CA-3 Level Rotations at Shands, Shands Jacksonville, Malcolm Randall VA Medical Center, and St. Vincent's - Jacksonville click here
CORE
ROTATION INFORMATION
General Goals
- Develop knowledge of cardiovascular
anesthesia (anesthesia for the patient with cardiovascular disease) and
the skills for lifelong continuing education
- Develop technical and monitoring
skills necessary to cardiovascular anesthesia
- Develop judgment and skills,
including planning, necessary to deliver cardiovascular anesthesia
- Administer anesthesia for a
wide variety of cardiothoracic cases and develop interest in further learning
- Develop an understanding of
the major issues involved in the perioperative care of the
child with congenital heart disease
SPECIFIC COMPETENCIES:
(General
Competencies also apply)
PATIENT CARE
SKILLS:
- Assess anesthetic risk and prepare
both adults and pediatric patients for cardiac surgery
- Be able to apply / insert invasive
m onitoring devices including:
- Arterial catheters
- Central Venous Catheters (subclavian,
internal jugular, external jugular (rarely), femoral (rarely)
- Pulmonary artery catheters
- Spinal Drains (for thoracoabdominal aneurysms)
- Interpret
data obtained from these monitoring devices including:
- Invasive
arterial blood pressure monitoring
- Pulmonary
artery (PA) catheter monitoring
- PA waveforms and pulmonary capillary wedge (PCW) tracings
- Cardiac output by thermodilution and waveforms
- Mixed venous oxygen saturation and changes in it
- Transesophageal
echocardiography
- Be able to recognize the four chamber and gastric short-axis views and
name all normal structures.
- Cerebral Oximetry
- Activated Clotting Time
- Choose appropriate anesthetic
techniques for patients with different types of cardiovascular disease
- Understand the steps involved
in initiating and discontinuing cardiopulmonary bypass
- Work as a team member with fellow
anesthesiologists, surgeons, perfusionists, and nurses
- Maintain good clinical judgment
under stress and act quickly and accurately in diagnosis, interpretation,
and treatment of intraoperative problems
- Be able to place endotracheal tubes
to facilitate one-lung ventilation as needed during thoracic surgery
including:
- Double-lumen endotracheal tubes
- Univent tubes
- Bronchial blockers
- Use of fiberoptic bronchoscopy to
precisely determine proper placement of these tubes
- Be able to adjust ventilatory
parameters to improve oxygenation during one-lung ventilation
- Be able to recommend / provide
appropriate postoperative pain control for patients undergoing
cardiothoracic surgery including:
- Patient controlled analgesia
- Thoracic epidural anesthesia /
analgesia
MEDICAL KNOWLEDGE:
(See also
General Competencies)
- Cardiovascular physiology
(Frank-Starling Law)
- Effect of preload on cardiovascular
function
- Effect of afterload on cardiovascular
function
- Factors determining inotropic state
- Cardiac cycle and the function of all
four valves
- Differences in function between the
neonatal / pediatric heart and the adult heart
- Cardiovascular pharmacology
- Effects of commonly used anesthetic
drugs on cardiac function
- How these effects may lead to a
particular choice of drug for a patient with a particular
cardiac lesion (e.g. use of halothane for patient with LV
outflow obstruction from SAM)
- Pharmacology of inotropic
(catecholamine and non-catecholamine) drugs
- Pharmacology of vasodilators
- Pharmacology of calcium channel
blockers
- Pharmacology of beta-blocking agents
- Cardiovascular anatomy (especially
as relates to TEE below)
- Pulmonary artery catheter
- Normal and pathologic waveforms
- Difference between wedge pressure
and pulmonary artery diastolic pressure measurement
- Thermodilution cardiac output -
principles of operation and factors causing errors
- Principles of operation of continuous cardiac output catheters
- Physiology of mixed venous oxygen
saturation - factors determining changes in measured values
- Basic Concepts and operational
principles of transesophageal echocardiography
- Basic principles of operation of a
cardiopulmonary bypass machine and pump oxygenators
- Pulmonary physiology
- Relationship between ventilation
and perfusion, concepts of shunt and dead-space
- Interpretation of arterial blood
gas measurements.
- Recognition of metabolic and
respiratory acidoses or alkaloses
- Knowledge of effects of
changes in arterial blood gases (pH, pCO2, pO2) on the
pulmonary circulation
- Mechanism for the effects of
PEEP / CPAP, complications and side-effects associated
with PEEP / CPAP
- Pulmonary pharmacology
- Effects of anesthetic drugs
and adjunctive drugs (inotropic agents, vasodilators,
vasoconstrictors) on ventilation and perfusion
PRACTICE-BASED LEARNING AND
IMPROVEMENT
INTERPERSONAL AND COMMUNICATION SKILLS,
PROFESSIONALISM
SYSTEMS-BASED PRACTICE
- Practice cost-effective, safe anesthesia
- Be able to provide fast-track anesthesia to
appropriate patients
- Be able to use medical informatics to learn
about the various cardiovascular medical conditions in patients presenting
for cardiovascular surgery
III. Evaluation to Determine Goal
Achievement
- You are evaluated every week
by all attendings who worked with you. The attending physicians complete
a Departmental Resident Evaluation Form, which is reviewed by the Clinical
Competence Committee quarterly and by the program director continuously. Your advisor informs you of any problems identified,
and serious problems will be discussed with you immediately after they
occur.
