Table of Contents
Introduction for CA-1 Residents; “Basic Expectations”
How to set up a room
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What to do at a code
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General OR - University of Colorado Hospital (UCH) 8
Children’s Hospital Colorado (CHC)
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Obstetrics (Labor and Delivery) - UCH 57
Useful websites
75
Reading/Preparing for Boards 77
Maps 79
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Foreword
ANNIE SLAUGHTER, MD & JAKE LOYD, MD
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Throughout its many versions, the "Little Green Book" has served as a valuable resource for anesthesiology
residents at the University of Colorado. We pride ourselves on fostering a team environment within and
between resident classes, and this tool serves as a testament to that. Each section is written by a senior resident,
with the primary goal of making the transition to new hospitals and subspecialty rotations as smooth as possible.
It is not meant to replace the classic "heavy-hitter" texts as a source of fundamental anesthesia knowledge.
Rather, this book provides residents with important logistical details of rotations specific to our program,
including contact information, individual attending preferences, hospital logistics, and how to avoid common
pitfalls that prior residents may have suffered. Familiarizing yourself with this information ahead of time
hopefully avoids having to worry about the distracting particulars of residency, so that you can focus your
attention on mastering the science and art of anesthesia.
It takes a significant group effort to maintain this valuable resource from year to year, and we would like to
thank each of the contributors to the 2018/2019 "Little Green Book." We also want to give a special thanks to
the editor-in-chief, Kristin Barney, for coordinating updates for each section and compiling them into an
outstanding final product.
Please take advantage of all the hard work that went into this great resource. Feel free to contact the individual
section authors, Kristin Barney, or the chief residents if you have any questions or would like further
clarification on these topics.
Introduction for CA-1 Residents; “Basic Expectations”
SARA CHENG, MD, PHD; TYLER MORRISSEY, MD; KEN HOWARD, MD; NICK SCHIAVONI, MD
Here are some pointers to get you up and running. I know, they may sound basic, but people have gotten into
trouble multiple times in the past for not doing these things. Rather than getting pummeled with the “you
should have known” hammer, it’s just better to hear these things up front:
• Before starting at each hospital, try your very best to GET A TOUR of the place. At DH, Drs. Benish and
Miller give a great orientation and will hook you up with one of the residents to show you around. At the
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VA, Dr. Beck or one of the residents will show you around. At the U, it is best to find a resident to
a tour. At CHC, Dr. Notides gives a thorough orientation and you are not expected to go to the hospital
early. In July, you are not expected to have had much time to get an orientation before your first day in the
OR. Later in the year, before your first day at a new hospital, PLEASE be proactive and arrange with
someone to get a tour. You can do it before call, post-call, or after your scheduled cases with the on-call
resident. Do NOT be the guy/gal who shows up at 3 PM on their first day for their first call and doesn’t
know where the OR is, where to get drugs, etc. etc. – it is painful for you and un-cool for everybody
involved. Believe me, it’s happened!
• Each day, you should find the next day’s OR schedule (emailed to you or on EPIC at the U/CHC/DH, on the
lounge table at the VA). This usually comes out around noon every day. LOOK UP YOUR PATIENTS on
the computer and fill out what you can on an H&P, including pertinent labs and imaging. Past anesthetic
records are readily available on the computer at all sites (can be tricky to find at DH) and are always useful.
Then, try to FORMULATE A BASIC PLAN in your head for each patient (see below). Then, either FIND
OR CALL YOUR ATTENDING about tomorrow’s cases. CA-1 year, you should always call your
attending to go over the plan for each patient – this is a basic expectation. It gives them a chance to go over
stuff before the busy morning and relieves their anxiety as much as yours. If they don’t answer, leave a
brief message with your plan. If they don’t call you back, at least you fulfilled your obligation.
• Presenting to your attending:
• Brief one-liner: (age) year old (M/F) undergoing a (surgery) with Dr. (surgeon).
• Pertinent HPI: Why are they getting the operation? Prior treatments/operations? Pertinent imaging?
• Significant PMH: systems based with pertinent medications, labs, imaging
- Example: PMH significant for GERD on omeprazole; anemia with a baseline Hb of 9.2; HTN well controlled
on Lisinopril 10 QD (last BP in clinic note); a-fib taking metoprolol 25 BID, successfully rate controlled on last
ECG “date”; CAD s/p DES to the RCA on “date” currently taking ASA and plavix, previously negative stress
test (give results and date; look for an echo), current smoker with a 30 pack year history, chronic pain on
oxycontin 20mg BID, T2DM on glargine 35u QHS and SSI.
• Significant PSH, including any prior anesthetic records (paying particular attention to prior airway note,
induction medications, any significant hemodynamic shifts requiring vasopressors or vasodilators, etc)
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Formulating a plan:
1. Be sure to consider and incorporate the patient’s comorbidities into each section
2. Pre-op:
- Further questioning (Assess GERD severity to determine if patient needs RSI, frequency of
inhaler use for asthma, severity of PONV history, etc).
- Any pre-op meds (scopolamine patch, nebulizer, PO APAP/NSAID/Lyrica).
- Any pain procedures (nerve block/epidural)?
- Any labs (type and screen or blood preparation)?
3. Intraop:
- What kind of anesthetic (general, neuraxial, regional, local anesthesia, MAC).
• If a general, what kind of airway (ETT vs. LMA)
- Induction plan (IV vs inhalation, RSI vs Standard).
• Know drug dosages and order of administration
- Additional lines (Central line, 2nd IV, arterial line)
• Arterial line indications (beat to beat variability, inability to get cuff pressure, frequent lab
draws)
• 2nd IV if running TIVA, expect significant blood loss, arms tucked/prone, bored and want
practice, etc.
• Central line if expecting significant blood loss, use of vasoactive drips, poor peripheral IV
access, etc.
- Plan for muscle relaxation, pain control, and PONV prophylaxis
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Every morning, every case: PREPARE YOUR ROOM (see next section). SEE THE PATIENT &
OBTAIN CONSENT. Look at vitals, do a focused physical exam of the heart/lungs/airway. Find and talk to
your attending. Once you and OR nursing are ready, administer pre-med if appropriate and bring patient
back to OR. Make sure to take the patient chart with you. Get your monitors on and start preoxygenating. Call your attending (or overhead page) for induction.
Turning over a room in 30 minutes or less should always be your goal. That means time from patient out of
room, to the next patient in the room! At the University, this is much more strict, with OR nursing pushing
you to hustle. It’s always wise to plan ahead, because you’ll find that 30 minutes is not much time! Any
extra work you can get done before your first case is a bonus.
Turnover workflow:
PACU or ICU to drop patient off
Handoff to PACU RN staff, write post-operative note
Drop off or waste controlled drugs from previous case, get new controlled drugs
Back to room, brief machine check (see below – How to Set Up a Room), and any additional room setup,
including any additional drugs.
Pre-op for next patient, obtain consent (if your attending hasn’t already), confirm the room is ready, and
you’re off!
How to set up a room
SARA CHENG, MD, PHD; NATHAN LAMBORN MD, MBA; NICK SCHIAVONI, MD
Setting up your room each morning and in between cases can seem like a routine chore; however, take
advantage of this time to set up your work station in a manner that ensures the delivery of a safe and effective
anesthetic. You have some leeway in minor details, such as where you put your roll of tape, but there are some
essential components and equipment checks that must be done for EVERY CASE. As anesthesiologists, we are
always trying to expect the unexpected, and to do this, basic preparation is imperative. Your plan (as outlined
in previous section) is very fluid, and you must be prepared to change gears at any moment. A routine MAC can
change to a general at any time if the patient is too squirmy, the spinal wears off, the patient becomes apneic,
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etc, etc. A thorough, organized routine and mental checklist can help ensure yourself that you are adequately
prepared for each case. YOU are ultimately responsible for the availability and functionality of all equipment,
sensors, alarms, etc. This is how we do it but there are many ways…
1.
Turn on your machine. If your machine has an automatic start-up protocol, start it and follow the
directions. Otherwise, start the oxygen sensor calibration, as this takes some time.
2.
While that’s going, set up your drugs:
• Emergency drugs to have drawn up or have unopened vials placed next to labeled syringes:
Succinylcholine 5cc@20mg/ml, Ephedrine 10cc@5mg/ml, Atropine 2cc@0.4mg/ml,
Glycopyrrolate, 2cc@0.2mg/ml, several Phenylephrine syringes10cc@100mcg/ml.
At the U the phenylephrine sticks are in the top drawer of the drug cart, in the multiple pyxi in
preop and sterile corridors, or at the pharmacy window. They are in the common OR fridge at
the VA and in the in-room pyxis at DH.
• Induction drugs – draw these up if you’re planning to do a general anesthetic. Usually propofol
20 cc@10mg/ml X2, occasionally etomidate if CV unstable, lidocaine 5cc@20mg/ml if using
propofol through a peripheral IV (propofol burns!), rocuronium 5-10 cc@10mg/ml.
• Narcotics etc. – fentanyl, midazolam, hydromorphone – usually at least 2 mg of midazolam and
250mcg fentanyl. Avoid midaz in folks >70 yo
• To work ahead you can draw up 4-10 mg decadron and 4 mg ondansetron.
• To really work ahead make empty syringes for subsequent cases
• Whatever else you and your attending have discussed.
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Finish machine checkout:
• Reattach your oxygen sensor.
• Check that monitor is on and displaying appropriately.
• Check that backup oxygen canister is full.
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Check that the vaporizers are full, that the vaporizer you want (i.e. sevoflurane, isoflurane,
desflurane) is present and that the dials turn.
• Check that all gas flow knobs work by turning them all on, then turn air off, then turn oxygen off
– when you do, nitrous should also turn off (safety mechanism).
• Check for a circuit leak.
• Check that the gas sample line is connected and patent (blow on the end through your mask to
see CO2 appear on monitor).
• Check CO2 scavenging canister – if it is purple, you likely need a new one!
4.
Monitors: Put pulse ox and BP cuff at head of bed or on the ET tube holder. Place EKG leads on bed –
for 5 lead- green and white on right. If using invasive monitors, make sure you have transducers in the room
and connected to the monitor with tubing wet down & zeroed. The anesthesia techs can help you with this. If
using other noninvasive monitors (such as BIS, Sedline, or cerebral oximetry), make sure that you have the
monitoring device in the room. The anesthesia techs can also help you with this.
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Etc: Make a bite block from rolled 4X4s, pick out a temperature probe (nasopharyngeal or esophageal),
+/- OG tube, get tape to cover eyes, make sure suction is on and placed at head of bed. Make up 2nd IV kit and
materials for A-line when appropriate. Consider videolaryngoscope or bed ramp if obese or difficult airway.
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Airway (SALTT)- Suction on and at head of bed, Airway (oral) in 2 sizes, Laryngoscopes with 2
different blades and lights working, Tube (endotracheal) in 7.0 and 8.0 sizes with balloon tested, syringe
attached, and stylet available, Tongue depressor. Also, it’s always good to know where the emergency LMAs
are located (in the room or in the anesthesia workroom, depending on your site), where the boogie/eschmann
is, where the Ambu bag is.
Some favorite mnemonics:
MSMAIDS: machine check, suction, monitors, airway, IV access, drugs, special/specific to case.
MMM SALT: machine, meds, monitors, suction, airway, laryngoscope, tube.
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All Electric Gadgets Need Proper Stimulation (emergency meds): Atropine, Ephedrine, Glycopyrrolate,
(neostigmine), Phenylephrine, Succinylcholine
As always, go over all this with an attending or senior resident during the first week. It seems like a lot but
you’ll be able to get it done in 15 minutes eventually.
What to do at a code
SARA CHENG, MD, PHD; BRIAN DUGGAR, MD; BRENNAN MCGILL, MD; KRISTIN BARNEY, DO
After you have been a CA-1 for about a month, you will start taking overnight call and will sometimes hold the
airway pager. At UCH, the airway pager is held by anesthesiology residents in the following order: SICU
resident first, CTICU resident second if the SICU is being covered by a surgery resident, OR call resident third
if both ICUs are being covered by surgery. At DH, it is always held by the call resident. Before your first time
holding the airway pager, familiarize yourself with the location of the airway boxes (one at the OR front desk,
one in PACU, one in each of the ICUs).
The airway pager can go off for a few reasons. These include a code, a code pager test (call the operator and tell
them you got the page), an urgent intubation, or someone calling because they need sedation for a procedure
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and don’t know any other way to get in touch with anesthesia. When the airway pager goes off for real,
be a text-page that says CODE BLUE with a patient location. When you see this message, do the following:
1) Go get the closest airway box
2) Consider grabbing a CMAC from the OR if you are not going to the ED or an ICU (there is a McGrath in
the airway box-usually)
3) Call the main OR charge attending (in the Cisco phones under AIP CHARGE MD at 85920)
4) Go to the patient’s room
Your job at a code is to manage the patient’s airway and intubate if needed. When you arrive at the patient’s
room, announce your presence as the anesthesiology resident and ask loudly if an airway is needed. If so, place
yourself at the head of the bed and prepare to manage the airway. Remain calm and remember that after 30 days
of being an anesthesia resident you likely know more about airway management than most of the people in the
room. Sometimes there are residents from other specialties (Internal Medicine, Emergency Medicine, etc.) who
wish to intubate. Clear this with your attending and stay until there is a definitive airway.
Try to bag-valve-mask with a one handed technique but have a low threshold to switch to a two handed
technique with someone else squeezing the bag if it’s difficult with one hand (RT is always present at codes).
Think about placing an oral airway or nasal trumpet if one is not already in place. As you are bagging the
patient, try to assess the airway. You won’t be able to do a formal airway exam, but you can still look for things
like morbid obesity, no neck, c-collar, etc.
Ask others to assemble intubation equipment: suction on and within reach, laryngoscope/videoscope,
endotracheal tube, free flowing IV, drugs (induction agent and paralytic). Ask about contraindications to
succinylcholine (hyperkalemia, crush/burn injury, SCI, etc). You typically don’t need to use an induction agent
if the patient is unconscious. If the patient is awake, use etomidate over propofol unless the blood pressure is
very stable. By the time your airway equipment is assembled, your attending should be there.
You shouldn’t interrupt chest compressions to intubate. Intubation needs to happen during chest compressions
or during the 10 second pulse/rhythm checks. If you don’t think you can get it done during compressions or
within the 10 second window, just keep bagging the patient until ROSC, then do it immediately once they have
stopped compressions (keeping in mind that sometimes ROSC only lasts a few seconds before compressions
have to be resumed).
Always take the time to position the patient optimally for intubation, just as you would in the OR. Even if
everyone looks very busy and they are in the middle of chest compressions, move the bed away from the wall,
adjust the height, and boost the patient up in the bed towards you. It could be the difference between a first shot
successful intubation and an initial failed laryngoscopy that gets bloody and more difficult. Once you’ve
successfully intubated, hold on to your tube for dear life until it is safely taped as it can easily come out during a
code.
If the airway bag was taken from the OR, put it in the tech room so it can be restocked. If it was taken from an
ICU, either call the overnight anesthesia tech or call the dayshift anesthesia tech first thing in the morning to
come stock the box.
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General OR - University of Colorado Hospital (UCH)
ZACHARY BRYAN, MD; CRISTINA WOOD, MD; BETHANY BENISH, MD;
COLBY SIMMONS DO, MBA, JUSTIN MERKOW MD, ERIN ROSS DO.
Important people:
Program Coordinators:
Christine Cook, Office: 303-724-1758, Fax: 303-724-1761, Email: Christine.Cook@ucdenver.edu
Kathy Riggs, Office: 303-724-1765, Fax: 303-724-1761, Email: Kathy.Riggs@ucdenver.edu
Medical Student Coordinator: Krystle Wetherbee, Office: 303-724-8373, Email:
Krystle.Wetherbee@ucdenver.edu
Anesthesia IT: Ken Bullard, Email: ken.bullard@ucdenver.edu.
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Phone Numbers:
UCH Main Hospital Number: 720-848-0000
AIP Charge: 720-848-5920
AIP Charge RN: 720-848-4351
OR Rooms: 307 + OR # (Ex. OR 3 is 30703)
Before you start:
• You must have your ID badge (use it for parking, getting scrubs and getting through doors), codes for Pyxis
(talk to Clark Lyda at the OR Pharmacy window for problems with Log-in), and of course EPIC (which is
the same user name and password as your UCD webmail. Every time you change this in one system it
changes it in the other)
• When in doubt, call Christine, Kathy or the chiefs. They are lifesavers. Call a resident who is over at the
University to give you a tour before starting.
• Pre-ops can be done from home, if you haven’t already done them in the OR. This is accomplished by going
to https://virtue.ucdenver.edu. First click on the UCH Citrix apps tab on the Left hand side under "Important
Links". You can also go directly to the website: https://myapps.uchealth.org . Bookmark this page on your
home computer and it will save you time in the future. Log-in using your webmail username and password.
(The first time you log-in you will have to download Citrix to run EPIC. A link is posted for both Windows
and Mac operating systems. Click this link and follow the instructions.) To log-in to EPIC PRD icon and
log-in with your EPIC (same as webmail) username and password. Go to the OR board as you normally
would and find your patient cases.
EPIC:
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Learning EPIC, the intraoperative charting system, is paramount before starting a case. If this is your first
month of CA-1 year, you will have an orientation scheduled for you at the University during orientation.
You will have a couple weeks with someone paired and you’ll be a pro in no time!!!
The system itself runs off the UCH OR board. To make sure this is your setting, click on the EPIC tab at the
top left, find change context down towards the bottom and make sure your name is located under provider
and that ZZ ANESTHESIA is below under department. Click ok and this will bring you to the Status Board
setting window.
On the OR Status Board all the cases for the day will appear in order of room number; add-ons appear at the
top until they are assigned to a room. For the main OR, you will want to have the AIP Intra-op Status board
or AIP all areas selected. Under the location tab it will show you the areas that will appear on your status
board- this tab should always show "AIP Operating Room" (which are the main ORs) and AIP Ancillary
Operating Rooms which shows cases posted for EP, IR, Rad sedation, cath lab and GI in addition.
To get you to the cases that you have been scheduled for in the EPIC system, you can select My cases direct
to the left of All ORs.
If you have any difficulties with EPIC or want to try and schedule EPIC training please contact Leslie
Jameson, MD directly (720-848-3273) or via email (which I recommend).
If you don’t start at the U, make sure to come in and have a resident show you the ropes prior to your
first day. Orient yourself with the anesthesia machine and learn where things are stored on the
anesthesia carts.
Weekday Daily Work Flow:
• Complete pre-ops the day prior and call to discuss pertinent topics/anesthesia plan with your attending the
next day. Work and personal cell phone numbers are available on the virtue webpage. Click the "Pocket
Phone Card" tab under Important Links. They will not always answer and may not call you back, but is your
responsibility to make every effort to reach them
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• Pre-op’s should include: PMH, labs, EKG, CXR, TTE etc. from EPIC. You will complete the Anesthesia
pre-op evaluation note. Pertinent information can be found under Chart Review, Patient Summary,
Anesthesia Records, among many others.
o The pre-op note can be found under the Pre Op tab, which is found at the left column of selections.
Click on "Anesthesia Pre Op Eval" to open note. When you select this, it will open a template that
you can directly select + / - on selection under each organ system. To add procedural information of
pt. history specific to the diagnosis (like for example hypertension or sleep apnea) click on the actual
diagnosis and a single line box will appear that will allow you to type history that you want to
include in your pre-op. Try to be as inclusive as possible for this. The next screen you will need to
complete is the physical exam, which can be filled out by clicking at the top left the physical exam
tab. You basically go through and click the tab that fit each portion of the physical exam. Just like on
the previous history tab, you can click on each individual part of the physical exam to add hand
written notes (for example, description of a murmur heard on cardiac exam). The final tab of the
three to be filled out is the anesthetic plan. Here you click the appropriate boxes for ASA status,
additional case details (arterial lines, fiberoptic intubations etc.), as well as consent (that it has been
done). After you are done, you will sign by clicking this button in the lower right corner.
▪ Should you need to update or edit any additional information, you can find your pre-op on
the pre-op page at the bottom and by hovering over the area an update button will appear.
Click on this button and your pre-op will appear. You can edit any portion of it and sign as
you previously did to save all changes.
▪ If there is a recent pre-op from another procedure/surgery, you can click on the notebook
with the arrow pointing right labeled "copy note", found on the upper right corner of your
pre-op after you open it. This will copy all information from the previous anesthesia record
and you can update pertinent sections as needed. Remember to delete old text regarding
procedure and plan.
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Give yourself at least 30 minutes to set-up your OR before any morning conferences:
o Monday- Grand Rounds 6:45
o Friday- Cardiac lecture 6:30
Arterial lines: Pressure bags and transducers are located in the Anesthesia workroom. You can call the
anesthesia techs if you need one emergently, but it is your responsibility to set up you’re a-line if you know
about it in advance
Be sure that if you need infusions you have all the pumps you need in the room. Pumps can usually be found
in each room. Extra channels are usually located in the Anesthesia workroom or you can call one of the
techs prior to your start. Prime all drips and place them on “hold”, ready to just hit run once induction is
complete. Always keep an extra channel for the possibility of pressors or addition of other agents. Make
sure that you change the mode to the "anesthesia mode" under the options.
In prone cases, be sure to check that you have a prone view pillow. Ask the techs or grab one from the
workroom. You will start an extra IV for most prone/spine cases that require TIVA.
Get patient’s narcotic bag from Pyxis in Pre-op or from the pharmacy (It is called Narcotic Bag on the list)
and includes (with recent shortages the amounts below may change, always look at each bag closely!).
EPHEDRINE is now a controlled substance at UCH.
o 2 x 2mg Versed
o 2 x 250mcg Fentanyl
o 1 x 2mg Dilaudid
o 2 x 200mg Propofol
o 1 x 50 mg Ephedrine
Other meds like Phenylephrine/Mannitol/Nimbex/Heparin/Insulin are in the Pyxis/refrigerator in the
substerile areas between the ORs and premade phenylephrine syringes are in the pre op pyxis (where you
get your narcotic bag) or the top drawer of the anesthesia cart. Sufentanil syringes are at the main OR
pharmacy. You can always call the pharmacy (86132) to make up a drip for you. Remifentanil is in the
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pyxis, it can be made up in 1mg or 2 mg/40 ccs for the low and high concentrations. Clark Lyda, the head
pharmacist, is always an excellent resource for any and all drug-related questions. All emergency drugs are
in your cart in the OR. When adding extra narcotics or pulling out meds for a TIVA be sure to re-list the
added meds you pulled out for the patient to your total on the narcotic bag. Example for a TIVA: get a large
clear bag and write out what you pulled in regards to propofol on it. You can easily return the un-used
propofols in the large bag…. It also makes for easier accounting. Remi and Sufenta can be accounted for on
the other narcotic tab on the narcotic bag. You can always pull out more narcotics for patient cases, just be
sure to be diligent about accounting for them.
Make sure you get EPIC loaded up in the OR before you head to pre-op; you will want your intra-op screen
for the case going into the OR up. You’ll click the anesthesia machine check on the intra-op record when
you have done that before going to pre-op. Having this up will also allow you to click the next buttons
easily as soon as you enter the room with the patient.
o One thing you want to check early is that your anesthesia machine is validated to the correct
workstation in EPIC. If you look at the top right of each monitor where the vitals are displayed, each
will have a label with UCH OR then a two-letter state. On the top left of the strips buttons located at
the left of the intra-op record is button called Mon Caps. Here this label and state should be
displayed. If not then search for it in this window and add it. Once added correctly it should appear
to the left.
Arrive in Pre-op around 6:45-7:00 (8:00 on Mondays).
Find your patient. (The EPIC screens in pre-op show the bay number.)
o Complete pre-op H&P in EPIC while talking with the patient. Nurses chart vitals in the patient EPIC
chart and you should be the see those on the main pre-op page. If not just ask and they can help you.
o Fill out the Pre-op Orders (this should be done the night before when completing your pre op note).
Nurses need official orders to start the PIVs, hang IV fluids, EKG, labs, scopolamine patch prior to
case starts. The pre-op order set can be found under the order tab when you first open the pre-op
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page at the top (with the other tabs you frequently use on the pre-op page). The order sets can be
found by searching within the box labeled "order sets". To add sets to your favorites, you can do so
by right clicking over the order set and clicking "add to favorites". You want “UCH pre-op
anesthesia.” Plasmalyte is ordered for most cases in the AIP. “UCH PACU Post-op” is another
you’ll want to add as you’ll use it daily.
