INDIANA UNIVERSITY DEPARTMENT OF ANESTHESIOLOGY
ADVANCED--Thoracic Anesthesia
Goals and Objectives
GOALS and OBJECTIVES (ADVANCED Thoracic Anesthesia)
This advanced rotation is meant to provide you with the competencies required to meet the
expectation for a Board Certified (Consultant) Anesthesiologist.
The goal of the Advanced Thoracic Anesthesia Rotation at the Indiana University School of
Medicine is to train physicians to be competent and compassionate practitioners of Thoracic
Anesthesia. We expect the residents to be able to more readily evaluate and develop treatment
plans regarding patient care issues than during their previous rotations in the Cardiac Anesthesia
rotation. This rotation, like the core rotation in Thoracic Anesthesia, is designed to enhance your
overall knowledge, understanding, and application of thoracic anesthesia principle. However,
given the advanced nature of this rotation emphasis will be placed upon enhancing your skill in
the areas of analysis, synthesis and evaluation of the patient. We would again reemphasis that
this rotation is meant to provide you with the competencies required to meet the expectations of a
Board Certified (Consultant) Anesthesiologist.
Basic Thoracic Anesthesia Resident Duties:
Basic duties for the thoracic anesthesia residents include:
1. Preoperatively evaluate patients and develop a plan for the administration of a safe
thoracic anesthetic
2. Intra-operatively maintain safe anesthetic care for the patient mindful of the impact of
pulmonary disease upon the delivery of anesthesia
3. Post-operatively evaluate the patient for potential complications associated with the
administration of anesthesia and for those sequelae specific to thoracic anesthesia
interventions
4. Attendance at didactic conferences
5. Taking night call on a rotating schedule
6. Responding to requests for thoracic anesthesia consults in a timely fashion
7. Maintaining a personal program of self-study and professional growth
8. Completing medical records promptly
9. Documenting all duty hours
10. Documenting all procedures
11. Monitoring self for fatigue
12. Dressing appropriately
13. Acting in a professional and ethical manner
14. Completing the appropriate evaluation instruments used by the department, including
QA forms
Educational Strategy:
The Thoracic Anesthesia Rotation is a one-month block. During the Thoracic Anesthesia
Rotation residents will be will be supervised by various members of the anesthesia teaching
faculty. The Director of Thoracic Anesthesia is Dr. Jerry Young. In his absence, Dr. Jon
Anagnostou will fulfill these responsibilities. During the rotation in thoracic anesthesia,
residents are expected to participate in journal clubs, and morbidity and mortality conferences
(QA).
Core Competencies:
The six core competencies are used as a template to evaluate residents during all Anesthesia
rotations. The terms used to define these competencies are similar to those used for other
rotations. The Goals and Objectives that follow have been specifically modified to meet the
needs of the specific teaching rotation in which you are to participate. These Goals and
Objectives are not intended to be comprehensive but have been developed to help you acquire
the core competencies in the area of Clinical Anesthesia. These core rotations should serve as
the foundation upon which the subspecialty anesthesia rotations are based. We ask you as the
learner to consider how each of the subcategories within these six competencies might relate to
cognitive, motor and affective characteristics of your education and your professional behavior.
If while reading this document you discover an area that requires revision or improvement please
bring these issues to the attention of either the Course Director or the Program Director. We seek
changes that will improve your educational experience.
EDUCATIONAL OBJECTIVES (ADVANCED Thoracic Anesthesia)
Medical Knowledge:
After completing this rotation, residents will have gained knowledge and practical experience in
the care of thoracic patients by:
1. Understanding the pathophysiology of disease states and co-morbidities commonly
present in thoracic patients
2. Studying the normal anatomy of the lung and pleura
3. Understanding the principles and practical application of diagnostic and therapeutic
fiberoptic broncoscopy
i. Used for diagnosis
ii. Used for optimal placement of “double lumen” tubes, bronchial blockers,
and the like.
