The (N) rotation is the primary
neuroanesthesia rotation for residents in our program and all residents will
complete at least the N rotation during their 3-year residency. The VAN
rotation is a secondary neuroanesthesia rotation designed to provide early
exposure to simpler neurosurgical cases to first year
residents or to provide extra exposure to
neuroanesthesia to senior residents who choose it.
CA-3 Level Rotation information - click
here.
CORE ROTATION
INFORMATION
General Goals:
- Administer anesthesia safely
to patients with neurologic disease who are undergoing neurologic or non-neurologic
surgery, diagnostic procedures requiring anesthesia, or nonsurgical interventions
requiring anesthesia
- Understand the basic concepts
of central nervous system (CNS) physiology as they relate to neuroanesthesia,
specifically, mastery of autoregulation of blood flow, blood flow response
to CO2, blood flow response to cerebral oxygen (CMRO2)
and glucose (CMRglu) metabolic rates, and cerebrospinal fluid physiology
- Know the effect(s) of commonly
used anesthetic agents and adjuvant agents, for example antihypertensives,
on cerebral physiology
- Understand the anesthetic implications
of the most common neurosurgical procedures; that is, what is likely to
happen during neurosurgery that will affect anesthetic management
- Understand the basic concepts
behind electrophysiologic monitoring of the brain and spinal cord
- Understand how concurrent medical
illnesses affect anesthesia during neurologic surgery
SPECIFIC COMPETENCIES:
(General
Competencies also apply)
Patient Care Skills
History / Physical Examination
- Review the medical history and
physical examination of patients; assess their major neurosurgical problem
as well as other medical problems that may affect anesthetic care; and
know what information about nervous system function and pathology is important
to the anesthesiologist
- Recognize
both the adult and pediatric patient with poor elastance or increased intracranial
pressure (ICP)
- Evaluate
the patient with subarachnoid hemorrhage and intracranial aneurysm by means
of the Hunt-Hess and Fischer grading systems; recognize preoperative vasospasm;
and anticipate which patients are likely to require special techniques
such as barbiturate protection, hypotension, induced hypertension, or temporary
vessel occlusion
- Differentiate
between radiculopathy and myelopathy and understand the anesthetic implications
of each, that is, which patients require awake intubation and positioning
Performance Skills:
Perform the following specific procedures and
monitoring techniques
necessary to care for the neurosurgical patient:
- Choose
appropriate premedication and agents for anesthetic induction and maintenance
based on a knowledge of their effects on cerebral physiology and on neuropathology.
- Choose
and place the following monitors and monitoring devices for use during
spinal and intracranial surgery:
- Arterial line, central venous (CVP) or pulmonary artery (PA) pressure
catheters by all approaches, especially the basilic or cephalic veins
- Intravascular electrocardiography for appropriate positioning of a CVP
line for air aspiration
- Precordial Doppler and interpretation of sounds
- Perform
techniques for awake intubation and positioning of the neurosurgical patient
with either an unstable neck or myelopathic signs and symptoms
- Assess when awake intubation and positioning are needed
- Intubate an awake patient such that coughing or movement are minimal
- Master anesthesia for awake intubation, including but not limited to,
superior laryngeal and glossopharyngeal nerve blocks and transtracheal
injection of lidocaine
- Detect
and treat air embolism during neurosurgery.
- Apply general principles of positioning
to the patient undergoing neurologic surgery and be able to correctly
and safely position patients in the following positions:
- Lateral
- Prone
- 3/4 prone
- Supine-head turned
- Sitting--theoretical knowledge only because this position is no longer
used at our institution
- Be able to safely perform the following
special procedures used during neuroanesthesia:
- Induced hypotension (uncommon
now)
- Induced hypertension
- Moderate hypothermia
- Barbiturate cerebral protection
- Be able to recognize causes and
appropriately treat intraoperative
intracranial hypertension ( "tight brain") using available treatment
modalities.
