WORKSHEET FOR EDUCATIONAL ACTIVITIES AT THE
2014 ASA ANNUAL MEETING
This worksheet can be used as a guideline when obtaining the data for the mandatory fields that are
required in the online submission.
The lead speaker will be required to include disclosure for all speakers (if applicable). Please use this
document as a guide in obtaining disclosure.
Lead Presenter/Moderator (Must be an ASA member)
First Name
MI
Last Name
Degree(s)
E-mail
Title
(e.g., Professor of Anesthesiology)
Affiliation
(e.g., University of Chicago Hospitals, Chicago, Illinois)
Session Information
Title of Session
Type of Session:
Clinical Forum
Refresher Course Lecture
Panel
Point Counterpoint
Workshop
Learning Objectives: Learner will
(e.g., Learner will be able to 1) Differentiate among techniques for securing a critical airway; 2) Choose applications
for different airway techniques; 3) List the advantages and disadvantages of these techniques. Please do not use
language such as “understand”, “learn”, “know”, “appreciate”, or “believe”.
Description
Comments
Suggested Educational Track
Keywords (please select at least one)
Airway Management
Ambulatory Anesthesia
Anesthetic Action/Biochemistry
Chronic and Cancer Pain
Clinical Neurosciences
Drug Disposition
Endocrine/Metabolic Diseases
Ethics/Professionalism
Experimental Neurosciences
History
Medicolegal
Obstetric Anesthesia and Perinatology
Operating Room/Practice Management
Patient Safety/Complications/Outcomes
Perioperative Management
Regional Anesthesia
Transfusion Medicine/Coagulation
Allergy/Inflammation
Anesthesia Outside the OR
Anesthetic Techniques
Clinical Circulation/Cardiothoracic Anesthesia
Critical Care/Resuscitation
Education
Equipment/Monitoring/Technology
Experimental Circulation
Geriatric Anesthesia
Local Anesthesia
Neuromuscular Transmission
Occupational Health
Pain Medicine
Pediatric Anesthesia
Pharmacology
Respiratory/Pulmonary Physiology
Trauma/Emergency Anesthesia
1
Vascular Anesthesia
Session Unavailability Information - Your session will be scheduled any one of the 5 days of the
Annual Meeting. You must list if you and/or your presenters are unavailable because of a religious
holiday or a member of the House of Delegates. Due to the size of the Annual Meeting, these are the only
two considerations that will affect scheduling. If any presenter has unavailability for religious reasons or is
a member of the House of Delegates, please select the appropriate box next to his/her name below.
Unavailability for Lead Presenter/Moderator: Religious Holiday
HOD
Session Presenters
All presenters must be included at the time of submission and must be an ASA member. (Please forward
any Nonmember speaker name and contact information to the ASA office: j.jacobson@asahq.org). Lead
Presenters must contact all additional presenters before submitting a session (exception is Refresher
Course Lectures). Include a subtopic for panels, clinical forum*, point counterpoint, and, if applicable,
workshops.
*Please also see special instructions for clinical forum listed below.
Disclosure:
First Name
MI
Last Name
Degree(s)
E-mail
Subtopic for Panel, Clinical Forum, Point Counterpoint or, if applicable, Workshop
Unavailable for:
Religious holiday
HOD
Disclosure:
First Name
MI
Last Name
Degree(s)
E-mail
Subtopic for Panel, Clinical Forum, Point Counterpoint or, if applicable, Workshop
Unavailable for:
Religious holiday
HOD
Disclosure:
First Name
MI
Last Name
Degree(s)
E-mail
Subtopic for Panel, Clinical Forum, Point Counterpoint or, if applicable, Workshop
Unavailable for:
Religious holiday
HOD
Disclosure:
First Name
MI
Last Name
Degree(s)
E-mail
Subtopic for Panel, Clinical Forum, Point Counterpoint or, if applicable, Workshop
Unavailable for:
Religious holiday
HOD
Disclosure:
First Name
MI
Last Name
Degree(s)
E-mail
Subtopic for Panel, Clinical Forum, Point Counterpoint or, if applicable, Workshop
Unavailable for:
Religious holiday
HOD
*Special Instructions for Clinical Forum
List cases here for Clinical Forum. You may have up to three cases; one case is required.
2
(e.g., A 53-year-old 90 kg man with well-controlled hypertension underwent multilevel posterior spinal instrumentation
and fusion in the prone position under general anesthesia. The procedure lasted 10 hours with an estimated blood
loss of 3.5 L. The anesthetic course was unremarkable, with systolic blood pressures around 95-105 mmHg
supported by intermittent infusion of phenylephrine and fluid administration consisting of 8L crystalloid, 4 units packed
red blood cells, and 4 units fresh frozen plasma to maintain a hematocrit of 28-30. Upon awakening, the patient had
tightly swollen eye lids and he complained of inability to see in the PACU. He was subsequently diagnosed with
bilateral posterior ischemic optic neuropathy.
Case #1
Case #2
Case #3
3