ROTATION: Anesthesia Rotation for the Oral Surgeon - Shands OR
TYPE: Required
DURATION: 6 months
FACULTY: Michael E. Mahla, MD
PREREQUISITES: None

General Goals:

• Understand and operate all the different types of equipment and monitors required for safe conduct of a general anesthetic
• Know the special considerations and techniques required to anesthetize patients in locations outside of the operating room, specifically the Oral Surgery Suite and / or Dental Office
• Work with other members of the OR team, including surgeons and nurses, to optimally care for
  surgical patients, especially develop communications skills
• Perform preoperative medical evaluations of patients undergoing many different types of operations, both for inpatients and outpatients, with an emphasis on assessing the patient undergoing oral surgical and ENT procedures
• Learn to develop appropriate and optimum anesthetic plans, depending on the type of operation and the patient's condition
• Develop and refine the basic clinical skills to administer intraoperative anesthesia

SPECIFIC COMPETENCIES: (General Competencies also apply)

PATIENT CARE SKILLS:

• Perform preoperative evaluation of inpatients and outpatients
• Learn to prioritize problems and to present cases clearly and systematically to attending
  physicians
• Prepare for and administer General Anesthesia, Regional Anesthesia, or Monitored Care with or without sedoanalgesia
  • Perform the anesthesia machine check and prepare basic equipment necessary for all anesthetic cases
  • Prepare drug table: select appropriate drugs for a case and develop a good system for arranging the drug and work tables
  • Place standard monitors, for example, electrocardiogram, noninvasive blood pressure device,
    precordial stethoscope, neuromuscular blockade monitor, pulse oximeter, and capnograph
  • Demonstrate proper techniques of preoxygenation
  • Induce anesthesia, both routine induction and rapid sequence induction, and demonstrate pertinent mechanical skills and appropriate choice of drugs
  • Perform airway management using all the various procedures and equipment:
    • Face mask ventilation, including appropriate uses of mask straps and oral and nasal airways
    • Endotracheal intubation using:
      • Direct laryngoscopy with Macintosh (MAC) and Miller blades
      • Fiberoptic techniques
        • Bullard or Wu laryngoscopes
        • Flexible fiberoptic scopes
      • Light-wand techniques
      • Blind techniques
      • Appropriate use and monitoring of muscle relaxants during intubation
      • Failed or Difficult Airway Algorithm of the American Society of Anesthesiologists (ASA)

• Laryngeal mask airway management

• Provide safe, appropriate maintenance of general or regional anesthesia
  • Appropriately choose and use anesthetic and adjuvant drugs such as muscle relaxants and monitor their effects
    • Assessment of anesthetic depth - using both "traditional techniques" including autonomic signs and recently developed techniques such as bispectral index (both knowledge and application of technology);  Appropriately adjust anesthetic technique
    • Monitor neuromuscular blockade and adjust dosage of muscle relaxant appropriately for surgical and anesthetic needs
  • Accurately assess volume status
  • Replace intraoperative fluid losses appropriately
  • Safely administer blood and blood products
  • Be aware of  the effects of different types of surgical procedures on anesthetic management and adjust anesthetic techniques and drugs appropriately
  • Appropriately order and interpret intraoperative laboratory tests; use obtained information to alter management appropriately
• Become skilled in catheterizing or cannulating the following vessels for sampling blood, measuring
  concentrations or pressures, or administering drugs or fluids:
  • Veins: normal adult and adolescent patients, healthy children
  • Arteries: radial and other sites
• Become skilled in using and interpreting the following routine noninvasive and non-routine invasive monitors intraoperatively:
  • Electrocardiogram with ST-segment analysis
  • Noninvasive blood pressure
  • Capnograph: interpretation of both numeric value and the waveform
  • Pulse oximetry: values and changes in values, waveform (perfusion index, "cycling" with ventilation)
  • Neuromuscular blockade monitor
  • Invasive arterial pressure: waveform and changes in the waveform, "cycling" with ventilation
• Become skilled in discontinuing anesthesia and monitoring the patient's emergence from
  anesthesia
  • Reversal of neuromuscular blockade and assessment of degree of residual block (clinically and via neuromuscular blockade monitoring
  • Determination of appropriate time for extubation
  • Monitoring of airway adequacy during and after emergence
•  Become skilled in perioperative pain management
• Become skilled in techniques of conscious and unconscious sedation
  • Appropriately select patients for conscious sedation based on patient characteristics and planned surgery
  • Appropriately select drugs for use in conscious sedation
  • Monitoring depth of sedation using clinical and EEG (BIS) measures
  • Recognize when conscious sedation has become unconscious sedation and the implications of this state

