The
UNOFFICIAL
University of Colorado
Anesthesiology Resident
Survival Guide
2013-2014
Contributors
Bethany Benish, MD
Rachel Boggus, MD
Zach Bryan, MD
Mindy Cohen, MD
Matthew Coleman, MD
Sara Cheng, MD, PhD
Heidi Green, MD
Jay Hacking, MD
Kellie Hancock, MD
Haley Hutting, MD
Gillian Johnson, MD
Matthew Koehler, MD
Allison Losey, MD
Matthew Maloney, MD
Emily Mcquaid-Hanson, MD
Aaron Murray, MD
Joe Peetz, DO
Estee Piehl, MD
Prairie Robinson, MD
Matthew Rowan, MD
Anne Rustemeyer, DO
Jim Ryan, MD
James Sederberg, MD
Andrew Sullivan, MD
Sarena Teng, MD
Mario Villaseñor, MD
Barbara Wilkey, MD
Joel Wilson, MD
Greg Wolff, MD
Cristina Wood, MD
Jessica Yanosik, MD
Megan Zanger, MD
Andrea Zatlin, MD
Table of Contents
Foreword
2
Introduction for CA-1 Residents
3
Basic Expectations
4
How to set up a room
5
What to do at a code
6
General OR - University of Colorado Hospital
7
General OR - Denver Va Medical Center
12
General OR – DHMC Hospital
16
Pre-op/PACU Rotation - DHMC
21
ICU
25
CTSICU
27
Cardiothoracic Service
30
Acute Pain Service (APS)
34
Chronic Pain Service
39
Children’s Hospital Colorado
41
Obstetrics (Labor and Delivery)
44
Transplant Service
46
Outpatient Anesthesiology (AOP - UCH)
50
Sample Notes
52
Useful websites
54
Reading/Preparing for Boards
55
Maps
57
Foreword
MEGAN ZANGER, MD
This little green book has been an absolute lifesaver over my residency. My suggestion to new CA1s is to
keep this book in your back pocket at all times because you never know when you will need a phone number,
a door code, or a map. I’ve found it helpful to jot down all of my login names and passwords for each of the
various hospitals in the margins of this book so that I can refer to them months later.
This edition of the survival guide has been painstakingly updated to include accurate phone numbers and
info about each rotation. Enjoy.
Introduction for CA-1 Residents
SARA CHENG MD, PHD
Welcome to the University of Colorado anesthesia residency program! We’re glad you’re here. If
you’re reading this, you’ve jumped through a dozen hoops, maybe moved across the country, replaced
electrolytes a bazillion times, and ADC VANDIML is your middle name. Congratulations- internship is
over! You’re doing what you really want to do, finally- passing gas.
That being said, you’re probably a little nervous. It may have been a long time ago that you did any
anesthesia! And your daily routine is going to be far and away different from what you’ve been doing this
past year. You’re not alone- everyone says the first couple of weeks/months can be very anxiety provoking.
I certainly didn’t sleep very well those first couple of months. Rest assured- read when you can, and come to
work every day ready to play ball- you’ll get through it just fine.
This little book is meant to help you through your first week at each new hospital. It is meant to be a
practical guide to those little daily details that will be second nature to you in a couple of months. It is NOT
meant to be a medical reference or a guide to anesthesiology. It was put together by CA-2 and CA-3
residents, for UCD residents only, and is not endorsed by the administration formally. Therefore we take no
responsibility for anything wrong or omitted by this guide- it will not substitute for reading, common sense,
or talking to your attending. It is simply meant to ease the pain just a little bit, and hey, I’m all about easing
the pain.
Never hesitate to ask for help when you need it. If you’re in the OR, first call your attending. If
he/she is unavailable and you’re in need of urgent help, call the charge attending or page overhead for any
available anesthesia attending. Also, don’t hesitate to ask more senior residents for advice about how to set
up or prepare for a case…we’re here for you. Finally, everyone goes through tough times during residency
at some point- when it happens to you, don’t think you’re alone! Talk to your friends, your spouse, a friend
in the program whom you trust… it helps to get you through it.
Basic Expectations
SARA CHENG, MD, PHD
Here are some pointers to get you up and running. I know, they may sound basic, but people have gotten in
trouble multiple times in the past for not doing these things…rather than beating them with a “you should
have known” hammer, I think it’s just better to say these things up front:
 Before starting at each hospital, try your very best to GET A TOUR of the place. At DH, Dr. Humphrey
gives a great orientation. At the VA, Dr. Rai or one of the residents will show you around. At the U, it’s
best to find a resident to give you a tour. At CHC, almost anyone will do it; they are so darn nice! In July,
you’re not expected to have had much time to get an orientation before your first day in the OR. But
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 pre-call or post-call, or after your scheduled cases with an 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, doesn’t know 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 Centricity/EPIC at the U, on
the lounge table at the VA, in the workroom at DH). LOOK UP YOUR PATIENTS on the computer and
fill out what you can on an H & P form or on Centricity at the U, including recent labs and imaging. At
the VA and DH, past anesthetic records are readily available on the computer too and are always useful.
Then, even at this stage, try to FORMULATE A BASIC PLAN in your head for each patient (see below).
