CA-3
Rotation Information, click here
Acute Pain Service Guidelines and Policies
GENERAL
GOALS: To teach anesthesia residents
the art and science of regional anesthesia.
PATIENT
CARE SKILLS:
- Recognize
patients and surgical procedures suitable for regional anesthesia
techniques
- Rationally
select regional anesthesia techniques and choice of local anesthetic
for particular patient encounters.
- Assess adequacy
of regional anesthesia before the start of surgery, and demonstrate
appropriate plans for supplementation of inadequate blocks.
- Provide effective
anxiolysis and sedation of patients by both pharmacologic and interpersonal
techniques.
- Select appropriate
monitors for specific patient encounters, and document performance
of regional anesthetic adequately.
- Develop peripheral
nerve block skills
- Graduating
residents will be required by the RRC to have administered
a minimum of 50 peripheral nerve blocks by the COMPLETION of their
residency. This does NOT include epidural and spinal anesthesia.
- Residents
should be able to perform and manage intraoperatively upper extremity
blocks including interscalene, subclavian perivascular, supraclavicular,
infraclavicular, axillary and intravenous regional anesthesia.
- Residents
should be able to perform and manage intraoperatively lower extremity
blocks including sciatic, femoral, 3-in-1, psoas compartment block,
lateral femoral cutaneous, popliteal and ankle blocks.
- By examining the patient in the immediate postoperative period, residents will be able to assess the efficacy of their blocks in meeting desired postoperative pain goals (residents placing blocks are expected to assess and record the efficacy of blocks placed each afternoon prior to leaving for home).
- Central Neural
Blockade: Graduating residents will be required by the RRC to have
completed 50 subarachnoid AND 50 epidural blocks by the COMPLETION
of their residency.
- Residents
should be able to properly perform central neuraxial blocks including:
- subarachnoid
- epidural
(lumbar and thoracic)
- cervical
epidural (theoretic knowledge only - may not perform unless
appropriate patient presents for surgery)
- continuous
subarachnoid blocks.
- Appropriately
care for patients with continuous and / or patient controlled regional
analgesia postoperatively including:
- Thoracic
or lumbar epidural analgesia using local anesthetics, opiates
or both
- Continuous
nerve or plexus catheters using local anesthetics
- Nerve
sheath catheters placed directly by the surgical team using local
anesthetics
- Safe supplementation
of regional techniques with intravenous medications, especially
when epidural opiates are used
- Appropriate
management of side-effects or complications of continuous / patient-controlled
regional analgesia including:
- Itching
- Nausea
/ vomiting
- Hypotension
- Urinary
retention
- Numbness
- Muscle
weakness
- Appropriately
care for patients receiving intravenous Patient Controlled Analgesia
with a basal infusion rate
MEDICAL
KNOWLEDGE
- Know general
principles of local anesthetic pharmacology, including the pharmacodynamics
and pharmacokinetics of various local anesthetics. This includes onset,
duration, motor/sensory differentiation, and toxicity profile of various
local anesthetics.
- Know the principles
for use and indications for various local anesthetic adjuvants including:
Epinephrine, phenylephrine, narcotics, sodium bicarbonate, carbonation,
hyaluronidase, alpha-2 agonists, anticholinesterases.
- Know the relevant
anatomy for regional techniques, including: Spinal canal and its contents,
neural plexuses of the limbs, major autonomic ganglia, major peripheral
nerves.
- Know the physiologic
changes associated with spinal and epidural anesthesia.
- Know the indications
for and the contraindications to regional anesthetic techniques including
central neuraxis blocks, peripheral nerve blocks, sympathetic nerve
blocks.
- Understand
the anatomy, pathophysiology, and appropriate management of complications
and side effects of regional anesthetic techniques, including:
- Local
anesthetic complications - toxicity and its treatment
- allergy
- the use of test doses
- total
spinal, or subdural blocks - assessment and treatment
- Spinal,
epidural hematoma and abscess - assessment and treatment
- Postdural
puncture headache - assessment and treatment
- Pneumothorax
- assessment and treatment
- Physiologic
side effects: sympathectomy, phrenic nerve block, intercostal
nerve block - assessment and treatment
- Peripheral
nerve injury - assessment and follow up
- Know indications
for, advantages, disadvantages, side effects and complications associated with various types of postoperative pain control including:
- Intravenous
patient-controlled analgesia
- Lumbar
or thoracic epidural analgesia - continuous and /or patient controlled
- Continuous
nerve or plexus catheters
- Nerve
sheath catheters
- Combinations
of the above
INTERPERSONAL
AND COMMUNICATION SKILLS, PROFESSIONALISM
- Develop communication
skills to assist in management of awake or sedated patients during
surgery conducted under regional anesthesia (relates directly to skills
associated with providing sedation for surgical procedures)
- Ability to
appropriately counsel and teach advantages of regional anesthesia
to patients and their families
PRACTICE-BASED
LEARNING
- Become proficient
at providing safe levels of anxiolysis and sedation for patients undergoing
surgery using regional anesthesia
- Gain proficiency
at rapidly setting up for and performing regional blocks
- By examining the patient in the immediate postoperative period, residents will be able to assess the efficacy of their blocks in meeting desired postoperative pain goals (residents placing blocks are expected to assess and record the efficacy of blocks placed each afternoon prior to leaving for home).