• If any labs are needed… especially a type and cross/screen, try and make sure you order
those the night before.
o Consent the patient. (Check with attending about type of anesthesia first). The consent is found at the
front of the chart.
o Start IV if not done already (rare). Try to put in 18 gauge or larger. PIV kits can be found at the
bedside and IV fluids primed and ready to go are found around the Pre-op front desk. If you need
anything else, just ask!
o Verify antibiotics and that they are on the bed, or on the way to the OR.
o Check with patient’s nurse and the OR nurse before wheeling out. This allows them to mark an out
time. You can call the circulator RNs directly, there is a phone for every room. The numbers are
posted in pre-op or in the ORs, but are generally 863 + OR # (Ex: OR #12 would be 86312). The
new OR’s (26-30) are 307 + OR #.
Once in the room, get patient moved over and start pre-oxygenating first!
EPIC has buttons that allow charting to begin once the patient is in the room. These buttons are located on
the lower left of the intra-op record. After clicking the "anesthesia machine check" tab, the next tab is
"anesthesia start", followed by "patient in room" and "immediate pre-induction check". Click these buttons
as soon as you’re in the room. This will start the charting once vitals are collected as you start the case.
• If your vitals don’t move over or you forget to click these buttons, you can still collect vitals by
validating the vitals located in each monitor….. they save them, thankfully! By clicking on the "Mon
Caps" button again, your monitor will be displayed at the left. Click on the monitor and a chart of
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your vitals will appear. Click the upper left corner of this chart and it will highlight all the vitals
within the box in yellow. Click "validate" to add these to the patient record (alternatively, you can go
through and highlight them individually and drag the yellow area over vitals you want included). I
recommend playing with this feature as a lot of times the vitals feature of EPIC is down and you can
manually add vitals into the record this way (instead of manually entering them).
Put on monitors. Start BP.
Call your attending to tell them you are in the OR. All communication at the U is via cisco phones. Have all
the induction drugs ready to go, even plugged into the IV line. Do not push the sedative drugs yet, however
titrating in fentanyl will allow it to work by the time you are ready to start induction.
Your attending will come in for the induction....have fun!!
After induction, begin charting. Everything is charted in EPIC through buttons located on the left of the
record. They are all pretty self-explanatory. Go through each and chart the specifics of each case. Meds is
probably the most crucial along with the intubation. Common meds can be charted through a macro
(Reminders: AIP Inductions Meds or AIP Standard induction). You can also input meds manually as well
through the meds tab. Gtts for TIVAs are under infusions. You just need to familiarize yourself with all of
these functions prior to starting a case.
Make sure you complete the PACU orders before going to PACU (can be done any time in the case). This,
like the pre-op order set, is something you will want to add to your favorites from the orders tab. Search
PACU post op order set and add to your favorites. Make sure to sign them when done.
Click “surgery end” when it happens.
Call attending prior to extubation, no exceptions. If they don’t show up immediately or give you a
time frame then make sure to call again!
After you extubate, fill out the extubation tab/LMA removed, then click “out of room” as the last thing you
do before you leave to PACU. It’s after “patient transported with oxygen.”
•
•
•
•
•
Transport to PACU (remember to ask the OR circulator the PACU bay # you are going to before leaving the
room). Complete Post-op note and give brief report to PACU RN: IVFs, drugs, drips, complications, special
orders.
Finish EPIC Record by putting TGF to 0, stopping all IVF with total volumes, finish charting any meds
given in PACU, write your extubation note, write your post-op note, and fill in EBL / Urine output. Open
your intra-op record for the F sum button, at the end of your case time, and total all fluids given. Remember
to click “Anesthesia Stop” which you will find under your post op note.
Write your totals on narcotic bag; make sure they match EPIC totals. No needles! Only blue caps!!!!
Drop it off in the metal box next to the Pyxis in Pre-op or next to the pharmacy window with a patient
sticker! Get meds for the next case. (If you have quick cases, you may want to pull out multiple narcotics
first thing in the morning).
Usually will get “coffee” (15min. morning around 9am), lunch (30min. 1100-1300), and “tea” (15min.
afternoon around 1500) break.
The OR schedule with anesthesia assignments comes out around 12pm. It is emailed to us as a PDF and
hard copies are available at the OR desk. Look up patients for the next day and call your attending the night
before to discuss plans. See all inpatients the night before and have the consent signed. A good habit is to
call your attending to discuss the case for the next day prior to going home. That way it’s all done, and you
have the rest of the night to study up.
Weekday Hours:
• R1: This means overnight call: 3pm-7am. You will finish all of the late cases for the day and all of the
emergency overnight cases.
• 12 hour: Normal am-7pm: Start with the first cases of the day and you are in house until 7pm.
• O: You usually finish and can leave after you have finished your cases, or about 3-5p. If you finish
early, always check with the charge anesthesia attending to see if you are needed elsewhere.
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Call Nights/Weekend Call:
• On weekday call nights, arrive ready to start a case at 3pm. Check OR board and/or with Anes Charge
(85920) to see where you’re needed (usually your name will be written in red on the main OR board to tell
you your assignment when you arrive). Keep your pager/Cell on during the day; they may need you to come
in a little early if they are very busy (rarely, if ever, happens).
• Weekend call is a 12 hour shift, changing over at 7am/7pm.
• Call Room: Located on the 2nd floor between AOP and AIP. Room # 2016.2 and 2016.3. Code is 0623 or
101010
Code Pagers/Badge:
• When on call, you sometimes carry a code/airway pager with a badge when a STICU/CTICU anesthesia
resident is not on-call. This badge should let you into any door and elevator. The ICU resident carrying it
for the day is responsible for bringing you the pager.
• Codes (See Section “What to do at a code”): Your responsibility is the “A” of the ABCs. Get to the head
of the bed, assess need for airway intervention. It’s OK to push RTs, RNs, and other residents out of the
way. Before intubation remember “VISA” V-ventilator or ambu-bag ready?, I- patent IV functioning?, Ssuction ready?, A- airway tools available? Always remember to grab the Airway Box prior to heading to
the code location.
• Airway Box Locations: 1) main OR anesthesia workroom, 2) in PACU, 3) in STICU located at main
nursing pod, 4) CTICU by the signout room
• You will carry the trauma pager when on call at UCH as well. If you are not in a case, you should go
down to the ED for all trauma activations (more to come on this as UCH will soon be a Level 1 Trauma
center).
University Phone Numbers
OR front desk
84351
RN Charge
83512
Pre Op
86252
PACU
86203
OR Pharmacy
86132
Anes. Tech
85912
Blood Gas/TEG
83169
Blood Bank
84444
University Codes
Locker Room: Badge Access
Staff Lounge (next to locker rooms): 04507#
Anes Work Room: 04507#
Leprino Call Room: 312
•
General OR – Denver VA Medical Center
HALEY HUTTING, MD; JOE PEETZ, DO; BARBARA WILKEY, MD; BENJAMIN ABRAMS, MD;
CARA CROUCH, MD; SHELBY BADANI, MD; GREG SCHMITZ, MD
Important People:
Head of VA Anesthesia: Ian Black – Cell: 307-221-0513
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Pre-op nurses: Shirley Pfister, RN, Mary Buckley APN, Terra Sharp APN.
Anesthesia Department controller: Donald Cranmore, Donald.Cranmore@va.gov
Attendings: Dan Beck (C) 773-744-4996 (P) 303-201-3846, Phil Pian (C) 617-909-8641, Mohammed
Javed (H) 303-993-3620 (P) 303-201-0347, Wayne Soong 312-485-3278, Mario Villasenor 210-364-6534,
Slobo Todorovic 434-806-9908, Kahlil Glenn 301-875-3332, Bonelle Klinger 305-302-2495
Phone Numbers:
Main Denver VA Medical Center: 303-399-8020
VA OR Nursing: 303-610-7983 (pager)
Anesthesia Office: 303-393-2883
Locations:
ORs: 4th floor, to the right when getting off main elevators (follow the signs)
Anesthesia department secretary’s office: 4th floor right next to the ORs
Pre-op/PACU: This is the same area, it is on the right once you go through the “OR Doors”
Locker rooms/Scrub Pyxis: Go to the right off the main elevators, you will see a little ramp with a badge
access door on your 2nd left (first left goes to ORs- you’ll see a bunch of equipment in the hallway)
SICU: Directly across from the ORs (there’s a “SICU” sign)
Before you start:
• You will need an ID badge, scrub card, parking hang tag, Omnicell access, and computer access. This
whole process will take several weeks, and likely 3-5 visits to the hospital. You should contact the
department secretary (Donald Cranmore) at least 6 weeks prior to starting there to make sure things
are in motion. There is a checklist of items you must complete, including fingerprinting, online computer
training, and applications for credentials. This is a very harrowing process and no one will be checking to
make sure it is proceeding for you. If you stall (and sometimes even if you don’t), you will be stuck trying
to get around without access for the first couple of weeks you are there. Not fun.
• 1-2 months prior to starting: go to the badging office and get your fingerprints done. You don’t need an
appointment, but they close at 4pm. After you get your fingerprints done, go to the HR building (820
Clermont Street, Suite 100) to get your WOC letter (you will need your passport or social security card for
this). Email Don prior to doing this so he can fill out the paperwork to “sponsor” you.
• 1 month prior to starting: Go back to the badging office to get your ID – YOU WILL NEED AN
APPOINTMENT (email Don Cranmore to have him arrange an appointment for you, you have to have an
appointment or they will not do anything for your even if they aren’t busy). Also, at this point you need to
start emailing Don to make sure that he sets up your computer access: you will need CPRS access (for
patient notes/info) AND Omnicell access (pharmacy/drugs access).
• 2 Weeks prior to starting: Email Don again to confirm that you have CPRS access and Omnicell access.
At this point you will need to make another trip to the VA (once you have your badge) and have Don set up
OR access for your badge. At this time, make sure he gives you your Omnicell login information. While you
are there, have Don take you down to the computer access department where they will give you an envelope
with your computer access codes and then go by the main hospital pharmacy to sign the narcotic
logbook. Go to a computer and make sure you are able to log in, also go to the Omnicell in the preop area
and make sure you are able to login to this as well (these are the two most important things). To get
fingerprint access, you will need to talk to the head Anesthesia Tech.
• Before you start you should have (1) your badge, (2) Omnicell access (VERY IMPORTANT), (3) CPRS
access, (4) OR access for your badge, (5) Scrub card (You may be able to get a scrub card from the outgoing
resident, coordinate with them), (6) Parking Pass.
• You need to pick up your parking card from Christine Cook. The current parking lot is located in the
Condos across 9th from the VA at the intersection of Clermont and 9th.
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• If you don’t have a parking pass, you can park at the Rose Medical Center parking deck and walk 2
blocks to VA.
• Again, having Omnicell access is essential prior to your first day (you really can’t do anything without
it), work with Don to help him understand how important this step is.
• Bless him, but emailing and/or calling Don does not guarantee that he will start getting everything set up
for you. If you do not explicitly get a response from him, you should probably just stop by the VA and
personally talk to him or someone about getting everything started.
Weekday Daily Work Flow:
• The pace at the Denver VA Medical Center is a little more leisurely than it is at the other hospitals, but
they are really trying to get cases started on time and speed up turnovers as much as possible. You can
definitely help the process by putting gentle pressure on the OR nurses to get the room turned over, for
example, by letting them know that you are ready to take the patient back (or once you get to know them
better, suggest that you start taking the patient back “slowly”). On the plus side, the slower pace gives you
more time for placing blocks and lines without feeling rushed (check with your attending, but many will
appreciate getting an arterial line placed before heading back to the OR in order to save time; this is
something to consider later in the year once you have done a bunch asleep).
• The anesthesia techs here are very friendly, but you should definitely expect to be doing more of your
own turnover and set up compared to the other hospitals. It is always appreciated if you set up your own
arterial line for first case starts. Don’t worry, you will still not be the limiting factor for starting the next
case.
• Pacer magnets are on the fridge in the anesthesia workroom. You will have many patients with
pacemakers/AICD’s.
• You need to do all of your H&P’s the day before, including seeing any inpatients. Most of
the attendings prefer a quick discussion in person instead of a phone call later in the evening. You should
try to look up at least your first case during lunch so you can talk with them before they head home for the
day. The VA computer system is archaic, but very thorough once you get it figured out. Unlike the other
hospitals, you will not be able to access the system from home.
• Cases start at 08:30 on Monday, and 07:45 Tuesday through Friday. You no longer place your own
PIV’s in preop, but most of the time they are smaller than we want (20g or less), so be aware if you think
you need large-bore access. Also, plan for time to do any blocks or epidurals if indicated (see below). The
surgeons include anesthesia consent into their own, so you don’t need the patient to sign
anything. However, since the surgeons typically have no idea what we actually do, you should still review
your anesthetic plan and major risks with the patient when you meet them that morning.
• You will do all of your own nerve blocks and epidurals at the VA. The attendings expect to start the
procedures right after they meet the patient, usually around 7:15 or 7:30 (later on Mondays). To achieve
this, you need to have your room ready, your pre-op H&P complete, a functioning IV, and the patient needs
to be on monitors with nasal cannula flowing before your attending arrives. Try to let the pre-op nurses
know that you will be doing a regional procedure, so that they can put the patient in an area where monitors
are available. There are four groups that must see a patient before any sedation is administered - pre-op
holding nurse, surgeon (consent/marking), OR nurse, and anesthesia attending. Notify the OR RN if you
would like to proceed with a block that requires sedation and they have not seen the patient. Anesthesia can
site mark/verify laterality for a block if a surgeon is not available.
• Lectures: Mondays 06:45-07:45 is Grand Rounds. There is a sheet in by the computers with instructions
to log on and view grand rounds.
• All other days, lectures start at 06:30 and finish around 07:00. Each resident will give at least one
morning lecture, so check the schedule outside the conference room at the start of each month so you can
prepare.
• To contact your attending, have the OR nurse call overhead if urgent/emergent or just call/text
your attending on their cell phone.
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• All patients with planned admissions to the SICU go directly there after the case, even if they are stable
and extubated. This includes all patients with epidurals. Also, after hours and weekends, patients will go to
SICU for wake up because there are no evening/weekend PACU nurses. The SICU should send their own
transport monitors with the bed (we have the same monitors available in the OR, but they inevitably go
missing upon arrival to the SICU, which the anesthesia techs will give you a hard time about).
• On non-call days, you usually go home around 1530 - 17:00. On call days, you stay until the last room
is finished. You will have a post-call day if you stay later than midnight (this very rarely happens).
• Printed schedules for the next day are located in the conference room and by the scrub machine. They
are usually available by lunchtime. Changes are frequent, so make sure to check the white board in pre-op
for the latest schedule.
• Most patients will be seen in the pre-op anesthesia clinic. The N.P.’s in the preop clinic are all very
friendly, but do NOT rely on their notes for much more than a current medication list. Take the time to read
old anesthesia records, discharge summaries, cardiology notes, TTE’s, etc. on your own to make sure
nothing important has been missed.
• Since you won’t be able to look patients up in the OR or from home, the residents need to help each
other out with pre-ops. For example, if the resident on call is going to have a late night in the OR, the other
CA-1’s should try to look up their cases for them. The same goes when residents are on vacation, and need
their cases looked up for Monday. Be a friend- it makes life at the VA so much better.
Acute Pain Service:
• The VA is the only hospital that has you follow your patients outside of the OR as an acute pain
consultant. This means you will need to round on all peripheral nerve and epidural catheters that you place.
• The attendings understand that most CA-1’s will not have had an APS rotation yet, so they expect you to
ask them about pretty much everything. Don’t feel stupid asking ANYTHING.
• Any issues over night or on weekends will be handled by the on call team. As such, you should “sign
out” your catheter to the on call resident before leaving each day.
• It is a good idea for the on-call resident to check on the epidurals before leaving for the night- this can
prevent many phone calls at home and even having to return to the hospital later. Some attendings will grab
you and round on epidurals before leaving so you are both on the same page as far as a plan, which is very
helpful in the middle of the night. Make sure to ask about how to write epidural orders before going home
on your first call. CPRS is NOT intuitive.
• Each day, you will round on the patient, write orders, write a note in CPRS, and update the dry erase
board in the anesthesia lounge that lists all the patients with catheters.
• Epidurals can only be managed in the SICU, so patient transfers to the floor may an indication for you to
pull it. Peripheral nerve catheters can go to the floor in place. It is likely that your peripheral catheters may
go home with an On-Q system for continued pain control. Ask the attending you placed the catheter with
about how to manage these orders.
• Rounding: It is definitely encouraged to follow-up and help with seeing an epidural or nerve catheter
that you placed, however, there is now a team (consisting of a nurse named Wyatt and usually Dr.
Villasenor) that will round and write daily notes on these patients during the week. For the weekends, there
is a sample note in the binder they give you, and this can be used to figure out what you need to know on
rounds (pain at rest/exertion, PRN narcotic requirements, DVT prophylaxis, dermatome levels, infusion
rate, LE symptoms, acute events over night, etc). The peripheral catheters are less complex to round on—
big things here include DVT prophylaxis, and ensuring that you haven’t given a dense motor blockade that
might put them at a fall risk (eg. assess quadriceps function on femoral nerve catheters). You will then staff
your catheter with the attending that placed it with you, or the attending on call. Finally, write a brief note
following the template in your packet.
• Some peripheral nerve catheters go home with the catheter and a “pain ball.” You need to call them
everyday, and eventually walk them through pulling the catheter themselves over the phone. You still need
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to staff these patients with an attending, and write a quick “phone note” each day. There is no longer an
acute pain pager.
• Over the weekend, the call person rounds on all catheter patients (see below).
• There are both anesthesia intensivists and pulmonary/critical care intensivists that cover the SICU. The
former will do most of their own epidural trouble-shooting, as they understand you are in the OR most of
the day. The latter are mostly clueless when it comes to epidural management, so it is particularly useful to
see patients early when they are on service.
• The attendings understand it is nearly impossible to manage epidurals from the OR, so don’t be afraid to
ask them to cover your room briefly while you go troubleshoot.
• It is easiest to plan to pull epidurals around 10:00 am (4 hours after morning heparin, 2 hours before the
afternoon dose). Some of the nurse practitioners in the SICU will pull epidurals for you, so good
coordination and rapport with them can save you some work.
VA Computers:
• Get all codes for general access and CPRS access through IRMS (1st floor by Clermont entrance). Codes
expire after a few months, so if this is a repeat performance at the VA, you need to come in ahead of time to
get new codes. An application for your access needs to be submitted by the department secretary (Don
Cranmore), so make sure this is done before you show up.
• Make sure to set up a signature code in order to be able to sign orders and view images through VISTA.
• Talk to pharmacy if you are unable to write orders, you may need to sign some narcotic paperwork
through the pharmacy office.
Paperwork:
• Drop your anesthesia record in the PACU folders or with your PACU nurse. When you drop someone
off in the ICU, make a copy of your record to leave the copy in the chart. Then return the original record to
your attending’s folder in the PACU. There is also a folder in the PACU for blood product records.
• Intra-op: you should complete an anesthetic record, a time-in/time-out/antibiotic administration/beta
blocker sheet, and PACU orders, and a QI sheet. If you run out of room on an anesthesia record, there are
additional forms hanging in a folder behind the anesthesia machine.
• Blood gases are uploaded into the computer, but if you are going to check a few, it is also nice to have
the anesthesia techs print them out for you.
• Check VISTA Imaging in CPRS for previous anesthesia records. Also, if the patient has had an
operation within the last calendar month, you can check CPRS. Occasionally when a case is cancelled
(frequently at the VA), someone has done a pre-op and left it in the large file cabinet in the conference
room. Place your unused pre-ops here for your cancelled cases
• Post-op Orders are pretty standard and are generally placed by your attending.
• The VA is the only site with IV Acetaminophen at your disposal. It is available from the pre-op
Omnicell only, so grab your daily supply when you swing by.
Pharmacy:
• The Omnicell in the OR has most of the medications you will need, including narcotics. Notable
exceptions include larger propofol bottles and IV Tylenol. These are in the Pre-op/PACU.
• The PACU Omnicell can be accessed with your same codes.
• When finished with a case, waste your narcotics with an attending via the Omnicell CACTUS system in
the PACU. This can only be done with an attending as opposed to other residents/CRNAs, even an
attending that you didn’t work with. Even if you administer all of your narcotics, you still need to log into
the PACU Omnicell to record these amounts. However, you can do this on your own without an attending
to witness, and from any Omnicell station.
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• Equipment and most medications for peripheral nerve blocks are located in the block cart and nearby
cabinets in pre-op. Code for the block cart is 1-2-3, then turn the dial to the right. Block anesthetic records
are also in this cart and should be done for all blocks and neuraxial procedures.
• The OR pharmacy is not as available or efficient as the other hospitals. If you are going to need a special
infusion for a case the following day (eg. Octreotide), let them know the day before the case. They are
usually gone during lunch and for the day by about 3:00 pm, and are not there on weekends. There is an
Omnicell between OR 1 and 7 with various medications like antibiotics that the circulator nurse can access
for you. There is an additional Omnicell in the anesthesia work room with more “fancy” anesthesia
medications (vasoactive drugs, etc) that your attending can access for you. Of course, you have access to
both of these Omnicells and can remove medications on your own when you are not in the OR. Take a look
at both of these during your first week to get a sense of their contents.
• There is a refrigerator in the anesthesia workroom with various premade medications, including
cefazolin, vancomycin, phenylephrine (sticks and drips), and insulin drips.
• Nitroglycerin is in the refrigerator in one of the side rooms of OR 5.
Call & Weekends:
• Call at the VA is HOME CALL. Most people give Don Cranmore their cell phone numbers, which will
appear on AMION the day you are on call. It’s also worth making sure the nurses of patients with epidurals
have the correct number when you tuck them in for the night.
• When you are on call, you may receive calls regarding catheters/patients during the day. Your number is
listed on AMION (the call system) for that day and night, meaning sometimes you get random calls asking
about anesthesia things. If you are in the OR, just let your attending know the situation and they will help
orchestrate a solution.
• Get a copy of the call schedule from the bulletin board at the beginning of each month- it has phone
numbers for all of the attendings.
• On weekends, store extra scrubs in your bag as the machine will not be stocked until Monday morning.
• First: The surgery resident will call you when a case needs to go at night or on the weekend. Your
involvement in this step is essential for preventing delays. Ask about any major medical problems, vitals,
and lab abnormalities. Depending on the case, this is the time to make sure the surgery resident has ordered
appropriate blood products. It is also important to make sure the resident has spoken to the surgery
attending (this ensures that the patient actually needs surgery, and that you won’t have to wait an hour for
the attending to show up to the hospital). Some residents will call just for a “heads up” about a possible
case- clarify their intentions. You also need to make sure that the surgery resident has called the nursing
supervisor to mobilize the OR staff (The surgery resident should do this! Do NOT let them try to make this
your job.) Finally, ask which OR the nursing supervisor is planning to use, so that you know which one to
set up once you arrive. If this is not clear and you have a big set-up, begin setting up an OR and let the team
know which OR you have set-up.
• Second: Only call your attending about cases that are WITHOUT A DOUBT going to the OR. They do
NOT want to hear about possibilities for later on. Some attending want to be called immediately, some
want to be called when the nurses arrive. Clarify their preferences before you leave for the day (it is
typically a matter of how far from the hospital they live).
• You are expected to be within 30 minutes of the hospital while on call.
• Rarely, you will get calls for ED anesthesia or difficult airways. These should be immediately discussed
with the attending (do not come in first). When in doubt, call your attending in this situation.
• Try to clean up your anesthesia machine after night/weekend cases (pick up monitors, throw away
drugs, etc.). All drugs not stocked by pharmacy need to be removed from your work area at the end of the
day.
• Weekend call is also Home Call. You are expected to come in each day to round on ANY catheters that
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were placed during the week.
• On-call Acute Pain Service: Consider showing up to the hospital around 09:00 on weekend days, so that
you can evaluate patients and be able to pull catheters without issues involving their heparin dosing. You
may need to come in to the hospital to troubleshoot epidurals, especially if a pulm/critical care attending is
covering the SICU. Do NOT try to work through issues over the phone, unless an anesthesia intensivist is
involved. When in doubt, drive in to go see the patient. Call attendings with any issues (while they will get
annoyed by phone calls about “possible” OR cases, they expect phone calls about issues with
catheters). Note that calling an attending with trouble-shooting questions is probably an indication for you
to physically be at the hospital (an anticoagulation question is a common exception to this rule). As you get
more comfortable with the process and various attendings, you will likely just send them text messages with
updates on the weekends.
• In general, anesthesia is not responsible for intubations/codes outside of the OR. There are some
circumstances when we do get involved. If you have any questions, call attending.