It may be as basic as “I think this patient needs general anesthesia with a tube and no invasive monitors”
but that’s still a plan. Then, either find or CALL YOUR ATTENDING about tomorrow’s cases. At the
beginning of the year, you should always call your attending to go over the plan for each- 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 call you back or don’t talk very much, then at least you fulfilled your
obligation. Later in the year, as you get to know them better and get more comfortable, there will be
some attendings for some simple cases you won’t call, but for now- it’s safest to always call the first time
you’re working with an attending (especially at the U!). If someone establishes themselves as one who
doesn’t call back, then now you know.
 Formulating a plan: take a stab at these basic questions when you present to your attending. What kind
of anesthetic does this patient need to have this operation safely and comfortably? (general vs. neuraxial
vs. nerve block vs. local anesthesia). If a general, what kind of airway (ETT vs. LMA) and what kind of
induction (rapid sequence vs. standard). What drugs will you use? Do you need any additional IV
access? Do you need any invasive monitors? Are there co-morbidities that will complicate your
management? You will not know the answers to many of these things initially, but have them in the back
of your mind and you’ll look like a thinker from the beginning.
 Every morning, every case: PREPARE YOUR ROOM (see below). SEE THE PATIENT. Look at
vitals, do physical exam focusing on heart/lungs/airway. Obtain consent. Talk to your attending. Once
you and nursing are ready, start antibiotics/administer pre-med if appropriate and bring patient back to
OR. Get your monitors on. Call your attending for induction.
 POST-OP CHECKS: you are expected to go see your patients if they are still in the hospital within the
first day or two after surgery. You should ask them about intraoperative recall, pain control, and any
questions/concerns about their anesthetic. Write just a couple of lines in the chart, documenting this
conversation. An example: “Anesthesia f/u note: 64 yo POD#1 s/p ex-lap under GETA. Denies recall.
Denies complaints. Pain controlled. Questions answered. Signing off.”
How to set up a room
SARA CHENG, MD, PHD
You should always set up a room to be prepared to put a person to sleep under general anesthesia, even if
you are planning on using a different anesthetic technique. Patients get too uncomfortable, change their
minds, go apneic… you get the idea. The important thing about room setup is that you should use a system
consistently. An organized system is a safe one. This is how I 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:
a. Emergency drugs to always have drawn up: Succinylcholine 5cc@20mg/ml, Ephedrine
5cc@10mg/ml, Atropine 2cc@0.4mg/ml, Glycopyrrolate, 2-3cc@0.2mg/ml, Phenylephrine,
several syringes, 10cc@100mcg/ml
b. Induction drugs- draw this up only if you’re planning to do a general. Usually propofol 20
cc@10mg/ml, occasionally etomidate if CV unstable or thiopental for craniotomy, lidocaine
5cc@20mg/ml if using propofol through a peripheral IV (propofol burns!)
c. Narcotics etc.- fentanyl, midazolam, dilaudid- usually at least 2 mg of midazolam and
250mcg fentanyl.
d. Whatever else you and your attending have discussed.
3. Finish machine checkout:
a. Reattach your oxygen sensor.
b. Check that monitor is on and displaying appropriately
c. Check that backup oxygen canister is full
d. Check that the vaporizers are full, that the vaporizer you want (i.e. sevoflurane or desflurane)
is present (there are only 2 spots and occasionally you’re want to use a gas that’s not thereyou’ll have to ask the anesthesia tech to get it for you), and that the dials turn.
e. 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 go down to off too (safety mechanism).
f. Check for circuit leak.
g. Check that gas sample line is connected and patent (blow on the end through your mask to see
CO2 appear on monitor)
h. Check CO2 scavenging canister - purple=need a new one.
4. Monitors: Put pulse ox and BP cuff at head of bed. Place EKG leads on bed- for 5 lead, green and
white on right. If using invasive monitors, make sure you have transducers in room and plugged in,
wet down.
5. Airway (SALTT)- suction on and at head of bed, airway (oral) in 2 sizes, laryngoscopes with 2 different
blades and light working, tube (endotracheal) in 7.0 and 8.0 sizes with balloon tested, syringe attached,
and stylet available), tongue depressor. Also, always good to know where the emergency LMAs are
located (in the room or in the anesthesia workroom, depending on your site).
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)
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 all done in 15 minutes eventually.
What to do at a code
SARA CHENG, MD, PHD
After you have been a CA-1 for approximately 30 days, you will start taking overnight call and will be
handed a small, scary, black plastic thing called the code pager. The first several times this thing goes off
your heart will start beating very fast and you may briefly contemplate running away. Instead, you will run
and grab the airway box, having checked earlier that day that you knew where it was and that it was stocked
appropriately, and run your butt over to the patient’s room. Your job as the anesthesiologist is to manage the
airway and intubate if needed.
On the way there, call your attending and tell them where the patient is so that they’ll meet you there.
Once there, eyeball the situation.
Is the patient lying there, out of it, but all vital signs on the monitor are stable and there are no people
buzzing around? You probably have time to talk to the nurse/team and figure out the history, as well as wait
for your attending. Remember the indications for intubation: oxygenation, ventilation, airway protection,
operative procedure.
On the other hand, is there a full-blown resuscitation going on with an RT or nurse bagging the patient?
You’re going to need to intubate. Remain calm and remember one thing: that after 30 days of being an
anesthesia resident you may know more about airway management than most of the people in the room. So,
your place is at the head of the bed, not milling around talking to people or trying to assemble your stuff.