SYSTEMS-BASED
PRACTICE
- Learn how
regional anesthesia and perioperative pain management can improve
the overall surgical experience for patients - both inpatient and
ambulatory.
- Learn requirements
for and how to run a hospital-based acute pain service
EVALUATION
TO DETERMINE GOAL ACHIEVEMENT
- The resident
should have developed a plan for pre, intra, and postoperative anesthesia
care to be prepared to discuss the case with the attending anesthesiologist.
Part of the evaluation will be based on these preoperative discussions.
- Attending
evaluation of daily clinical performance in the operating room in
the following areas:
- Preparation
for the case and ability to carry out plan discussed the night
before, including the rational choice of regional technique and
local anesthetic.
- Recognition
of problems and communication with the attending, including the
use of supplementation and sedation, toxic reactions, tourniquet
pain, and changes in volume status.
- Technical
skill during the placement of the regional block.
- Each attending
you work with will evaluate you weekly with the Departmental online
evaluation form. This form is reviewed quarterly by the Clinical
Competence Committee and continuously by the program director. Your advisor will inform you of any problems identified. Any serious
problem will be discussed with you immediately after it occurs.
- 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 weakness may result
in adjustment of the above goals.
TEACHING
RESOURCES TO ACCOMPLISH THE OBJECTIVES
- 11,000+
patients per year from the following surgical services (~20% children):
- Orthopedic
surgery including: Total Joint Arthroplasties, foot and ankle,
musculoskeletal oncology, hand, sports, and pediatric orthopedic
cases.
- Gynecology
- benign and oncologic patients
- Plastic
surgery including burn patients
- Urologic
surgery
- Vascular
surgery
- General
surgery - especially bariatric surgery patietns
- Regional
anesthesia workbook provided by the department. The technical skills
sheet will be included in this workbook.
- Compendium
of Regional anesthesia provided by ASTRA.
- Regional
anesthesia block lectures.
- Reference
List of pertinent articles. (see attached)
- Multi
media resources available include Regional Anesthesia interactive
CD rom available in the Resident Library. A film library is available
to any resident interested in particular techniques.
- Regional
Anesthesia Core Education Materials Web Site (now includes Dr. Boezaart's Training Videos)
- Faculty
members:
- Jill
Freedman, M.D.
- Lori
Dangler, M.D.
- Kayser
Enneking, M.D.
- Brian
Ilfeld, M.D.
- Jerry
Berger, M.D.
- David
Mackey, MD (chief)
- Sno
White, MD
SKILLS SHEET FOR RESIDENTS ON THE
REGIONAL
ANESTHESIA ROTATION
1. Demonstrate
proficiency in the performance of the following regional anesthesia techniques:
______
axillary block
______ continuous brachial plexus blockade (catheter
placement)
______ interscalene block
______ subclavian perivascular block
______ sciatic nerve block
______ femoral nerve block, or 3-in-1 block
______ popliteal block
______ ankle block
______ epidural block
______ spinal
______ continuous spinal
______ IV regional upper extremity
______ IV regional lower extremity
______ other
2.
Demonstrate understanding of the following concepts:
______
General principles of pharmacology of local anesthetics.
______ Anatomic rationale for the choice of regional
anesthetic technique.
______ Preemptive analgesia and the use of regional
anesthesia/analgesia in the
postoperative period.
______ Know the recommended doses of local anesthetics
and the relative blood levels
anticipated for each block.
________ Understand the use of local anesthetic additives.
________ Local anesthetic toxicity, its treatment and
assessment.
________ Complications of regional techniques; incidence,
assessment and treatment.
CA-3
Rotation Information
CA-3
residents completing the Regional Anesthesia Rotation
PATIENT
CARE SKILLS:
- Independently
select patients for regional anesthesia, recognizing patients that
will do better either with general anesthesia or with a combined regional
/ general technique
- Independent
rational selection of regional anesthesia technique and choice of
local anesthetic for particular patient encounters.
- Properly and
efficiently and independently perform blocks for operations on the
extremities
- Upper: axillary,
interscalene, and infraclavicular brachial plexus blocks; less
commonly, median nerve and ulnar nerve blocks
- Lower:
psoas compartment, femoral, obturator, lateral femoral cutaneous,
popliteal, sciatic and ankle blocks
- Intravenous
regional anesthesia
- Properly and
efficiently and independently perform continuous neuraxial blockade
including
- Lumbar,
thoracic, and cervical (rarely) epidural anesthesia
- Continuous
or single-shot subarachnoid block
- Ability to
independently assess adequacy of regional anesthesia before the start
of surgery, and demonstrate appropriate plans for supplementation
of inadequate blocks.
- Independently
provide effective anxiolysis and sedation of patients by both pharmacologic
and interpersonal techniques.
- Independently
select appropriate monitors for specific patient encounters, and document
performance of regional anesthetic adequately.
MEDICAL KNOWLEDGE: (See
also General Competencies)
- Depth of knowledge
of topics listed above in the core rotation should support independent
practice and be able to assist the resident to defend his / her choices
in management techniques and choice of medications
PROFESSIONALISM,
INTERPERSONAL AND COMMUNICATION SKILLS, PRACTICE-BASED LEARNING and
SYSTEMS-BASED PRACTICE: See
core rotation descriptions and General
Competencies
Dr.
Berger is the faculty member responsible for this rotation.
RETURN
TO INDEX FOR GOALS AND OBJECTIVES
Revised 9/25/06
|