CA-2/3 Advanced Clinical OR Rotation
Curricular Milestones
Prepare Anesthesia Work Station for Basic OR and advanced general cases
1. Complete Machine Check
2. Prepare standard monitors
3. Prepare and set up for invasive monitors
4. Prepare standard emergency drugs
5. Set up for case in a reasonable time
Perform pre-operative assessment for ASA 1 & 2 patients receiving monitored
anesthesia care or general anesthesia
1. Adequate presentation to supervisor
2. Obtain relevant medical history and medication lists including previous anesthetics
3. Perform relevant physical exam including airway exam
4. Summarize pertinent patient diagnostic data
5. Determine if additional diagnostic tests are needed and order/ interpret as
appropriate
6. Understand ASA classification system and assign the appropriate class
7. Consent patient for monitored anesthesia, regional anesthesia and/ or general
anesthesia
8. Identify potential ethical issues (e.g. Blood transfusion refusal, Do Not Resuscitate,
etc.)
Perform pre-operative assessment for ASA 3 & 4 patients receiving monitored
anesthesia care and/ or general anesthesia
1. Adequate presentation to supervisor
2. Obtain relevant medical history and medication lists including previous anesthetics
3. Perform relevant physical exam including airway exam
4. Summarize pertinent patient diagnostic data
5. Determine if additional diagnostic tests are needed and order/ interpret as
appropriate
6. Understand ASA classification system and assign the appropriate class
7. Consent patient for monitored anesthesia, regional anesthesia and/ or general
anesthesia
8. Identify potential ethical issues (e.g. Blood transfusion refusal, Do Not Resuscitate,
etc.)
9. Optimize preparation of complex patients
Choice of anesthesia
1. Identify possible difficult mask ventilation and/ or intubation
2. Understand the choice of regional versus general anesthesia
3. Apply patient medical history and current disease process to anesthetic plan,
including possible chronic pain state and resultant implications
4. Recognize key landmarks, contraindications, and complications of regional and
neuraxial anesthesia and select appropriate technique and agents
5. Select and administer appropriate pre-medications
6. Understand how the surgical procedure impacts the anesthetic plan and discuss
anticipated issues with surgical team
7. Incorporates evidenced-based medicine into practice; cites peer-reviewed articles
Procedures for ASA 1&2 patients
1. Understand the indications for invasive monitoring
2. Understand the timing of monitor placement (pre- v. post-induction)
3. Place intravenous catheters
4. Place arterial catheters
5. Placement of basic neuraxial and regional anesthetic techniques (spinal +/epidural)
6. Understands prioritization of procedure completion in context of efficient case start
7. Anesthesia techniques for ambulatory surgery including regional anesthesia, use of
short acting agents and multi-modal analgesia
Procedures for ASA 3&4 patients
1. Understand the indications for invasive monitoring
2. Understand the timing of monitor placement (pre- v. post-induction)
3. Place intravenous catheters
4. Place arterial catheters
5. Place central venous catheters
6. Place pulmonary artery catheters
7. Placement of basic neuraxial and regional anesthetic techniques (spinal +/epidural) for complex general, orthopedic and vascular cases
8. Understands prioritization of procedure completion in context of efficient case start
9. Performs anesthesia in remote locations
10. Understands setup for and management of trauma patients including use of rapid
fluid/blood infusers and use of massive transfusion protocol
Manage monitored anesthesia care +/- regional anesthetic
1. Initiate sedation at appropriate time
2. Avoid oversedation leading to airway obstruction and need to mask ventilate
3. Recognize need to convert to general anesthesia
4. Communicate need for general anesthesia with attending anesthesiologist and
surgical team.
5. Participation in time-out process
Manage induction of general anesthesia for ASA 1 & 2 patients
1. Application of standard monitors
2. Choice of appropriate induction method and agents
Manage induction of general anesthesia for ASA 3 & 4 patients
1. Application of standard monitors (Including pre-induction advance monitoring)
2.
3.
4.
5.
