SURGICAL ANESTHESIOLOGY-VAMC
Goals and Objectives
CA 1 and CA 3 Level
Definition
This is a 3 month rotation for CA-1 residents and a 1 monthrotation for CA-3 residents, which includes anesthesia for general and colorectal surgery, vascular surgery, urologic surgery, orthopedic and plastic surgery, ENT surgery, cardiac surgery, neurosurgery, and minimally invasive surgery.
Curriculum
Didactics include daily programs including monthly journal club, weekly Grand Rounds, clinical case discussions, QA case discussions, and assigned anesthesia topic presentations by staff and residents.
General and Colorectal Surgery: The resident will be assigned to cases involving abdominal, perineal and other general surgery procedures. Monthly journal clubs will provide subspecialty information.
Vascular Surgery: Assigned primarily to CA-3s. The resident will acquire the skills necessary to manage the elderly, high risk vascular surgical patient peri- and intraoperatively in a safe and logical manner. Since the vascular patient usually has multiple complex medical problems, the scope of knowledge should include related diseases, including hypertension, diabetes, cardiopulmonary, renal-vascular and cerebrovascular diseases. The degree of difficulty of the cases is graded to provide increasingly challenging cases as the level of training and skill progress.
ENT Surgery: The resident will manage anesthetic care for patients undergoing a variety of ENT surgical procedures. Anesthetic care includes preoperative assessment of the patient, the formation of an anesthetic plan, intra-operative application and management of the anesthetic plan, patient monitoring, safe emergence and postoperative care. The surgical procedures include airway laser cases, airway endoscopies, head and neck cancer procedures including reconstructive facial surgery, nose and sinus surgery, laryngeal and tracheal reconstructive surgery, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty, tracheotomy, and ear surgery. While managing these anesthetics, the resident will have to work in close proximity with the surgeon and learn to safely share one primary field, the airway, while having less access to the patient.
Urologic Surgery: The resident will be assigned to provide anesthesia for cystoscopy, prostate surgery, urologic oncology, kidney transplantation, procedures to ensure the continuity of the urinary tract and reconstructive urologic procedures.
Orthopedic and Plastic Surgery: The resident will be assigned to major and minor procedures involving elective, emergency and trauma surgery involving orthopedics and plastic surgery.
Minimally Invasive Surgery: This rotation will expose the resident to minimally invasive surgery for general, colorectal, urologic, gynecologic, and spine procedures. Because of the emphasis on short hospitalization, there will be an emphasis on rapid-emergence anesthetic techniques and issues relevant to ambulatory surgery.
Neurosurgery: The resident will be assigned to spine and intracranial procedures. Anesthetic care includes preoperative assessment and formulation of plan and intra-operative application of this plan as required for the surgery anticipated. The residents will have to interact with surgeons and with the neuromonitoring personnel as required for the surgery.
Cardiac surgery: Assigned primarily to CA-3s. The resident will acquire the skills necessary to manage this high risk population and perform the specific procedures such as line placement, TEE, pacemaker management, and cardiovascular medication manipulations that are required. The resident will have to work closely with the surgeons and with the bypass machine techs.
Medical Knowledge
General and Colorectal Surgery: The resident should be able to describe:
1.appropriate ventilator settings for abdominal surgery in an adult patient.
2.the physiological consequences of abdominal surgery.
3.the anesthetic issues with thyroid and parathyroid procedures.
4.procedures and risks with prone, lateral and lithotomy positions.
5.fluid management for abdominal surgery.
6.the indications for blood transfusion.
7.the causes, prevention and treatment of hypothermia.
8.the indications for rapid sequence induction of anesthesia.
9.the indications for invasive monitoring.
10.the complications of invasive monitoring.
11.the impact of chronic steroid use in the perioperative period.
12.neuromuscular blockage and neuromuscular blockade monitoring for abdominal surgery.
13.the anesthetic issues associated with total parenteral nutrition.
Vascular Surgery: The resident should understand:
1.the anatomy and discuss the physiology of the cardiovascular system.
2.invasive hemodynamic monitoring and make treatment decisions based upon the findings or derangements to maintain hemodynamic stability.
3.medical problems frequently associated with vascular disease as outlined above.
