Rotation:  Introductory Anesthesia Rotation (S0 or VA0); (Includes PGY-1 Experience)
Duration:  Variable - 2 weeks to 3 months
Type:  Required
Faculty:  Michael E. Mahla, MD (Shands, FSC), Robert Kirby, MD (VA)
Prerequisites:  None 

General Goals

SPECIFIC COMPETENCIES:  (General Competencies also apply)

PATIENT CARE SKILLS:

• Properly prepare an ASA 1 or 2 patient for anesthesia with consideration of both the patient and procedure – make sure all appropriate preoperative evaluation, lab tests, medication and blood orders are appropriately completed.   Obtain appropriate consent for anesthesia.
• Properly prepare the anesthesia work station for care of ASA 1 and 2 patients.
• Properly perform a checkout and preparation of the Ohmeda or Draeger anesthesia machines located in the Shands, VA, or FSC operating rooms.
• Obtain peripheral IV access for patients in or destined for the operating room.
• Place all necessary non-invasive monitoring devices on patients in the operating room.
• After induction of anesthesia, be able to ventilate the patient by mask prior to placement of the endotracheal tube.
• Properly place and verify placement of airway devices (oral and nasal airways, endotracheal tube and laryngeal mask airway) and be able to use both Miller and MAC blades for intubation
• Establish proper mechanical ventilation settings for patients in the operating room.
• Appropriately adjust anesthetic agents during different phases of surgery
• Define and determine the following:
  • Estimated blood volume
  • Allowable blood loss
  • Estimated blood loss
• Be able to accurately complete an anesthetic record that is fully medicare-compliant.
• Assess patients for readiness for extubation and extubate patients safely.
• Safely transport patients to the proper post anesthesia care unit following the operative procedure and provide proper report to the caregiver.
   

MEDICAL KNOWLEDGE: 

• 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
• 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).
• List at least 3 differential diagnoses and rationale treatment plans for the following:
  • hypertension
  • hypotension
  • hypoxemia
  • hypercarbia
  • hypothermia
  • hyperthermia
  • high peak airway pressure
  • bradycardia
  • tachycardia
  • ST-T changes
• Know criteria for safe extubation of patients emerging from general anesthesia.
• Be able to explain the steps in preparing a patient for induction of general anesthesia from meeting the patient in the preoperative area to completion of intubation including but not limited to:
  • Chart check prior to giving any medication
  • Placement of an intravenous catheter and assuring proper operation of the IV.
  • Administering premedicant drugs
  • Appropriate placement of standard ASA monitors
  • Preoxygenation and how to determine if preoxygenation is adequate
  • Administration of induction agents – sequence and dose for hypnotic agent, opiate agent, muscle relaxant, and any inhaled agents used during induction
  • Intubation
  • Finishing touches to be completed prior to the maintenance phase (securing ET tube, eye care, any additional monitors, warming devices....)
• List key elements of an anesthesia record including starting times, event times, ending times, ASA status, and all other items listed in the housestaff manual.

INTERPERSONAL AND COMMUNICATION SKILLS   (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. 

PROFESSIONALISM  (See general competencies section)

PRACTICE-BASED LEARNING AND IMPROVEMENT  (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.

SYSTEMS-BASED PRACTICE  (See general competencies section)

Evaluation:  During this period, you will be monitored carefully by the resident with whom you are paired and by the faculty with whom you work.  The program director  (Shands, FSC) or rotation director (VA) will speak weekly to both you and your pairee to determine the appropriate timing and method for moving on to the unpaired, S1 or VA general OR rotation.  Your pairee will complete a written evaluation at the end of each week which will be returned to the program director. 

EVALUATION TO DETERMINE GOAL ACHIEVEMENT

The following evaluation form is completed weekly for paired residents.  The form is completed primarily by the paired resident's supervising senior resident with input from faculty.  The forms are reviewed weekly by the program director (who also observes performance) and determination is made whether the resident is ready to be unpaired and function directly under facutly supervision. 

Weekly Paired Resident Performance Evaluation and Checklist                                   Date:   
Resident Name:                                                            Experienced Trainer Name:

 

Knowledge / Task       Performance Level (1 = Independent  2 = with assistance  3 = Unable to perform or not observed)

 

Preparatory skills:                                                                                              1            2            3

1. Can perform the preoperative evaluation of the patient or

    assess the adequacy of preop evaluation by

    someone else.  Includes assessment of the airway.

2. Prepares machine and equipment;  Room setup

3. Selects drugs and prepares workstation

4. Sets up IV including setup of routine fluid warming

5. Meets patient and has positive, comforting interaction

6. Can evaluate chart for consent and any needed information

7. Can select and administer appropriate premedication

8. Can place an IV catheter; hooking up appropriate fluid

 

Induction skills

1. Places routine ASA non-invasive monitoring (including BIS)

    correctly and efficiently.

2. Knows drugs and dosages commonly used for induction of anesthesia

3. After induction of anesthesia, can mask ventilate the patient

4. Able to properly place oral or nasopharyngeal airway devices

5. Using either a MAC or Miller blade – able to intubate the

    normal airway and able to confirm proper placement of the ET

    tube.

6. Able to properly place a laryngeal mask airway

 

Maintenance skills

1. Able to establish appropriate mechanical ventilation - includes

    basic operational knowledge of anesthesia ventilators and the

    appropriate ventilator settings

2. Able to appropriately adjust anesthetic agents during different

    phases of surgery

3. Appropriately titrates neuromuscular blockade using

    neuromuscular blockade monitor – includes knowing when

    neuromuscular blockade is needed, when it is not, and when it

    is inappropriate. 

3. Accurately and completely fills out a medicare compliant

    anesthesia record.

4. Knows proper use of basic vasopressors including ephedrine

    and phenylephrine.

5. Assesses patients for readiness for extubation – includes clinical

    assessment of adequacy of reversal of neuromuscular blockade

6. Able to safely extubate patients and assess immediate postextubation

    ventilation

7. Transports patient to PACU and gives the receiving nurse an

    appropriate, and accurate report. 

8. Assesses patients for adequacy of ventilation and pain control, and

    appropriately assesses hemodynamic status on arrival to

    PACU

 

TOTAL SCORE:  (ranges from 22 to 66)  Consistent scores under 30                   _______

                             suggest readiness for unpairing)

 

Revised 7/2005

 

Text:  Stoelting and Miller.  Basics of Anesthesia ("Baby" Miller text)

Faculty:  All UF Anesthesiology Faculty participate in this rotation.  The faculty member responsible for this rotation is Dr. Mahla at Shands and FSC and Dr. Kirby at the VA.

Revised 8/2005