CA-1 General OR Rotation

Curricular Milestones

Prepare Anesthesia Work Station for Basic OR case

  1. Complete Machine Check
  2. Prepare standard monitors
  3. Prepare standard emergency drugs
  4. Set up for case on time

Perform pre-operative assessment for ASA 1 & 2 patients receiving monitored anesthesia care or general anesthesia

  1. Adequate presentation to supervisor
  2. Obtain relevant medical history and medication lists including previous anesthetics
  3. Perform relevant physical exam including airway exam
  4. Summarize pertinent patient diagnostic data
  5. Determine if additional diagnostic tests are needed and order/ interpret as appropriate
  6. Understand ASA classification system and assign the appropriate class
  7. Consent patient for monitored anesthesia care and/ or general anesthesia
  8. Identify potential ethical issues (e.g. Blood transfusion refusal, Do Not Resuscitate, etc.)
  9. Include or rely on family members or medical power of attorney in pre-operative discussion and consent process as appropriate

Perform pre-operative assessment for ASA 3 & 4 patients receiving monitored anesthesia care and/ or general anesthesia

  1. Adequate presentation to supervisor
  2. Obtain relevant medical history and medication lists including previous anesthetics
  3. Perform relevant physical exam including airway exam
  4. Summarize pertinent patient diagnostic data
  5. Determine if additional diagnostic tests are needed and order/ interpret as appropriate
  6. Understand ASA classification system and assign the appropriate class
  7. Consent patient for monitored anesthesia care and/ or general anesthesia
  8. Identify potential ethical issues (e.g. Blood transfusion refusal, Do Not Resuscitate, etc.)
  9. Include or rely on family members or medical power of attorney in pre-operative discussion and consent process as appropriate.

Choice of anesthesia

  1. Identify possible difficult mask ventilation and/ or intubation
  2. Understand the choice of regional versus general anesthesia
  3. Apply patient medical history and current disease process to anesthetic plan, including possible chronic pain state and resultant implications
  4. Recognize key landmarks, contraindications, and complications of regional and neuraxial anesthesia and select appropriate technique and agents
  5. Select and administer appropriate pre-medications
  6. Understand how the surgical procedure impacts the anesthetic plan and discuss anticipated issues with surgical team

Procedures for ASA 1&2 patients

  1. Understand the indications for invasive monitoring
  2. Understand the timing of monitor placement (pre- v. post-induction)
  3. Place intravenous catheters
  4. Place arterial catheters
  5. Placement of basic neuraxial and regional anesthetic techniques (spinal +/- epidural)
  6. Understands prioritization of procedure completion in context of efficient case start

Procedures for ASA 3&4 patients

  1. Understand the indications for invasive monitoring
  2. Understand the timing of monitor placement (pre- v. post-induction)
  3. Place intravenous catheters
  4. Place arterial catheters
  5. Place central venous catheters
  6. Place pulmonary artery catheters
  7. Placement of basic neuraxial and regional anesthetic techniques (spinal +/- epidural)
  8. Understands prioritization of procedure completion in context of efficient case start

Manage monitored anesthesia care +/- regional anesthetic

  1. Initiate sedation at appropriate time
  2. Avoid oversedation leading to airway obstruction and need to mask ventilate
  3. Recognize need to convert to general anesthesia
  4. Communicate need for general anesthesia with attending anesthesiologist and surgical team.
  5. Participation in time-out process

Manage induction of general anesthesia for ASA 1 & 2 patients

  1. Application of standard monitors
  2. Choice of appropriate induction method and agents
  3. Participation in time-out process.

Manage induction of general anesthesia for ASA 3 & 4 patients

  1. Application of standard monitors (Including pre-induction advance monitoring)
  2. Choice of appropriate induction method and agents
  3. Understand the timing of monitor placement (pre- v. post-induction)
  4. Placement of IV Catheters/ Arterial Line
  5. Place central venous and/or PA catheters
  6. Participation in time-out process

Basic Airway management

  1. Ventilate lungs via mask
  2. Place and troubleshoot supraglottic airways
  3. Intubate trachea of patients with easy to moderately difficult airways
  4. Choose appropriate Endotracheal Tube
  5. Recognize situations appropriate for airway adjuncts, video laryngoscope and / or FOB
  6. Preparation of back-up airway devices