4. Understanding and participating in the delivery of anesthetic care to the thoracic
patient including placement of double lumen endotracheal tubes and bronchial
blockers
5. Understanding and applying pharmacological principles to the care of the thoracic
patient
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6. Understanding the impact of pulmonary embolism on the administration of anesthesia
7. Understanding and managing the pulmonary and cardiovascular changes that occur
with one lung ventilation
i. “Normal” hypoxic pulmonary vasoconstriction (HPV)
ii. Effects of anesthetics and other drugs on HPV
8. Identifying and interpreting pulmonary artery catheter information in the setting
lateral positioning and positive pressure ventilation
9. Managing post-operative pain with special emphasis on epidural (lumbar vs. thoracic)
and spinal techniques
In addition to the above general teaching points regarding medical knowledge, please see below
an expanded overview of materials as outlined in the ABA content outline.
RESPIRATORY SYSTEM
1. Physiology
a) Respiration: Lung Functions and Cellular Processes
1) lung volumes
(a)
definitions; methods of measurement; normal values; time constants
(b)
spirometry; static and dynamic volumes; deadspace; nitrogen
washout, 02 uptake, CO2 production, exercise testing
2) lung mechanics
(a)
static and dynamic compliance, pleural pressure gradient, flowvolume loops and hysteresis, surfactant, LaPlace law
(b)
resistances; principles of gas flow measurement
(c)
methods of measurement
(d)
work of breathing
(e)
regulation of airway caliber
3) ventilation - perfusion
(a)
distribution of ventilation
(b)
distribution of perfusion, zones, hypoxic pulmonary vasoconstriction
(c)
measurement of ventilation/perfusion (V/Q) ratio, implications of
Alveolar-arterial 02 gradient (A-aDO2), arterial-Alveolar CO2
gradient
(a-ADCO2), dead space to tidal volume ratio (Vd/Vt), shunt fraction
(Qs/Qt), lung scan 4) diffusion
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(a)
definition, pulmonary diffusion capacity
(b)
apneic oxygenation, diffusion hypoxia
5) blood gas transport
(a)
02 transport; 02 physical solubility; oxyhemoglobin (Hb-O2)
saturation, Hb-O2 dissociation curve; 2,3-diphosphoglycerate (2,3DPG), P50, respiratory enzymes; hemoglobin (Hb) as a buffer
(b)
CO2 transport; blood CO2 content; carbonic anhydrase; CO2
dissociation curve; Bohr effect, Haldane effect
(c)
systemic effects of hypercarbia and hypocarbia
(d)
systemic effects of hyperoxia and hypoxemia
6) regulation of ventilation
(a)
respiratory center
(b)
central and peripheral chemoreceptors; proprioceptive receptors;
respiratory muscles and reflexes; innervation
(c)
CO2 and 02 response curves
7) non-respiratory functions of lungs : metabolic, immune
2. Anatomy
a) Nose
b) Pharynx: Subdivisions; Innervation
c) Larynx
1) innervation; muscles; blood supply; cartilages
2) vocal cords, positions with paralysis
3) differences between infant and adult
d) Trachea
1) structure and relationships in neck and chest
e) Lungs
1) divisions and bronchoscopic anatomy
2) bronchial and pulmonary circulations
3) microscopic anatomy
f) Muscles of Respiration, Accessory Muscles
3. Biochemistry
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a)
Normal Acid-Base Regulation: Buffer Systems; Compensatory Mechanisms;
Effects of Imbalance on Electrolytes and Organ Perfusion; Strong Ionic
Difference (SID); Anion Gap; Temperature Effect on Blood Gases: Alpha-stat vs.