4.ischemic cardiac episodes intraoperatively and effectively treat and manage them.
5.the anesthetic implications for management of the patient with vascular disease.
6.preoperative anesthesia assessment for vascular patients, present the assessment to the staff anesthesiologist in a logical and organized manner and develop a reasonable and safe anesthetic plan which takes into account those implications peculiar to this group of sick and elderly patients.
7.regional as well as general anesthetic options for a given vascular surgical procedure and discuss the risks and benefits.
8.frequently used vasoactive drugs, their pharmacology, pharmacokinetics and appropriate usage.
9.a “routine” anesthetic plan for a given vascular surgical procedure.
10.a postoperative pain control plan for the vascular surgical patient.
11.blood gas analysis results and institute appropriate therapy.
12.issues related to anticoagulation.
13.the anesthetic issues with endovascular aortic surgery.
ENT Surgery – Laser Airway Procedures: The resident should be able to:
1.define Laser principles.
2.classify the various kinds of lasers used in ENT procedures.
3.review the risks of laser use in the airway.
4.apply safety principles to airway laser procedures.
5.appraise the available endotracheal tubes for laser procedures and select the appropriate one.
6.formulate a safe anesthetic plan for airway laser surgery.
7.summarize a plan of action to deal with airway fires.
8.explain the principles of venturi jet ventilation when used during laser procedures on the larynx or trachea via a rigid bronchoscope or laryngoscope.
9.evaluate Propofol and narcotic mixtures for these procedures and compare with an inhalation technique.
Endoscopies: The resident should be able to:
1.describe the sequence of events during a pan-endoscopy.
2.plan an anesthetic including patient monitoring, for fiberoptic or rigid bronchoscopy.
3.summarize the possible complications of pan-endoscopy.
4.explain the rationale for eliminating nitrous oxide from the anesthetic mixture during apneic periods.
5.discuss apneic oxygenation and the speed of rise of PaCO2 during its use.
6.review neuromuscular monitoring for depolarizing and non depolarizing block, including the diagnosis of phase II block.
7.rank the various techniques available for control of the hemodynamic response to rigid laryngoscopy and bronchoscopy.
Major Head and Neck Cancer Procedures: The resident should be able to:
1.summarize the common co-existing problems in head and neck cancer patients.
2.evaluate the monitoring modalities available and the rationale for avoiding the use of neck veins for central monitoring.
3.describe the rationale for use of intracardiac EKG tracing during antecubial central line placement.
4.discuss intraoperative fluid management of these cases.
5.plan a general anesthetic for a patient undergoing a glossectomy or mandibulectomy with free flap reconstruction.
6.prescribe and administer pain medication to insure a comfortable and smooth emergence for the patient at the end of the procedure.
7.critique the methods available for prevention of hypothermic and their utility in head and neck cases.
8.describe the rationale for the use of a neuromuscular stimulator or nerve conduction monitor by the surgeons and its influence on the planned anesthetic.
9.describe the end result of various laryngeal surgical resections such as hemilaryngectomy, supraglottic and total laryngectomy.
Nose and Sinus Surgery: The resident should be able to:
1.review the interaction of catecholamines and inhalation anesthetic agents.
2.critique the use of cocaine and epinephrine as mucosal vasoconstrictors by ENT surgeons.
3.describe possible contraindications to the use of cocaine.
4.discuss the management of inadvertent intravascular injection of epinephrine.
5.plan emergence and extubation in the presence of pharyngeal blood.
6.review anesthetic management for patients with asthma and nasal polyps.
Laryngeal Reconstructive Surgery/T-tube Insertion: The resident should be able to:
1.reconstruct the natural history of laryngeal and tracheal injury and stenosis.
2.review the clinical picture and differential diagnosis of tracheal stenosis.
3.review the presentation and clinical management of acute laryngeal trauma.
4.describe the Montgomery T-tube and its use as a stent in reconstructive surgery.
Uvulopalotopharygoplasty (UPP): The resident should be able to:
1.interpret a polysomnogram report to stage sleep apnea patients.
2.evaluate the degree of airway compromise in patients scheduled for UPP.
3.review the pathophysiology of sleep apnea.
4.plan a general anesthetic and airway management plan for a patient with sleep apnea.
