CA-2 Level Information (S2), click hereCA-3 Level Information (S3), click here
General Goals:
- Understand and operate all the different types of equipment and monitors an anesthesiologist uses
- Know the special considerations and techniques required to anesthetize patients in locations outside of the operating room, for example, the Cardiac Catheterization Laboratory, Electroconvulsive Therapy, Burn Unit, Genitourinary Clinic, Magnetic Resonance Imager, Radiology, and Radiation Therapy
- Develop consultant skills in Anesthesiology
- 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
- 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 (see PREOP rotation for specific competencies that also apply to inpatients)
- 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
- Laryngeal mask airway assistance
- Additional techniques such as retrograde wire intubation and surgical cricothyroidotomy, both of which will be learned first on a mannequin
- Appropriate use and monitoring of muscle relaxants
- Failed or Difficult Airway Algorithm of the American Society of Anesthesiologists (ASA)
- Laryngeal mask airway management
- Combitube insertion for airway management (likely learned and used only on a patient simulator)
- Awake intubation using:
- Airway topicalization
- Airway nerve block, for example, superior laryngeal nerve and glossopharyngeal nerve block
- Blind nasal technique
- Fiberoptic nasal and oral techniques
- Light wand techniques
- Retrograde wire technique (learned first on a mannikin / HPS and may never be seen in the OR)
- 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, for example, effects of aortic cross-clamping, 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
- Central vessels: internal jugular, subclavian routes
- Pulmonary artery (rarely)
- 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 techniques for regional anesthesia (see regional rotation); This will be primarily intraoperative management of patients who already received blocks in the Block Area.
- 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 (see PACU and Regional Rotations)
- 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
- Become skilled providing anesthesia outside the operating room:
- GU clinic
- Radiology (diagnostic and interventional)
- Special techniques and monitoring requirements for MRI
- Burn unit
- ECT suite
- Cardiac catheterization laboratory
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
- Combitube (be aware of indications - skills with this will likely only be learned on the simulator and during airway labs)
- 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
- Pulmonary artery catheter and CVP
- Normal and pathologic waveforms
- Difference between wedge pressure, pulmonary artery diastolic, and central venous pressure measurements
- Thermodilution cardiac output - principles of operation and factors causing errors
- Physiology of mixed venous oxygen saturation - factors determining changes in measured values
- 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
- Intravascular volume monitoring
- Clinical signs and limitations of clinical signs
- Intravascular pressure measurements - know indications, contraindications, and complications associated with:
- Arterial line placement
- Central venous catheter placement
- Pulmonary artery catheter placement
- TEE placement
- Urine output (includes limitations of urine output as a monitor of volume status)
- TEE
- 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
- Electrophysiologic monitoring of the nervous system:
- EEG
- Somatosensory and auditory evoked potentials
- EMG
- Transesophageal Echocardiography (basic understanding only)
- Know basic indications, contraindications, advantages, disadvantages, and complications of regional anesthesia as well as appropriate surgical procedures for regional anesthesia
- Know patient selection characteristics for regional anesthesia
- 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
- Postoperative epidural infusion (opiates, local anesthetics)
- Patient-controlled analgesia
- Adjunctive nerve blockade
- Use of adjunctive drugs that may potentiate analgesics
- Be familiar with ASA Guidelines for Anesthesia Outside the Operating Room. Know special anesthetic considerations for procedures conducted outside the OR in the following locations:
- GU Clinic:
- Transurethral resection of the prostate: recognize and treat hyponatremia; know different anesthetic options and advantages and disadvantages of each
- Irrigation fluid options: know advantages and disadvantages of each
- Anesthetic techniques for extracorporeal shock wave lithotripsy
- Anesthetic considerations for percutaneous nephrostomy and nephrolithotomy
- Radiology suite
- Management of patients with dye allergies
- TIPPS and other interventional procedures
- Management of patients for neurologic interventional procedures including embolization of AVM and GDC coiling of aneurysms
- Special considerations for magnetic resonance imaging (MRI)
- Monitoring options
- Special anesthetic equipment (machine, oxygen tanks, etc)
- Electroconvulsive shock therapy (ECT)
- Preoperative evaluation - especially anesthetic considerations caused by psychotropic
medications- Anesthetic techniques and drug effects (also adjunctive drugs) on seizure duration
- Hemodynamic responses to ECT and appropriate treatment
- Cardiac catheterization laboratory
- Anesthetic considerations for cardiac catheterization children with congenital heart disease or heart transplants
- Anesthetic considerations for adults and children undergoing electrophysiologic tests/radiofrequency ablation
- Anesthetic consideration for children and adults undergoing interventional procedures (such as valvuloplasty)
- Anesthetic considerations for cardioversion
- Burn Unit Operating Room
- Fluid and electrolyte management of the burned patient
- Choice of anesthetic agents, especially muscle relaxants
- Intravascular monitoring
- Special vascular access considerations
- 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. The resident will build on these skills to develop speed, efficiency and ability to handle more complex cases in the CA-2 and CA-3 years.