pH-stat
4. Clinical Science
a)
Respiratory System
1) obstructive disease
(a)
upper airway: congenital, infectious, neoplastic, traumatic, foreign
body, obstructive sleep apnea
(b)
tracheobronchial: congenital, infectious, neoplastic, traumatic,
foreign body
(c)
parenchymal: asthma, bronchitis, emphysema, lung abscess,
bronchiectasis, cystic fibrosis, mediastinal masses
2) restrictive disease
(a)
neurologic: CNS depression, spinal cord dysfunction, peripheral
nervous system
(b)
musculoskeletal: muscular, skeletal, obesity, chest trauma
(c)
parenchymal: atelectasis, pneumonia, interstitial pneumonitis,
pulmonary fibrosis, respiratory distress syndrome (ARDS),
bronchopulmonary dysplasia
(d)
pleural and mediastinal: pneumo-, hemo-, and chylothorax, pleural
effusion, empyema, bronchopleural fistula
(e)
other: pain, abdominal distention
3) management of the patient with respiratory disease
(a)
evaluation: history and physical examination, chest X-ray, arterial
blood gases (ABGs), pulmonary function tests (PFTs); assessment of
perioperative risk
(b)
anesthetic management
(1)
preoperative preparation: respiratory therapy, drug therapy
(antibiotics, bronchodilators, mucolytics, steroids), tobacco
smoking discontinuation
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(2)
intraoperative management
(a) monitoring
(b) choice of anesthesia
(c)
anesthetic techniques: nonpulmonary surgery, thoracic and
pulmonary surgery, one-lung ventilation, thoracoscopic
techniques, lung transplantation
(3)
postoperative care: pain management, respiratory therapy,
ventilator support, extubation criteria
(c)
management of respiratory failure
(1)
nonventilatoly respiratory management: 02 therapy and toxicity,
tracheobronchial toilet, positive airway pressure,
respiratory drugs
(2)
ventilatory management
(a)
criteria for ventilatory commitment and weaning
(b) mode of ventilation: conventional mechanical ventilation,
PEEP, CPAP, IMV, SIMV, pressure support, pressure
control, high frequency ventilation (positive pressure, jet,
oscillation), prone ventilation, BIPAP, airway pressurerelease ventilation
(c)
complications and side effects of mechanical ventilation:
volutrauma, barotrauma
(3) other management adjuncts: nitric oxide, steroids (4) lung
transplantation: anesthetic implications
(d) management of bronchospasm: bronchodilator drugs,
anti—inflammatory drugs, acute and chronic
management, perioperative management
Patient Care:
Using the above medical knowledge the resident is expected to:
1. Evaluate thoracic patients and develop a treatment plan
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2.
3.
4.
5.
6.
a. Resident is expected to appraise and make recommendations about the
impact of the patients co-existing diseases and the impact that these will have
on the safe administration of anesthesia
b. Resident is expected be able to verbalize an appropriate anesthetic plan
c. Resident is expected to be able to manage all aspects of perioperative
anesthetic delivery from the preoperative evaluation, inter-operative
management and post-operative care of all patients
Anticipate and manage problems commonly encountered during thoracic anesthesia
a. Resident is expected inventory available resources in order to assure that
appropriate can be provided
b. Resident is expected to determine the appropriate level of subspecialty
consultation
Formulate a comprehensive plan for peri-operative assessment and management of
the thoracic patient
Demonstrate the ability to function as a thoracic anesthesia consultant
Understand the administration/complications/benefits of the various pharmacologic
agents sufficiently to make sound medical judgments appropriate for thoracic
anesthesia
Skillfully perform invasive interventional procedures, including, but not limited to:
a. Placement of central venous lines
b. Placement of arterial lines
c. Placement of pulmonary artery catheters
d. Post-operative spinal analgesia for pain control
e. Pre-operative placement of epidurals for post-operative pain management
Interpersonal and Communication Skills:
After completing this rotation, residents will have gained experience and competence in:
1.
2.
3.
4.
Obtaining an accurate useful patient history appropriate for thoracic anesthesia
Completing an informative, legible medical record
Communicating skillfully with patients and family members
Communicating information about anesthetic procedures with other colleagues
including referring physicians, nurses, and workers on ancillary services
5. Effective counseling of patients and families regarding methods of thoracic
anesthesia, alternatives, and risks and benefits of treatment options
6. Obtaining informed consent for thoracic anesthesia procedures
7. Answering questions from the patient and or family members regarding thoracic
anesthesia issues in a fashion that is readily understood
Professionalism:
After completing this rotation, residents will have gained experience and competence in:
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1.
2.
3.
4.