- You will complete a Departmental
Rotation Evaluation Form.
- The Program Director
will evaluate the results of the In-Training Examination for the American
Board of Anesthesiologists (ABA) in general and for areas of departmental
weakness. Consistent weaknesses may result in adjustment of the above goals.
IV. Teaching Resources to Accomplish
the Objectives
- Approximately 450 adult and 150
pediatric cardiopulmonary bypass cases per year at Shands Teaching Hospital
and 150 adult cases per year at the Veterans Administration Medical Center
requiring the following procedures:
- Aortic
repairs
- Congenital
repairs--pediatric
- Coronary
artery bypass grafting and valves--adults
- Electrophysiology
- Thoracic
surgery
- Transplantation--heart
and lungs
- Text books (on
reserve at the Health Center Library)
- JA
Kaplan: Cardiac Anesthesia
- J Benumof: Anesthesia
for Thoracic Surgery
- C Lake: Pediatric
Cardiac Anesthesia
-
Online Classic
Articles Library
- Equipment
- Transesophageal
echocardiography machines (n = 3) dedicated to operating room use
- Computer
program for teaching transesophageal anatomy and techniques (TEECHER®)
- Faculty :
- Laurie K.
Davies, MD
- Nicole Dobija, MD
- Nikolaus Gravenstein, MD
- Gregory
Janelle, MD (Chief)
- Emilio B. Lobato, MD
- David
A. Paulus, MD
- Yonggang Peng, MD, PhD
- Felipe Urdaneta, MD
- Albrecht Wobst, MD, PhD
Dr. Janelle is the faculty member
responsible for the CV and Dr. Urdaneta is responsible for the VACT rotation.
CA-3 Advanced Clinical
Track Cardiovascular Rotations
Advanced Clinical Track Rotations in CV
Anesthesiology may be performed at: Shands Hospital at UF, VA Medical
Center, Shands at Jacksonville, St. Vincent's Hospital in Jacksonville, and the Texas Heart Institute in Houston, Texas. The Goals /
Competencies are the same for all five rotations. Rotation Directors
are listed below.
Goals: In addition to those outlined for
the basic rotation in Cardiothoracic Anesthesia:
- Expand the knowledge base with regards
to cardiovascular and pulmonary physiology and pharmacology and pathophysiology developed during CA-1 and
CA-2 years.
- Develop clinical judgment to provide
anesthetic care for more complex cardiovascular and thoracic procedures.
- Develop technical skills necessary to
conduct more complex cardiothoracic cases.
- Gain sufficient experience for independent practice of high-volume cardiovascular anesthesiology in private practice.
Patient Care Skills and Medical
Knowledge: In addition to those
outlined for the basic rotation in Cardiothoracic Anesthesiology:
- Be able to complete a thorough
preoperative evaluation for all cardiothoracic patients,
recognizing impact of their disease
states on perioperative management. For routine cardiothoracic procedures,
accomplish preoperative preparation and anesthetic planning independently.
For complex procedures, preoperative preparation and planning will occur
with assistance from the attending anesthesiologist as needed and as
appropriate.
- Plan and carry out anesthetics for
routine cardiothoracic procedures with minimal assistance from the
attending physician.
- Perform anesthetics for complex
cardiothoracic procedures with as needed assistance from the attending anesthesiologist.
- Perform all invasive monitoring
techniques and interpret information obtained reliably with minimal
assistance from the attending anesthesiologist.
- Develop beyond a basic understanding of
transesophageal echocardiography, be able to insert the probe. Be able
to obtain and interpret 4-chamber and short-axis views, recognize most
common pathology including valvular lesions and wall motion abnormalities.
Be aware of and able to discuss documented
advantages and disadvantages of the use of TEE monitoring during
cardiothoracic procedures.
OPERATIONAL DETAILS: When rotating at St. Vincent's, please observe the following policy with respect to getting cases started in the morning: You are expected to arrive each morning at 0630 every day except Thursday where the expectation is 0730. This will give you time to visit your postoperative patients, write a note, set up your room and have your patient in the operating room in a timely fashion.
Evaluation: As described in the
primary cardiothoracic rotation. However, in addition, your ability to
practice cardiothoracic anesthesia as an independent consultant anesthesiologist will be
assessed.
Resources: As described in basic Cardiothoracic Rotation
Responsible Faculty:
- Shands at UF: Dr. Janelle
- Gainesville VA Medical Center: Dr. Urdaneta
- Shands at Jacksonville: Dr. Redfern
- St. Vincent's Hospital in Jacksonville: Dr. Kevin Donovan
RETURN
TO INDEX FOR GOALS AND OBJECTIVES
Revised 7/14/06