Age of Patients (Required-choose only 1)
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Preterm (<37 wks PCA at birth) and <45 wks PCA at surgery
Full term neonate ( 37 wks PCA at birth) and < 5 weeks old at surgery
5 weeks - 6 months
7 – 12 months
1 -2 years
3 – 11 years
12 – 17 years
18 years or older
ASA (Required- choose only 1)
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ASA 1
ASA 2
ASA 3
ASA 4
ASA 5
ASA 6
ASA 1E
ASA 2E
ASA 3E
ASA 4E
ASA 5E
ASA 6E
Procedures (select all that apply)
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Arterial cannulation
Central venous cannulation
Flexible fiberoptic technique (for intubation or bronchoscopy)
Alternative intubation technique, other (not flexible fiberoptic or direct laryngoscopy)
Techniques for Anesthesia (select all that apply)
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General
Sedation
Regional
Type of Surgery (select all that apply)
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Airway surgery (excluding T & A)
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Cardiac catheterization
Cardiac-with cardiopulmonary bypass
Cardiac-without cardiopulmonary bypass
Craniofacial surgery (excluding cleft lip/palate)
EXIT procedure
Fetal surgery
Intraabdominal (intracavitary; excl. inguinal hernia)
Intracranial-neuro (excluding shunts)
Intrathoracic-non cardiac (intracavitary)
Interventional radiology procedure (not cardiac catheterization)
Major orthopedic surgery (scoliosis, tumors)
Neonatal -Diaphragmatic hernia
Neonatal -Gastroschisis and/or Omphalocele
Neonatal -Necrotizing enterocolitis & bowel
Neonatal -TEF (tracheoesophageal fistula)
Neonatal -Other (e.g. myelomeningocele, sacral teratoma )
Solid organ transplant – Heart
Solid organ transplant – Kidney
Solid organ transplant – Liver
Solid organ transplant – Lung
Solid organ transplant – Multivisceral
Solid organ transplant – Other (intestine, pancreas, etc.)
Other (Operative, not included above)
Other (NON-Operative, to include imaging studies and other diagnostic procedures)
Acute Pain Management (for post-procedural pain)(select all that apply)
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Initial consultation
Initial PCA orders
Chronic Pain Management (for chronic pain NOT immediately following a
procedure)(select all that apply)
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Initial consultation
Follow-up consultation
Pain Management Techniques (select all that apply)
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Epidural, cervical/thoracic (indicate catheter or single shot)
Epidural, lumbar (indicate catheter or single shot)
Epidural, caudal (indicate catheter or single shot)
Intrathecal
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Peripheral nerve block (indicate catheter or single shot):
o Head/neck block
o Upper extremity block
o Truncal block
o Lower extremity block
Other pain therapy procedure (acupuncture, trigger point injection, etc.)
Ultrasound guidance for a pain procedure
Nerve stimulator guidance for a pain procedure
NOTES/OTHER REVISIONS NOT INCLUDED ABOVE:
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Change name of *B category from assisted to supervised.
Calculate case totals from the ASA category rather than age category
Add a searchable log so that program director or trainee could pull out via a
search things like number of neonatal CPB heart surgery cases or number of
adult cases (>18 years) by ASA class
Design improvement: when a trainee clicks on “transplant” under “type of
surgery”, the types of transplant pop up for selection. Could be used elsewhere,
such as neonatal emergencies, peripheral nerve blocks, etc.
Include a guide with the case logs that describes what is expected in each
category. Include an FAQ page.