence and PACU/ICU Care
1. Prepares the patient for emergence from anesthesia
2. Understands and applies the criteria for extubation
3. Transfer the patient to the PACU/ICU and manages hemodynamics throughout
the transition period
4. Provides appropriate hand-off to the PACU/ICU staff
5. Manages common post-operative problems (ie. pain, hypotension, hypertension,
PONV)
6. Performs post-operative visits as appropriate
Non- Extubation Situations
1. Recognizes that a patient is not appropriate for extubation
2. Plans anesthetic to maintain hemodynamics and sedation during transport
3. Provides appropriate hand-off to ICU staff
4. Performs post-operative visit