- Reverse
general anesthesia rapidly with a minimum of hemodynamic change to allow
early postoperative assessment of the patient and recognize when failure
to emerge from anesthesia is not likely an anesthetic effect
Medical Knowledge
-
Understand and be able to apply to
patient care basic neurophysiologic and neuropharmacologic
principles including:
- Effects of CO2 on the cerebral and
spinal circulations
- Effects of changes in blood pressure
on the cerebral and spinal circulation (autoregulation)
- Effects of commonly used anesthetic
agents on cerebral and spinal cord blood flow, intracranial
pressure, metabolism
- Effects of commonly used drugs to
control hemodynamic responses to anesthesia and surgery on
cerebral and spinal cord blood flow and metabolism
-
Understand basic cerebral and spinal
column / cord anatomy, specifically:
-
Basic structure of the skull including
anterior, middle and posterior fossa
- Know what cerebral structures are
located in each of these areas
- Be aware of positioning implications
of operations designed to correct pathology in each of these
locations.
- Basic structure of the spinal column
and surrounding soft tissues
- Basic structure of the spinal cord,
specifically, location of major sensory and motor pathways
- Know
the basic differences between the following types of brain, spinal cord,
and metastatic tumors of the CNS and their association with edema and intraoperative
blood loss:
- Acoustic neuromas
- Ependymomas
- Gliomas
- Meningiomas
- Pituitary tumors
- Understand
the following different types of spinal operations as well as their anesthetic
implications:
- Anterior cervical discectomy and fusions, anterior cervical corpectomies,
posterior cervical fusions, laminectomies, and foramenotomies
- Laminectomies for excision of spinal cord tumors, both intramedullary
and extramedullary
- Lumbar laminectomies, microdiscectomies, corpectomies, and fusions with
instrumentation
- Thoracic laminectomies and discectomies, lateral extracavitary,
endoscopic and transthoracic discectomies or corpectomies
- Know premedication for and anesthetic considerations during electrocorticography
- Be aware of
airway and sedation requirements for stereotactic neurosurgical procedures
conducted with either general anesthesia or monitored anesthesia care
- Know which monitors best detect air embolism
and what monitoring patterns are associated with air embolism
- Recognize the relative
risks of different procedures and positions for air embolism
- Know
general principles of positioning the patient for neurologic surgery and
the advantages and disadvantages of each position:
- Lateral
- Prone
- 3/4 prone
- Supine-head turned
- Sitting--theoretical knowledge
only because this position is no longer used at our institution
-
Understand basic principles
of neurophysiologic monitoring of the brain and spinal cord
including effects of commonly used anesthetic drugs on
somatosensory and auditory evoked responses. Be aware of
the most common accepted uses and limitations of
neurophysiologic monitoring.
- Know
anesthetic effects on the electrocardiogram (EEG) and evoked potentials
and basic implications of and appropriate responses to changes in each
- Understand the basic indications and techniques
for the following
special procedures used during neuroanesthesia:
- Induced hypotension
- Induced hypertension
- Moderate hypothermia
- Barbiturate cerebral
protection
- Cardiopulmonary bypass and
circulatory arrest--theoretical knowledge only in most instances
PRACTICE-BASED LEARNING AND
IMPROVEMENT
INTERPERSONAL AND COMMUNICATION SKILLS,
PROFESSIONALISM
SYSTEMS-BASED PRACTICE
- Appropriately utilize consultants and
preoperative laboratory testing to optimize patient condition prior to
surgery.
- Anticipate the impact of each patient's
neurosurgical pathology and planned surgical procedure(s) on the level of
postoperative care required.
- Utilize appropriate anesthetic techniques to
minimize the impact of perioperative anesthetic management on the
patient's subsequent recovery
- Practice cost-effective, safe anesthesia
Evaluation to Determine Goal Achievement:
You will be evaluated according to how well you have
met the general goals and specific competencies listed above. The most
important activities that will generate your evaluation are:
- Preoperative discussion with the
attending physician
- Attending evaluation of daily clinical
performance in the operating room in the following areas:
- Preparation
for case and ability to carry out plan discussed the night before
- Recognition
of intraoperative problems and communication with the attending; ability
to appropriately respond to changing clinical situation; clinical judgment
- Mechanical
skills of managing the airway, placing lines and positioning the patient
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- Application
of basic and clinical science knowledge and skills to the neurosurgical
patient
Each neuroanesthesia attending will evaluate you
weekly using the Departmental
Web-based, Contact based Resident Evaluation Form. These evaluations will
be reviewed quarterly by the clinical competence committee and continuously by
the program director. Significant issues will be shared with your faculty
advisor and with you. You have continuous online access to your
evaluations, and the system will notify you when you receive an evaluation
either and unacceptable or below expected competence evaluation. You are
advised to check these evaluations weekly.