Random Tips:
• There are new machines at the VA now—different from any machines at UCH, CHCO, or DH. Ask a
tech to go through the machine check with you.
• Don’t leave any drugs out on the carts
• Don’t forget to utilize your classmates that have recently rotated at the VA, things change frequently and
they are an invaluable resource.
• Check, re-check, triple check that your codes, badge, access is rolling before Day 1 start- this system is a
quagmire, but you will emerge victorious if you are persistent!
• You will not be assigned a locker, but you may be able to usurp one. If you put a lock on it, it will be cut
off.
Important Numbers – Denver VA Medical Center:
Main Phone number: 303-399-8020
Door Codes
Conference room 4-3-2-1
Anesthesia Workroom 4-3-2-1
Womens locker room – 2-9-4-9
Mens locker room- 4-1-0-9
***The new Anschutz Campus VA will be opening August 6th 2018
-Most of the operational information above will remain the same regarding attending-resident interactions,
home call, and daily work flow.
-There is much that will change that cannot be anticipated at this time and staff will be updated through AugustSeptember as things get figured out.
BASIC INFORMATION:
The hospital is a North-South spine that runs from Colfax to 17th street, with inpatient on the East side and
outpatient on the West side (towards Children’s). Employee parking (and probably residents?) is located north
of the hospital and 17th street. Your VA badge will be required for entry. Alternatively, park at the U,
Children’s, and walk.
The ORs are located in the Diagnostic and Treatment Center-South (DAT), located on the 3rd floor on the east
side of the building, near Elevator 1. This area will contain the ORs, and all off-site anesthesia locations (GI,
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EP/Cath, Interventional radiology) in one area with a common Phase I and phase II Pre-op/PACU. Anesthesia
staff offices will primarily be located just outside the OR, and across the spine to the west side of the building in
the Pain Clinic area. There is an anesthesia dedicated conference and break room just outside the OR doors.
There are 7 ORs. Each OR will contain an anesthesia machine, an Omnicell, and a Work Cart that are all
located towards the center core entrance of each room.
An electronic medical record (Innovian) will be implemented at the new facility. Details still pending, but there
will be some cut/paste from CPRS for pre-ops, but all other documentation will occur in this record and it will
be linked to your vitals/ventilator.
There is still a lot of clinical work flow TBD as we enter the new facility. Stay tuned and look for updates as
you start your rotations.
General OR – Denver Health Medical Center
ALLISON LONG, MD; RACHEL L BOGGUS, MD; HEIDI GREEN, MD; ANNE RUSTEMEYER, DO; ZACH HESSE, MD;
NICK STRINGER, MD; ERIN ROSS, DO
Important people:
Residency Site Director: Beth Benish cell (402) 350-4138
Senior Secretary: Veronica Morales (303) 602-5945
Main anesthesia office: 303/602-1105
Phone Numbers:
Main DHMC Hospital: (303) 436-6000
OR Bridge/Charge RN: (303) 602-1061
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Denver Health is our Level 1 community hospital here in Denver. It is a resident favorite rotation; the
attendings are very helpful, nice and funny. This is where you will get a lot of your trauma experience so try to
jump in on as many as you can!
Before you start:
• Speak to Veronica at least 2-3 weeks prior to your arrival to arrange the following: parking tag, ID badge,
locker assignment and code to the locker, scrub machine access, who to call for computer access codes and
Pyxis access code. Resident parking is located at the Delaware Lot (the corner of 6th and Delaware St). Irene
will give you a parking tag for this lot to hang from your rearview mirror prior to starting the rotation.
However, residents can park inside the Delaware garage during inclement weather or when the Delaware
Lot is full usually without issue.
• You can contact the Help Desk for passwords at 303-436-3777.
• Contact Dr. Benish 2 weeks prior to your arrival to arrange a tour before your actual start day. If Dr. Benish
is not available, arrange for another Attending to show you around. You will need to confirm that your
Pyxis access, Epic access, and scrub access card work (the scrub machine is located right outside the men
and women’s locker rooms near the SICU).
• Have someone show you how to navigate both EPIC and the old Denver Health EHR, EDM (purple square
icon on the desktop). This will make reviewing patient records much easier for your pre-ops. You can also
view the OnBase Patient Viewer under the Encounters tab on Epic to see previous paper anesthesia records
(anything prior to 2014) that have been scanned into Epic from EDM.
Weekday Daily Work Flow:
• The OR schedule for the next day is usually assigned on EPIC by 2 to 3PM. The patient, surgical procedure,
anesthesia and surgical attending, and OR # will be listed for you. If you are post-call, you can access EPIC
and complete your pre-ops from home (https://dhremoteaccess.dhha.org) vs. having one of your co-residents
at the hospital to help you out. You will need to contact Daniel Demetry from IT and complete a request for
remote access form before you can use the website above. His email is daniel.demetry@dhha.org.
• Some patients may go to the pre-op clinic prior to their procedure and the pre-op assessment on EPIC will
be completed for you by one of the residents/advanced practitioners. If it’s not, you should complete it prior
to leaving the hospital. If you are scheduled to take care of an INPATIENT, you MUST see the patient in
person, perform a focused H&P, obtain consent from the patient and complete the pre-op assessment in
EPIC before you head home the night before. If you are post-call, you can ask one of your co- residents to
check your assignments and do any inpatient pre-ops for you.
• You should call your attending the afternoon/early evening the night before your case to discuss your
anesthetic plans for the day. They may or may not answer but your attending will appreciate your initiative
and that you called them.
• Arrive 30 min prior to morning conference to set your room up in the morning (around 0545-0600 so that
you can go to 0630 conference)
• Get all medications (including narcotics) out of the Pyxis in your OR room. Make sure to label/date/time all
your meds because they fill the Pyxis in the mornings. Of note, ephedrine has recently become a scheduled
drug and must be accounted for in your intra-op record/ wasting medications in PACU. Also, Propofol is
NOT considered a scheduled drug at Denver Health like it is at UCH. You must remember to label all
medications w/ the date, time, and your initials that you keep in the top drawer of your Pyxis as they may
get thrown away by Pharmacy if not. Remember to lock your Pyxis whenever you leave the OR for any
reason. Do not leave any controlled mediations on the top of the Pyxis.
• Mondays- Grand rounds are teleconferenced to DH at 6:45 a.m. on Education channel 2. Lectures on
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Wednesday, Thursday and Friday are from 6:30-7:00 a.m. in the conference/lunch room near the OR
bridge- see bulletin board in that room for exact schedule. There is no conference on Tuesday mornings.
Instead, you will have afternoon UCH Teleconferences every Tuesday from 1500-1700. Tues afternoon
UCH lectures are viewed just like Grand Rounds on TV channel 2 (education channel). The Main OR
large conference room has been reserved for this. This room is located just down the hall across from the
main Pav A patient elevators between the SICU waiting room and the OR waiting room, as if you are
heading to the Pathology Lab. This will be a private, quiet area to watch your lectures. You can also
view it from the Anesthesia conference/lunch room but there may be more people interrupting you in
there. If the TV channel isn’t working, it is also streamed to http://140.226.244.25 which can be
accessed from any computer. The DH Attendings do their best to get the residents out for these
afternoon lectures but for L1 & C1 residents, it will depend on the OR schedule/staffing.
• After conference (or before if you have time), see your patient in pre-op. There is a large monitor in preop with your patient’s name and assigned bay number where they are located. Finish the pre-assessment
on EPIC (physical exam, anesthetic plan), consent the patient, and establish IV access (usually nurses do
the IVs, unless they are difficult, in which case they will give it a try or two and then call you to place
it). Make sure to click the Anesthesia Ready for Procedure (located under the pre-procedure tab at the
bottom) button once you have finished with the pre-op assessment/consent/etc.
• After all consents have been signed and the circulator and pre-op RNs have completed their handoff, the
patient can have pre-medication and can be brought back to the OR. Don’t transport patients past the main
OR bridge (as it violates HIPPA w/ patient identifiers listed on the computer monitors on the wall).
• Overhead page /call your attending when you are in the room if you have not already seen them so that
you can perform timeout.
• At DH, they generally use an overhead paging system to reach attendings, anesthesia techs, etc. After
picking up the phone, you press the “OH page” button and then say your message (“Dr. Chandler ready for
timeout/waking up in OR 5” or “Anesthesia tech, please bring the Glidescope to room 1”) then hang up the
•
•
•
phone. If you pick up the phone, press “OH page,” then hear a busy signal, then someone else is paging
overhead at that time, so just try again in a few seconds.
Upon arrival to the PACU, you should give a detailed report of your patient’s intra-op course to the PACU
RN (PMHx, anesthetic used, meds given, EBL/fluids/UOP, etc). Under the post-procedure tab, you should
click both the Handoff to Receiving Nurse AND the Anesthesia Stop buttons. You do not have to fill in a
post-procedure evaluation note like you do at the University as your attending will do this for you.
Unused narcotics (and now ephedrine) have to be “wasted” with another resident, CRNA, nurse, or
attending by having them witness you discard medications at a Pyxis machine. Ask someone how to show
you how to do this. You can save all leftovers throughout the day until you have some time to do this
(although it makes much more sense to do this right after your PACU handoff to avoid mixing up
medications), and just stick a patient sticker on each syringe. You should ALWAYS label your narcotics
with the correct time, date, and patient name.
The Cafeteria (including Starbucks) is located in the basement of the hospital. Irene will give you a cafeteria
meal card at the beginning of your rotation. Vending machines are located near the elevators on the second
floor. There is a resident lounge on the 1st floor next to the pre-op clinic. The door says “staff only”& the
code is 5210*. There are TVs, couches, and a mini fridge stocked with juice, milk, etc. We also get a meal
card for the Subway located on the 1st floor near the hospital entrance. Subway is open 24 hours and is the
place to go for late-night food when on call (the cafeteria closes at 6PM on weekdays and around 1-2 PM on
weekends).
Computer programs for patient information:
• EDM: EHR before EPIC was launched. You can view old outpatient notes, cardiology reports (e.g.,
ECHOs, stress tests, EKGs.), radiology, and pulmonary function studies on here. Also, this is where the old
anesthesia records are scanned. It is a purple square icon located on the desktop after you login to any
computer.
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• EPIC: main EHR that you will use at Denver Health (intra-op charting, pre-op assessments, intubation
notes, etc). You will have EPIC training during your orientation week at the University. There are small
differences between EPIC at UCH and Denver Health, but for the most part, it is very intuitive and easy to
navigate.
• It is highly recommended that you ask an attending/ seasoned resident to show you how they would
look up previous records/ review a chart both on EDM and EPIC at the beginning of your rotation.
Call Nights/Weekends
• Weekday call (C1) - 3 pm-7am. Check board or contact charge attending to see where to go when you first
arrive. Nights at DH can be very busy, so do not expect much sleep as you will provide anesthesia for all of
the cases unless a second OR opens up which the overnight CRNA will cover.
• Weekend call is 12 hr. shifts 7AM-7PM, 7PM-7AM
• When you arrive for call, check that both Trauma ORs (OR 1 which is the Main Trauma OR, and OR 5,
which is primarily the Neuro Trauma OR) have been set-up. Make sure that both trauma rooms have at
least the following items available:
-Arterial line setup, Central line supply kit, IV setup
-ETTs (7.0, 8.0) w/ stylet & 10 cc syringe, Oropharyngeal Airways, OGT/NGTs
-Laryngoscope X 2 (ensure blade light works)
-Level 1 fluid warmer w/ available NS fluid bag (don’t wet down until the trauma arrives in the room)
-Infusion pumps (located in anesthesia supply room)
-Glidescope video laryngoscopes (located in anesthesia supply room)
-Forced Air Warmer, Temp probe
-Emergency medications stocked (succinylcholine, etomidate, vasopressors, etc.). Most emergency
medications are in prefilled syringes. Please do not draw up other medications until you are planning to
use them as many of these are experiencing national shortages.
•
•
•
•
-Syringes (1cc, 5cc, 10 cc, 20 cc) w/ blunt needles for quick medication draw-up
It is important to have the trauma ORs set-up ahead of time, as there is usually little to no time when a
trauma patient is on their way up to the OR.
The anesthesia techs will usually stay until 10-11 PM on the weeknights and 3-4PM on the weekends. It is
your responsibly to turn over your anesthesia workstation (replace the breathing circuit and suction,
Caviwipe down monitor wires, etc.) after your case is finished once the anesthesia techs go home for the
evening. Transport monitors that have been used to transfer patients to the SICU from the OR should be
placed in the soiled utility room for cleaning located near the main ORs behind the charge desk.
Late (C2) - arrive at usual morning time and you will be the last resident to leave (excluding the call
resident). You are usually out by 1900 or so.
O - You are not on call, arrive at usual morning time and you will likely be relieved around 3pm. This is
pretty consistently true at DHMC, which is lovely.
• The call room is in the main hall by the elevators near the hospital chapel. You punch in the code, the
door key pops out to unlock the door. The door will lock when closed, so don’t leave the key in the
room if you get called to do something. The lockbox code is 1492 (Columbus sailed the ocean blue).
Have another resident/CRNA show you where this room is on your first day.
On-Call Resident Phone (77102):
• You will carry this when you are on call. The float CRNA/on-call resident will give it to you when you
arrive and you can hand it off post-call to the new float CRNA/on-call resident.
• These phones recently replaced the voice pagers - write down the message if needed (room number of the
emergent intubation, epidural, incoming traumas headed to DH, etc.)
• Always call yourself when you first get the phone to ensure that it is functioning - if not, give your cell
phone number to the charge nurse (you can also write it on the whiteboard underneath the computer
monitors at the charge desk). The OR charge nurse also has the number to the call room if they can’t get in
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touch with you by resident phone or cell.
• The attending also carries a phone while on call. They can be reached at 77118. Call your attending when
you get called to codes and emergent airways. Let them know where you are heading. They will also need to
be called before starting emergent over-night cases.
1. Airway box location- It is just inside the anesthesia workroom to the right on top of the shelf when
you walk in (grey tacklebox). The Glidescope and Fiberoptic cart are also stored in this room. You
should grab the airway box prior to heading to any code/emergent airway page. The ICUs will usually
have an intubation tray with emergency drugs as well as a glidescope waiting for you so the airway box
will usually not even have to be opened (unless you are called to the floor where this equipment may not
be available). If you do open the airway box, make sure you or the anesthesia tech replace whatever was
removed so that it is ready for the next code/airway you are paged to. It is wise to carry a stick of
succinylcholine, etomidate and phenylephrine in your pocket, just in case. You should always ask
when the patient has last eaten and what their most recent K+ level is prior to emergent
intubations in the ICU or on the floor. If you get called to an emergent intubation anywhere besides
the SICU or MICU, bring a Glidescope in addition to the airway tacklebox.
2. MICU door code is 1-5-9, everywhere else is accessed using your DH badge.
You will also carry the trauma pager when on call. This pager should only alert you for TRAUMA
ACTIVATIONS and CODE BLUEs. If you are not already in a case, it is best to go down to the ED
and be on standby for airway assistance as well as knowing if the patient is coming up to the OR.
STICU Rotation
JAY HACKING, MD; JAMES SEDERBERG, MD; MATTHEW MALONEY, MD; BETHANY BENISH, MD; SARENA TENG,
MD; AARON PERSINGER, MD; BEN LIPPERT, DO; JOSH DOUIN, MD; ZACHARY ASHNER, PA
Important People:
Anesthesia Attendings: Jason Brainard, MD; Fareed Azam, MD; Naveen Kukreja, MD ; Ben Scott, MD;
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Jean Hoffman, MD (dual EM/Anesthesia)
Surgical ICU Attendings: Robert McIntyre, MD, Erik Peltz, DO, Arek Wiktor, MD, Frank Wright, MD, Juan
Pablo Idrovo, MD, Lisa Ferrigno, MD, Catherine Velopulos, MD, Lauren Steward, MD.
STICU PA’s: Zach Asher, Lucas Dietrich, Katherine Ann Arnim
STICU Resident Phone: 85916
STICU APP Phone : 81836
Schedule and Call:
• Call- Weekdays you come in at 3pm. You will likely get sign out or do a brief walk/work rounds to find out
what happened during the day. Dr. Scott, in particular, prefers walk rounds. Then send the other resident
and PA(s) home. At that point, you and your attending (+/- fellow) will manage the team overnight (fellow
and attending will likely not be in house unless needed, however). Weekends/Holidays - come in and round
like a normal day at 6am, stay all day and overnight. That day the call person’s job is to get the other
resident/PA home as quickly after rounds as possible. Round with the charge RN around 10pm to see if the
bed side RN needs anything or has any questions/concerns- this also decreases the amount of calls you will
get in the morning. Friday night call residents are expected to stay until noon on Saturday to help with
patient care (as needed pending census and acuity).
• Post call- after rounding, your fellow resident should get you out of there ASAP; DO NOT VIOLATE
WORK HOURS. If you are nearing 28hrs, let your attending know so they can get you out!!
• This rotation can approach 70-80hrs a week, therefore, make the effort to get the post-call resident home as
soon as possible after their patients are seen.
• You don’t come in on the weekends except the days you are scheduled to be on call.
Daily Work Flow:
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•
Pre-Rounds: Arrive around 6 AM. First, get sign-out from the resident on call to see what happened to
your patients overnight (they bled, they coded, etc.), and see if there were any overnight admissions that
need to be seen. Then go around and see your patients, talk to their RN, & perform a quick and focused
exam. Pre-rounding physical exam should include surgical wound exam and knowledge of color,
consistency, and volume of all surgical drains. Next review patient data (labs, I/Os, cultures) in EPIC, start
the daily progress note (see EPIC instructions below) and write any urgent orders (transfuse, replace ‘lytes,
etc…).
Getting to the SICU before 6 AM is not recommended as patients are divided between the residents / PA’s
at that time
If time permits, write/review orders for the next day’s labs, films, etc. The STICU is a single order entry
unit. We (the STICU team) put in most of the orders. However, the co-managing surgical team (TACS,
Green, Transplant, ENT, etc.) places the initial admission orders.
Make sure everyone is seen by the time rounds start.
Rounds: STICU rounds start at 8 AM on weekdays and weekends. Rounds are variable and attending
dependent, but expect to go from room to room (often starting with the post-call resident’s patients) and
each resident will present their patients. The other resident (who is not presenting) should grab a
“workstation on wheels” to round with and write any orders that might come up and make sure there are
orders for the next AM. If not presenting or placing orders, updating sign out as the patient is presented is
helpful. Once rounds finish, get the post-call/short resident out and the remaining resident does any work
that still needs to be done. On Tuesday mornings, The TACS resident will present all of the TACS patients
during rounds, even if you are taking care of those patients on the STICU team.
Presentations: All Attendings prefer system-based presentation. Start with Name, POD# s/p surgery.
Followed by significant 24hr events. The bedside RN will present pain, sedation, mobility, skin, and
indwelling lines. Then jump to Assessment/Plan by system: Neuro-including sedation/pain, CV, Pulm, GI,
Renal, ID, Heme, F/E/N. Finish with review of invasive lines, big plan and disposition. Make sure to know
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urine and drain output – both quantity and character (i.e. 150cc of serosanguinous output overnight).
Rest of the day: Check the OR board for expected ICU admits. If time permits read about them briefly and
add them to sign-out.
All major changes in clinical status (intubation, pressors, etc.) should be communicated to the
primary teams
Monday, Tuesday, Wednesday, and Friday there is lecture from 3-3:30 about various critical care topics.
Please make every attempt to attend. It is located in the conference room on the 5th floor in AIP2 unless
otherwise specified. Thursdays there is noon critical care grand rounds.
Check the Code/Airway Tackle box EVERY DAY. Make sure that it is stocked with appropriate drugs
(sux/etomidate), ETTs, LMAs, and an Eschmann bougie. Take the airway box with you to all airway and
code calls. If you use the box (or break the seal), take the box to the Anesthesia Tech on call and they will
fill and return the box.
You will carry the code pager & badge when you are on call, and usually during the day. This badge will
open just about every door in the hospital.
New admits:
• When a patient is admitted to STICU, the primary team writes the initial admission orders. They also should
talk to you either in person or over the phone to give you report (reason for admit, OR events, plans). There
is now direct OR to ICU so all patients should arrive with an OR RN, anesthesia provider, and member of
the surgical team unless they go to PACU because ICU was not initially intended or there are no ICU beds.
Make sure you evaluate the patient, do a focused physical exam, & review EPIC for pertinent info (brief
medical hx, meds, labs). The OR Anesthesia team should also contact you to give you report (OR course,
airway, I/O’s, drugs given, drips, IV access, invasive monitors, etc.). You will write a STICU Accept Note
in EPIC. Then order/follow up on labs/CXRs and manage critical care issues that arise including placing
•
•
any invasive monitors if needed. Note: Some teams are VERY hands on (transplant), and some don’t care
what you do (ENT, ortho).
In general, discuss all major management decisions with the primary surgical service (during the day); not
for their permission but just to maintain good communication among the team members.
For transplant patients, run just about every management decision (no matter how small) by the transplant
fellow. You will quickly get a feel for how hands on vs. off they will be about each individual patient.
EPIC for STICU:
How to modify your EPIC for ICU use:
Use the EPIC button on the top left to “change context” to “zz intensivist” from “zz anesthesia”
o From the “patient summary” button use the wrench function to add parameters to your toolbar.
• ip comprehensive flow sheet
• ip pain management
• ip microbiology
• ip vitals last day
• ip mar
• ip fever
o
o
Add order sets to your favorite list by right clicking on “order sets” Useful ones are:
• Adult insulin infusion
• Sedation management for Mechanically ventilated patient
• Blood administration
• Heparin Continuous Infusion
• SQ insulin: Glargine and Lispro for PO, NPO and Bolus Tube Feeds
• IV PCA
• Enteral tube feeds
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To get to the STICU Patient listsPatient lists at top→Shared Patient lists→STICU… To add someone to your shared lists (SubIs or new
Residents coming on service), Click on the list, Click “Properties” the “Advanced” tab. Scroll to the
bottom of the list and add the name and under Access Level—type “5” then Accept.
Add & Remove Patients from the STICU list as they are admitted and discharged.
(Remember to also add the patient to the SICU Sign-Out Report)
Do not copy and paste from EPIC to the signout. This messes up the font. It is acceptable to copy and
past from the signout to EPIC.
o
To add templates for STICU notes:
EPIC Tools Smartphase Manager Change USER to Anesthesia, Resident click GO. This will
automatically import STICU progress note, STICU accept note, STICU CT progress note templates that
have been created and have already been shared with you. Highlight all templates. Then click on
“Share” then Accept to share this with yourself.
Now to start a note---go to “New Note” then to add a template, click on the “list my phases” to the left
of the green plus sign (little dude in purple shirt). Pick STICU progress note (or STICU accept note for
new patients)
Finish note by scrolling through dot phrases etc. using F2 button.
Remember you can copy your progress note from the day prior by highlighting your old note—clicking
COPY, then hit the little green refresh button (refreshes with most recent labs/vitals, etc.). Then you just
need to update with the 24hr new events, etc. and save at your new note. Be sure to edit all the info in
that note, so that you aren’t still writing that the patient is intubated and sedated when they are not.
STICU Pearls:
It is helpful to come to the STICU as time/schedule permits to get orientated, access to the shared
patient list, and a tour a day or two prior to starting your STICU rotation.
1. Never transfuse a transplant patient without talking to their team first (usually not team pager but
fellow or attending).
2. Call your attending with any major issues, or with any questions, they would rather you call than
not, and they only do 1 week at a time, so it’s not as bad for them.
Discuss all consults with primary team especially ID and palliative care
Sign out should be given to the primary team for all downgraded patients especially ortho and TACS
3. Talk to the nurses about what they might need BEFORE you lay down, if you get the chance
(between 8pm and midnight is a good time). Walking around with the charge nurse and a
“workstation on wheels” during these unofficial rounds helps ensure everyone is on the same
page and allows you to rapidly add/change orders. This will save you 2 am phone calls and build
your rapport with the nursing staff. This vastly improves your ICU experience!
4. There is ALWAYS an in-house intensivist (MICU) to call if you need help with a line or if there
are any questions in addition to a surgical R3 who may available, in the ER, or OR.
5. When extubating, get ABG on PSV, weaning parameters (NIF, FVC, secretions), RSBI, and then
call the attending with your plan. Only write the order to extubate after confirming with you
attending. The RT will usually do the physical extubation for you, but it is a good idea to be
present.