Announce you’re with anesthesia. Push others out of the way if you need to. Try to assess the airway
(morbidly obese/no neck/in C-collar or halo/jaw wired shut=BAD) and bag the patient. If it's difficult, twohand mask and ask someone else to squeeze the bag. Ask others to assemble the minimum needed for
intubation: suction on and within reach, airway (oral), laryngoscope, endotracheal tube, free flowing IV,
drugs (induction agent and paralytic). Ask about full stomach (rapid sequence induction with cricoid
pressure), if recent potassium was high or if stroke/myopathy present (contraindications to sux), whether
blood pressure has been stable (use etomidate over propofol). If the patient is unconscious or almost
unconscious then you may not need drugs- just do your DL and if the cords are closed you can push some
sux. By the time you’ve started some of this stuff your attending will be there and you guys can get on with
intubation together.
One very important pearl: 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,
take the 10 seconds to get everyone to 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.
OK, one more very important pearl: Once you’ve successfully intubated, hold on to your tube for dear life
until it is safely taped. In the middle of a code, it can easily come out again (an event that caused personal
asystole in this author 3 years ago).
Some favorite mnemonics:
VISA (vent/ambu, IV functioning, suction on and within reach, airway tools)
SALT (suction, airway (oral), laryngoscope, tube
General OR - University of Colorado Hospital
ZACHARY BRYAN, MD; CRISTINA WOOD, MD; BETHANY BENISH, MD
Important people:
Program Coordinator: Allison Glover, Office: 303-724-1758, Fax: 303-724-1761, Email:
allison.glover@ucdenver.edu
Administrative Assistant: Kathy Riggs, Office: 303-724-1765, Email: kathy.riggs@ucdenver.edu
Anesthesia IT: Ken Bullard, Email: ken.bullard@ucdenver.edu.
Phone Numbers:
UCH Main Hospital Number: 720-848-0000
AIP Charge: 720-848-5920
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 Allison 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
through the remote access tab on the virtue.ucdenver.edu website. First click on the UCH Centricity apps
tab (11th tab down on left side of virtue webpage under the title intranet links). You can also go directly
to the website: https://ctxapps.uch.edu/vpn/index.html. 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 the Centricity update to run EPIC. A link is posted to the right side
for both Windows and Mac operating systems. Click this link and follow the instructions.) To log-in to
EPIC click the remote access tab (4th link down on left hand side) and log-in with…. You guessed it your
UCDenver username and password. Go to the OR board as you normally would and find your patient
cases.
EPIC:
 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 prior to
starting a case (actually you will be told you will have one but will basically learn it on your own). You
will have a couple weeks with someone paired so learn from them 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 that happens to be selected will appear in order of room
number; add-ons appear at the top until they are assigned to a room. When your EPIC window first
launches, a new window with Status Board Settings will open. This is where you can select the date and
the area within the operating/procedures rooms you'd like to view. 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. The date will allow you to select cases for today’s date (which
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shows up as a T) and future or past dates. Select the date by clicking the hour glass to the right of the
date. When you select Run at the bottom this will bring up all patients scheduled for any procedure
scheduled in an OR or procedural room. At the top left to get you to the actual status board of cases, you
will click All ORs.
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 (303-333-0869) or via email (which I recommend).
Weekday Daily Work Flow:
 Do Anesthesia Pre-ops on patients coming into the hospital as best you can with info (including latest
labs, EKG, CXR, TTE etc.) from EPIC. To look up this information, use the chart review function on
EPIC. By selecting the patient from the OR board (or alternatively from My Cases at the top left of the
OR board screen). You will be taken to the Pre-op screen with the Pre-op, Intra-op, Post-op and Orders
selection tabs at the top of the page. The Chart Review, Patient Summary, Results Review, Notes etc.
functions are located at the top left side of the page. I would recommend finding everything other than
labs under the "chart review" function (lab results are best located under the results review function).
Under the chart review function, prior anesthesia records, notes (including H&Ps and inpatient notes),
procedural notes (EGDs, TTE, TEEs etc.), imaging (CTs, CXRs, U/Ss etc.) and ECGs can be located and
transferred to the actual pre-op note you will create.
o The pre-op note can be filled out under the Anesthesia Pre-op, which is found at the left column
of selections specifically on the pre-op chart. When you select this feature 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.
 Give yourself at least 30 minutes to set-up your OR before any morning conferences (Monday- Grand
Rounds 7:00, Thurs- ITE lecture /Board prep 6:30, Fri- Cardiac lecture 6:30). The techs are great and
usually will set up arterial lines and central lines for you, but you may need to do these yourself as well.
You can always call the techs to help (see numbers below). Pressure bags and transducers are located in
the Anesthesia workroom. With the ongoing construction, the location of certain items is constantly in
flux, and finding something may require somewhat of a hunt. You can always call the techs to find out
where things are.
 Be sure that if you need infusions (i.e. TIVA- total intravenous anesthetic), 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. Ideally all your gtts will have
been primed and will be ready to just hit run (hold the infusions during induction by using the "hold"
feature and put in the max hold time of an hour…. you’ll look like a rock star when it comes time to hook
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them up). Always keep an extra channel for the possibility of pressors or addition of other agents. Make
sure you select critical care and that you change the mode to the "anesthesia mode" under the options.
This will ensure that all the needed medications will be available for running gtts.
