ROTATION: Ambulatory Anesthesia at the Florida Surgical Center (FSC) 
TYPE: Required or elective 
DURATION: 1 month
FACULTY:  F. Kayser Enneking, MD
PREREQUISITES: 6 months of clinical anesthesia experience 

CA-3 Level Rotation Information, click here

CORE ROTATION INFORMATION

General Goals

• To know and use recommended guidelines for ambulatory anesthesia based on the core curriculum proposed by the Society for Ambulatory Anesthesia 
• Participate in the following educational activities at FSC: 
  • Present cases related to ambulatory anesthesia in case conferences
  • Participate in administrative activities including quality improvement programs
  • To improve efficiency in providing anesthesia care and room turnover

SPECIFIC COMPETENCIES:  (General Competencies also apply)

PATIENT CARE SKILLS:

• Be able to effectively evaluate ambulatory pre-operative patients by various modes of screening including:
  • Visits by appointment or same day preoperative evaluation
  • Telephone interviews the night before surgery regarding medications, fasting, and social issues.
  • Health questionnaires completed during initial surgical evaluation
• Order appropriate preoperative laboratory tests and be able to defend your choices
• Preoperatively prepare and premedicate ambulatory adults AND children
• Provide appropriate ambulatory intraoperative management using:
  • Necessary monitoring equipment
  • General anesthesia
  • Regional Anesthesia
  • Blocks for the operations on the extremities
    • Upper: axillary, interscalene, and infraclavicular brachial plexus blocks
    • Lower: femoral, obturator, lateral femoral cutaneous, popliteal, sciatic and ankle blocks 
    • Local infiltration
    • Intravenous regional anesthesia
  • Monitored Anesthesia Care (see Shands OR goals for details) 
• Proper anesthetic management for special outpatient procedures as
  follows:  
  • Endoscopy (multiple types)
  • Laser surgery of the airway
  • Extracorporeal shockwave lithotripsy
  • Interventional pain management
• Provide pain management that provides for prompt discharge and allows for extension of analgesia well into the period after the patient goes home.
• Provide appropriate postoperative care 
  • Appropriately manage the discharge process for the ambulatory surgical patient
  • Determine appropriate length of PACU stay considering the surgical procedure, length of the anesthetic, patient responses to anesthesia and surgery, and pain management needed.
  • Determine appropriate monitoring needed for recovery period
  • Provide appropriate postoperative pain relief that will not unnecessarily prolong the discharge time from the recovery room 
  • Provide needed and effective antiemetic management following ambulatory surgery
  • Recognize complications following ambulatory surgery and their management
  • Appropriately determine need for continued inpatient care (admission)
  • Know when medical intervention without admission is appropriate
  • Appropriately manage minor side-effects
• Postoperatively follow-up patients to determine patient satisfaction and elicit unexpected complications of anesthetic and surgical care

MEDICAL KNOWLEDGE:   (See also General Competencies)

• Know criteria by which patients are selected for surgical procedures at a free-standing ambulatory surgical center and appropriate management of complex cases--both adult and pediatric--in this environment.
• Know which preoperative evaluation technique is appropriate for the individual patient.
• Know preoperative indications and contraindications for premedication and factors influencing choice of premedication
• Know drugs and the properties that make them drugs of choice for ambulatory surgery, know toxicities and complications associated with each drug:  specifically, drugs designed for the ambulatory surgical patient 
  • Inhalational - desflurane, sevoflurane, nitrous oxide
  • Intravenous - propofol, midazolam
  • Muscle relaxants - rocuronium, mivacurium, succinylcholine
  • Local Anesthetics - both short-acting for surgery and long-acting to provide prolonged postoperative pain relief - lidocaine, bupivacaine, ropivacaine, mepivicaine
    • Know adjunct drugs used with local anesthetic to prolong their action and the effects these drugs have on the recovery process.
• Know side effects and complications associated with regional anesthetic techniques used at an ambulatory facility.
• Know mechanism of action of intravenous regional anesthesia, agents used, indications, contraindications, and complications
• Know discharge criteria for ambulatory patients from a free-standing facility Know discharge teaching needed for ambulatory patients to assure smooth recovery at home. Know appropriate criteria for unplanned admission to the hospital

INTERPERSONAL AND COMMUNICATION SKILLS, PROFESSIONALISM

• See general competencies section
• Ability to work with nursing and ancillary personnel to provide rapid, efficient, and compassionate patient care in this high turnover environment

 PRACTICE-BASED LEARNING AND IMPROVEMENT

• See general competencies section
• Learn skills that will allow rapid turnover of cases and completion of a large volume of cases in a short period of time.

SYSTEMS-BASED PRACTICE

• Know role of ambulatory surgery setting in the overall context of surgical care
• Appropriately utilize preoperative laboratory testing and consultants to optimize patient condition prior to surgery.
• Anticipate the impact of each patient's surgical pathology and planned surgical procedure(s) on the level of postoperative care required and appropriate plan to allow rapid discharge from facility
• Utilize appropriate anesthetic techniques to minimize the impact of perioperative anesthetic management on the patient's subsequent recovery and allow rapid, safe discharge home
• Practice cost-effective, safe anesthesia

Evaluation to Determine Goal Achievement