6. Ask for help if you need it, from nurses, CT residents, other anesthesia residents or attendings.
7. The STICU packet of protocols that Dr. McIntyre and Dr. Brainard have put together is a helpful
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resource. It’s quite lengthy to read from start to finish, but is a good idea to look it over before
starting the rotation to familiarize yourself with its content, and is great for consulting with
regard to things like SBT’s, extubation criteria, how to approach A Fib with RVR in the ICU,
etc…
8. The STICU PAs are Zach Asher, Lucas Dietrich and Katherine Ann Arnim. They see about the
same # of patients as you during normal working days and Sundays currently They are a valuable
source of information about how the STICU service works, critical care, and attending
preferences so learn from them and treat them well. There is also frequently a STICU fellow,
who is also helpful. Please notify Zach Asher (Zachary.asher@ucdenver.edu) if there are any
concerns about the Pas in the STICU. The Fellow may run rounds, do procedures with you, or
act as first call or attending during certain times.
Door Codes:
Call Room badge access
Store/Pyxis Room 3030#
Acute Pain Service
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AUTHORS: PRAIRIE ROBINSON, MD; ESTEE PIEHL, MD, KELLIE HANCOCK, MD; JESSICA YANOSIK, MD; ANDREA
ZATLIN, MD; ZACHARY HESSE, MD; BENJAMIN REYNOLDS, MD; LAURA KIRK, MD; JAKE LOYD, MD; KELEIGH
MCLAUGHLIN, MD
Important People:
Director, Acute Pain Service: Dr. Olivia Romano
APS Attendings: Drs. Alison Brainard, Roland Flores, Adrian Hendrickse, Kyle Marshall, Dominique Schiffer,
Marina Shindell, Inge Tamm-Daniels, and Matt Lyman
APS Fellows: Dr. Ross Mirman
APS Advanced Practice Providers (APPs): Rob Montgomery (Lead), Lynn Hornick, Jennie Johnson, Robin
Konrad, Adam Sheely
Acute pain is a different month since you are not in the OR. You will be placing pre-operative regional nerve
blocks and epidurals for post-operative pain management. You will be managing patients with epidurals and
nerve block catheters on the floor, and you will be performing pain consults throughout the hospital for patients
with complex pain management. It can be hectic at times and being very organized is key! You will be
managing orders and checking out drugs for many different patients over the course of the day and there is a lot
of paperwork!
Prior to starting…
• Get an orientation from the residents currently on service. Be sure he or she shows you where to find
equipment in the storeroom, how to make the daily block lists, the order-sets for blocks/ultrasound and
epidurals, and where the phones/pagers are kept.
•
•
Meet with Rob Montgomery. Rob is our Clinical Nurse Specialist on service and is very helpful in
familiarizing you with the ins and outs of the EPIC and APS Rounding lists as well as how to navigate
the ZZ PAIN MEDICINE context.
MOST IMPORTANT: READ!! You will be expected to know WHY you are performing the blocks, not
just HOW to do them. This is a good time to familiarize yourself with topics such as:
o Local anesthetics -- mechanisms of action, toxicity, allergies, use in peripheral v. neuraxial
anesthesia
o Upper extremity blocks -- interscalene, supraclavicular, infraclavicular, axillary
o Lower extremity blocks -- femoral, saphenous, popliteal, ankle
o Neuraxial -- Epidurals (difference between thoracic and lumbar), spinal, combined spinal
epidural
o Some good resources
▪ The course syllabus
▪ Anesthesia Tutorial of the Week from the World Federation of Societies of
Anesthesiologists
▪ Easy-to-read overview of nerve distribution, ultrasound images, practice
questions, etc. for each block
▪ TrueLearn, M5 practice questions
▪ Barash, Miller, Morgan and Mikhail
▪ ASRA.com
▪ Latest guidelines and advisories
▪ NYSORA.com, SafeUltrasound.org
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• Videos and ultrasound images of the various blocks
Each afternoon…
• “The List”
o The OR Schedule for the following day will be delivered to you by the pre-op charge nurse in the
late morning or early afternoon. Your job is to mark the cases that will need blocks with a “B” on
that list and then fill out the indicated information on the APS block list worksheet for the
following day.
▪ The columns include: Patient name, Procedure/Block, Sedation/Meds, Block Note,
PostOp Orders, APS Rounding List, Anesthesia Consult, EPIC List
▪ Once you have finished writing down the info you need from the case list, return it to the
charge nurse so those patients can be placed in bays near the APS desk in the morning.
This is usually one of their final tasks before going home, so they appreciate your
expedience in returning it to them ;).
o If you are unsure if a particular case or patient requires a block, ask your attending or fellow. It
has become customary to email the attending surgeon the day prior to confirm if they want
regional anesthesia for their patient(s).
▪ Most Orthopedic surgeons (Dayton, Hogan, Seidl, Park) expect blocks for their total
joints and typically do not need to be emailed unless there are extenuating circumstances.
However, you MUST email the Ortho Trauma surgeons (Gorman, Stoneback) and Dr.
Lindeque for confirmation. They often prefer post-op blocks or no block at all.
•
•
▪ Be sure to CC the following day’s APS team including the attending, fellow, and resident
(if not yourself), as well as the in-room attending and resident to be sure everyone is on
the same page.
o Note the number of first-case starts as you may need to call in reinforcements (e.g. APS
Rounding Resident) to get them all done. You should prioritize peripheral nerve blocks over
epidurals as you will have opportunities on other rotations for performing epidurals.
▪ If there are transplant or thoracic patients requiring epidurals, the in-room resident is
responsible for performing that procedure unless you have time. However, it is your
responsibility to contact and confirm this with that resident. You will need to get the
pertinent information from this resident for The Rounding list (LOR, catheter depth, etc.)
and to complete orders.
o The above communication with the other residents and the surgeons should be noted on the
Block List.
Peri-Op Order Sets
o There is an APS Peri and Post op order set (see end of section). This order set has been organized
as a combined effort between these surgical teams and the APS to include certain pain
medications these patients should receive perioperatively and post op (Total Joints). If patients
are on a particular pain regimen at home, this needs to be reviewed with the patient prior to
going into surgery and addressed at the time of placing postop orders. It may be appropriate to
reorder home pain meds immediately or have alternative analgesia ordered. It is best to
coordinate these decisions with the primary team.
o Getting these orders in the night before eliminates confusion and keeps things moving in the
morning. It is helpful to put these orders in while you are making the Block list for the following
day as you will already be in the patient’s chart at that time.
30
Equipment
o Syringes for controlled meds
▪ The APS administers ketamine and versed for procedures that are separate from the inroom provider’s standard narcotic bag. Be sure to have 3cc syringes with 18g needles on
them ready.
o Neuraxial Blocks
▪ Epidurals
• There are lists of what items should be gathered for an epidural hanging in the
storeroom. Make sure the current resident on service shows you how to put these
together.
• ProTip: If you ever have to place an epidural on the floor or in the ICU, be sure
to take 2 of everything with you because these supplies are lacking in off-site
locations. Also, be sure to grab a pair of gloves for your attending.
▪ Spinals
• Intrathecal morphine (ITM) and other spinal injections are typically performed in the
OR by the in-room providers. They should be prepared to get their own supplies for
these procedures in the morning.
• HOWEVER, you are still responsible for the other ‘administrative’ tasks surrounding
that patient so the rounding team can follow-up on POD1...more on that later...
o Peripheral Nerve Blocks (PNBs)
▪ Note in the “Cookbook” (in the storeroom, have the current resident on service show you) the
likely volume you will need and set up your syringe/3-way stopcocks accordingly (Ex: 1-
20cc and 1-10cc syringe on a 3-way stopcock will get you through most PNBs). You cannot
draw up drugs the night before but doing preparing the syringes will increase your efficiency
for the next morning.
Overnight call
• Please refer to the Rounding resident responsibilities for information on call/weekend tasks including
the role our APPs play in the care of our patients.
In the morning…
• You should arrive early to make sure there have been no major changes to the OR schedule affecting
your planned first-case starts
• Beginning at 0630 (0730 on Mondays), you may begin consenting the patients. However, you should
arrive much earlier than this to allow time for any unanticipated roadblocks that may result in a late firstcase start.
o Prior to 0630, you should double-check the schedule (as previously mentioned) making sure you
have heard back from the surgical team regarding blocks you may have been unsure about the
evening prior. If you have not heard back and still have questions, now is a good time to look in
Amion and page the surgical team to find out. (Amion password: uco)
o This is also a good time to start drawing up local anesthetic into the syringes you set up the night
before (look at you, master of efficiency!)
• Consents
o As each patient is ready to be consented, be sure to do the following:
▪ Introduce yourself as part of the APS and what your role is (will not be in the OR,
Rounding team plans to follow-up with you on POD1, despite looking so young31you are
in fact a doctor, etc.)
▪ Perform a brief H&P
• H/o regional/neuraxial anesthesia?
• Allergies to local anesthetics?
• On blood thinners?
o If so, what? When was last dose?
o You will need to familiarize yourself with the ASRA guidelines (get the
ASRA App) regarding anticoagulants/antiplatelet medications for this
rotation -- AND THE BOARDS!
• Any neuropathies? Weakness? Numbness? Movement disorders?
o Make sure you document these in your block note, it’s called CYA!
• Airway exam
• Chronic pain issues, and home pain regimen
• LOOK AT THE SITE TO BE BLOCKED!
o Note any rashes, bruising, swelling, scars, hardware, bandages/casts
Consents should include, but not be limited to: risk of infection, bleeding, nerve damage, failed block, pain,
LAST
Be sure to always consent for general anesthesia along with your neuraxial/peripheral block and any other lines,
procedures, depths of anesthesia the in-room providers may need.
Once you consent the patient, indicate that on the Block list. Before you move on to the next patient, politely
ask that patient’s nurse to begin putting on monitors so once you grab your local, ultrasound, ketamine/versed,
and gown up -- you’re all set!
Performing the block
• Make sure all consents are signed prior to administering versed. If there is not a surgical consent yet
avoid sedating medicines. If absolutely unable to wait for surgical consent, you can administer fentanyl,
however ketamine and versed are a no go.
• Make sure the primary team has placed an order for an "IP Consult to Anesthesiology" for any patient
getting a block, this can be followed up on after the block is performed. You will know if this is done if
there is a bullseye with a syringe coming out of it on the left hand side of the patient’s case on the OR
list.
• Make sure to place an order for the “Ultrasound Guided Nerve Block-APS” so you can pull the patient
up on the MindRay ultrasound and save the block images to their chart. This order is located in the
Nerve Block Order Set and the Preop Anesthesia Order Set.
• Politely ask family members to step out. Be sure to have on your mask, cap, and sterile gloves. Perform
a time out with the patient’s preop nurse; make sure you touch on allergies, pre-existing
neuropathy/weakness, and anticoagulation.
• Block with the attending present.
• Once you have finished your block, be sure to clean up your sharps, return the ultrasound to the
storeroom and clean it, use the block list to document your narcotics, loss of resistance and catheter
depth, test dose, time of placement, and any other pertinent information needed for your epidural orders
or block note -- which you can write a little later when things settle down.
Block Documentation (or “Blockumentation” -- sorry, I couldn’t help myself)
• It is your responsibility to place each new block patient on both the APS Rounding AND EPIC32Lists
(this also includes the patients on Total Joint Protocol who do not get a block)
• APS Rounding list can be found at virtue.ucdenver.edu. Click on "Residents" on the L hand side, then
"APS Database"
o Include the specifics of each block, PCEA settings, PCA settings, and prn meds on your sign out.
Also include pertinent home meds, such as their pain regimen, and pertinent medical history.
Rob is great in terms of instructing you on how to fill out the Rounding list.
▪ Ex: T8-9, PCEA B0.1 H7 8/4/15 (i.e., bupivacaine 0.1%, hydromorphone 7 mcg/ml,
basal 8ml/h, demand 4ml, q15 min lockout). Save time and effort by abbreviating as
much as possible, but don’t sacrifice the meaning.
• EPIC list: find "patient lists" tab on the top of the EPIC screen. Find "shared patient list" on the left side
and click the "+" sign. APS should pop up. To add your patient, click [Add Patient], and then click on
them under the recent patients tab.
o All blocks also need to be charted in EPIC. To do this, get into the intraop record and click the
button titled "blocks". Follow the tabs and fill out accordingly.
Rounding Resident Duties:
NOTE: Most days you are expected to arrive in time to help with first start blocks. Work this out with
your co-resident and fellow.
Pre-rounding
Rounding is best done from the ZZ Pain Medicine context (also used in your pain clinic rotation). You can do
some rounding activities from the ZZ Anesthesia context, but it is much less robust: with a patient highlighted
in patient lists, choose the “Rounding” button in the patient list menu directly above the list.
You are expected to look up the floor patients (pre-round) in EPIC after placing first start blocks in order to
speed up team rounds. Pay close attention to pain scores, vitals, PCA/PCEA usage, labs, anticoagulation,
primary team notes. In the Summary activity tab within ZZ Pain, add (wrench in) the following reports: Pain,
Adult Comprehensive, Med History, Active Meds, Labs. If you aren’t too busy with AM blocks, join the
daytime APP for their sign out from the overnight APP, which is around 6:45-7am in either the preop area or
faculty lounge.
AM Rounds
• Weekday: Team rounds (attending, resident, pharmacist, +/-APP) typically start at 9am but this may
vary depending on census or attending. Discuss the rounding plan the evening before with the rounding
attending. The day APP will divide the rounding list between you and the other APP(s) on that day.
Make sure you print a list for the attending as well. You will see all the ICU patients and typically also
patients you rounded on or blocked the day before. The list is usually divided evenly to distribute the
workload.
o If you remember your intern year, it is typically good form to see your patients before rounding
with your attending- look at their epidural/peripheral block site, ask them the pertinent questions,
and make changes if needed immediately (eg hypotension- you can change the concentration of
the epidural, with approval of your attending of course). Pre-rounding will make rounds much
more efficient and the attendings will appreciate it!
• Pharmacists will place orders under your direction during rounds, be sure to clearly communicate with
them so as not to forget or duplicate orders, or have mistakes.
• After rounds, write notes for all the patients that you rounded on, refer to helpful Smart (dot) phrases
below.
• Weekends: Sign out from the overnight APP will occur at 7am. Touch base with your attending
33
beforehand to decide a start time for rounds.
• There are no day APPs on weekends so you are responsible to round and write notes on all patients. The
night APPs cover 7p-7a.
• Contact pharmacist prior to starting so they can meet you before rounds.
• After rounds, write notes on all patients and take care of floor duties. You are expected to stay at the
hospital covering the service / pager until sign out to the overnight APP at 7pm
• There is an iPad (passcode 123456) in the block cart that may be useful for writing notes during rounds
(be sure to prep your notes while you pre-round).
• ProTip: Make a little bag with 1% lidocaine, phenylephrine, dressing supplies to bring on rounds to
troubleshoot epidurals. Note: Do not change/bolus a PCEA or IVPCA pump on rounds or in PACU. If
something needs to be done immediately, notify the RN and they will do it. If you syringe bolus an
epidural with local anesthetic, you are responsible for staying at the patient’s bedside for at least 30
minutes monitoring the patient. (See APS Protocol for Epidural Placement/Bolus on the Floor).
Post-Rounds
• After your notes are done, you take care of any floor duties and try to follow up on patients that were
blocked that day, either in the PACU or on the floor. When it’s busy, prioritize checking on the
epidurals so you can give the overnight APP a good sign out about them. Update both the APS
Rounding and EPIC lists, ensure all new patient’s info is entered, including their room numbers so the
overnight APP can do PM rounds on them. In the afternoon between ~3-4pm, the day APPs will sign
their patients and any new consults out to you, after which you will be responsible for all of the patients
on service and any new consults until sign out to the overnight APP at 7pm. Of note, some attendings
may want to do PM rounds whereas others just run the list.
PM Sign Out
• There will be an APP in house overnight every day of the month except for some Sundays when you are
on for 24hrs (see below). Sign out occurs in the APS area of preop, have an updated Rounding list (with
room numbers) printed to review with the APP.
When to Sign Off of Patients
• Epidurals: will follow until the day you pull the epidural out. Be sure to check if the patient is on any
anticoagulants and follow the ASRA guidelines in regards to timing for pulling epidural catheters. It is
recommended to d/c or modify the current anticoag order to skip a dose, then reorder as appropriate.
Using a nursing communication to hold an anticoag dose can be missed by the RN. It is standard to
transition the patient to oral pain medicines after the infusion has been stopped but before pulling the
actual catheter (make sure their pain is controlled with PO meds!). Place a note after pulling the catheter
noting the patient's anticoagulation status and include that the "tip was intact". Moreover, always discuss
your plans with the surgical team before pulling your epidural (especially CT!) Patients with chest tubes
typically maintain their epidural until their chest tube is removed.
• IT Duramorph/hydromorphone/spinal anesthetic: sign off 24 hrs post-block.
• Peripheral nerve blocks: sign off POD#1 if single-shot block performed (ensure complete block
resolution). For nerve catheters, follow patients for as long as they have catheter in place.
In-house call
• You are expected to do one in-house, 24 hour call shift on one Sunday during the month, from34
7a
Sunday – 7a Monday. It’s suggested to round in the evening to make sure everyone is tucked in before
heading to bed. Your call room is on the 4th floor of the Leprino building (cross bridge to Leprino, take
elevator to 4th floor, take North hallway to NE corner of the building, use badge entry door labeled call
rooms, your room should be labeled anesthesia call room. Enjoy the TV!
Helpful tools:
• Smart/Dot Phrases:
o Rob will share with you dot phrases for use in writing notes. Be sure to consistently use these
note templates to initiate new notes and to copy forward existing notes where appropriate.
• Order sets:
o UCH APS Peri & Post op Pain Management
▪ Protocol for total joints, open abdominal and thoracic cases. Place preop orders the night
before.
▪ Must follow all total joints for at least 24h regardless of whether a block or spinal
morphine is placed (see Total Joint Pain Management Protocol)*
o UCH Continuous Nerve Block Infusion and Single Shot Nerve Block
o UCH Intrathecal Morphine Injection
▪ normal dose 100-250mcg Duramorph (if shortage, 50-100mcg IT hydromorphone)
o UCH IV PCA
o UCH PCEA
o UCH Ketamine Continuous Infusion for Analgesia
o UCH Intrathecal Infusion Analgesia
o UCH Ambulatory Continuous Nerve Block Infusion
•
Phone Numbers
o APS Regional Attending = (720) 553-4428
o APS Regional Resident = (720) 848-3324
o APS Pain Attending = 3-4427
o APS Pain Resident = 3-4426
o Acute Pain Service Pager = (303) 266-6493
35
CTICU - UCH
SARENA TENG, MD; NATHANIAL BROWN MD PhD; COREY TINGEY, MD, KRISTIN BARNEY, DO
Important People:
CTICU Attendings: Breanden Sullivan, MD; Karsten Bartels, MD; Muang Hlaing, MD; Scott Wolf, MD; Erik
Peltz, DO; David Fullerton, MD; Sam Gilliland, MD, Tim Tran, MD, Martin Krause, MD
Cardiac Attendings: David Fullerton, MD; Joseph Cleveland, MD; Brett Reece, MD; Muhammed Aftab, MD
Thoracic Attendings: John Mitchell, MD; Michael Weyant, MD; Robert Meguid MD
CT Fellows:
Jordan Hoffman
Marshall Bell
Andy Mesher
Chris Holley
(p) 4758
(p) 3487
(p) 5452
(p) 5451
(c) 310-597-2455
(c) 303-990-1140
(c) 206-251-7786
(c) 402-216-4634
CTICU APPs: Caitlin Blaine, PA (lead); Alexys Keyworth, PA; Elizabeth Devine, PA; Erin McIntyre, PA
Overview:
The CTICU rotation works a bit differently from the STICU rotation. There are 2 separate rounds, fellow
rounds @ 6:15-6:30 then rounds with the ICU attending usually ~8 AM. Fellow rounds are BRIEF and
typically take 2- 5 minutes per patient. You only present the cardiac patients on fellow rounds. A big focus of
these rounds is drips (inotropes, vasopressors), drains, line, and wire management. The fellows will make
36
decisions on which drains to pull based on your I/O info so make sure they are accurate. Pay close attention to
the location of the drains, typically mediastinal or pleural (sided R or L), the fellows will get really frustrated if
you just list output numbers and do not know their location. Try to ask the fellow when the patient is admitted
from the OR and then list them on the sign-out sheet. Try to remind the moonlighting resident to record this info
for you on the sign-out sheet for any patients they admit overnight. Remember ensure that labs and CXRs are
ordered for morning rounds (on overnights I would do this around MN to ensure it would get done). Almost all
CT patients will need an AM CXR and I would recommend just ordering one if you are unsure.
Rounds @ 8 AM with the ICU attending will be similar to STICU rounds with complete presentation in a
systems based format.
• The fellows (Cardiac & Thoracic) are great and readily accessible. Call them with any questions, and
ALWAYS call them before transfusing, making changes to pressors, or if there is any change in pt
status. When in doubt, call them.
• Always call primary team to update with significant status changes as well.
Daily Work Flow:
• Pre-Rounds: Arrive around 5:45 - 6:00 AM depending on the census. Typically the overnight resident has
printed off a sign out list for you and filled in many of the numbers (Vitals, Swan numbers, I/Os) for the
Cardiac patients. The overnight resident will then presents all the cardiac patients on fellow rounds. Then you
will usually split patients with your co-resident and/or APP for rounds with the ICU team. The night resident
will briefly present cardiac patients ONLY to the Cardiac Fellow for the month around 6:30am – there you
will hear a brief daily plan from the fellow/night resident. Thereafter, the night resident will give sign out on
the rest of the unit patients (Thoracic and Vascular patients) and answer any questions.
• Tuesday is cardiac conference and Wednesday is thoracic conference. Each start at 06:30 in specified
locations. On conference days, the overnight resident will present patients to fellow after the conference.
Please make sure to write in PA cath numbers as well on conference days as we don’t have computers with us
when doing fellow rounds.
• Next, the patients will be divided equally between yourself, the other day resident or APPs. Then go around
and see your patients, talk to their RN, & perform a quick and focused exam. Next review patient data (labs,
I/Os) in EPIC, start the daily progress note and write any urgent orders (transfuse, replace ‘lytes, etc.); always
try to glance at the daily CXR before rounds.
• Make sure everyone is seen by the time rounds start
• Rounds:
• CTICU attending rounds start around 8 AM and are quite variable depending on the attending, ranging
from brief to comprehensive.
• Presentations: Start with Name, POD# s/p surgery. Note any significant intraoperative events. Then
significant 24hr events. Then jump to Assessment/Plan by system (Neuro-including sedation/pain, CV,
Pulm, Renal, ID, Endo, FEN. Finish with review of invasive lines, meds and dispo.)
• After rounds, you will spend the rest of the morning implementing the plans discussed on rounds: writing
orders, notes, pulling drains and lines, transferring patients to the floor, etc.
• You should also scout out the OR board to see which cases are going to be admitted. During the first week or
so have the NP or PA help you place post-op and transfer orders so that you know how to do them when you
are on by yourself on the weekend. Transfers can be confusing in that depending on the surgery (heart
transplant vs. thoracic, etc.) the step-down and floor destinations will vary, just touch base with the NP/PA or
fellows about which floor to send patients to until you are comfortable with it.
• There is a CTICU list in EPIC under “Patient Lists” then “Shared List.” You will have to have your
predecessor add your name to access that list. Click on the list, Click “Properties” the “Advanced” tab. Scroll
to the bottom of the list and add the name and under Access Level—type “5” then Accept.
• Most days there is an admitting APP who will come in around noon and stay until the last admission (as late
as midnight) to handle new admissions. It is entirely your prerogative to take new admissions if you want to
37
during the day; just communicate with the team and they will make it happen.
• Night resident comes in around 4pm and you will sign out your patients at that time and go home.
• Night call is 4pm until after Fellow Rounds.
• Weekend Call is 24hours and 7am – after Fellow Rounds the next day.
Helpful order sets: Helpful to ask APPs for their input.
Adult IV Insulin Infusion
Blood Administration: Inpatient and Emergency Department
Cardiac Surgery Post-Operative Admission
Cardiac Transplant Post-Op (ICU)
Cardiac Transplant Pre-Op
Circulatory Care: Mechanical Assist Device (MAD) Transfer to IMCU / Floor
Circulatory Care: Mechanical Assist Device (MAD) Post-Op
General Thoracic Post-Op
Heparin Continuous Infusion
ICU Electrolyte Replacement Guideline
Intravenous Patient Controlled Analgesia (IV PCA)
Neuraxial Narcotic Administration
PACU Post-Op
Patient Controlled Epidural Infusion Analgesia (PCEA)
Sedation Management for the Mechanically Ventilated Patient in the ICU
Subcutaneous Insulin: Glargine and Lispro for PO, NPO or Bolus Tube Feedings
Conference schedule:
• On Mondays there are both Anesthesia and Surgical grand rounds, you can choose either, depending on the
topic and its relevance to your interests, if the surgical grand rounds is CT related.