Teaching Resources to Accomplish the
Objectives
- Clinical cases as follow:
- 1000
craniotomies annually distributed among:
- Posterior fossa procedures
- Pituitary surgery
- Supratentorial brain tumor removal
- Seizure control procedures
- Aneurysm and arteriovenous malformation repairs
- Stereotactic procedures
- 1200
spine procedures annually distributed among:
- Anterior cervical discectomies, fusions, and corpectomies
- Posterior cervical procedures
- Thoracic and lumbar spine procedures including discectomies, corpectomies,
laminectomies, fusions, and excision of tumors
- 60-80 carotid vascular
surgical procedures annually
- Endovascular treatment of Ruptured and
Unruptured Cerebral Aneurysms and Arteriovenous malformations
- Neuroanesthesia block lectures
- Textbooks include:
- Cucchiara, Michenfelder and
Black: Clinical
Neuroanesthesia, 2nd ed. Churchill-Livingstone
- Cottrell and Smith: Anesthesia
and Neurosurgery, 3rd ed, CV Mosby
- Miller: Anesthesia, 4th ed, Churchill-Livingstone;
chapters 21, 38, and 56
- Kirby and Gravenstein: Clinical
Anesthesia Practice, WB Saunders; chapters 22, 54,
and 73
- Russell and Rodichok: Primer of
Intraoperative Neurophysiologic Monitoring,
Butterworth and Heinemann
- Faculty members
- Dietrich
Gravenstein, MD
- Michael E. Mahla, MD
(Chief)
- Steven Robicsek, MD, PhD
- Christoph N.
Seubert, MD, PhD (Director Neurologic Monitoring Laboratory)
- Cheri Sulek,
MD (VAMC)
Dr. Mahla is
the faculty member responsible for the N rotation, and Dr. Sulek is the
faculty member responsible for the VAN rotation.
CA-3 Advanced Clinical
Track Neuroanesthesia Rotation
Goals: In addition to those outlined for
the basic rotation in Neuroanesthesiology:
- Expand the knowledge base with regards
to CNS physiology and pharmacology and
pathophysiology developed during CA-1 and
CA-2 years.
- Develop clinical judgement to provide
anesthetic care for more complex neurosurgical procedures.
- Develop technical skills necessary to
conduct more complex neurosurgical cases.
Patient Care Skills and Medical
Knowledge: In addition to those
outlined for the basic rotation in Neuroanesthesiology:
- Be able to complete a thorough
preoperative evaluation for all neurosurgical patients,
recognizing impact of neurologic disease
state on perioperative management. For routine neurosurgical procedures,
accomplish preoperative preparation and anesthetic planning independently. For complex procedures, preoperative preparation and planning will occur
with assistance from the attending neuroanesthesiologist as needed and as
appropriate.
- Plan and carry out anesthetics for
routine neurosurgical procedures with minimal assistance from the
neuroanesthesia attending physician.
- Perform anesthetics for complex
neurosurgical procedures with as needed assistance from the attending
neuroanesthesiologist.
- Perform all invasive monitoring
techniques and interpret information obtained reliably with minimal
assistance from the attending anesthesiologist.
- Develop beyond a basic understanding of
neurophysiologic monitoring and be aware of the most common uses of
neurologic monitoring during neurosurgical procedures. Be aware of and able to discuss
documented advantages and disadvantages of the use of neurologic monitoring
during neurosurgical procedures.
Evaluation: As described in the
primary neuroanesthesia rotation. However, in addition, your ability to
practice neuroanesthesia as an independent consultant anesthesiologist will be
assessed.
Resources: As described in basic Neuroanesthesiology Rotation
RETURN
TO INDEX FOR GOALS AND OBJECTIVES
Revised 6/2005
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