In prone cases, be sure to check that you have a prone view pillow. Ask the techs or grab one from the
workroom.
Get patient’s narcotic bag from Pyxis in Pre-op or from the pharmacy (It is called Narcotic Bag on the
list and includes 4mg Versed, 500mcg Fentanyl, 2mg Dilaudid and 400mg propofol). Other meds like
Phenylephrine/ MannitolEPIC/Nimbex/Heparin/Insulin are in the Pyxis/refrigerator in the pod areas
between the ORs and premade Sufentanil syringes are at the pharmacy (window is located in the same
hall as the main OR board). You can always call the pharmacy to make up a drip for you. 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. 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. (Paper OR schedule in pre-op on countertop shows bed number and nurse.)
** Learn the preop and PACU nurses/names, they are a wonderful resource and really will help you
if you make the effort!**.
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 (nurses need official orders to start the PIVs, hang IV fluids, EKG,
labs, scopolamine patch prior to case starts). You can also do this from the night before. The preop order set can be found under the order tab when you first open the pre-op 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".
 If any labs are needed… especially a type and cross/screen, try and make sure you order
those pre-op.
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. 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.
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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 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. I always put on pulse ox first, then BP and while it is cycling, I get on the EKG leads.
Call your attending to tell them you are in the OR. All communication at the U is via cell 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, you will have to 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.
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 transporting to the PACU, help the PACU nurse apply patient monitors and give him/her your
report. It’s helpful to take a look at the sheet they fill out so that you can have an idea of what they want
to know.
Make sure the PACU orders have been completed. This, like the pre-op order set, is something that you
will want to add to your favorites from the orders tab. First search for PACU post-op order set and add to
your favorites as above. All the choices within this set already have predetermined ranges and maximum
doses. If you feel you need to change anything, you can do so by clicking on the actual order. Sign them
at the bottom right once done.
Write totals on narcotic bag; make sure they match EPIC totals. No needles! Only 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).
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.
Usually will get “coffee” (15min. morning), lunch (30min.), and “tea” (15min. afternoon) 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:
 C1: 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: 7am-7pm: Start with the first cases of the day (you need to be there at about 6am to set up your
room just like you would on a normal day) and you are in house until 7pm or until down to 4 rooms (C1C4…. This is ideally how it works…).
 O: You usually finish and can leave after you have finished your cases, or about 3-5p (usually closer to
5p). If you finish early, always check with the charge anesthesia attending to see if you are needed
elsewhere.
Call Nights/Weekend Call:
 On weekday call nights, arrive at 3pm, but always check (look @ relief time on OR/Anes schedule).
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
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.
 2 call rooms: 1) Leprino Office Building (near parking garage). 4th Floor, East side, door code is 3-1-2.
Then go to the far North side of building to find our call room (first left, dead end, left then second to last
door on right…. Its labeled people). 2) SICU anesthesia sleep room- must use if you are carrying the
code pager. Door code 2-0-2-0… leave nothing in this room as everyone has the code. This room is
louder so if you don’t have the code pager, then I recommend going to the leprino call room.
Code Pagers/Badge:
 When on call, you sometimes carry a code pager and badge when a SICU anesthesia resident is not oncall. This badge should let you into any door, and the key attached can override the elevator.
 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?, S- suction ready? (is often missing), A- airway tools available? (hopefully you remember
the box…. An Eschmann often times comes in handy.
 Airway Box Locations: 1) main OR anesthesia workroom, 2) in PACU, 3) in SICU supply room on top
of cart immediately to side of fridge (ask any SICU RN…. Code to the room is 9-8-7 and the room is
located closer east side of the SICU pod).

University Phone Numbers
University Codes
OR front desk
RN Charge
Pre Op
PACU
OR Pharmacy
Anes. Tech
Blood Gas/TEG
Blood Bank
84351
83512
86252
86203
86132
85912
85309
84444
Locker Room:
Lounge:
Anes Work Room:
Leprino Call Room
SICU call room:
SICU clean supply:
04507
04507
2311
312
2020
987
General OR – Denver VA Medical Center
HALEY HUTTING, MD, JOE PEETZ, DO, BARBARA WILKEY, MD
Important People:
Head of VA Anesthesia: Dr. Dev Rai – Cell: 720-837-4766
Pre-op nurse: Shirley Pfister, RN, fund of knowledge about accessing pt records.
Anesthesia Department controller: Carrie Shurmantine , she handles all badge & ID questions. Office:
303-393-2883. Email: carrie.shurmantine@va.gov
PharmD: John Hawk, handles Pyxis concerns (and is a fantastic resource for drugs).
Other attendings: Dr. Henri Acosta (C) 312-841-8845, Dr. Dan Beck (C) 773-744-4996 (P) 303-201-3846,
Dr. Jake Friedman (H) 303-388-4295 (P) 303-609-3590, Dr. Mohammed Javed (H) 303-993-3620 (P) 303201-0347, Dr. Peter Rowe (C) 720-323-3349 (H) 303-927-7113, Dr. Allison Long (C) 720-987-4298 (P)
303-201-1013 (all are super-friendly and excellent teachers)
Phone Numbers:
Main Denver VA Medical Center: 303-399-8020
Anesthesia Office: 303-393-2883
Before you start:
 You must have your ID badge, scrub card, parking hang tag, and computer codes. Immediately call
Carrie, even if you are not starting at the VA for a few months. To obtain a badge, you have to make an
appointment with the badge folks. This can only be accomplished via Carrie and can take up to several
months.