• On Tuesdays there is cardiac conference in one of the AIP2 1st floor conference rooms located just south of
the ER at 6:30AM. Wednesday is thoracic conference in AO1 in the conference room on the 6th floor.
After these conferences the overnight resident will present the cardiac patients on “sit-rounds” with the
team, then return to the ICU and start working.
New admits:
• When a patient is admitted to the CTICU service, they usually are coming from the OR, which means they
already have been admitted to the hospital and will have an H&P prior to going to the OR. Since they are
continuing on the CT service, you do not have to write H&Ps on your OR admits! (This is different than
when STICU patients are admitted to the ICU. They all need H&P’s from the ICU team since we are a
“consulting service” for the primary surgical team) You will still need to write admit orders for Cardiac
service patients – Not thoracic or vascular. Though a new H&P is not required, an ICU accept note should
be written documenting the immediate post surgical course and plan.
• If a patient gets transferred from an outside hospital, for example, with a ruptured AAA, then you WILL
need to do an H&P and orders on that patient.
• In general, discuss all major management decisions with the CT fellows. They do not like to be surprised
in the morning.
Call schedule:
We are Q4 call in the CTICU. Weekday call shifts start @ 4 pm (not at 3pm) you will get sign-out from the day
team and then cross-cover and admit patients until the next morning. As stated earlier, the overnight resident
presents all the cardiac patients on fellow rounds like a regular day. On weekends you will come in at about
7am at which time the overnight resident will present the whole unit to the attending and CT fellow. The
38
overnight resident is then allowed to go home and the day resident and usually one APP split up the unit. The
APP will typically stay until around 5pm on weekends. You will be responsible for the whole unit overnight.
Cardiothoracic Service – UCH
PRAIRIE ROBINSON, MD; SARA CHENG, MD, PhD; GREG WOLFF, MD; JIM RYAN, MD; GRANT AMOUR, MD;
EMILY McQUAID-HANSEN, MD. BENJAMIN LIPPERT, DO; ANTASIA GIEBLER, DO; KRISTIN BARNEY, DO.
Attendings
Ben Abrams, MD. Bryan Ahlgren, DO (Fellowship Director). Karsten Bartels, MD. Nathan Clendenen, MD,
PhD. Jake Evers, MD. Lyndsey Graber, MD. Muang Hlaing, MD. Tamas Seres, MD, PhD. Breandan Sullivan,
MD (Co-Medical Director CTICU). Nathaen Weitzel, MD. Barb Wilkey, MD.
The cardiothoracic month is busy and you will learn a lot. Expect to work hard and as part of a team.
There are five residents on service, but there may be only four residents to share the caseload because
people often take vacation. Teamwork is therefore mandatory and can significantly improve your overall
experience and wellbeing. Residents take CT1-CT5 shifts and can be assigned to RFTs or the general OR if
there are not enough cardiac and/or thoracic cases. You may occasionally get a TEE, pager call, or reading
day. The CT1 resident is the last to leave. Both CT1 and CT2 residents are on (home) call until 7am the
following morning. When you are finished with your cases, or at any point when you have downtime, do
39copreops and consent inpatients for the following day (even if they are not your patients). Call your
residents to offer breaks prior to leaving, or relive the higher number call resident if applicable. Cardiac
conference is every Friday morning at 6:30 am (attendance is required).
Discuss the specifics of the anesthetic plan with your attending prior to each case, including which
medications to have prepared vs readily available. When you first start, focus on learning how to take
care of the patients and understanding the cardiothoracic pathophysiology, pharmacology, and types of
procedures. This will help when you’re rotating in the CTICU. Your most important role is to take care
of the patient. If you are ever unsure of anything, ask the fellow or attending. It is your
responsibility to respond to changes in the patient’s condition and vital signs, including during line
placement. Ask for help if you notice anything concerning while you are scrubbed in.
Before you start (highly recommended to reduce start-up pain)
▪ Ask the Anesthesia Techs to demonstrate how to setup and calibrate the Swan box, in addition to
anything else you may be unfamiliar with. It is important to be able to setup on your own in case
you’re called in overnight or on the weekend, or the techs are busy.
▪ Get a tour of the heart room and discuss the set-up with a resident who has done CT.
▪ Check out A Practical Approach to Cardiac Anesthesia from the anesthesia office (Dr. Gravlee is one
of the authors). We recommend reviewing the short section “typical CPB sequence” in the chapter
on anesthetic management during CPB.
▪ Review the cardiopulmonary physiology and anesthesia chapters in a book that you like to read,
such as Morgan and Mikhail, Anesthesiology Core Review: Advanced Exam, or Baby Miller.
▪ Review the online syllabus for cardiac anesthesia written by Dr. Seres. The syllabus is somewhat
out of date, but it does provide useful information. Of note, please do not draw up all of the bolus
▪
meds or spike all of the drips to help avoid waste (although these medications should be in the
room in case they are needed).
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/Anesthesiology/Edu
cation/fellowships/cardiacfellowship/Pages/syllabus.aspx
When you’re coming back for more
▪ A key difference between getting by vs killing it on the cardiac service is how well you understand
what’s going on across the drape. Don’t forget that the surgeons and their fellows are a valuable source
of information. We have a friendly group of CT surgeons (mostly). If you read about the procedures, ask
pertinent questions, and pay attention to how those answers impact you as the anesthesia provider, the
surgeons will remember and your CT rotations will become increasingly pleasant.
Heart room set-up
▪ The anesthesia techs will help setup the triple transducer, Level One, Swan box (ex-vivo
calibration), pacer box, TEE machine, etc. Check that the lines are zeroed, free of bubbles,
stopcocks are properly aligned, and connections are tight. Make sure the patient’s information has
been entered into the Swan box (ex-vivo calibration). The techs will not set up your lines
(cordis/MAC and PAC).
▪ Equipment: Alaris PC unit x2 with infusion pumps x4. Level 1 primed with Plasmalyte. TEE
machine/probe. Pacing box (batteries must be replaced the day of surgery and the date must be
clearly displayed on the box). Oximetric swan box. Cerebral oximeter. BIS. There is a higher
incidence of intraoperative awareness during cardiac surgery, so if your patient is at high risk it is
a reasonable consideration. Most attendings prefer to start the dexmedetomidine infusion during
CPB for this reason. Triple transducer. A-line supplies (be prepared to start the a-line in preop,
unless working with Dr. Seres. Dr. Seres prefers you wear sterile gloves). 2nd IV setup. Cordis
40 or
MAC. PAC. Gown and gloves (double glove if placing PAC). Ultrasound. ABG syringes (heparinized).
ACT syringes (not heparinized).
▪ Drips: discuss what infusions to have ready with your attending the night before. Do not spike
everything. Starting rates are only suggestions.
• Carrier: normal saline 500mL with 6 port manifold
• TXA gtt (pharmacy) – bolus and start at sternotomy
• Phenylephrine gtt (Pyxis or pharmacy)– start at 0.5 mcg/kg/min
• Epinephrine gtt (Pyxis or pharmacy) – start at 0.03 mcg/kg/min
• Norepinephrine gtt (Pyxis or pharmacy) – start at 0.03 mcg/kg/min
• Vasopressin gtt (pharmacy) – start at 0.04 units/min
• Dobutamine (Pyxis or pharmacy) – do not spike, but if necessary start at 5 mcg/kg/min
• Milrinone (heart resuscitation box) – do not spike, but if necessary start at 0.375
mcg/kg/min
• Nicardipine gtt (heart resuscitation box) – do not spike, but if necessary start at 5 mg/hr
• Nitroglycerine (heart resuscitation box) – do not spike, but if necessary start at 0.1
mcg/kg/min
• Dexmedetomidine gtt (pharmacy) – start at 0.4 mcg/kg/hr during or shortly after coming
off CPB. Continue through transport to CTICU
• Insulin gtt (Pyxis or pharmacy) if diabetic, or when working with Dr. Fullerton who uses a
high-dextrose cardioplegia solution
• Vancomycin gtt to be re-dosed (along with cefazolin) after coming off CPB. Usually infused
over an hour.
Alaris channels can be finicky. Set up your drips early, program the pumps, and let them
run onto a chux or towel for a couple of minutes to confirm the pumps are working and
there is no air in the lines.
Drugs: prepare what you will most likely use, and have the others readily available.
• Heart resuscitation box, fast track box, and albumin 5% 500mL x2 from Pyxis
• Cardiac narcotic bag with fentanyl 20mL x2 and midazolam 10mL x1
• Regular narcotic bag if working with Dr. Seres
• Have ketamine and etomidate available
• Uppers: phenylephrine 100mcg/mL x5; ephedrine 5mg/mL x1; pharmacy will supply
epinephrine 10mcg/mL x2 and vasopressin 1U/mL x1. Norepinephrine 12.8mcg/mL if
working with Dr. Ahlgren
• Downers: nicardipine 100mcg/mL (5mL from bag + 5mL NS). Nitroglycerin 20mcg/mL
(1mL from bottle + 9mL NS). Esmolol 10mg/mL
• Heparin 30mL x2 (300U/kg)
• Protamine (provided by the OR nurse. Do not draw up until off CPB)
• Rocuronium 10mg/mL x10mL
• Have succinylcholine, atropine, glycopyrrolate, lidocaine, and magnesium available
Blood: make sure blood is available and checked before starting the case, especially with redo
sternotomies.
•
▪
▪
Cardiopulmonary bypass case flow:
Pre-bypass:
▪ Preop: don’t forget the basics – PMH, physical exam (including airway exam), and have a CMAC
available if indicated. Consider having a lower threshold for video laryngoscopy as these patients
may not tolerate hypoxemia/hypercarbia well. The preop nurse will place a large bore PIV.
41
Consider using ultrasound for placing the a-line in preop (or in the room if working with Dr. Seres)
since the patients are awake, and try to avoid excessive bleeding. Do not give your patients any
meds in preop unless discussed with your attending.
▪ Induction: cardiac induction – i.e. slow/smooth and hemodynamically stable induction
(midazolam, fentanyl, sevoflurane, propofol/ketamine/etomidate, paralytic).
▪ Post-induction: 2nd large bore PIV (14 or 16g). 2nd a-line for circ arrest. The fellow or attending
will insert the TEE (don’t forget the bite block) prior to you placing the central line. Right IJ cordis
or MAC. PAC if indicated (we do this for most of our cardiac cases). Titrate anesthesia to a BP
within 20% of baseline.
▪ BIS monitor (Seres) vs cerebral oximeter. OG tube. The nurse will place a temperature-sensing
Foley.
▪ Connect Level 1 to the side port of the cordis or MAC. Connect drips to the VIP port of the PAC or
SLIC (only after PAC has been floated, otherwise connect it to a side port). Make sure there isn’t
too much tension on the central line (tape it to the bed or hook it on to the Christmas tree). Attach
the monkey bar to the IV poles.
▪ Send baseline ACT and ABG. Consider baseline labs if patient has not had recent labs and they
were not drawn in preop.
▪ The surgeons will pass you the pacing wires. Connect them to the pacer box (right side is atrial
pacer, left side is ventricular pacer). Attach the coronary sinus line to the CVP port at the
transducer and flush when the surgeons ask you to.
Sternotomy:
▪ Per attending, give fentanyl prior to sternotomy. Hold ventilation. Start TXA bolus then infusion at
sternotomy.
Prior to cannulation and initiation of CPB, give heparin bolus (300U/kg, confirm dose with
perfusionist) and draw ACT three minutes later. ACT goal >500. You may need to re-dose heparin.
If unable to achieve goal ACT, consider heparin resistance in the setting of ATIII deficiency.
▪ MAP goal ~60, SBP 90-100 during aortic cannulation as HTN increases the risk of aortic dissection.
If hypertensive pre-sternotomy, consider test dose of nicardipine or nitroglycerin to see how the
patient responds.
▪ Measure UOP prior to CPB. Chart cross clamp and bypass times (ask perfusionist for times if you
miss them).
▪ You may need to re-dose paralytic, narcotics, or midazolam at initiation of CPB or immediately
after (higher risk of awareness during CPB).
Bypass:
▪ Turn the ventilator and isoflurane off when pump flows are adequate. Make sure perfusionist has
turned on their iso.
▪ The perfusionist will draw labs and transfuse blood when needed during CPB. Follow H/H,
glucose, and lytes, and treat as indicated (communicate with the attending/fellow, surgeon, and
perfusionist).
▪ MAP goal >40. Titrate drips as needed (usually vasopressin or phenylephrine). The perfusionist
may also give vasopressin or phenylephrine boluses.
▪ No fluids running except your infusions.
▪ UOP goal ≥100mL/hr. Follow UOP and inform perfusionist if less than goal.
▪ TEE on standby.
Discontinuing bypass:
▪ During rewarming and preparation to discontinue bypass, assess the functional status of the heart and
peripheral vasculature to determine what pressors, inotropes, or vasodilators will be needed for
successful separation.
42
▪ Turn on all monitors and alarms.
▪ Re-dose paralytic (attending dependent). Consider midazolam, fentanyl, or Dilaudid.
▪ Depending on the heart rhythm and rate, defibrillation or pacing may be necessary. Discuss giving
additional lidocaine and/or magnesium.
▪ Give calcium chloride 1g within 10min of the cross clamp being released and the QRS has narrowed.
▪ When asked, re-expand the lungs until visually reinflated. Make sure there is no tension on the LIMA
graft. Turn the vent back on.
▪ The protamine dose will be provided by the perfusionist. Confirm dose and timing with attending.
Administer test dose through PIV. If no evidence of reaction, slowly give the remaining protamine.
Inform the surgeon and perfusionist when one third of the total dose has been given. Draw an ACT three
minutes later.
▪ After successful separation from CPB, send PT/INR, PTT, fibrinogen, TEG with and without heparinase,
and CBC. Continue to follow ABGs.
▪ Record UOP while on CPB and tell perfusionist.
Post-bypass/transport:
▪ Follow coags/TEG and bleeding status. Transfuse products as indicated (discuss with attending/fellow).
▪ Continue dexmedetomidine drip.
▪ Remove TEE, organize lines, buff cap/disconnect PIVs for transport, leave infusions/carrier running, and
have a bolus line hooked up to the side port of the cordis/MAC.
▪ Replace dressing on cordis/MAC if necessary (antibiotic disc and Tegaderm).
▪ Patient remains intubated most of the time.
▪ Transport to CTICU (bring emergency drugs).
▪
Attending preferences
The following are updated statements directly from each attending (unless otherwise specified).
Dr. Ahlgren (updated 2018)
▪ Know your patient and discuss induction with attending or fellow the night before.
▪ Know optimal hemodynamics for valvular disorders.
▪ When any doubt of easy airway securement- use a CMAC. CMAC for all double lumen tube placements.
▪ Pre-induction a-line if you are going to use an a-line (why not have it for a hemodynamically significant
part of the case (induction)).
▪ Put TEE probe in before central line placement and always use ultrasound for line placement- if you are
struggling with the a-line- use an ultrasound- don't turn your patient into a bruised mess.
▪ When in doubt of bleeding risk- use a MAC- more access is always better.
▪ When doing lines, untangling IVs, etc- watch the patient.
▪ MAP above 60 at all times.
▪ Doesn't care how paralyzed pt is, as long as reversible and doesn't move unless waking up for
extubation.
▪ Defib pads on for all redos, mitral stenosis, VADs, heart transplants, left main dx or left main equivalent.
▪ Levophed poppers 12.8 mcg/mL should be available for most cases- along with standard poppers.
▪ Have ketamine for most cases.
▪ If you don't understand something- ask.
▪ If you have never done something- ask before you do it.
Dr. Bartels (updated 2017)
▪ 18g PIV and pre-induction a-line is fine for most cases.
▪ TEE pre-CVC placement. I prefer MAC for most all cases.
▪ Once MAC is in avoid using PIV. Level 1 to white 12g port. Med line to push drugs to brown port.
43
Pressers to extra port of PAC or SLIC.
▪ Please cap lines and syringes when not in use. Always use aseptic technique.
Dr. Hlaing (updated 2018)
▪ For cardiac cases, A-line in preop unless arch procedure with good EF
▪ Induction: 10cc midazolam, 20cc fentanyl, +/- propofol but always have vial available, no need to draw
up etomidate or ketamine for induction.
▪ TEE before central line.
▪ MAC if redo/difficult access, otherwise cordis.
▪ Okay to re-dose roc but always check twitches before leaving the OR
▪ Be very judicious with vaso boluses (call if needing to give more than once).
▪ Infusions: wet down precede (start any time on bypass without bolus), antifibrinolytic, insulin if diabetic,
phenylephrine, everything else have available but no need to hang
▪ Bolus syringes: phenylephrine, epi, vaso
Dr. Seres (updated 2018)
▪ Call him for discussion of the patient and prepare talking about:
• Echo data: systolic function, diastolic function
• BP and heart rate
• Cath lab data
• Presence of pacemaker
• Exercise tolerance
• Airway
▪ Formulate plan for induction and specific medications or drips based on the above data. He asks you to
select induction agents for cardiac cases based on H&P data. Examples:
•
•
•
•
▪
▪
▪
▪
▪
▪
▪
▪
▪
▪
Normal or high BP and normal EF: propofol with fentanyl
Normal or high BP low EF: etomidate with fentanyl
Low BP normal EF: etomidate with fentanyl or propofol, fentanyl with phenylephrine
Low BP low EF: etomidate or ketamine with fentanyl
Don’t use stylet in ETT if you anticipate easy intubation.
He likes to give Dilaudid 2mg before skin incision.
Does not like to use paralytic after CPB. Prefers fentanyl titrated PRN.
Rarely if ever uses midazolam. If he does he does not use more than 2mg.
Prepare for doing all the lines when you work with him. He does not like to start a-line in the holding
area. He puts the monitors on and pre-oxygenates the patient while you start the a-line in the OR. After
induction and intubation, he inserts the TEE probe and cleans the neck while you prepare for the central
line. He or the fellow will start a second IV if time is limited.
Lines:
• Patient has good veins: introducer and 2 peripheral IVs, one of them 16G.
• Patient has poor venous access: MAC catheter and 1 peripheral IV.
Room preparation: he is looking for the premade syringes from pharmacy: phenylephrine, epinephrine
and vasopressin.
He does not want premade syringes of succinylcholine, esmolol, nitroglycerin, ephedrine, atropine or
glycopyrrolate.
Drips: carrier, phenylephrine, and epinephrine. Extra drips based on the specific history or
hemodynamics during the case.
He is looking for your vigilance on hemodynamics: use phenylephrine and glycopyrrolate to keep SBP >
100, HR > 50.
Dr. Sullivan (updated 2018)
44
▪ All inpatients need to be seen and consented the night before.
▪ Resident should know the hemodynamic goals for the lesion being fixed.
▪ Resident should know the medical comorbidities of the patient undergoing the surgery.
▪ Resident should know the basics of the surgery being performed.
▪ Resident should have an induction plan and a plan for lines.
▪ Drugs to have available: epi syringes, epi infusion, NE infusion, nicardipine infusion (don't need to open
it), ketamine, dobutamine (don't need to open it), milrinone (don't need to open it)
▪ I prefer the ultrasound to be on the same side as the IJ that you are planning to access.
Dr. Weitzel (updated 2018)
▪ Have clear patient history and anesthestic plan when you call the night before.
▪ Induction with midazolam/fentanyl/sevo/muscle relaxant.
▪ Only put in 14 gauge peripheral IVs.
▪ Be in the room on time. Anesthesia ready time (i.e. all lines in) within 30 minutes of in room time.
▪ Pre-induction A-line in pre-op
Dr. Wilkey (updated 2018)
▪ Wants inpatients seen and consented the day before.
▪ Look for antibodies on type and screen so case is not delayed due to difficult cross match.
▪ Have a clear induction plan when you call to tell her about the patient. Induction plan should be based
upon patient and situation. Generally does not like propofol as primary induction agent but can be
convinced in some cases. Consider having a vial of propofol available for patients who need to avoid
hypertension with induction.
▪
▪
▪
▪
▪
▪
▪
A-line before induction for all cardiac cases and lung transplants. For first start cases, arterial line should
be in by 730 Tuesday through Friday and 830 on Monday. No strong preference pre-op versus in room,
just wants it done on time.
Defib pads on for all redos and patients with inactivated ICDs.
If pt has pacemaker have a plan to manage it peri-operatively.
Put TEE probe in before central line placement and always use ultrasound for central line placement.
Call for all bad intra-operative events, even if you think you can handle it. She may or may not come but
needs to stay in the loop.
Start Precedex without bolus after hemodynamically stable off bypass.
Place OGT after TEE probe removed but before transporting to ICU.
Dr. Evers (updated 2018)
▪
Know your patient and discuss induction with attending or fellow the night before
▪
Drips: carrier, phenylephrine, and epinephrine. Extra drips based on the specific history or hemodynamics during
the case
▪
Any working PIV and pre-induction a-line is fine for most cases. Aline in preop if possible, but if difficult or
likely to be difficult then in room.
▪
Induction: Have drawn up: 10cc midazolam, 20cc fentanyl, +/- propofol and etomidate, but always have both
available.
▪
MAC for almost all cardiac cases
▪
Level 1 to brown port. Second bolus line to white port. Infusions to auxiliary port of PAC or SLIC
▪
Defib pads on for all redos, mitral/aortic stenosis, VADs, heart transplants, left main dx or left main equivalent
▪
CMAC in room for all double lumen tube placements
▪
Call for all significant intra-operative events, even if you think you can handle it. When in doubt, just call (or
text)
▪
Start Precedex without bolus after hemodynamically stable off bypass.
45
Pain Medicine Service – UCH
NATHAN LAMBORN, MD MBA, LAUREN MCLAUGHLIN, DO.
People:
Attendings: Rachael Rzasa-Lynn, MD (pronounced "Razzah"); Narayana Varhabhatla, MD;
46
Dominique Schiffer, MD.
Fellow 2018-2019: Nathan Lamborn, MD
Phone numbers:
Pain Medicine pager: 303-266-7291
University Clinic phone: 720-848-1970
Overview:
Pain Medicine (formerly known as Chronic Pain or Interventional Pain) is a specialty whose
fellows can come from anesthesiology, PM&R, neurology or psychiatry. At the University Hospital
you will work with an attending and fellow who are anesthesiologists. There are PM&R staff that
you will see on Wednesday morning Pain Didactics and noon Journal Club. Residents used to
rotate through the VA but do not at the time. During this rotation, a variety of pain conditions are
primarily treated using fluoroscopy- and ultrasound-guided injections. These range from familiar
peripheral nerve blocks (femoral, popliteal, TAP), familiar neuraxial procedures (epidural steroid
injections), to Pain Medicine specific procedures like vertebral facet medial branch blocks, trigger
point injections, Botox injections for migraines, spinal cord stimulator implants, and many other
things. Time on this rotation is roughly equally divided between performing these procedures and
seeing new and follow-up patients in clinic. In clinic you will do H&Ps and get the chance to help
manage chronic pain specific medications. This rotation is a definite change of pace from the OR
with many back-to-back patients and quick transitions. Overall this is a fast-paced month with lots
of hands-on experience and a chance to brush up on anatomy while learning more advanced
procedures and specialized medications.
Preparation:
Plan on stopping by the UCH plain clinic prior to starting your rotation in order to orient yourself to
the new area and get help setting up your new Epic for the month. Set your Epic context to "ZZ
Pain" for the correct screen layout. Ask the fellow, or an outgoing resident to help you set up your
Epic clinic schedule and receive pertinent shared SmartPhrases. Start reading to become familiar
with the field and learn about the unique blocks and medications. Common topics to look up:
medial branch blocks; SI joint injections; epidural steroid injections; trigger point injections;
lumbar sympathetic blocks and celiac plexus block; fibromyalgia, complex regional pain syndrome;
back pain, and back physical exam; radiation safety. Faust, M&M and Miller have pain medicine
chapters. You will receive material through your email to review as well before starting the month.
Location:
The clinic is at UCH on the first floor near AOP. The clinic space is shared with PM&R, Ortho
spine, and Neuro spine. Follow signs that point toward "Interventional Pain Clinic.” You may need
to email someone to get badge access, see emails. There are scrubs and lockers available.
Schedule:
Residents typically arrive for clinic or procedures at 0645 and stay until the last patient is seen,
which is usually about 1600. Check next day's schedule for first patient start time and to review
what procedures you will be performing. If multiple residents are on rotation it’s possible you can
stagger early and late starts. Plan to go to all normal resident lectures (ITE, Grand Rounds,47
etc).
