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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 2 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 3 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 4 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 5 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. 6 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 7 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: 8 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 9 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 10