MEDICAL KNOWLEDGE

• Preoperative Evaluation:
  • Know appropriate indications for preoperative laboratory evaluation
  • Know literature relating to the evaluation of patients with cardiovascular disease presenting for non-cardiac surgery
  • Know appropriate preoperative evaluation and anesthetic considerations for patients with significant pulmonary disease
  • Know appropriate preoperative evaluation and anesthetic considerations for the management of the diabetic patient
  • Know appropriate preoperative evaluation and anesthetic considerations for the morbidly obese patient
• Premedication
  • Demonstrate basic understanding of what regularly taken patient medications need to be continued and what patient medications should be held (rare) in the perioperative period.
  • Know indications and contraindications for premedication with sedative / hypnotic drugs and /or analgesic medications.
  • Know indications for use of adjunctive premedications such as antiemetics, antihypertensives, gastric motility agents, and H2 blockers
  • Know premedication doses for commonly used agents
• Induction and maintenance of anesthesia:
  • Know basic pharmacology, indications, dosing, and side effects of:
    • Induction agents (thiopental, etomidate, propofol)
    • Maintenance anesthetics agents (isoflurane, sevoflurane, nitrous oxide)
    • Analgesic medications (fentanyl, sufentanil, morphine)
    • Neuromuscular blockade agents (succinylcholine, atracurium, rocuronium, vecuronium, pancuronium) and reversal agents (neostigmine)
    • Anxiolytics / amnestic agents (midazolam)
    • Vasopressors (ephedrine, phenylephrine, epinephrine)
    • Anticholinergic drugs (atropine, glycopyrrolate)
    • Local anesthetics (lidocaine, bupivacaine, ropivacaine).
  • Know the available methods of airway management for induction and maintenance of anesthesia - in addition to techniques described above,
    • Know different types of LMAs and advantages / disadvantages of each
      • Techniques for placement of LMA
      • Contraindications for LMA placement
  • Know the ASA Difficult Airway Algorithm described above
• Monitoring of Anesthesia and Patient condition
  • Depth of Anesthesia:  Clinical signs and EEG (BIS) monitoring
    • Know basic technology, indications and limitations of BIS monitoring
  • Cardiovascular function and supporting physiology and pharmacology knowledge
    • Cardiovascular physiology (Frank-Starling Law)
      • Effect of preload on cardiovascular function
      • Effect of afterload on cardiovascular function
      • Factors determining inotropic state
    • Cardiovascular pharmacology
      • Effects of commonly used anesthetic drugs on cardiac function
      • Pharmacology of inotropic (catecholamine and non-catecholamine) drugs
      • Pharmacology of vasodilators
      • Pharmacology of calcium channel blockers
      • Pharmacology of beta-blocking agents
  • Respiratory function and supporting basic science knowledge
    • Capnography - significance of end-tidal CO2 value and waveform
      • Normal relationship between end-tidal CO2 and arterial CO2.
      • Pathologic factors that may increase the gradient between arterial and end-tidal CO2
    • Pulse oximetry
      • Basic technology and limitations
      • Significance of waveform and changes in morphology
• Know technology indications, advantages, disadvantages, limitations, and complications (if any) associated with the following monitoring devices
  • Electrocardiogram with ST-segment analysis
  • Noninvasive blood pressure
  • Capnograph: interpretation of changes in numeric value of ETCO₂ and the waveform morphology
  • Pulse oximetry: values and changes in values, waveform (perfusion index, "cycling" with ventilation)
  • Neuromuscular blockade monitor
• Know different types of IV fluids, indications for use, advantages, disadvantages, and complications associated with each type including:
  • Dextrose-containing solutions
  • Lactated Ringers solution
  • Normal Saline
  • Hypertonic saline
  • Hetastarch
  • Albumin solutions (Plasma-Protein Fraction, 5% and 25% albumin solution)
• Know different types of blood and blood products, indications for use, advantages, disadvantages, and complications associated with each type including:
  • Whole blood
  • Packed red blood cells
  • Platelets
  • Fresh-frozen plasma
  • Cryoprecipitate
  • Individual factor replacement
  • Blood substitutes (theoretical knowledge only)
• Monitors of coagulation function including:
  • Thromboelastography
  • Activated clotting time
  • PT, PTT, platelet count
• Know differential diagnoses and rationale treatment plans for the following:
  • Intraoperative hypertension
  • Intraoperative hypotension
  • Intraoperative hypoxemia
  • Intraoperative hypercarbia
  • Intraoperative hypothermia
    • Know major mechanisms of perioperative heat loss in adults, children, and neonates, and be aware of strategies for prevention of hypothermia
  • Intraoperative hyperthermia
  • High peak airway pressures
  • Intraoperative bradycardia
  • Intraoperative tachycardia
  • Intraoperative ST-T changes
• Know criteria for safe extubation of patients emerging from general anesthesia based on:
  • Patient's surgical procedure
  • Patient's general medical condition
• Know indications, advantages, disadvantages, contraindications, and complications associated with the following perioperative pain management techniques
  • Patient-controlled analgesia
  • Use of adjunctive drugs that may potentiate analgesics
• Know elements of a complete, accurate, medicare compliant anesthetic record.