There is Pain Medicine Didactic Lecture and journal club Wednesdays at 0700 and 1200.
Weekends are off.
Call
The residents and fellow will divide call for the month. It is home pager call and so you do not need
to stay within 30 minutes of the hospital. The fellow will email you the call schedule and pager
instructions prior to the rotation. A majority of pages are regarding in-patient pain management and
so should be directed to the Acute Pain Service. Pages are rare.
-Average DayUCH Interventional Pain Clinic:
* Double check the schedule as it may change month-to-month. Typically arrive around 0645 for
first patient at 0700. Time slots are typically 15 - 30 minutes per patient for procedures, 1 hour for
new patient visit. There are usually 15 - 20+ patients per day. Lunch is from 12 to 1. The last
patient is scheduled around 1545. After that you will finish notes then go home. UCH is fast paced
but you will adapt quickly.
* The day will typically be split between the fluoro suite (procedure) side and the clinic side. On
the fluoro suite side you will see the patient briefly in the pre-op area before performing the
procedures. On the clinic side you will see new patients and perform some head and face nerve
blocks and Botox injections.
* For procedures, there are five steps: 1) After the patient has arrived and their dot turns green on
EPIC, copy forward their last procedure note, update it accordingly (see below), then share it. 2) Go
see the patient and briefly consent them and get an update (see below). 3) Remove appropriate
drugs from the Pyxis and ready the procedure room. 4) Perform the procedure. 5) Finish the note. A
medication guide near the Pyxis lists what drugs you should pull for a given procedure. Supplies
for procedures are located in the fluoro room and the ancillary staff will help you set up. For notes,
the best way to learn is to have the fellow or a returning resident show you. In brief, for returning
patients (vast majority), you will copy forward an old note and update the "Plan" section. For new
patients receiving their very first injection, make a new note from one of the .painpro templates.
Learning Epic notes takes practice but is crucial to make the day run smoothly.
* When you see the patient in pre-op you should discuss today's procedure with them and have
them sign the consent. There is a list of common side effects and complications for each injection
located by the procedure computer that you should mention. Then, ask the patient how much and
for how long their last injection helped them (you can find out what type of injection they last had
from previous pain notes in Epic). Include in your procedure note “Plan” how much benefit they
received last time, what you did today, and what injection(s) you plan on doing next time. It is
important to actually read through the whole note to make sure it is up to date and accurate, as
sometimes the notes have been copied forward incorrectly a few times and therefore contain errors.
* For new patients on the clinic side, the MA will bring the patient’s paperwork to the workroom
once the patient is checked in. Review any useful notes in Epic from other providers, and any
available imaging. It is recommended to start your H&P then fill out parts before and while talking
to the patient; it is now possible to “Pre-Chart” on the patient days in advance; if the patient
48does
not present for the visit your documentation with disappear within 30 days. Then, go see the patient
and perform a history and appropriate physical exam. Then, report to the attending. You will return
to see the patient together. Finally, type/finish a new patient H&P. The fellow or attending will
show you the Epic note template plus the instructions will be in your emailed information.
Children’s Hospital Colorado (CHC)
GILLIAN JOHNSON, MBBCHIR; CRISTINA WOOD, MD; JOEL WILSON, MD, ALLISON LOSEY, MD; BENJAMIN LIPPERT, DO,
GREG SCHMITZ, MD; KENTON HOWARD, MD.
Primary Contact:
Associate Director, Pediatric Anesthesia Resident Education,
Thomas Notides, M.D. x76005, (c) 720-838-4002 (call or text me to get in touch ASAP)
Thomas.notides@childrenscolorado.org
Director of Education at CHC: Dr. Larry Schwartz: x72628
Administrative Assistants:
• Lindsay Baumgartner : x74999 (rotation coordinator),
• Jessica M. Hynes: x76248 responsible for OR daily schedule
Phone Numbers: (also see your cards)
Main CHC Hospital Operator: 720-777-1234
Emergency Operator/Codes/Massive Txfn/Security: x75555
Anesthesia in Charge: 720-777-8339 (x78339)
Anesthesia emergency overhead page: x19550
Main OR Front Desk:
76492
APS phone:
75433 (7LIFE)
Charge midlevel PCD:
72255
Anes tech main:
73939
General Computer Help:
7HELP
Epic Anesthesia help: Megan McGrew: 71500, (or main# x 7EREX)
Chronic pain clinic/consults
74122
One Call (paging provider to provider): 73999
ICU/OR pharmacy
PICU
NICU
75568
73239
76857
Remote access, including Epic and CHC intranet: https://my.childrenscolorado.org
49
Phone tips:
To reach an extension from off campus call 720-77 + [the 5 digit extension starting with 7]. Extensions starting
with 6 can only be reached from off campus via the CHC operator.
During orientation you need to get a laminated card that clips to your ID with all the anesthesia PCD numbers.
Also, you will be provided a phone list each month (“roster”) with all the attendings’ home/office phone
numbers and pager numbers for calling your attending the afternoon or evening before cases.
On Day One:
Your first day will solely be orientation. You do not need to get oriented prior to this from other residents (as
with most other rotations). This will include a morning of Epic training, badge collection and parking
information and access. Please try to complete this and get some lunch by 1 pm, then contact Dr. Notides
x76005 (or Lindsay, #above). On the first day you may park in the visitor lot out the front of the hospital. On
subsequent days you will be ticketed if you do not park in the assigned lot. Your badge will be your method of
access to the parking lot, hospital and all departments and doors in the OR (includes the anesthesia work room.)
After your Epic training, Dr. Notides will meet with you and provide a tour of the ORs, procedure center, MRI,
etc.
At completion of your tour please be sure to accomplish the following:
• Locate your departmental mailbox, pick up your PCD (ensure your number works and is correct on staff
roster sheet)
• Check that Lindsey has your correct contact info, including your UCH email (very important that you
confirm your email is included in daily case assignments and OR schedules), new PCD#, cell phone#,
and obtain the phone # cards, lecture and call schedules
• Check you have working Omnicell and Epic access
• Know where the items are on the list at the end of this document
50
• Obtain iStat training (Dr. Morris Dressler, or Nita, can be on a later day)
• Know how to access the resident SharePoint site
• Take a look at the OSA screening (STUBR) training on the resident SharePoint site
• Please read this manual as well as the orientation guidelines received this day and ask questions if
anything doesn’t make sense.
• Lindsey Baumgartner will assign lockers, you need to bring your own lock.
Following orientation, start working on your pre-op’s for the next day so that you may call your attending in a
timely manner.
General Info:
• Mailboxes are located behind the desk of Lindsay Baumgartner in the faculty office area (across bridge
on 2nd floor to admin area and take first right).
• Attendings will sometimes run their own room, sometimes work one on one with residents and other
times have 2 residents and fellows to supervise.
• For your first 5 days as a CA-2, you should be scheduled with an attending one-on-one.
• There are also anesthesia assistants (AAs) and CRNAs working at Children’s
• All patient information is on electronic boards in pre-op, post-op and ORs. Check this board before you
set up anything as cases cancel/delay more often than at UCH.
• Be sure to communicate with pre-op and OR nurses about pre-meds if you have ordered them.
Weekday Daily Work Flow:
Set up:
• The next day schedule should be out by 1-4 pm by email. All names by initials (see Roster).
• Do your pre-op H&P’s on Epic for outpatients patients coming into the hospital as completely as you can
•
•
•
•
•
•
•
the night before. Mark note as incomplete until finalized (very important to do—otherwise your pre-op will
be deleted that evening at midnight!).
Contact your attending (early in the afternoon/evening if possible) to present your plan (and explain why)
for your patients. Before 5-6 pm is typically better.
See and/or most importantly obtain consent for all inpatients scheduled for the next day.
Give yourself 30 minutes to set-up your OR before any morning conferences.
Check the Epic status board before you set up since there may be last-minute changes!
Let the anesthesia techs know, in advance, if you need any special equipment for your case. Please (1) write
it on the white board with room number and (2) speak with the tech (PST).
Please ask your attending to show you how to avoid iatrogenic contamination of your patients and keep
lines air-free.
We are currently re-structuring our work area’s but generally do not place syringes that have touched the
patient’s lines, dirty airway equipment, dirty fingers/gloves, or anything else “dirty” on or in the omnicell.
The anesthesia machine is generally considered a dirty area after the start of the case.
Pre-op:
• Arrive in Pre-op by 7:00 (8:00 on Mondays) to see your patient. Our window is 07:00-07:10, but you can
see them earlier if they are “ready” per the pre-op RN (purple on Epic status board).
• To find your patient- check the electronic board showing name and room. Child may be in the play area,
you will see a sign on/next to the door to their pre-op room.
• Make sure you ID the child and find correct parent(s).
• You can use the in room computers to fill out your pre-op note.
• Decide early on (ideally > 30 min prior to OR) if your patient needs pre-anesthesia PO midazolam (“pre
med”) as it takes some time for the RN to administer and to reach clinical effect. The 2-4 year age group is
most common. You will need to inform the pre-op RN directly for timely administration of the premed.
51
• You must fill out the STUBR score and click ready for procedure when Epic pre-op work is complete,
prior to the patient going back to the OR.
• If doing an inhalation induction ask the child which smell he/she wants for her mask.
• When done with pre-op, you may wait for the patient in the OR—nurses bring patients and parents back to
OR.
• Many times you will need an interpreter—typically there is an in-person interpreter floating around pre-op
for first case starts. If you need an interpreter for a case later in the day, you likely will need to use a
translator phone unless you are lucky.
• First case start times and turnover for subsequent cases is a little more lax than at UCH, but it is always
good practice to get your preop done and room ready—try not be the reason there is a delay.
• Some attendings will pre-op the next patient while others will not. Be prepared to drop a patient off in
PACU, speak with that patient’s parents in the waiting area, and then go to pre-op to see your next patient,
all prior to going back to the OR to get your room ready and waste your drugs for the next case.
Counseling families, Parental Presence at Induction:
• Appropriate videos or video games on your phone/iPad or OR video screens also work very well for many
children!
• Please consent the patient/parents, nothing to sign, but informed discussion with the family. Anesthesia
written consent is obtained as part of the surgery consent by the surgeon (except for radiology scans).
• Remember to talk about who is coming back to the OR with the child. (NO parents back to OR for emergent
cases, significant airway issues, PSF cases, during weekends, children under 12 months, or at the call of the
attending).
• Tell the parents what to expect as the child goes to sleep in a way that is appropriate to the listening child.
Reassure that we will make it as non-scary as possible and it will not be painful.
•
•
•
Tell them they will exit the OR before the child is not completely under GA, but past the point of recall.
Assure them we will continue to get them more asleep before proceeding further. The process can be
upsetting to parents acutely, but are grateful to have been allowed access. This can be amplified by a
difficult induction and mitigated by being fully informed.
Toddlers may resist. Most children will wiggle during stage II, so let the parent know that after their eyes
are closed, and the child is “asleep,” the body will move but they are NOT aware.
If the child is a teen and almost adult size then you may choose IV induction vs. inhalational induction.
Discuss this with attending, patient, and family and prepare child for either method.
In the OR:
• Go back to the room and do a final check while you wait for the child to come back to the OR with the
circulating nurse. (This is nice….you do not bring the patients back to the OR).
• Now is a good time to touch base with your attending and confirm the plan you discussed the previous
night.
• Before induction, follow the pre-induction “anesthesia time-in” checklist, line by line.
• Be sure to introduce yourself clearly at timeouts and signouts in the PACU and ICU and to the colleagues
you will be working with for the day.
• Pay attention and avoid doing other tasks during this and during the time in and surgical time out.
• SCD’s must be on prior to induction, if indicated.
• Use your skills to keep the child engaged and happy while you give approximately 35 to 40% nitrous oxide
in oxygen. Usually okay to turn on 8% sevoflurane for induction except for certain patients (ie, T21).
• Open communication and distraction with something interesting and enjoyable to the child is commonly
preferred over repeated reassurances of “you’re ok” which are in stark contradiction to what the patient is
experiencing.
• N2O is an odorless way of getting the induction started. NOTE - if the patient is a small baby and is asleep
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then leave the pacifier in and perform a “steal” induction without touching the baby and hopefully without
waking them.
• Some kids do better if sitting up on the OR bed or being held by a seated parent - wrap a warm blanket
around their shoulders and hug their arms to their sides as they drift off.
• The circulator or anesthesia tech will escort parents out of the room.
• Often the attending will take the airway while you get IV access. This can sometimes be a challenge,
especially in the chubby 2 yo child. You will quickly improve and learn to use the tools (WeeLight, snake
light, wires) to help you. Saphenous sticks are common in babies and those getting caudal blocks for
urological procedures.
• Anesthesia techs place airway bags on anesthesia machine—be sure correctly size tubes (cuffed and
uncuffed) and blades (with working lights) are available in these bags.
Emergence, Post-op:
• You will chart in EPIC similarly to at UCH, with a few minor changes.
• PACU orders are done in EPIC, complete before leaving the OR.
• For efficiency, orders may be filled out prior to the case start if the patient weight and allergies have been
entered for that encounter.
• You will frequently remove the patient’s ETT/LMA before awakening or “deep extubate.” However, there
are a few medical/attending specific exceptions such as airway concerns, very large, very small, etc. Also be
aware, for PICU bound patients, they will not receive the same airway attention that our PACU patients
receive.
• Please take sux/atropine on a capped syringe with an IM needle available, (+/- narcotics, propofol) and the
MASK with you to the PACU.
• In PACU, do a verbal hand off by following step-by-step the green handoff sheet that will be on the paper
chart.
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For each patient, a handoff will need to be completed, but is typically done by our PACU nurses
For each patient, a post-op note will need to be completed, and is typically done by the attending, but help is
always appreciated.
Also see PICU section below
For complex cases that stay >24-48 hrs (major trauma, major ortho, major neuro, index cases, etc.) a post op
follow-up note should be placed as a matter of professionalism and for your education of typical post op
course, but is not mandated.
Also see PICU/NICU section below for additional info
End of day:
• Ask for feedback and go over your milestones eval with your attending before leaving on a daily basis.
Please be proactive and help to facilitate this.
• If you get out of the OR more than an hour before you colleagues, please work as a team and help your
fellow resident with pre-op’s if they are going to be stuck there late. You can either break them out or see
their inpatients for them. This is especially helpful when a resident has a late case one day with a busy
ENT/urology room the following day (sometimes up to 10 pre-ops).
• Before going home, make sure all pre, intra, and post-op documentation for all your patients are complete.
• Work on your pre-op’s and see inpatients for the next day
• For adverse outcomes or near misses, use AIRS on Epic. Coordinate w/ your attending.
• Discuss with your attending who will be responsible for completing the post op notes for your patients
ICU (NICU and PICU):
• A member of the anesthesia team must call the ICU to give a brief report to the ICU attending or fellow/PA
prior to leaving the OR. Usually shortly prior to closing.
• Typically, patients going to the ICU will go directly to the ICU without going to PACU first. Extubated
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patients should be managed so that little airway support is needed by the ICU staff . ICU has neither the
same resources nor the experience in managing a heavily sedated patient’s airway as does our PACU.
• There is a separate protocolized sign-out for the ICU that is done as a multi-disciplinary team after the first
set of vital signs are obtained. Your OR RN will provide the template for you. Follow line by line.
• For PICU bound patients you must chart your own handoff in this scenario.
• Ask attending about how to appropriately document VS and transport events in Epic
Drugs/Pharmacy:
• Controlled drugs are located in omnicells in each OR
• Omni by the main OR desk has additional meds.
• At CHC ephedrine is in your Pyxis machine and considered a monitored substance, and propofol has to be
accounted for, like other controlled substances.
• At the end of each case, the unused/dirty medications need to be returned to the bin on the right side of the
omnicell before the next patient enters the room.
• Please charge for all mediations taken out of the omnicell.
• Our pharmacy is now adjacent to the OR’s, by the locker rooms.
• Pharmacy will make up drips and epidural infusions for you. Some cases will have order sets that make it
extremely easy to order drips from pharmacy.
• Main OR desk tube station is 520.
• Epidural infusions, however, should be sent to the PACU and set up there on a pump and then brought into
the OR.
• Any infusions continued post op must be made up by the pharmacy. You can make up your own infusions if
solely used in the OR.
• Drug vials are treated as single dose only and have to be discarded before the next patient enters the room.
• Draw-up and charge the sux/atropine to the first patient of the day, or to floor stock. (Please let me know if
people are telling you not to draw it up.)
• Get in the habit of calculating IM doses of sux/atropine for all patients—induction takes place prior to IV
placement thus you may need to give meds IM in case of laryngospasm.
• IV acetaminophen is available from the OR pharmacy—clarify with attending if okay to use since it is
expensive
• Drugs given in the OR need to be charted on Epic by the time you sign out
• On Epic, there is a link to protocols and educational materials on sharepoint via the “Anes Sharepoint site”
• Look for the i-care emergency button in the column just to the right of the anesthesia chart for emergency
flow charts and drug doses.
• All drugs need to be labeled, including propofol. All ORs now have label printing machines, which print
labels as well as charges for drugs. Be sure to double check concentrations as some drugs need to be diluted
(ie, narcotics, ephedrine, epi).
Lectures:
• You are expected to attend all morning lectures Tues, Wed, Thurs +/- Fridays at 6:30-07:00 (check your
email for location)
• Mondays you will attend any CHC M&M or grand rounds. If there is no presentation at CHC, attend the
CU grand rounds. You will not attend department staff meetings.
Call Nights/Weekend Call:
• There is an anesthesia attending in house at all times. Typically they can be reached by the charge phone
x78339, their PCD#, or the OR front desk, x76492.
• No regular weekday C1 call for residents and thus no post-call days.
• C2 Friday (07:00 Friday to 07:00 Saturday AM): Report in the AM, as like any other work day. You will
be on pager call from home after you are relived from cases in the OR, which will be late in the day
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(typically 7pm-11pm or so). You will be expected to be in the OR within 30 minutes of being paged back to
CHC from home, if needed.
• Saturday C1 (15:00 Saturday to 07:00 Sunday AM): You should plan to arrive around 14:00 (2 pm) in
order to receive handoff from the APS nurse, change, and get sign-out in the OR from the mid-level shortly
before 3 pm. You can come a bit later than 2 pm once you know you way around and exactly how much
time you will need. Call the APS phone when you arrive (x75433) to arrange for sign out. Please keep your
pager/phone on Saturday morning in case of a massive causality situation where we would need all available
help. If you would not be available at all (out of town) please let the charge attending know in advance.
• Sunday C1 AM (07:00 – 19:00): Report in time to takeover (6:30-6:45) any ongoing cases by 07:00, or
enough time to set up for a 07:30 start. Check the board on Epic to see what is scheduled or call the
attending charge phone (this is a dynamic process on weekends). You may be covering this same shift on
holidays at as well.
• Occasionally you may have a weekend or holiday C2 call if the fellows cannot cover it. You will be
expected to report to the OR in the AM for C2 call without being called. However, if you think you
may not be needed (check the OR board from home) call the attending in charge 06:00-06:30 to see if you
need to come in. If not needed for first case, you must be able to be in the OR in 30 min after being
contacted at all times during your shift. C2 call is typically for 24 hrs. You should be receiving extra pay
for weekend or holiday C2 call.
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Lines of communication responsible for on C1: Personal CHC PCD#, Code/trauma pager and code blue
access card, APS phone x75433
Call room: located on the 2nd floor, past the bridge and Castle Peak conference room and through the
double doors. Code 8-6-4-2. Our call room is labeled (#3) and the code is again 8-6-4-2.
Pass on the PCS’s, badge, and unforward phones before going off call. Pain phone and pain service sign-out
to RN coming on. Code pager/access card go to the oncoming Sunday call resident.
Acute Pain Service
• Will give you sign out and their PCD on C1 overnight call.
• When you come in, call the PCD at x75433 to meet up for sign out.
• Keep track of any patients added overnight/changes made for AM sign-out.
• Always see patients when an evaluation is needed.
• Briefly document all significant changes in plan and all patient visits on Epic.
• There is an APS attending on call every night, available by phone. Make sure you get their contact info at
sign-out. Call for all updates and changes in pain management.
• Ask plenty of questions at APS sign-out, especially about the plan for problems
• Give report to the pain service APN or fellow by 7am the next morning.
• APS team will sign out to C2 fellow or mid-level on Sunday PM, so Sunday resident does NOT cover APS
Codes:
• Coordinate with your attending by phone or in person for all codes
• Level One Trauma or Trauma Red – MUST attend STAT. Sign in when you arrive via access card
reader
• Level Two Trauma – do NOT need to attend.
• Our responsibility is the airway. Once verified/secured, ask the code/trauma code leader (ICU, surgery, or
ED attending/fellow) if you need to provide additional assistance, otherwise return to your other
responsibilities.
• When called to the ER, the ED fellow may ask to place the airway. Use your discretion and do what is best
for the patient. You may respectfully decline if you do not feel comfortable with this. Please discuss with
your attending, if possible.
• They have a Glidescope, LMA’s, and standard intubation equipment available in the ED.
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• Emergency Medical Response/”Code Blue” – MUST attend. If in OR, call your attending immediately.
• Stroke alert level 1 – heads-up. May require urgent imaging (typically MRI) under anesthesia. Begin to
prepare and pre-op patient if possible, coordinate with your attending
• Stroke alert level 2 – Need to start scan now.
• RRT – ICU team will respond to eval. Not required to attend, but 30% will become a code blue. Review
prior anesthetic record, co-morbidies on Epic and be prepared for possible escalation.
• Don’t forget to swipe your code access card when you exit the elevator to release it.
• Airway Box - there is NO tackle box at CHC, but you may need to take a Glidescope if going to a difficult
airway child. Also, no neonatal microcuff tubes or LMA’s on the units, so bring those with you if you
know they are needed. Be sure to call your attending as soon as you get the code.
• Please fill out a paper code/trauma response form after the event. They are located above Megan’s desk
in the anesthesia area.
• Discuss with your attending how to document all patient care delivered outside the OR, including
procedures.
Blood:
• Please leave blood products in the OR refrigerator until you are going to transfuse them (except
emergencies) to avoid temperature indicator color change.
Rotation specific items:
• Please speak with Thomas Notides or Larry Schwartz regarding any concerns or specific requests or
cases or other educational exposures you’d like to have during your time here to ensure you have the
best experience possible.
• Since you are not taking overnight weekday call your weekdays will tend to be longer than other
rotations to ensure you are getting sufficient experience during your time here. Please let us know if this
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is becoming onerous.
We realize that you may have important meetings or appointments that need to be scheduled during the
work week. There are now 3 reading days that you can choose over your 3 months in advance for these
situations. Please contact Thomas Notides and Lindsay Baumgarter at least one week in advance so that
we may schedule you appropriately to facilitate your needs.
You should be getting out earlier on the Monday following your Sunday call shift whenever possible.
Please contact Thomas Notides if this is not happening, or if you have any concerns regarding work
hours.
We realize that taking care of very ill and traumatically injured children can be emotionally challenging.
Please let us know if this is an issue so we can address it sooner rather than later. Good resources are:
Drs. Notides, Markowitz, or Janosy.
You may find yourself being more closely supervised at CHC than other rotations, especially when you
are new here. Do not take this personally. As we get to know you that will typically change.
Spine fusions, acetabular osteotomy cases, VPS, ERAS, and transplant cases are complex and highly
protocol-driven. Please ensure you obtain a copy of the protocol from sharepoint (clinical section),
discuss the case with your attending, and give yourself adequate time to set up. Always look to see if a
protocol exists for major cases (or ask attending during pre-op discussion if one exists).
Please use the central line insertion kit for all central lines
Please wash, gown and glove for all catheter placements. Use a probe cover for all U/S blocks.
You will need to log out of the Omnicell and both computers when you leave the room and secure all
medications.
Please refer to the CHC policies and procedures for additional information on topics such as: trauma
codes, massive transfusion protocol, blood transfusions, admission follow GA due to young age, and
others. https://info.childrenscolorado.org/sites/search/Pages/results_policies.aspx?k=
There are now 2 computers screens in all OR’s. The one above the APL valve is touch screen and
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automatically links to anesthesia machine (you must login on this computer in order for VS to
automatically load into Epic); the regular computer is not linked to anesthesia machine (you must
manually link it if you want it to record vitals).
Attendings here have trained in a variety of places—it is very common to do very similar cases and
procedures one way with one attending and completely different another day with another attending. It
can be extremely frustrating at first, so be very patient. Be sure to have a thorough and complete plan
for your cases that day. In the end, it is good to see different ways of doing things so that you can adapt
and develop your own practice based on what has worked for you.