 Also, in your first few days you should get Omnicell (like Pyxis) access from John Hawk
 You need to get your parking hang tag from the parking office at the U (in Bldg 500 across from the
Bookstore), which is only open from 8am-4pm! You will likely do this at orientation.
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. The
difference is that you will have to pick up a lot of the slack for the little things that the techs do not do,
such as connecting your circuit and putting stylets in your tubes.
 The anesthesia techs here are friendly but lazy. Often, you’ll need to set up your own a-lines and grab
the prone face pillows, glidescope, etc
 The pumps for drug infusions (ketamine, propofol, sufentanil, remifentanil) are in the workroom on the
back wall. Each one has a different magnetic label
 Pacer magnets are on the fridge in the workroom. You will have a patient with a pacer/AICD at the VA.
 H&Ps for all your cases should be done the day before they are scheduled and discussed briefly with
your attending (especially at the beginning of the year). The VA computer system is very thorough but is
not accessible from home, so the work has to be done before you leave. Under "tools"/"vista imaging" at
the top left of the page, you will find previous anesthesia records, imaging, and EKGs.
 Also, if you have cases that have possible blocks for the next day, you should check the block cart in preop before you leave and restock it (or ask an anesthesia tech to restock it). Certain attendings have
preferences on what they mix in their blocks. Ask them. The handouts they give you on regional stuff is
very useful
 Cases start at 07:45 Tuesday through Thursday, 08:30 on Monday. You will start your own IV’s, so get
there early enough to do this. Also, plan for time to do any blocks/epidurals if indicated. It is expected
that if you are doing a first case block that you’re ready to block right after lecture
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If you will be doing a block, try to see your patient and have everything set up before you go to lecture at
6:30 -7am, depending on the day. Otherwise, you should plan to be done interviewing the patient by
07:15 (08:15 on Monday).
Lectures: Monday 7 am, Wednesday 0630 and Friday 0630. Make sure to check the schedule on the
door of the anesthesia conference room. Residents are scheduled to give one lecture each month. Friday
is usually QA or CCC (Clinical Case Conference) = oral board style
There are four groups that must see a patient before sedation - pre-op holding nurses, surgeons
(consent/marking), OR nurses, and anesthesia. Do NOT start your block or give any sedation before
verifying that everyone has seen the patient.
All OR communication is done via Vocera. You will need to get set up with one of these, so ask Carrie
about getting one on your first day.
All patients go to the PACU EXCEPT patients being admitted to the ICU. They go directly to the ICU
(even if extubated).
All patients with epidurals and more than 1 level spine cases go to ICU
Also, after hours and weekends, patients will go to ICU for wake up because there are no
evening/weekend PACU nurses. Propaqs are stored in the pre-op area. Please return them after transport
and plug them in to charge.
Since the VA is a smaller hospital with fewer ORs, everyone needs to help out in order for things to run
smoothly. If you have a cancelled or delayed case, try to get your own breaks/lunch and give breaks to
others if you have time - be proactive.
On non-call days, you usually go home around 1530 - 17:00. On call days, you stay until the last room is
finished. One of the things that is different about the VA is that you relieve the CRNAs at 15:00
Printed schedules for the next day are located in the conference room, usually mid-day. Changes are
frequent, so make sure to check the white board in pre-op for the latest schedule. Make sure to check the
board for a blue triangle (pending labs, usually tox screen) or orange rectangle (anesthesia NP workup
available).
The pre-op anesthesia workup is very helpful, most patient have one in the computer system
Look out for your fellow residents; when someone is gone on vacation, do their pre-ops on Friday for the
day they come back on Monday. And it is greatly appreciated if you print out the H&P/pre-op for
someone still in the OR, if you get done early
Try and print out your pre-ops on your break, if the schedule is out, it saves you time
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.
 Make sure to set up a signature code in order to be able to sign orders and view images through VISTA,
ask the attendings for help with this
 Talk to John Hawk if you are unable to write orders, you may need to sign some narcotic paperwork
through 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 in the chart, and return the original to the PACU
 Intra-op: you should complete an anesthetic record, finish the H&P if you haven’t documented
everything, and a time-in/time-out/antibiotic administration/beta blocker sheet, and QA sheet.
 Pre-op evaluations (Shirley Pfister, Mary Buckley or Tara Sharp): On complex pts, Shirley or Tara will
do a pre-op evaluation of most patients and make a computer record of it.
 Check VISTA 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 written on blank order sheets that are found in the PACU
 Blood paperwork – There is paperwork that accompanies each unit of transfused blood.
Pharmacy:
 All non-controlled substances are stored in the anesthesia workroom (fridge). Phenylephrine and
Ephedrine sticks are in the fridge, as are some antibiotics and phenylephrine bags
 Controlled substances are in the anesthesia cart in your room
 Occasionally you will need to get controlled substances from the Pyxis in PACU. It’s the same access as
your cart
 When finished with a case, waste your narcotics with an attending. You can occasionally waste narcotics
with another resident, but don’t get in the habit of doing this. Waste your meds early because you don’t
want to be caught at the end of the day with narcotics from multiple cases and nobody to waste with
because everyone has left (this has happened).