INTERPERSONAL AND COMMUNICATION SKILLS, PROFESSIONALISM 

(See general competencies section)

In addition, the following specific competencies must be mastered:

• Able to communicate with surgeon and circulation nurse effectively in order to:
  • be aware of important surgical activities that impact on anesthetic management
  • communicate needs of the anesthesia team to the OR team
• Demonstrate appropriate respect for OR team personnel members
• Communicate effectively with patients in order to:
  • elicit historical information important to anesthetic care
  • reassure patients and their families regarding the pending anesthetic /surgical experience
• Communicate effectively with attending physicians in order to:
  • Discuss preoperative evaluation and develop an anesthetic plan
  • Inform the attending physicians of important intraoperative events that require his / her input or attention
• By working with several different senior residents and attendings, the resident will be exposed to a variety of styles, techniques, attitudes, and approaches to the safe administration of anesthesia.  The resident must develop enough flexibility to deal with these differences. 

PRACTICE-BASED LEARNING   (See general competencies section)

In addition, the following specific competency must be developed:

• Blending of skills and knowledge discussed above resulting in a smooth, deliberate rhythm of perioperative routine patient care from preparation to induction to emergence to postoperative care. 

SYSTEMS-BASED PRACTICE  (See general competencies section)

Evaluation to Determine Goal Achievement

• You are evaluated every week by all attendings who worked with you (contact-based online computer evaluation system).   These evaluations are reviewed quarterly by the Clinical Competence Committee and continuously by the program director. 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 Residency Program Director will evaluate the results of the In-Training Examination for the
  American Board of Anesthesiologists (ABA) for areas of departmental weakness. Consistent
  weaknesses may result in adjustment of the above goals.

Teaching Resources to Accomplish the Objectives

• 16,000 patients per year, roughly 20% to 30% being children, requiring care in the following areas:
• Surgery - Main OR
  • Otorhinolaryngology
  • General Surgery
  • Gynecologic surgery, both benign and oncology
  • Neurologic surgery
  • Ophthalmologic surgery
  • Oral and Maxillofacial surgery
  • Orthopedic surgery
    Plastic surgery, including burn débridements
  • Organ Transplantation (liver, kidney, pancreas, heart, lung)
  • Urologic surgery
  • Vascular surgery
  • Cardiothoracic surgery
• Cardiac catheterization lab: Pediatric and adult catheterization, electrophysiologic studies and ablative procedures, TEE, Interventional procedures, both adult and pediatric
• Psychiatry area: electroconvulsive shock therapy, Amytal interviews
• GU Clinic
• Radiation therapy
• Radiology suite (diagnostic procedures, interventional procedures - general and neurologic, MRI
• Textbooks:
  • Kirby RR, Gravenstein N, eds. Clinical Anesthesia Practice, 2nd edition (reading list attached below)
  • Stoelting RK, Miller RD, eds. Basics of Anesthesia
• Classic Anesthesia Articles Library with Article of the Week and Article for Weekly Discussion
• Faculty:  All clinical faculty at the University of Florida participate. The faculty member
  coordinating this rotation is Dr. Michael Mahla
• Reading list is as follows:

Your reference for your six month rotation is Clinical Anesthesia Practice by Kirby / Gravenstein.  You will need to sign for your copy and return it at the conclusion of your rotation.  The appropriate sections to read during your rotation, in order, are:

 

PART 1

Chapter 1

Chapter 2

Chapter 5

Chapter 6

 

PART 2

Chapter 15   The Anesthesia Machine

Chapter 16   Airway Devices

Chapter 18   Introduction to Monitoring

Chapter 19   Respiratory Monitoring

Chapter 20   Cardiovascular Monitoring

 

PART 3

Chapter 26  Autonomic Nervous System and Sympathetic Blockade

Chapter 28  Positioning the Surgical Patient

 

Part 4

Chapter 30  Basic Pharmacologic Applications in Anesthesia

Chapter 31  The Preoperative Visit and PRemedication

Chapter 32  General Anesthesia:  Induction, Maintenance, and Emergence

Chapter 33  Intravenous Anesthetic Agents

Chapter 34  Inhalation Agents

Chapter 35  Local Anesthetics

Chapter 37  Muscle Relaxants

 

Part 5

Chapter 40:  Fluids, Electrolytes, Blood, and Blood Substitutes

Chapter 41:  Clinical Applications of Acid-Base Chemistry and Physiology

Chapter 53:  Management of the Difficult Airway

Chapter 68:  Otolaryngologic and Maxillofacial Surgery

 

This reading should able to be completed during your Anesthesiology Rotation.

RETURN TO INDEX FOR GOALS AND OBJECTIVES
Revised 1/2006