Tracheotomies: The resident should be able to:
1.describe the anatomy and placement of a tracheotomy.
2.review the possible complications of tracheotomy.
3.contrast the anesthetic management for a tracheotomy performed for long term ventilation to that performed acute for airway obstruction.
4.predict the special setup required for transporting patients with severe ARDS from the ICU to the operating room.
5.compare the tracheotomy tubes and airway stents to the usual endotracheal tubes.
Vocal Cord Injections and Arytenoid Medialization: The resident should be able to:
1.review the anatomy of the larynx.
2.draw the appearance of the vocal cords in various nerve injuries.
3.discuss the rationale behind vocal cord medialization procedures.
4.review the major causes for vocal cord paralysis.
Tonsillectomy and Adenoidectomy (T&A): The resident should be able to:
1.draw the lymphatic structures in the head and neck area.
2.review the complications of T&A.
3.design a safe anesthetic technique for T&A, including premedication and postoperative pain control.
4.compare various methods for managing a bleeding tonsil.
Ear Surgery: The resident should be able to:
1.review the anatomy of the middle and inner ear and the course of the facial nerve in relation to the ear structure.
2.discuss the causes of high incidence of post operative nausea and vomiting in ear surgery.
3.summarize the effect of N2O diffusion on the middle ear.
4.describe the fluid and ventilation management for intracranial ear procedures.
5.classify the paragangliomas of the head and neck.
Difficult Airway Management: The resident should be able to:
1.review the innervation of the upper airway, larynx and trachea.
2.describe topical anesthesia of the airway for awake intubation.
3.summarize the ASA Difficult Airway Management Algorithm.
4.plan an induction technique for a difficult airway and an alternative plan for managing a “cannot ventilate-cannot intubate” scenario.
5.review the anatomy of the cricothyroid membrane.
6.describe needle cricothyrotomy.
7.compare the pressure required for transtracheal ventilation in adults and children using the Sander’s injector.
8.describe the possible complications of transtracheal ventilation.
9.diagram emergency cricothyrotomy.
10.summarize the principles of fiberoptics and name the various parts of the fiberoptic scope.
Urologic Surgery – The resident should understand:
1.the indications for urologic surgery.
2.the perioperative implications of renal failure.
3.the physiologic consequence of endoscopic prostate surgery.
4.positioning issues for nephrectomy.
5.the perioperative implications of renal malignancy with extension into the interior vena cava.
6.regional anesthesia for major urologic procedures.
7.anesthetic implications of lithotripsy.
8.TURP syndrome.
Orthopedic and Plastic Surgery – The resident should be able to:
1.identify common preoperative issues in reconstructive surgery patients and explain how they impact on an anesthetic plan.
2.create a reasonable anesthesia plan for most common, reconstructive surgical procedures.
3.identify and manage the common problems in trauma.
4.plan and select equipment and local anesthetic agents for most regional anesthetic procedures. Select and defend these local anesthetic choices for surgical procedures, depending on duration, location and severity of illness of the patient.
5.describe the basic pharmacology of a local anesthetic including the characteristics which determine onset, duration, potency and toxicity.
6.discuss the unique topics within anesthesia for orthopedic and plastic surgery, including pneumatic tourniquets, fat embolism, hemodynamic implications of methylmethacrylate and etiology of deep venous thrombosis.
7.describe the preoperative implications of co-existing diseases in reconstructive surgery patients, including hypertension, coronary artery disease, rheumatoid arthritis, diabetes mellitus, and ankylosing spondylitis.
8.explain and contrast postoperative pain control strategies including patient controlled analgesia (PCA) with various opiates, subarachnoid opiates, epidural analgesia, continuous peripheral nerve catheters, intra-articular local anesthetic and opiate, and non-steroidal anti-inflammatory drugs.
9.describe the techniques of autologous blood programs, cell salvage, hemodilution and perioperative blood conservation.
Minimally Invasive Surgery – The resident should understand:
1.the indications for minimally-invasive surgery.
2.the physiologic consequences of pneumoperitoneum.
3.the consequences of patient positioning in the lateral, prone and lithotomy positions.
4.the causes for the increased incidence of nausea after CO2 insufflation for surgery.
5.common PACU issues for MIS patients.
6.pneumomediastinum, subcutaneous emphysema and barotrauma.