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:
- Miller RD, ed. Anesthesia, 5th ed.
- Kirby RR, Gravenstein N, eds. Clinical Anesthesia Practice, 2nd edition
- Barash PG, ed. Clinical Anesthesia, 4th ed.
- 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.CA-2 Level Rotation Information
Goals and competencies for the resident rotating on the S2 or VA (CA-2) rotation are the same as described above with these additional competencies:
- Improved preoperative evaluation skills to consultant level by the end of the CA-2 year.
- The resident at the conclusion of the CA-2 year should be able to perform an anesthetic for any routine surgical procedure as well as uncomplicated subspecialty procedures with minimal direct input from the attending physician (this does not mean unsupervised - it means only that the resident should possess the necessary skills to conduct a safe, well-planned anesthetic on such a patient).
- The CA-2 level resident will be given more freedom to make management decisions during routine anesthetics. With the concurrence of the attending physician prior to starting the case, the CA-2 resident may make clinically indicated adjustments in perioperative management including but not limited to anesthetic technique (choice of drugs as well as techniques), ventilatory management, and fluid management.
- Become skilled in catheterizing or cannulating the following vessels for sampling blood, measuring
concentrations or pressures, or administering drugs or fluids:
- Veins: all age groups and all sizes, including sick children / neonates
- Arteries: radial and other sites
- Central vessels: internal jugular, subclavian, femoral, and "long-arm" routes
- Pulmonary artery (commonly)
- Become skilled in using and interpreting the following routine noninvasive and non-routine invasive monitors intraoperatively:
- Central venous pressure: values and waveform
- Pulmonary artery pressure: values and waveforms, pulmonary capillary wedge tracing
- Mixed venous oxygen saturation - significance of value and changes in value
- Cardiac output - thermodilution methods, continuous methods
- Electrophysiologic monitoring of the nervous system:
- EEG
- Somatosensory and auditory evoked potentials
- EMG
- Transesophageal Echocardiography (basic understanding only)
CA-3 Level Rotation Information
Goals and competencies for the resident rotating on the S3 or VA (CA-3) rotation are the same as described above with these additional competencies:
- A more extensive knowledge of surgical procedures, anesthetic considerations and techniques necessary for the management of patients undergoing procedures in the recognized subspecialties including neurosurgery, obstetrics, cardiovascular surgery, pediatric surgery (all subspecialties involving children), ambulatory anesthesia, and regional anesthesia.
- Through the process of being paired with beginning level residents, both in simple and complex cases, learn how to apply your knowledge and experience to the benefit of other, less experienced clinicians. Through this supervision / teaching of younger residents, the CA-3 resident will learn skills necessary to the supervision of and working with certified registered nurse anesthetists.
- Consultant level preoperative evaluation skills, including all types of anesthetics in all subspecialties.
- The CA-3 level resident will be given more freedom to make management decisions during both routine and complex anesthetics. With the concurrence of the attending physician prior to starting the case, the CA-3 resident may make clinically indicated adjustments in all aspects of perioperative management independently. The attending physician will maintain supervisory control, but using a hands-off approach except when otherwise required by the clinical condition of the patient.
- The resident at the conclusion of the CA-3 year should be able to perform an anesthetic for any routine surgical procedure as well as some complicated subspecialty procedures independently. The CA-3 resident should also be able to provide supervision / guidance to less experienced residents involved in general or subspecialty anesthesia rotations.
RETURN TO INDEX FOR GOALS AND OBJECTIVES
Revised 6/2005