 Equipment and meds for peripheral nerve blocks located in the block cart and the “block room” in preop. Ropivicaine and clonidine are in the pharmacy. Code for the cart is 1-2-3.
Call & Weekends:
 Call at the VA is HOME CALL. Keep your individual pager on. There is no VA-specific pager.
 Get a copy of the call schedule from the bulletin board at the beginning of each month- it has phone
numbers of the attendings on call on it!
 First: The surgery resident will call you when a case needs to go at night or on the weekend. Get
information about the patient. Ask if surgery attending knows about the patient and when they will be
ready to start. Also verify that surgery resident is calling the nursing supervisor, who will call in OR
nurses. The process from first phone call to case start usually takes at least one hour.
 Second: Talk to your attending – some want to be called immediately, some want to be called when the
nurses arrive. Ask before you leave for the day. Any calls for ED anesthesia or difficult airways should
be immediately discussed with the attending (do not come in first). When in doubt, call your attending.
The VA has in-house pulmonologists and hospitalists who can intubate
 Try to clean up your anesthesia machine after night/weekend cases (pick up monitors, throw away drugs,
etc.)
 Weekend call is also Home Call, but you are also in charge of the acute pain service, so you may have to
come in and round in the morning (see below).
 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.
Acute Pain Service:
 The VA is the only hospital that has you follow the pain service before you have you APS rotation, so
make sure you get all of your questions answered before you start a weekend call. You will be given an
introductory epidural lecture and ask your attendings for tips
 You will round on the patient, write orders, and write an APS note in CPRS on each weekend day. There
is an epidural clipboard in the anesthesia conference room that has one sheet of paper for every epidural
patient (document level, infusion, and verify that a note is written each day).
 Rounding: See the epidural patients, find out their pain with activity and rest, their RN opioid demand
needs overnight, get a dermatome level, assess urine output and vitals, then call your attending with a
plan after you’ve seen all the epidurals
 Over the weekend, the call person rounds on all epidural patients. During the week, generally the
resident who placed the epidural rounds on the patient. However, it is ultimately the call person’s
responsibility to make sure that a note is written in CPRS.
 Acute Pain Service Keys:
1. Write order to hold sq Heparin on mornings you are pulling an epidural.
2. Write order to restart Heparin two hours after epidural is pulled.
3. Discuss with primary team. All pain meds by primary team after epidural d/c’d.
4. Make sure all epidural catheters come out with the catheter tip intact and document this.
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
Locker room – 2-9-4-9
Anes Carts- Turn dial left, 1-2-3, turn dial right
General OR – Denver Health Medical Center
ALLISON LONG, MD; RACHEL L BOGGUS, MD; HEIDI GREEN, MD; ANNE RUSTEMEYER, DO;
Important people:
Residency administrator: Dr. Jack Humphrey, Phone 303/436-8371, Pager 303/851-4182 (prefers pager)
Senior Secretary: Irene Horton, Phone 303/602-1102
Main anesthesia office: 303/602-1105
Phone Numbers:
Main DHMC Hospital: 303-436-6000
Before you start:
 Speak to Irene at least 1-2 weeks prior to your arrival to arrange the following: parking, ID badge, locker
assignment and code to the lock, scrub machine code, who to call for computer access codes, Pyxis
access code.
 You can contact the Help Desk for passwords at 303/436-3777.
 Contact Dr. Humphrey 2 weeks prior to your arrival to arrange a tour before your actual start day.
Weekday Daily Work Flow:
 The OR schedule for the next day is available in the early afternoon and is in the “bull-pen"/front desk.
 Most patients go to the pre-op clinic and the H&P will be completed for you. Find them in the file folder
in the bull-pen. If it’s not there, they either did not go to the pre-op clinic and you can do it in the a.m., or
it is still being completed and may show up by morning.
 If you are scheduled to take care of an INPATIENT, you should see them and complete the green H&P
form before you go home the night before. If you are post-call, you should ask one of the residents to
check your schedule and do any inpatient H&Ps for you. You can have the resident call you to tell you
what you are doing the following day, too.
 Arrive 30 min prior to conferences to set your room up.
 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. If they find meds in there that are not labeled,
they will throw them away.
 Mondays- Grand rounds are teleconferenced to DH at 7 a.m. Lectures other days of the week are from
6:30-7:00 a.m. in the conference/lunch room- see bulletin board in that room for exact schedule, as some
days there are no lectures.
 After conference (or before if you have time), see your pt in pre-op. Marker board has pt’s name and
chair location. Complete H&P/Consent/IV access (usually nurses do the IVs, unless they are difficult, in
which case they will give it a try or two then call you).
 After all consents have been signed, pt can have premedication and can be pushed back to the OR in their
chair. Don’t transport patients past the main OR board, go around (it violates HIPPA).
 Overhead page your attending when you are in the room if you have not already seen them.
 At DH they generally use an overhead paging system to reach attendings, anesthesia techs, etc. After
picking up the phone, you press “OH page” and then say your message (“Dr. Sawyer please call room
one” 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
and just try again in a few seconds.
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Unused narcotics 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 do it. You can save all
leftovers throughout the day until you have some time to do this, just stick a patient sticker on each
syringe.
There is an underground tunnel from the basement of the parking garage to the basement of the main
hospital- it will save you much suffering during the winter months. You need to use your ID badge to
access it.