Advanced Airway Management

  1. Recognize need for advanced airway devices
  2. Able to successfully use video laryngoscope
  3. Able to perform asleep FOI
  4. Recognize need for, and utilize airway introducers (i.e. Eschmann)

Difficult Airway Management

  1. Awareness / understanding of ASA difficult airway algorithm
  2. Understand topicalization techniques for awake fiberoptic intubation
  3. Perform awake fiberoptic intubation

Maintenance of anesthesia for ASA 1&2 patients

  1. Understand the pharmacology of commonly used anesthetic drugs and their appropriate doses
  2. Accurately estimate fluid requirements in routine cases and choose appropriate fluids.
  3. Accurately estimate allowable blood loss and need for transfusion
  4. Participate in patient positioning and understand possible complications of different positions (lithotomy, beach chair, etc.)
  5. Sustain an adequate plane of anesthesia
  6. Understand the management of body temperature and maintain normothermia as appropriate
  7. Accurately chart in the anesthetic record
  8. Maintain appropriate contact with supervising staff

Maintenance of anesthesia for ASA 3&4 patients

  1. Understand the pharmacology of commonly used anesthetic drugs and their appropriate doses
  2. Accurately estimate fluid requirements in routine cases and choose appropriate fluids.
  3. Accurately estimate allowable blood loss and need for transfusion
  4. Participate in patient positioning and understand possible complications of different positions (lithotomy, beach chair, etc.)
  5. Sustain an adequate plane of anesthesia
  6. Understand the management of body temperature and maintain normothermia as appropriate
  7. Recognize need for and select appropriate vasoactive medication infusion
  8. Accurately chart in the anesthetic record
  9. Maintain appropriate contact with supervising staff

Coordinate within operating room environment

  1. Perform timely room turnover between cases
  2. Utilize anesthesia technicians and pharmacy staff as appropriate
  3. Maintain accurate records of controlled substance administration
  4. Arrange transfer of patients to and from the intensive care unit
  5. Understand the limitations of off-site practice

Management of unanticipated intraoperative events/ peri-anesthetic complications

  1. Identify, formulate a differential diagnosis, and treat basic intraoperative problems (hypo/hypertension, hypoventilation, hypoxemia, hypercapnia, oliguria, arrhythmias)
  2. Understand physiology of significant cardiovascular events (compression of vena cava by surgeons, hypovolemia, hypervolemia, pulmonary embolism, ischemia, myocardial depression)
  3. Understand management of increased intracranial pressure, changes with aortic or large vascular cross clamp, and fat or cement emboli.
  4. Have familiarity with ACLS guidelines and be able to apply them to OR situations
  5. Maintain appropriate contact with supervising staff
  6. Recognize when patients require change in post-surgical disposition (e.g. ICU monitoring, continued artificial airway +/- mechanical ventilation) and communicate this to supervising staff as well as surgical and OR nursing team
  7. Provide hand-off to ICU staff in cases where patients are taken directly to ICU post-op
  8. Participate in meeting with family after unanticipated intraoperative events as appropriate.
  9. Document unanticipated intraoperative events and surrounding communications and reactions in the medical record.

Emergence and PACU care for ASA 1&2 patients

  1. Prepare the patient for emergence from anesthesia
  2. Monitor, maintain and reverse neuromuscular blockade as appropriate
  3. Understand criteria for extubation and apply them appropriately to patient
  4. Transfer the patient to the PACU and provide smooth transition to the PACU staff
  5. Provide complete and detailed handoff and contact information to PACU staff
  6. Manage common postoperative problems (pain, nausea, confusion, hemodynamics, ventilation)
  7. Perform post-operative patient visits as appropriate

Emergence and PACU care for ASA 3&4 patients

  1. Prepare the patient for emergence from anesthesia
  2. Monitor, maintain and reverse neuromuscular blockade as appropriate
  3. Understand criteria for extubation and apply them appropriately to patient
  4. Transfer the patient to the PACU and provide smooth transition to the PACU staff
  5. Provide complete and detailed handoff and contact information to PACU staff
  6. Manage common postoperative problems (pain, nausea, confusion, hemodynamics, ventilation)
  7. Perform post-operative patient visits as appropriate