Professionalism:
• Please be helpful, respectful, and courteous to everyone you encounter at CHC. If you cannot address
their concerns, or have issues, please contact your attending.
• Be proactive in your communication at all times (from pre op planning, problems/concerns/questions,
and your documentation responsibilities)
• For complex cases and blocks, please make an effort to personally post-op patients that stay > 24 hrs
inpatient. See (or call patients at home) that had nerve blocks to see how they did with any blocks you
placed.
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Please know where the following items are prior to your first day:
o Belmont infuser
o Trauma line cart and central line omnicell
o Emergency ENT cart
o Advanced airway carts
o MH cart
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Code carts for OR and PACU
Main omni
520 tube station
Main OR blood refrigerator
Obstetrics (Labor and Delivery) - UCH
ESTEE PIEHL, MD; ALLISON LOSEY, MD; MATTHEW ROWAN, MD; NATHANIEL J BROWN MD PHD; ALEX BEHM,
MD; JOSH DOUIN, MD; BRENNAN MCGILL, MD; RALEIGH ANDERSON, MD
Codes:
4th Floor Work Room: 11154; 5th Floor Work Room: 11154
All Med Rooms: 84111; Nutrition Rooms: 11154
Women’s Locker Room: 84111/ 23985
Men’s Locker Room: 6667/0404
Call Room: 0404
Epidural Carts: 84111
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Phone Numbers:
OB Attending Phone: 8-5973
OB Resident Phone: 8-5972
OB CRNA Phone: 8-5911
Scheduled Meetings:
7am daily: OB sign-out (we can go to Grand Rounds on Mondays but let the CRNA know you are leaving
the unit)
12:30pm on Tuesday: MFM Clinic Meeting
8am Thursday: Team meeting after sign-out
Reading:
You will receive an email before your rotation starts with several attachments containing information
about the rotation: standard doses for spinals/epidurals (The cookbook), a procedure guide, and a
reading list. Read these before you start and print out the cookbook and procedure guide to carry with
you. You will also receive a “cookbook card” to attach to your badge when you start for quick reference.
The reading list books are in the OB anesthesia work room. As always, Morgan and Mikhail is not a bad
place to start.
Schedule:
The schedule on OB is different from every other rotation. You will be working 12 hour shifts from 6am –
6pm or vice versa. Note: the start time of the shifts may be changed by the residents on any given month
(most residents prefer 6-6 so you can get settled prior to sign-out). Please try to arrive with enough time
to get hand off from the on call resident so they can leave on time (about 15 minutes early). The
schedule is changing this year but will essentially involve the 2 CA2’s covering days during the first two
weeks and then nights for the last two weeks and vice versa for the CA3’s. This will allow the CA2’s to
have more daytime teaching prior to starting nights.
In addition to you, there is a CRNA on at all times. They work 24 hour shifts, 7am-7am, so they will know
what happened during the day shift which can be helpful on nights.
Don’t plan to get much sleep on OB at night. This is not like an OR overnight call where once you knock out
the cases on the board you have a good shot of getting a chunk of sleep for the rest of the night. You will
always get the first call for any epidurals, C-sections, etc. This is so that we can get the experience that we
need.
A note for people with kids: It will be a hard month if you have small children because you might not see them
a lot. Leaving at 5:30am and getting home around 7pm for 3-4 days in a row might mean that you won’t see
them for 3-4 days. (Not much to do about it - just a word of warning. You may want to enlist help/warn your
spouse in advance so they don’t kill you.)
That said, the OB rotation is a really good one, much loved by all for several reasons:
• We have great OB attendings that like to teach, and a good syllabus. The OB attendings are: Joy Hawkins,
Brenda Bucklin, Christina Wood, Jason Papazian, and Rachel Kacmar. They all like to teach and will
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happily discuss any OB topic that you pick for the day provided that there is time. They are usually on
service during the weekdays. That is especially helpful in the first month when you have no idea what you
are doing. Most of the attendings that cover nights will let you run the show. They should still be there
for every procedure. If you have any questions or concerns do not hesitate to call the attending
overnight. This is why we all do a lot of days at the beginning of our first month. Make sure that you learn
all you can from the OB attendings during days because at night you are often on your own.
• Tons ‘o Procedures!!! The OB attendings have worked very hard to make sure that we get called before the
CRNAs for procedures so that we can get experience. Again, tough in the middle of the night sometimes,
but that is what we are here for.
• We are emailed a “cookbook” with drug dosing for most OB situations. It is VERY helpful, so make sure
you print it out and put it in your pocket, or attach the card to your badge.
• As of 2017, a Pre-Test will be sent to all residents rotating on OB. This is lengthy but covers most of the
“syllabus” you are emailed at the beginning of the rotation. Many of us found it useful.
Pearls:
• ALWAYS CHECK YOUR ORs at the start of the shift. This is especially important at night when there
is less help. You never know when you’ll be crashing back to the OR.
• The ORs should always be set up for an emergent C-section type scenario. Believe me, you do not
want this scenario to happen when there is no laryngoscope in the OR… or no Etomidate/Propofol
available, etc. So just check that everything is ready to go as if you were going to do a crash section
This includes making sure videoscope is prepped/functional (either C-MAC or Glidescope in each L&D
OR).
•
We no longer have direct access to uterotonics (other than Pitocin). The other uterotonics are now
contained in the “tacklebox” which the floor nurses can pull for you. During the timeout, please discuss
the potential need for the tacklebox so the circulating RN can get it for you.
• Use the CRNAs as a resource. Many of the CRNAs that do OB have had a lot of OB experience. You
can ask them questions, ask them for help, whatever. This is especially helpful at night when the
attending is less available. Don’t forget to call them when the “you know what” hits the fan. They are a
really helpful second (or third) set of hands in those situations. Always call them for any STAT cases or
other emergencies.
• OB RNs are very involved with their patients. They really want what is best for their patients.
Sometimes that may come across as them trying to push us around. For the majority of them, this is not
true. They want us to put epidurals in ASAP so that their patients will not be miserable and in pain.
Exactly what we want. However, we all understand that we have to do it safely.
• Figure out how to restock the carts properly at the very beginning of the month. We have to restock our
own epidural carts from the workroom supplies. Learn how to do it at the beginning so all of the carts
aren’t missing stuff by the middle of the month. The carts must be restocked and cleaned in between
each patient and then placed back in the clean room ready for the next patient. The floor RN will bring
the cart to the anesthesia workroom for cleaning but you must place it back in the patient rooms. If you
do need anesthesia tech support, call the usual phone numbers, but Melissa is primarily responsible for
L&D issues.
• EPIC charting on the OB floors will look different than what you are used to in the OR. It is best to log
in and open the chart in the workroom or on a computer in the hall. There is a macro listed for OB Labor
Epidurals, OB regional C/S, etc. These are really helpful. When doing an epidural, pick the OB epidural
macro then Start Anesthesia and “link devices.” If you do not link the device, you will not receive
vital signs during the epidural placement. After you finish the procedure unlink the device. If you
forget to unlink, the nurses will call you because they cannot do their charting. You should remain
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the patient monitoring them for at least 15 minutes after the epidural placement or a bolus. After the
initial placement, you must put vital signs in the chart every hour to be able to bill for the time that we
are “readily available” but not in the patient’s room. It is easiest to get these vitals in EPIC under the
flowsheet and enter them in our record by hand. It is a good idea to do this a couple times during your
shift or whenever you get some downtime so you don’t get behind. Things can go from quiet to crazy
relatively quickly on the floor. After placing an epidural or performing a C/S, add the patient to our
shared OB patient list with any pertinent information to be followed up in a postop visit. More detailed
information regarding charting can be found in the procedure handout you receive prior to starting.
As always, it is best to spend some time on the OB floor getting oriented before your first day on OB.
There are many differences to your OB month and it is extremely helpful to have someone show you
things…like where the OR/workroom/pyxis/call rooms are located. This rotation can be a lot of fun, but
things happen quickly and it’s nice to be prepared.
Transplant Service- UCH
SARA CHENG, MD, PHD; AARON MURRAY, MD; ANDREW SULLIVAN, MD; LUKE JOHNSON, MD; LEAH WEBB,
MD; CARA CROUCH, MD
The primary focus of this month will be liver transplants; time will also be spent doing kidney and pancreas
transplants as well. Liver transplant recipients may have major derangements in multiple organ systems and the
surgery often involves significant blood loss, coagulopathy, and hemodynamic instability. These are big but
incredibly interesting and satisfying cases. The teaching is excellent on this rotation and you are guaranteed to
learn a lot; you will be 1:1 with your attending for liver transplants and they will be in the room for most of the
case.
Transplant Anesthesia team:
Susan Mandell - Head of Transplant Anesthesia
Other attendings: Drs. Fareed Azam, Ana Fernandez-Bustamante, Sam Gilliland, Adrian Hendrickse, Tim Tran,
Barb Wilkey, Scott Wolf
Transplant fellow: Cara Crouch
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Reading:
The very first thing you need to do is to review the Liver Transplant Guide that is on the virtue website
(Education Manuals/Protocols Liver transplant guide). This guide walks you through the OR setup/preparation of these cases as well as the intraoperative and postoperative care. It is essentially a step by step
guide and is extremely helpful!!!
Reading the relevant chapters regarding anesthesia for patients with liver disease and liver transplantation in
any of the major anesthesia textbooks (M&M, Barash, Miller, etc) provides a great background and helps you
understand the physiologic changes associated with liver disease. Also check out the DVDs of Sara Cheng’s
Grand Rounds on Liver Transplants, which provides an overview/summary (available in the library in the
anesthesia office). A good review is from the Lancet
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60121-5/abstract
I recommend trying to peak into a liver transplant during the month prior to starting (if you notice one is
happening while you are available) to try and get a basic idea of the set up – it’s a little daunting at first. As
always, get together with the resident who is on prior to your month and get a rundown of the ins and outs of the
rotation as well as any updates to any protocols.
Schedule:
Deceased-donor liver transplants are a semi-emergency due to the limited ability of the donor organ to tolerate
cold ischemia (goal is <12hrs). Live liver donor cases are also done at UCH; these will be scheduled cases (see
below). If you are the only resident on transplant, you’ll be on 24-7 call for all but 2 weekends of this month;
we are now trying to maintain two residents per month given the increased case numbers lately. The rest of the
time you will be working in the general OR during the day. Be proactive and ask the charge attending for good
cases on the next day’s schedule – they will usually give you liver resections if available. Also you can remind
him/her that you are the transplant resident - ideally, you should be relieved relatively early from your daily
duties, as you may be called back at any time. This doesn’t always happen and don’t expect it all of the time; we
are not entitled to reading days or early relief from general OR cases so appreciate when these things happen for
you but don’t come to expect that they should happen automatically. Keep your eye on the board and check in
with OR charge before you leave for the day--you’ll want to know if a transplant is added on for 6 PM, so you
can try to get relieved from your room and get some dinner, call your spouse, feed your dog, etc.
(If at all possible you can try to arrange to get a reading day on a Thursday, there is a selection committee
meeting every Thursday morning where the whole transplant team meets to discuss patients that are high on the
list. Not only is this really educational but it also gives you a “heads up” about any really sick patients that are
getting bumped up on the list.)
When you get called for a liver transplant:
1. When the OR desk calls you on nights/weekends for a liver transplant, they will usually give you at least
3-4 hours notice. Always call the desk again before heading into the hospital, as plans often change.
Important information to get: patient name, MR#, donor procurement time (this gives you a better idea
of the timeline), whether the attending has been notified.
2. Before you leave your house, call and confirm that the case is still scheduled AND if so, go into EPIC or
call the pharmacy and order your drips. This is especially important at night and on the weekends as the
inpatient pharmacy is not as quick as the OR pharmacy. Have your drips tubed to the OR front desk. Use
the guide on the virtue website to figure out which drips to order, don’t forget about antibiotics!
3. Plan for about 2-2.5 hours to set up the OR (you will get faster). Use the guide on the virtue website to
help you set up the room – it goes through the set up, which drugs to draw up, how to arrange your
infusions and how to arrange the Belmont, Level one, etc in the OR.
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Pre-op:
• Pre-op Note: Fill out the pre-op note as you normally would, always include TTE information and
calculate a MELD (use the online calculator link in the guide on the virtue website), determine the risk
category for blood products and antibiotics. There is a separate “tab” for transplants on the pre-op note
that should be filled out, titled “Liver TX” – it’s fairly self explanatory.
• Consent: Usually the attendings like to consent the patient themselves, you can ask them this when you
call to discuss the plan. If you do the consent: GA, arterial line, central line (+/- PA catheter), TEE (if
planned), and possible post-op ventilation
• Pre-med: These patients will get Ativan instead of midazolam if premedication is used. Do not give any
premedication until the UNOS time out has occurred in the OR.
• Blood: The attending will order the initial blood products, you are responsible for confirming that the
blood is in the room and checked prior to heading back to the OR. The nurses will usually check it for
you, but always double check that this has been done.
• Always confirm that everyone is ready prior to heading back to the OR. Typically, you will be ready to
roll and will have to wait for a green light from the surgical team (the organ has to be confirmed as
acceptable prior to heading back).
Intra-op:
• Chart: there is a separate macro for Liver transplants, again it should be fairly self explanatory.
• Timeout: You will perform a UNOS timeout prior to induction, include this information in the Epic
Record (there’s an “Event” button for this)
• Induction: RSI, all patients are presumed to have full stomachs. Succinylcholine for intubation,
cisatracurium is the preferred drug for NMB maintenance (more rocuronium is now being considered on
a case by case basis, discuss this with your attending). Don’t give lidocaine to patients with liver
disease!
•
•
•
Lines: arterial line (usually right radial), two large bore PIVs (convert one to a RIC), central access
(usually a triple lumen CVC and/or a cordis). If you have not placed a RIC or cordis before (and if it’s
been a long time since you last placed a central line), review these with a CA3 or a CA2 who has just
finished transplant or cardiac to refresh your memory.
o Connect your infusions (should all be connected to the manifold “octopus”) to one of the central
line ports, the CVP to another port and then crystalloid (can use the Level One tubing) to the
third port.
o The Belmont is usually connected to the RIC or a cordis. Use caution when connecting the
Belmont or Level One to PIVs, infiltration can occur and compartment syndrome can develop
extremely quickly.
Surgery: There are three phases to the surgical procedure, they are very briefly explained below, the
guide on the virtue website will go through the anesthetic goals of each stage and any textbook will walk
you through the other important aspects of each stage (it is a fantastic idea to read through the Liver
Transplant section of the Jaffe book to get a very basic idea of the surgical procedure)
o Stage 1 (Dissection/Pre-Anhepatic): Blood loss is likely your main concern during dissection.
Keeping up with blood loss and maintaining hemodynamic stability are the major goals.
o Stage 2 (Anhepatic): Reduced pre-load, continue pressor support, prepare for reperfusion
o Stage 3 (Reconstruction/Post-Anhepatic): monitor graft function, avoid hepatic congestion,
ensure hemodynamic stability to prepare for case end
The surgeons will place a Yankauer in the abdomen, pack it and leave for about 30-45min (pay attention
to the blood loss during this period). They will come back and re-inspect for any continued bleeding and
fix any issues.
Post-op:
• Extubation: The goal is to wake up/extubate these patients at the end of the case. If this occurs, they
62
usually go to PACU.
o It’s a good idea to stick around for a little bit to make sure there’s no significant bleeding or
other issues which would require immediately returning to the OR.
• Post-op intubation: If the patient has significant unresolved hemodynamic instability or very high blood
loss, they may be left intubated and will therefore go to the STICU.
• It’s always a good idea to go see these patients the next morning, not only will it give you feedback for
your management but it’s also good to know ahead of time if there are any complications.
o Remember, if they return to the OR – you are returning to the OR!
Live Donor Liver Transplant:
These cases are a bit different, they will be scheduled and the patients are usually not as sick. Here are a few
specifics of these cases but this is a constantly evolving protocol and may change.
• Living Donors:
o The living donor is managed by an attending (LT2) and an APP
o These patients are very healthy…complications in these cases are the type of thing that ends up
on the news. That’s not the type of media attention you want!
• Recipients:
o The recipient will be managed by the LT1 attending and the resident
o These patients tend to be slightly healthier than patients who are receiving deceased donor
organs, as they usually are not “sick enough” to get on the waitlist for a deceased donor organ.
• Coordination between the two surgical and anesthesia teams is very important, communicate with the
other room!
How to find the “Liver Transplant Guide” on the virtue website:
1. virtue.ucdenver.edu
2. “Education” tab on the right side of the page
3. “Manuals/Protocols” from the dropdown menu on the Education tab
4. “Liver Transplant Guide”
Outpatient Anesthesia (AOP)- UCH
MATTHEW COLEMAN, MD; ANH DANG, MD; JIM RYAN, MD, NEENA GUPTA, MD, JASON PAPAZIAN, MD; TYLER
MORRISSEY, MD; JENNY HONG, MD
This senior month is great. The OR staff is more relaxed and workflow is efficient and smoother. The attendings
provide a great environment for building autonomy and practice efficiency. There also are lots of opportunities
to do peripheral nerve blocks with seasoned attendings, gain experience with supraglottic airways, and learn
about PACU stays and discharge to home.
Important people:
AOP charge: Chris Lace, MD and John Armstrong, MD
Pharmacy: Mary Cousins, Carol McKinney (and Heidi & Jessie come over from AIP)
Anesthesia Techs: Johnnie (lead), Stephanie, Joe – call a posted tech # (as in AIP)
Before you start:
Know the lay of the land; Preop and PACU, ORs, GI, Pharmacy, Anesthesia workroom, Anesthesia Quiet
Room, John Armstrong/Chris Lace/Anesthesia Office, Locker rooms, Storage room where block equipment is
stored, and lounge. ORs include AOP 8, 9, 11-17, GI (except 13).
Schedule and Call:
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• Schedule: Monday – Friday 6:30 to 3-5 pm (rarely there past 5 pm).
• Call: Expect to cover liver transplant call 1+ weekend of the month if there’s only 1 liver transplant resident
• Cases: Ortho cases that require blocks, ENT (jet room), gyn, dental, GI, etc..
• The current agreement is that the residents in the AOP start and finish their rooms. You are not expected to
take over CRNA rooms if you finish early. They will get you out when staff is available (variable).
However, as of late for staffing purposes, residents have been relieved around 3pm to allow attendings to
leave on time.
• If you are out before noon, you should help give some lunches and make sure there are no potential add-ons.
Call the AOP charge before leaving, just as you would in AIP.
Daily Work Flow:
• Arrive in Pre-op around 7:00, unless you will block the first patient, shoot for 6:45. There is also a scrub
machine available at the AOP. Most patients are pretty healthy and the preops can usually be done in the
morning but give yourself more time if you’re doing urology, gyn, GI, dental, ENT as these patients
sometimes have more extensive histories. Also plan ahead with your ortho cases, as most of them get
blocks so you need more time. Note: Most patients that would be appropriate for a spinal in AIP will
still get a general (with an LMA) in AOP because the recovery time in PACU is typically shorter. If
you want to use a spinal have a good reason and discuss it with your attending beforehand.
• Take note of the yellow sheet on each PreOp patient’s chart—it is OUR RESPONSIBILITY to NOT
BRING THE PATIENT BACK until this sheet is complete! Ask the nurse to check for the H+P, marking,
surgeon consent, etc. if you cannot find them.
• First case patients transport MAY go direct to the ORs through PACU (short cut), but in general PACU
nurses request that we DO NOT go through PACU with any patients after 730 starts.
• Turn over time is AOP is 20 minutes!!
Daily Work Flow for AOP Block Resident:
• Your priority is placing/completing blocks on-time.
• Order preop medications for most ortho patients: APAP 1000 mg, Mobic 7.5-15 mg, Lyrica 75 mg
•
Order APS ultrasound
•
Adductor Canal and Popliteal blocks: bupivacaine 0.5%
•
Supraclavicular/Infraclavicular: bupivacaine 0.5% +/- dexamethasone (discuss with your attending) for
ortho cases, mepivacaine 1.5% for AVF
•
Help out with breaks whenever possible.
Pharmacy:
• Get narcotics bag from the pharmacy. Unlike AIP, your narcotic bags for all your cases are available in the
morning at the day surgery pharmacy – if you take all of them keep them locked in the cart in between
cases. You MAY just take one at a time and they will keep them for you to sign out as the day goes along.
In either case you just sign your name next to each patient on the preprinted pyxis form and take the bags.
Also pick up anticipated drugs for the day, e.g. propofol, ketamine, local for blocks, and phenylephrine
sticks (in the pharmacy refrigerator, 3 are in each OR anesthesia cart to start the day). Pharmacy hours are
6:30 am – 5:00 pm.
• A dedicated Pyxis for anesthesia is available in front of bay 35.
• If pharmacy is closed, the drop-off bin is in PACU
Anesthesia Techs and Workroom:
• The workroom is located on the southwest side of the AOP near OR 16. Anesthesia techs arrive later than at
the AIP. You should plan on obtaining LMAs, pumps, special ETT, etc. yourself. If there is a problem
64 with
your machine, room, equipment in the morning notify Johnnie—(he is both very knowledgeable and very
helpful as long as he can tell you were not just being lazy). The difficult airway cart lives in the “Anesthesia
quiet room” if you need it. If your room runs late be prepared to turn over your OR room from the day
before if the techs left prior to cases finishing.
Blocks:
• The block cart and Ultrasounds (3 of them) are in a storage closet located at the entrance to the preop area.
Ask the charge nurse to let you in (with her key) if you get there early. The block cart contains all the
necessary equipment for both single shot and catheter blocks, familiarize yourself because the organization
is obviously very different than the APS block room. Discuss the type and volume of local anesthetic with
your attending if you are unsure.
• Be sure and print a copy of the U/S images, as this is needed to bill for the U/S. Put a patient sticker on the
U/S image and staple it to a blank piece of computer paper and put it in the chart. If you have the newer
Sonosite, make sure you have the patient brought up from the worklist. Also make sure you put a “Block
Note” in EPIC and also list the meds you gave for the block on your intra-op record.
•
Sonosite instructions:
o
Place APS Ultrasound order in Epic
o
On right side of the screen, select Patient > Information
o
On the bottom right, you will see Worklist > select patient number > press “Select” > Done
Important AOP Numbers:
Anes Charge Attg
84439
Anes 2nd Charge
81507
RN charge
Pre-op
PACU
AOP pharmacy
Anes Tech 1
Anes Tech 2
AOP Front Desk
81508
81350
86203
81391
84459
85918
88130
OR
8
9
11
12
14
15
16
17
Anes phone
82201
81375
81342
81422
81419
81423
81421
81159
RN phone
83208
83209
82511
81412
81414
81415
81416
81417
Blood gas lab
Blood Bank
85309
84444
Door Codes: Anes Workroom 00701*; AOP Hallway 0608
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NORA Rotation- UCH
CHLOE INGOLDBY, MD; JENNY HONG, MD
Overview:
More and more, anesthesia providers are asked to care for patients outside of traditional OR settings. More and
more, anesthesia providers are asked to care for patients outside of traditional OR settings. This Non Operating
Room Anesthesia rotation exposes you to these environments where anesthesia is provided to complex patients
(GI, CV, IR, MRI, CT). In the past, the proceduralist was responsible for providing the sedation, however this is
not always adequate, particularly as more advanced and complex procedures are introduced. Patients, who
previously were considered poor candidates for high-risk invasive procedures, are now receiving these equally
high-risk but minimally invasive procedures. Coordinating patient care in these settings is a challenge not only
because of the type of procedure and patient population, but also due to working with a different non-OR team
members. For example, many nurses are not used to assisting anesthesia providers during induction. They
66 may
not know how to pull a stylet or manage airway emergencies like the nurses in the main ORs.
Cases may not necessarily start on-time because of the coordination of other providers and specific equipment.
One dedicated anesthesia tech cover the NORA cases; however, they are typically also turning over rooms in
the main OR. If you need special equipment, collect it for your first case, or notify them early on.
Communication is incredibly important as you will be engaging with different RNs and physicians. Ask
questions and make your needs known.
While your schedule during this 2 week rotation will vary, an example might be:
Example Schedule:
1st/3rd Mon - EP (Mac)
Tues - MRI
Weds - IR
Thurs - GI (high-tech)
Fri - CT/MSK ablations
2nd/4th Mon - EP (GA)
Tues - MRI
Weds - IR (neuro)
Thurs - EP
Fri - GI (luminal)
For this chapter, locations will be covered one by one given the distinct differences in workflow and
locations.