Choice of appropriate induction method and agents
Understand the timing of monitor placement (pre- v. post-induction)
Placement of IV Catheters/ Arterial Line
Place central venous and/or PA catheters
Basic Airway management
1. Ventilate lungs via mask
2. Place and troubleshoot supraglottic airways
3. Intubate trachea of patients with easy to moderately difficult airways
4. Choose appropriate Endotracheal Tube
5. Recognize situations appropriate for airway adjuncts, video laryngoscope and / or
FOB
6. Preparation of back-up airway devices
Advanced Airway Management
1. Recognize need for advanced airway devices
2. Able to successfully use video laryngoscope and various LMA types
3. Able to perform asleep FOI
4. Recognize the need for and utilize intubating stylets (i.e. Eschmann)
5. Airway management in remote locations
Difficult Airway Management
1. Awareness / understanding of ASA difficult airway algorithm and use of rescue
devices
2. Understand topicalization techniques for awake fiberoptic intubation
3. Perform awake fiberoptic intubation with appropriate sedation choice
4. Demonstrates use of jet ventilation
5. Know indications for surgical airway (ie., cricothyrotomy), may demonstrate in
simulation lab
Maintenance of anesthesia for ASA 1&2 patients
1. Understand the pharmacology of commonly used anesthetic drugs and their
appropriate doses
2. Accurately estimate fluid requirements in routine cases and choose appropriate
fluids.
3. Accurately estimate allowable blood loss and need for transfusion
4. Participate in patient positioning and understand possible complications of different
positions (lithotomy, beach chair, etc.)
5. Sustain an adequate plane of anesthesia
6. Understand the management of body temperature and maintain normothermia as
appropriate
7. Accurately chart in the anesthetic record
8. Maintain appropriate contact with supervising staff
Maintenance of anesthesia for ASA 3&4 patients
1. Understand the pharmacology of commonly used anesthetic drugs and their
appropriate doses
2. Accurately estimate fluid requirements in routine cases and choose appropriate
fluids.
3. Accurately estimate allowable blood loss and need for transfusion
4. Participate in patient positioning and understand possible complications of different
positions (lithotomy, beach chair, etc.)
5. Sustain an adequate plane of anesthesia
6. Understand the management of body temperature and maintain normothermia as
appropriate
7. Recognize need for and select appropriate vasoactive medication infusion
8. Accurately chart in the anesthetic record
9. Maintain appropriate contact with supervising staff
Coordinate within operating room environment
1. Perform timely room turnover between cases
2. Utilize anesthesia technicians and pharmacy staff as appropriate
3. Maintain accurate records of controlled substance administration
4. Arrange transfer of patients to and from the intensive care unit
5. Understand the limitations of off-site practice
Management of unanticipated intraoperative events/ peri-anesthetic complications
1. Identify, formulate a differential diagnosis, and crisis manage intraoperative
problems (hypo/hypertension, hypoventilation, hypoxemia, bronchospasm,
hypercapnia, oliguria, arrhythmias, malignant hyperthermia)
2. Understand physiology of significant cardiovascular events (compression of vena
cava by surgeons, hypovolemia, hypervolemia, pulmonary embolism, ischemia,
myocardial depression, manage pacers/AICDs)
3. Understand aspects of neuro anesthesia (management of increased intracranial
pressure for craniotomy), vascular anesthesia (changes with aortic cross clamp),
and orthopedic anesthesia (fat emboli)
4. Have familiarity with ACLS guidelines and be able to apply them to OR situations
5. Maintain appropriate contact with supervising staff
6. Recognize when patients require change in post-surgical disposition (e.g. ICU
monitoring, continued artificial airway +/- mechanical ventilation) and
communicate this to supervising staff as well as surgical and OR nursing team
7. Provide hand-off to ICU staff in cases where patients are taken directly to ICU postop
8. Participate in meeting with family after unanticipated intraoperative events as
appropriate.
9. Document unanticipated intraoperative events and surrounding communications
and reactions in the medical record.
Emergence and PACU care for ASA 1&2 patients
1. Prepare the patient for emergence from anesthesia
2. Monitor, maintain and reverse neuromuscular blockade as appropriate
3.
4.
5.
6.
Understand criteria for extubation and apply them appropriately to patient
Transfer the patient to the PACU and provide smooth transition to the PACU staff
Provide complete and detailed handoff and contact information to PACU staff
Manage common postoperative problems (pain, nausea, confusion, hemodynamics,
ventilation)
7. Perform post-operative patient visits as appropriate
Emergence and PACU care for ASA 3&4 patients
1. Prepare the patient for emergence from anesthesia
2. Monitor, maintain and reverse neuromuscular blockade as appropriate
3. Understand criteria for extubation and apply them appropriately to patient
4. Transfer the patient to the PACU and provide smooth transition to the PACU staff
5. Provide complete and detailed handoff and contact information to PACU staff
6. Manage common postoperative problems (pain, nausea, confusion, hemodynamics,
ventilation)
7. Perform post-operative patient visits as appropriate