Food/Lounge-Cafeteria is located in the basement. Dr Humphrey will give you meal vouchers monthly.
Vending machines are located in the nursing/staff lounge in the OR area. 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…
Computer programs for patient information:
 At this time, three separate computer programs are used to access patient info:
 LCR: Access recent labs, radiology, home meds, MAR while pt is inpatient, allergies, and current orders
(we can also write floor orders, although we rarely do this). You can also access EDM (the outpatient
records) from here.
 EDM: You can view outpatient notes, cardiology reports (e.g., echo’s, stress tests, etc.), radiology, and
pulmonary reports from here. Also this is where the old anesthesia records are scanned.
 Lifelink Clinicals: Here you can see vitals, I/Os, labs for inpatients.
Call Nights/Weekends
 Weekday call (C1) - 3 pm-7am. Check board or contact charge to see where to go.
 Weekend call is 12 hr. shifts 7a.m. to 7 p.m., 7 p.m. to 7 a.m.
 When you arrive for call, check that the trauma rooms (OR 1 and 5) have been set-up. See following
page on trauma room set-up. It is important to have them set-up, as there is usually no time when a
trauma patient is on their way up to the OR.
 Late (C4) - arrive at usual morning time and you will be the last resident to leave (excluding the call
resident), which means you will leave at 8pm or earlier.
 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.
Code pager 102:
 You will carry this when you are on call. The float CRNA will give it to you and you can hand it off
post-call to the new float CRNA.
 These pagers are voice pagers, the message repeats itself twice, then you can’t repeat the page, so write
down the message if needed (room number of the emergent intubation, epidural, etc.)
 The attending also carries a code pager on call: dial 123, wait for tone, then 118 to leave a short voice
message on their pager.
 At codes you have the same responsibility as other hospitals- primarily airway (see Section “What to do
at a code”).
 Airway box location- It is just inside the anesthesia workroom to the left of the door when you walk in.
The Glidescope and Fiberoptic cart are also stored in this room. You may occasionally get paged to
bring these things to a patient’s bedside. It is also nice to carry a stick of Succinylcholine and Etomidate
in your pocket, just in case.
Guidelines for Trauma Room Set-up at Denver Health:
 Anesthesia Machine, Circuit, and Work Area
o Standard anesthesia machine set-up and checked out, including suction
o Two functional laryngoscope handles and selection of blades
o Three prepared endotracheal tubes (7.0, 8.0, and 9.0) with stylets and 12 cc syringe in place
o Oral airways (80 mm and 90 mm) and tongue depressor
o 16f NG tube
o Esophageal temperature probe
 Monitors
o ECG cables deployed with electrodes attached, paper in ECG recorder
o Non-invasive BP cuff deployed at head of bed under mattress
o Pulse ox deployed on circuit tree
o Art line set-up on transducer with wet down pressure bag, pressure cable connected to machine.
Second pressure module and cable available, should CVP be needed
 Fluids, Warmers, IVs
o Two Level I warmers assembled with (1) D-50, and (1) D-100 style tubing, stop cock, extension,
and 1000 cc bag of LR, not wet down until needed
o One 250 cc bag NS with 400 mg dopamine, and one 250 cc bag NS with epinephrine (4 amps)
taped to their sides and IMED tubing placed in plastic bag hanging on Level I. Don’t inject the
meds until needed
o One two chamber IVAC pump
 Drugs Available with labeled syringes, but not drawn up
o Etomidate
o Vecuronium
 Emergency drugs prepared and stored in top drawer of Pyxis
o Atropine 400 mcg/ml
o Succinylcholine 20 mg/ml
o Ephedrine 5 mg/ml
o Neosynephrine 100 mcg/ml
o Epinephrine 2 syringes: syringe 1 – 10mcg/ml, syringe 2 – 100 mcg/ml
 Invasive Lines
o Arterial catheter start kit bundled and available
o Triple lumen catheter and Cordis introducer kits on top of anesthesia machine
o IV start kit bundled and available
Important DHMC Numbers:
Attending In Charge (AIC) 123-118
OB CRNA
123-104
Anesthesia Call Resident 123-102
Calling from outside:
Bridge
Blood bank
SICU
Preop
PACU
OR nursing phone
OR anesthesia phone
303-436-xxxx
303-602-xxxx
21061
66929
68333
21030
21020
210xx
212xx
Attending Physicians
Herren, Michelle
Chandler, Mark
Duke, James
Humphrey, Jack
Juels, Alma
Kumar, Sunil
Miller, Howard
Packer, Mac
Keech, Brian
Riggert, Ami
Meyers, Greg
Penning, Don
Sawyer, Mike
Valdivieso, Ron
Ciarrallo, Christopher
Pager
303/201-4160
303/208-1730
303/540-3983
303/851-4182
303/208-7049
303/208-0485
303/540-3982
303/891-3465
303/201-1390
303/201-1213
303/201-4706
303/234-3156
303/206-9785
303/208-1220
303/201-3691
Pre-operative Clinic
Goldsmith, Kathy NP
Pre-Op Center
Phone Ext.