MRI:
You may anesthetize patients in the MRI adjacent to OR 25 (3T) or in the basement MRI (1.5T). You need to
fill out an MRI screening form. once while in residency that will be kept on file. Prior to entering the MRI
room, don’t forget to remove ALL metal objects as well as other things that will be damaged by the magnet,
you can leave these in the control room. This includes many things that you may not even think of (pens, bobby
pins/hair clips, watches, cell phone, all credit cards or badges, etc). Oddly enough, rings and the needles on your
syringes are ok.
The MRI tech will always be present when you have access to the MRI room. In the basement, there is usually a
tech around; however, they only come up for scheduled scans (with or without our involvement) upstairs. The
phone number to the upstairs control room is 81690. The anesthesia tech also relies on the MRI tech to get into
the room to set up your machine and cart.
•
•
Pre-op:
o
Make sure the patient has filled out their MRI screening form before you give any sedation and go
back to the room. Many of these patients are receiving anesthesia because they are claustrophobic.
No proceduralist will be there because the scan was ordered by an outpatient provider.
o
Non-sedated patients can walk into the MRI suite and get onto the bed themselves. Otherwise, park
the gurney in the control room, the MRI tech will bring the MRI bed out and then help you wheel
that in once the patient is on it. You will typically induce on this bed next to the MRI, the tech can
help lower/raise/etc.
Monitors:
o
•
There are instructions on which monitor to enter into MonCap on the computer (UCHOR iMRI).
This will not acquire your vitals unless the screen in the control room is turned on.
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During the scan:
o
•
Misc:
o
•
Once the scan has started, you may be able to enter the room between sequences, however if
something happens in the middle of a sequence, the only way to get to the patient (administer meds,
etc) is to interrupt it then restart from the beginning once you’re done. Be sure to communicate with
the tech if there’s something you need and they will pause /stop for you.
The MRI compatible pump is a giant pain. There are instructions for troubleshooting that should be
with it. If possible, have someone walk you through getting it set up and get it working well before
you actually need to use it.
PACU:
o
You must call PACU at 86203 to let them know you are bringing your patient to them. In the
OR, typically the circulator RN handles this for you. Call 15-20 min before you anticipate arriving.
They will want to know the patient's name and whether they are going home after recovery.
Radiology (aka the basement):
You will sometimes go downstairs to the basement to sedate patients for LP or for procedures in the CT
scanner. Overall, this is very similar to MRI (and the 1.5T MRI is down here, as discussed above), however you
have access to these rooms without a tech. Make sure you have lead for yourself, particularly for the CT
ablations and things where you’ll be in and out during the procedure and scanning. Don't give sedation until
you're downstairs (often the proceduralist has not consented while your patient is in preop even though you
have). These monitors don't always pull vitals into Epic, when this is the case, you will have to chart everything
manually.
•
Postop: As above, call PACU at 86203 to let them know to expect you. Depending on the procedure
pre/post may be on the 2nd floor by the ORs or on 3 by CVC.
o Talk to your attendings about positioning specific to the procedure – sometimes it’ll be a surprise
(i.e. radiology likes to have patients prone for LPs).
o The anesthesia tech will set up your machine and cart. They usually know when things are scheduled
here, but check in and keep them updated if scheduling changes. I would suggest calling them first
thing of that day.
GI:
GI is adjacent to AOP. There are a couple of suites as well as a small pre/post area between the GI suites and
AOP area.
• Medications:
o The AOP pharmacy covers this area, their phone number is 81391. Similar to AOP, in the
morning the pharmacy will have med bags pre-prepared for all your booked cases. You can pick
up some or all bags in the morning, just remember that you can expect very fast room turnovers
(~20 min), so find a system to keep up with administering and wasting medications for the
correct patient, including when you get a break or your attending gets something out of the top
drawer.
• Some cases are simply done on the patient’s gurney while others will be done on a procedure table. The
anesthesia tech will turn over your room, their numbers are on the anesthesia machine.
• As with some subspecialties, there are some minor differences in the anesthesia carts here (Unasyn instead
of Ancef, glucagon in top drawer, albumin 500cc in bottom drawer).
• In general, you can anticipate to performing GETAs for: ERCPs and small bowel endoscopies. You will
typically perform MAC for EGDs, colonoscopy, and some stent removals, however, as always, ultimately
this depends on the pertinent details for that case or patient.
68
The CVC - IR/cath lab/EP:
The CVC is on AIP2 3rd floor. There are typically four anesthesia teams in this area for a normal day. We may
be involved with IR, neuro-IR, interventional cardiology, and EP cases. The CT-guided ablations are typically a
CVC team, although these occur in the basement CT scanner. On occasion, we provide anesthesia for vascular
surgery, pulmonology (bronchoscopies), MSK (kyphoplasties), and the ECHO cardiology service (sedation for
TEE) as well.
The culture in the CVC is quite different than the operating room. If you open a dialogue with folks generally
you will find that they are very willing to help, but don’t know what to do. Try to engage the procedure room
nurses when you are inducing and emerging. This will help them both learn what you need and allow them to be
helpful in the case of emergency. Write your phone number and your attending’s phone number on the white
board in the room. Unlike in the main OR, the nurses in the CVC usually do not have an up to date phone list. It
will take time for them to find your attending’s phone number if you need them to call for help!
If you have any questions, look on Virtue. Dr. Wilkey has put some procedures together for quick
reference.
• Finding stuff:
o EP rooms: #11, 12, 13. EP #13 is technically an MRI room. It is a very low Tesla MRI, and the
magnet is always on, behave accordingly. Most of your supplies will be in cabinets along the
back wall rather than in the anesthesia machine drawer. To find where you will be working,
there's a whiteboard in one of the EP control rooms that will say which doc/case is in which
room.
o IC cases are generally done in 6 or 15.
o N-IR cases are generally done in 7 or 9.
o Rooms 7 and 14 are set up with an anesthesia machine and cart M-Th 1700-0600, Fri-Mon 17000600.
o If you’re not sure which room you’ll be in, you can just ask at the main desk in the CVC work
area in the morning.
o The CVC tech phone is 87967.
•
•
•
•
•
•
Pre-op
o When you see your patient and consent them, be sure to fill out the orange pre-procedure
checklist on their folder (include your name, phone number, and the check box that the
anesthesia consent is complete). The CVC RN will bring the patient back to the room once they
confirm that everything has been done. Often the team does not want pre-medication prior to
timeout. Communicate with the in room RN if you’re not ready for the patient.
Medications:
o You should plan to get most of the medications and boxes you need from the main OR pharmacy
and pyxis. There is a pyxis in the CVC pre-post (room #3.424-A, access with your badge). Other
meds you need when you can’t go back downstairs can be sent to the CVC pre/post tube station,
number 687. If you request medications during a case, pharmacy will send it to the tube station
rather than walk it to you like in the main OR. Tell one of the nurses that you’re waiting for a
medication and they will check for you. The CVC work area tube station is #645.
Misc:
o Typically, time out is performed prior to starting your anesthetic with the procedure and
anesthesia teams. Use this time to confirm that everyone is on the same page if you haven’t
already.
o Once you are done with induction / starting sedation, tell the team. They don’t always realize
69
when you’re ready for them to start.
o Specific to EP, when you take over a case, ask for a timeout. Use this as a chance to introduce
yourself and review management issues with the EP proceduralist and current (leaving)
anesthesia provider. Be sure to discuss any significant BP support being administered. Document
the time out in the anesthesia record. ALWAYS wear the headset they give you, this is how
everyone communicates and you will miss important things without it. There have been many
near misses when people have not used it. Just make sure that it’s on mute if you are signing out,
complaining, etc.
Labs:
o From 0700 – 1900 someone from CVC must walk it to the OR lab (our stat lab personnel from
the main OR are not expected to come pick up from CVC) or send it through the tube station;
from 1900-0700, call 85309 and someone will walk from Leprino to pick it up. Let the nighttime
person know if you will be sending repeated/frequent labs. All TEGs must be walked down, the
sample cannot be used if it’s been sent by tube.
Computers:
o The IP addresses for the data ports on the booms in the CVC expire if not used after 30 days.
This means that if you are doing an anesthetic in a room that we don’t use often (like cath lab 5
or cath lab 6) there will not be internet access without a call to the computer help desk. This is
primarily an issue for interventional cardiology. IF you see that you are scheduled to do a case in
an infrequently used room, such as cath lab 5 or cath lab 6, please reach out ahead of time to the
nurses in that area and ask that the data port be issued a new IP address. Interventional
Cardiology will try to be pro-active with this, but please do your part by helping folks remember
or make the call yourself.
Supplies:
•
•
•
o There is an airway box in CVC pre/post in the same room as the pyxis (room #3.424-A, access
with your badge). The anesthesia equipment room is next to procedure room 1, it is room #3365
(the code to get in is the room number). It should have things like a CMAC, level 1, etc. There
are other random anesthesia goodies on a shelf in the back left corner (circuits, tubes, etc…).
Positioning:
o Currently the CVC does not have equipment for prone positioning. Some providers make due
with blanket rolls if the case is going to be short. Some providers borrow gel roles from the main
OR. The CVC is in the process of finding radiolucent gel rolls to purchase. We DO have yellow
foam! Some IR beds are equipped with a pull out at the head that allows some neutralization of
the C-spine when the patient is in a prone view, as well as a place to rest the arms in a superman
position.
Blood:
o Blood bank will also send things to the CVC work area tube station, #645.
Post-procedure:
o Non-ICU patients typically go to the CVC pre/post area, treat this like PACU. All ICU patients
will return to their ICU bed post-procedure. RNs will still bring them to the procedure room,
however you will transport them back.
Neuroanesthesia - UCH
STEVEN ANTONOVICH, DO; CLAUDIA CLAVIJO, MD
70
The neuroanesthesia rotation may be familiar to you by the time that you begin your actual rotation. It is
common to provide anesthesia for patients undergoing craniotomies, spines or emergent IR stroke cases while
on call or general OR days. This rotation allows you to see a wide variety of procedures and the considerations
that come with each of them.
Intracranial Procedures
• Perform your preoperative evaluation like you would for a general case.
• Look through the notes to find out if the patient shows any sign of increased ICP, if there are any neurologic
deficits at baseline or any other concerning factors. Document those changes in the pre-op evaluation. Doing
your own basic neurological exam as part of your pre-operative evaluation the day of surgery.
• Include imaging description as part of your evaluation. It is useful to know the location of a tumor and the
surrounding structures that may be at risk.
• Most patients will simply need 0.5 MAC of gas and narcotic/propofol unless there is evidence of increased
ICP on imaging/symptoms or neuromonitoring (NM) will be needed.
• It is necessary to know the NM techniques that will be used for the particular case since your anesthetic
technique of choice may need to be changed or modified base on the NM test performed. For example:
inhalational agents and neuromuscular blockers can’t be used if motor evoked potentials are included in the
NM. Neuromuscular blockers can’t be used if EMG monitoring is selected as part of the NM technique. On
the other hand, both inhalational agents and neuromuscular blockade can be used if ABRs is the only NM
technique selected.
• Open the email that is sent of the OR cases the afternoon before showing OR staff assignments. There is a
link in this email with information regarding whether neuromonitoring will be used, will the procedure be
•
•
•
•
•
•
awake vs asleep, will MRI be done prior to the procedure, etc. This will help to prepare your anesthetic plan
prior to calling your attending.
Some patients undergoing MRI prior to the procedure will require intubation after having a frame placed
under local anesthetic preoperatively by the neurosurgeon. This will require an awake intubation, which can
be discussed with your attending.
Neurosurgical patients will be turned either 90 or 180 degrees from induction position. All lines need to be
organized in a way that they are secured and not at risk of being pulled while turning and positioning. This
includes having an extension on your circuit and CO2 lines when needed.
Lastly, make sure you grab a neurobox for each case. The neuro box contains most of the medications
needed for neuro cases: (mannitol (with filter), keppra, labetalol, nicardipine, adenosine, fluoreseceine, IC
green, Albumin). You will also need plenty of pumps for the different infusions. Generally two brains are
needed.
The surgeon will tell you doses and what meds they want for the procedure.
A bolus of propofol is commonly given before head pinning. You should have enough left from induction to
bolus or have a second syringe ready before pinning. --Also, antihypertensive medications (esmolol,
labetalol, nicardipine) or a bolus of fentanyl are useful during this time. You have to have them ready.
Awake craniotomies have a few extra items to prepare in advance.
o If the procedure will be done awake, have an iGel LMA available in the event of urgent
intubation during the procedure as the head frame makes mask ventilation and intubation
practically impossible.
o Most surgeons prefer propofol and do not like precedex for sedation for awake craniotomies as
waking the patient up after frame placement/accessing the cranial vault tends to be slower. There
71
is a surgeon in particular who does not want any sedation provided to the patients. Your
attending will know the most common sedation technique for the particular case. The surgeons
are typically good at providing decent pain relief with local anesthetic for accessing the cranial
vault and meninges, but I would have some propofol in line just in case.
Spines
Most of you will have done plenty of spines prior to starting this rotation. You know that flipping can be
challenging, especially if the case is anterior and posterior. Work on line management and finding a strategy
that works best for you to make flipping the patient smooth.
Some other general considerations:
• Sedline monitoring is commonly used in spine cases. Secure it well with tegaderms, steri-strips, tape, etc,
otherwise it will detach when patient is in prone.
• Have a prone view available unless Mayfield frame will be used
• Esophageal temperature probe is preferable since nasopharyngeal probe and easily come out in prone
position.
• Know what type of neuromonitoring will be involved and plan appropriately.
• Soft bite blocks are needed for most spine surgeries. They are mandatory if motor evoked potentials are
going to be performed.
• Many patients have chronic pain. Have a plan in place to provide adequate pain control as these can be very
painful procedures.
• Know baseline neurologic deficits and document these deficits in the pre-op evaluation.
•
Take a peek at the neuromonitoring and ask questions. This might help solidify concepts that are typically
tested.
72
Pre-Operative Clinic and PACU- UCH
ANGELA SELZER, MD; KRISTIN BARNEY, DO
Pre-op Overview:
Preoperative medicine is a unique subspecialty within the field of anesthesiology. The successful preoperative
management of patients has been shown to lead to better outcomes: reduced morbidity and mortality, decreased
hospital lengths of stay, improved patient experience and a reduction in OR cancellations and delays. The field
of preoperative medicine is expanding and hospitals are looking to anesthesiologists to help manage and run
hospital preoperative clinics.
Our primary goal with this rotation is to ensure that each resident graduates capable of performing a thorough
evaluation and able to implement evidence-based plans for preoperative assessment and optimization. However,
we also seek to expose residents to the basic understanding of how a preoperative clinic is run, managed and
financed in order to assist them in their future careers and enable them to contribute to this burgeoning
subspecialty.
At our Pre-Procedure Services Clinic, in the University of Colorado Anschutz Campus, we see approximately
6,000 patients/year. These patients have complex comorbidities and are mainly ASA 3’s & 4’s. During their
two-week rotation, residents will see from 40-60 patients of their own, supervised by an attending
anesthesiologist, and complete a preoperative medicine curriculum.
Goals:
* To learn how to obtain a comprehensive medical history
* To perform a comprehensive physical examination
* To gain proficiency in point of care ultrasonography
* To appropriately order necessary diagnostic studies and tests
* To formulate an individualized pre-habilitation plan for each patient
* To integrate the information obtained to determine that a patient is adequately optimized or to develop a plan
to optimize the patient further
* To develop an appropriate anesthesia plan and communicate it to the patient
* To understand the basics of how a functioning preoperative clinic is staffed, managed and financed
The Details:
Clinic Location: AIP1 building, second floor. Follow signs to Pre-Procedure Services.
Clinic Phone: x81263
Prerequisites: Prior to starting your rotation, you will need to make sure that you have the appropriate EPIC
access and have completed E&M training (these visits will primarily be billed as level 3-5 consult visits). You
will have received information on how to complete this training, but you need to make sure that this has been
completed prior to day one of the rotation. We recommend stopping by clinic prior to the start of the rotation to
check in.
Clinic Hours: The clinic is open from 8am-5pm. By September, these hours may be expanded in order to
accommodate more patients.
Daily Schedule:
You will be seeing from 5-8 patients per day. The visits are scheduled for one hour. Your patients will mostly
73patients
be scheduled in advance but you may have one or two “walk-ins” or last minute add-ons. We try to see
a week before surgery, but more typically see them 2-4 days prior to surgery. Day before cases are made as
exceptions primarily for patients travelling from out of town.
The expectation is that you have completed a chart review prior to seeing the patient, and will have an idea of
what additional information and testing are needed prior to the appointment.
The schedule will likely look something like this:
Day 1: Morning: Orientation Afternoon: 2-3 patient visits
Day 2-5: 5-6 patient visits/day
Day 6-10: 7-8 patient visits/day
Daily Responsibilities:
* 5-8 Patient consults:
o Pre-visit chart review
o Review of systems, history taking and focused physical exam
o Presentation of findings and plan to attending
o Evidence based ordering of labs/EKG/testing, requests for records if applicable
o Providing an After Visit Summary to patient with day of surgery instructions
o Completion of consult note in timely fashion
o Follow up on labs/testing, addendum to notes when applicable
* Assist with NP/RN questions about anesthesia and preoperative evals
Rotation Responsibilities:
Before the end of the rotation you will present an article to the PPS clinic MDs, NPs and RNs. The article
should be approved by a Preoperative Medicine Attending.
You will also complete a preoperative curriculum, which will include daily reading assignments and topics for
discussion with your assigned attending. This will be provided to you prior to the start of your rotation.
You will be invited to attend clinic meetings where appropriate in order to get a better idea of how outpatient
clinics are run.
Clinic Staffing:
* Medical Director: Angela Selzer, MD is the Medical Director of the clinic. You can address any
questions/concerns/suggestions about the clinic or rotation to her.
* Daily Attending: You will work directly with an assigned attending anesthesiologist every day. The goal is for
a continuous week together—therefore, you will work with two anesthesiologists during your two week
rotation. There is a specific team of anesthesiologists assigned to clinic.
* Clinical Director: Katie Conyers, NP is the lead NP and Clinical Director of the clinic.
* Nurse Practitioners: There are currently six other NPs working with Katie in the clinic.
* Nurse Manager: There is a nurse manager for the clinic who supervises and manages the operation of the
clinic and the RNs, MAs and PARs.
* Charge Nurse: There is a charge nurse who helps with the daily management of the clinic.
* Registered Nurses: There are approximately ten RNs in the clinic, some of whom assist with scheduling and
coordinating clinic patient appointments, the rest are dedicated to calling patients prior to surgery and obtaining
a thorough history over the phone.
* Medical Assistants: There are four MAs in the clinic. They room the clinic patients, take vitals, draw labs and
EKGs. They also assist with scheduling, check-in and record retrieval.
* Patient Access Representative: There is one PAR who checks in patients and schedules upcoming
appointments.
PACU Overview:
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The PACU rotation is fairly laid back. Residents are expected to be available in the PACU from 10am-8pm.
The nurses prefer when the resident is sitting in the PACU at one of the computers at the main PACU desk. The
PACU resident should have the PACU Res phone 86203 on them at all times. One of the biggest complaints we
get from nurses is that the PACU resident is not visible during this rotation, so check in with the PACU Charge
RN if you need to leave the unit and round with your nurses throughout the day so they know you are available
and willing to help.
The PACU resident also covers 1-2 weekend shifts at either the U or DH.
Daily workflow:
Check in with the charge PACU RN when you arrive at 10am and look up the day’s cases on EPIC to see which
patients are likely going to be higher risk for postoperative complications. Round on patients as they come out
of the ORs and try to listen to as many hand-offs if possible- it will help if the patient goes south and the inroom providers become unavailable Mostly you will be writing PACU orders that the in-room provider forgot
to write. Always check with the surgeons before writing for Toradol, especially for Ortho and Thoracic cases. If
acute, emergent management (ie. intubation, pressors, blood administration, etc.) is needed, call the in-room
attending then the Charge Anesthesia Attending if they are busy and proceed with indicated management. Keep
the surgical team updated, but do not delay care to update the surgeons.
PACU residents also have the opportunity to perform rescue blocks and epidurals in the PACU if the APS team
is busy.
Check in with APS at 6:30pm then check in with the C1 Attending at 7:30pm to address any ongoing issues in
the PACU before leaving for the night.
Useful websites
Anesthesia department intranet site
http://virtue.ucdenver.edu/
Online evaluations
https://ucdenver.medhub.com/index.mh
ACGME case log
www.acgme.org/residentdatacollection
Online call schedule
www.amion.com, password: uco
Web-based email access
webmail.ucdenver.edu
CU Health Sciences Library
http://hslibrary.ucdenver.edu/
ASA homepage
http://www.asahq.org
ASA calendar of meetings, searchable http://events.asahq.org/
NYSORA website
http://www.nysora.com/home.shtml
USRA website
www.usra.ca
Critical care medicine from U Penn
http://www.ccmtutorials.com/index.htm
ASRA website
http://www.asra.com
Online simulator/TTE
http://pie.med.utoronto.ca/TEE/
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Reading/Preparing for Boards
EXCERPTED FROM AN EMAIL BY: GLENN GRAVLEE, MD
(YES, THE MAN WHO ACTUALLY HELPS TO WRITE THE BOARDS…)
Reading is by far the most important single thing you can do to prepare for Boards (written or oral).
Since so much of your time is taken up with bedside clinical or family-related activities (maybe even
some sleep time once or twice a week), it becomes critical that you use your reading time wisely.
Below is a table reflecting my views about various potential sources of reading preparation for Boards
(ratings go from lowest of 0 to highest of 5):
Big Blue
Morgan/Mikhail/ Miller or
Murray
Barash
Anes or A&A
Review
Articles
Editors’
reputation(s)
0
2
4
5
Authors’
reputations
0-1
2
4
5
Level of peer
review
0
2
3-4
5
Thoroughness
3
2
5
2 (limited by #
of articles,
individual
articles are @
5)
Conciseness
(inv prop to
thoroughness)
2-3
4
1
2
Use as Exam
0
source material
1
5
2-3
Accuracy of
info
1-2
3
4
5
Readability
(but different
folks like
different
styles)
3
4
3
2
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•
•
•
•
•
•
•
ITE is typically in Feb
Basic Board Exam is June of CA-1 year
There are new online question banks: M5 board review, Learnly (ask around, most people have a
discount code they can share with you)
CB year: Focus on general medical topics: Cardiology, endocrinology, nephrology, rheumatology,
pulmonology: It’s all good. Consider starting to read one anesthesiology journal regularly
(Anesthesiology or Anesthesia & Analgesia). Consider reading an introductory anesthesiology text like
Baby Miller. The primary focus should be on general medical knowledge, however.
CA1 year: Read Morgan and Mikhail, any assigned readings, and probably selected chapters in grown-up
Miller or Barash (or Longnecker/Fleisher).
CA2 year: Read the assigned weekly reading for the subspecialty rotations. Develop some strategy to
reinforce key material from these readings in your CA3 year, such as highlighting, underlining, index
cards, or key points.
CA3 year:
o Review Morgan and Mikhail unless you have had an aggressive reading strategy for Miller or
Barash. If you know this book well, you will likely pass ABA Part 1, but I don’t think you’ll ace it.
o Read or reread Miller or Barash SELECTIVELY for more depth in specific areas: Examples would
include pharmacology of induction agents, neuromuscular blockers, opioids/painkillers, inhalational
anesthetics, gas machine stuff, statistical tests, and maybe a few other topics.
o Review key topics from your subspecialty rotations such as common PACU problems (N/V,
hypothermia, discharge criteria), common Ob topics (labor analgesia, emergency C-section,
bleeding Cx, pre-eclampsia, neonatal resuscitation), Peds (not so much tube sizes and lengths as
neonatal emergencies, airway management complications, reasons for cancellation of elective
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surgery, apnea of prematurity, physiologic differences with adults such as cardiac and respiratory),
CAD/valvular heart disease, acute pain topics, regional nerve block anatomy, neuraxial blocks,
local anesthetics, common pain syndromes, sepsis, ICU ventilator management strategies for acute
respiratory failure. Do a quick review of ACLS if you haven’t recertified recently.
o Consider the ITE/key words handouts as a reasonable review source, but probably not as primary
preparation.
Maps
University of Colorado and Children’s Hospital Colorado- Anschutz Medical Campus
Anschutz Inpatient Pavilion, 12605 E. 16th Avenue, Aurora, CO 80045
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CRITICAL
VA Map
1055 Clermont Street, Denver, CO 80220
80
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Denver Health Medical Center
777 Bannock Street, M.C. 0218, Denver, CO 80204-4507
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