Patient Care
General and Colorectal Surgery – The resident should be able to:
1.prepare an operating room completely for a major case in a timely manner.
2.assemble the equipment for invasive monitoring.
3.assemble the equipment for blood transfusion.
4.place large-bore intravenous catheters (14-16 gauge)
5.perform induction of general anesthesia with minimal assistance for ASA I-II patients.
6.perform a rapid sequence induction under supervision for ASA I-II patients.
7.safely position anesthetized patients in the lateral lithotomy and prone positions.
8.correctly position the patient for internal CVP line insertion.
9.demonstrate skill at internal jugular catheterization. Complete the procedure in some (35%) cases with minimal assistance.
10.demonstrate skill in arterial line placement, succeeding in the majority (>75%) of cases.
11.perform neuromuscular blockade, monitoring and reversal with minimal assistance.
Vascular Surgery – The resident should be able to:
1.effectively communicate preoperative concerns or problems regarding preparation of the vascular patient for surgery.
2.set up equipment expeditiously for a major vascular surgery case.
3.execute simple vascular cannulations such as IV’s and arterial lines in the majority (>75%) of cases.
4.perform central venous and pulmonary artery catheter insertions with guidance.
5.perform spinal and epidural regional anesthetics with minimal assistance in the majority (>75%) of cases.
6.manage anesthesia for a routine vascular case fairly independently.
7.manage pulmonary artery catheters, pacemakers, defibrillators, TEG equipment, and continuous infusion of vasoactive drugs.
8.recognize and treat intraoperative hemodynamic derangements and complications.
ENT Surgery – The resident should be able to:
1.administer anesthesia for the procedures mentioned under Medical Knowledge.
2.evaluate an abnormal airway using clinical skills, radiological studies and consultation with the surgeon and patient’s record.
3.select, modify and prepare the appropriate endotracheal tubes for laser procedures.
4.modify the anesthetic mixture to minimize the risk of fire in airway laser procedures.
5.practice safety precautions for the patient and operating room staff during laser procedures.
6.perform jet ventilation using the Sander’s injector for laser cases performed with no endotracheal tube in place.
7.administer anesthesia for rigid and flexible airway endoscopy
8.control the thermodynamic changes caused by rigid airway manipulation.
9.treat the cardiovascular changes caused by the use of epinephrine and cocaine in nasal surgery.
10.insert an antecubital central line.
11.manage anesthesia for major head and neck cancer procedures, including patient monitoring, fluid management and postoperative pain control.
12.evaluate the various specialty endotracheal tubes available and utilize them in the appropriate situations.
13.perform elective fiberoptic intubation on patients with normal airways under general anesthesia.
14.perform topical anesthesia of the airway including transcricoid membrane injection of local anesthesia.
15.administer Propofol for general anesthesia and for awake sedation.
16.practice cricothyrotomy, needle cricothyrotomy and jet ventilation on the training model.
17.support the airway by utilizing positive airway pressure in situations of partial or potential upper airway obstruction.
18.prevent or modify postoperative nausea and vomiting by using appropriate doses of antiemetics.
Urologic Surgery – The resident should be able to:
1.manage an airway of normal to moderate difficulty utilizing a bag, mask, laryngeal mask airways, oral airways, and endotracheal tubes.
2.assemble anesthesia equipment for patients managed in this rotation including those with renal failure.
3.applying appropriate monitoring devices and describe the risk/benefit ratio of utilizing invasive monitoring.
4.provide and maintain venous access.
5.induce and maintain general anesthesia in ASA I-II patients with moderate staff direction, and in ASA III-IV patients with staff involvement as needed.
6.induce and manage spinal anesthesia with limited staff involvement.
7.interpret a blood gas, and define the most common acid-base abnormalities, including metabolic acidosis and alkalosis and define a treatment plan for abnormality.
Orthopedic and Plastic Surgery – The resident should be able to:
1.perform a spinal anesthetic with the correct equipment and agent and manage the patient intraoperatively with minimal staff intervention.
2.conduct a similar case with an epidural anesthetic.
3.perform an axillary block, with correct selection of equipment and agents.
4.perform an interscalene or a supraclavicular block for shoulder surgery, with correct equipment and agents.