Acting in a professional manner while providing patient care
Demonstrating reliability and dependability
Exemplifying compassionate and appropriate patient care
Acquiring teaching skills essential for creating a positive learning environment,
including involvement in the education of medical students
5. Showing respect for patients
6. Providing for the emotional needs of patients
Systems-Based Practice
After completing this rotation, residents will have gained experience and competence in:
1. Understanding their role as a patient care advocate
2. Becoming familiar with the costs associated with the delivery of anesthesia care
3. Incorporating the concepts of cost-benefit analysis when considering therapeutic
options
4. Interpreting the constraints associated with management of the operating room and be
able to integrate this understanding into best patient care practices
5. Emphasizing safety for the patient as well as operating room personal
6. Obtaining a better understanding of the tools that are being utilized to assess best
practices in anesthesia by organizations such as Magnet and Leapfrog
7. Working towards developing team building skills
Practice Based Learning and Improvement:
After completing this rotation, residents will have gained experience and competence in:
1. Self-directed learning
2. Becoming more efficient at locating medical information associated with acute pain
3. Reviewing the medical literature related to the field of acute pain and integrating this
information with the care of the patient
4. Learning to better utilize information technology to access on-line medical
information pertaining to innovative diagnostic and therapeutic modalities in the area
of acute pain
5. Transferring knowledge about acute pain to other members of the healthcare team
(medical students, ancillary care personal and nursing staff)
Trainee Evaluations:
The Anesthesia Clinical Competency Committee (CCC) meets every other month to evaluate the
progress of the trainees. Specifically addressed are the six basic competencies and the thoracic
anesthesia specific competencies outlined above. The instruments used to assess their progress
include an evaluation form which utilizes a scaled five point Likert scoring system which
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assesses each of the six competencies. In house testing is also performed twice yearly to insure
that the trainees are acquiring the knowledge associated with the provision of a safe anesthetic.
Residents are expected to take the in-training examination administered by the American Society
of Anesthesiologists/American Board of Anesthesiology (ASA/ABA).
On a more informal (and potentially more important) level, members of the teaching faculty
evaluate our trainees daily and provide them real-time feedback concerning their performance in
the delivery of anesthesia services. Informal discussions with the thoracic anesthesia residents
address any deficiencies in patient care or knowledge base. Additionally, we try to know our
trainees personally to better understand and/or address underlying stressors or personal issues
that may interfere with learning and performance.
Every six months, the American Board of Anesthesiology requires that the Clinical Competency
Committee submit a Resident Training and Evaluation Report. In addition to the basic
competencies, we submit our evaluation of a trainee’s progress in the following areas:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Demonstrates ethical/moral behavior
Is reliable, conscientious, responsible and honest
Learns from experience; knows limits
Reacts to stressful situations appropriately
Has no documented abuse of alcohol or illegal use of drugs during this report
period
Has no cognitive, physical, sensory or motor impairment that precludes individual
responsibility for any aspect of anesthetic management
Demonstrates respect for the dignity of patients and colleagues
Has no restriction, condition, limitation or revocation of license to practice
medicine
Understands anatomical, physiological, and pathophysiological concepts of organ
disease that culminates in the need for solid organ transplant
Collects and uses clinical data
Recognizes the psychological factors modifying pain experience
Communicates/works effectively with patients/colleagues
Demonstrates appropriate concern for patients
Demonstrates commitment to life long learning
Adapts and is flexible
Is careful and thorough
Generates complete, legible, and accurate medical record
Possesses business skills for effective practice management
Uses information technology to optimize patient care
Is an advocate for quality care
Recognizes gaps in knowledge and expertise
Demonstrates continuous practice improvement
Uses appropriate technical skills in diagnostic and therapeutic procedures
Completes study of management of acute pain, cancer pain, and chronic pain
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Suggested Readings:
Suggested reading assignments to expand knowledge and patient care for this rotation include
but are not limited to the most recent editions of the following textbooks:
Clinical Anesthesia-Barash
Thoracic Anesthesia - Kaplan
Thoracic Anesthesia-Benumof
Progress in Thoracic Anesthesia-Slinger
Textbook of Cardiothoracic Anesthesiology-Thys
Pharmacology and Physiology in Anesthetic Practice-Stoelting & Hillier
For guidance regarding regional analgesia for thoracic surgery the most recent editions of the
following textbooks are recommended:
Atlas of Regional Anesthesia – Brown
Neural Blockade – Cousins
Regional Block – Moore
Review articles on thoracic anesthesia topics in the following peer reviewed journals provide
useful reading:
Anesthesiology
Anesthesia and Analgesia
British Journal of Anesthesia
Journal of Cardiothoracic and Vascular Anesthesia
Regional Anesthesia and Pain Medicine
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