65995
65990
Anesthesia Technicians
Manzo, Katie
Montoya, Sophia
Martinez, Paul
Richardson, Sandra
von Holdt, Kevin
Door Codes
Resident call room- 1924
Resident lounge- 5210
123-338
123-325
123-105
123-125
123-905
Pre-op/PACU Rotation - DHMC
RACHEL L. BOGGUS, MD; JIM RYAN, MD
This is a rotation spanning 1 month – 2 weeks in the pre-op clinic and 2 weeks in the PACU. Dr. Chandler mans
the pre-op weeks and Dr. Sawyer mans the PACU weeks. They will decide how to split up the month for you –
speak with them before your rotation starts to confirm the order in which you will be doing these. NOTE: Some
of the information in this section will be changing as of the 2012-13 year for 2 reasons. Firstly, Dr. Myers is
trying to start an acute pain fellowship at DH, which will affect the PACU weeks. Secondly, the ORs at DH are
being remodeled so the location of things for the PACU weeks are in flux.
PACU:
 For the most part, this rotation is an opportunity for you to do blocks; however, you are also responsible for
being “around” and being available for other PACU issues that may arise. Some days are slow and you can
get a lot of studying done and some days are busy with lots of blocks.
 Issues that may require your attention include: airways problems, nerve blocks, orders that the nurses need
that are not already written, cardiovascular problems (high BPs, arrhythmias, etc.), calling consults if
needed (neuro for altered mental status, cards for arrhythmias or ST changes, etc.).
Daily Workflow:
 When you are on the PACU rotation you are expected to attend morning conferences. The lecture schedule
can be found posted in the anesthesia lounge.
 If there are no lectures that morning arrive around 7-7:30 UNLESS you are planning to do a pre-op nerve
block for a patient who is the first case of the day; then you are going to need to arrive earlier to get the
block done and still allow time for the OR resident or CRNA to get the patient back to the room on time.
 When you arrive at the PACU introduce yourself to the PACU nurses so they know you will be around to
help that day and give them your pager number. If they don’t know you are there then sometimes they call
the attending directly and you miss out on valuable learning. They are very good about coming to you for
any issues that may arise. They also are very good at letting you know if a patient may need a block.
 PACU nurses may come to you for a “sign-out.” As of now, you are allowed to sign-out a patient who will
be an inpatient (going to the floor or ICU), but NOT a patient going home. If you sign-out the patient, not
only do you need to make sure they are safe for transport, and that pain, BP, etc. are under control; but also
that all the appropriate attending signatures are present on the anesthesia paperwork. If you have any
questions, ask the attending before signing out a patient.
 There is a small computer nook in the back of the PACU – this is your “home base.” Start out there and
read/study/drink coffee/do whatever. (Again this location may be changing with the OR remodeling). This
computer space is shared with nurses and other residents too, so don’t be surprised if you lose your spot
when you leave.
 When you see a patient arrive to the PACU get up and help the patient get settled in – attach monitors,
change the O2 from the tank to the wall O2, etc. The PACU nurses appreciate your help. Then stay there
and listen to the report. After report ask the OR anesthesia provider if they anticipate any issues. Check on
the patient every 10-15 minutes or so to be sure they are doing ok. If there are major issues with a patient or
if you need to call a consult for something always make sure to run it by the attending for that case.
 The days on PACU usually end around 3-4pm (sometimes you may stick around later if you are waiting for
a patient to come out who you are planning on blocking). You don’t have to ask anyone for “permission” to
leave, just leave when you feel it is appropriate.
Performing blocks on the PACU rotation:
 Check out the schedule the day before to see if any of the first cases may need blocks. If so, run it by
whomever the attending will be and see if they want to do the block pre-op or post-op. If they want to do it
pre-op you will need to arrive earlier that day, if they want to do it post op then you can arrive at your
normal time. For all other patients who may need blocks and are NOT the first case of the day you can wait
until that day to see what the attending wants to do.
 When you arrive in the morning get an OR schedule and highlight all possible cases that may need blocks
(if you didn’t do this the day before). Talk to the attending for these cases and see if he or she wants to do
blocks. If they do, ask whether they want to do the block pre-op or post-op.
 Once you have determined a patient is a candidate for a block and confirmed the attending will do a block,
check in the APC/pre-op area and talk to these patients AND CONSENT THEM for blocks or ask the OR
team to consent them if they are already talking to the pt. Try to catch the patients as soon as they get there
so you are not delaying the OR team when they are trying to do everything in their 20 minute turnover
window. Consent them in the APC regardless of whether they are getting a pre-op or post-op block.
Remember to always consent them for GA as well.
 If the attending wants to do the block pre-op get it set up as soon as the patient gets there. This will require
some coordination on your part as you need to tell the pre-op and PACU nurses what you’re doing. When
the patient gets there let the pre-op nurse do their paperwork and get the IV in then make sure the anesthesia
and surgical HP/consents are done (if they aren’t then you cannot give the patient any sedation).
 Then take the patient over to the PACU and ask the nurses where you can do your block and hook the
patient up to monitors. You can’t do blocks in the pre-op area because there is not enough room and there is
not adequate monitoring equipment.
 The block cart and ultrasound are always in the PACU. If the ultrasound is gone, someone may be using it
for a central line or something- just page an anesthesia tech overhead and have them bring it to you.
 Get your block equipment all set up, then page your attending and do the block. (most use 0.25% Bupiv
Plain for post-op blocks or 0.5% Bupiv Plain for surgical blocks).
 Keep the patient on the monitors in the PACU and keep an eye on them until the OR team is ready to take
them back.
 If you are going to do the block post-op STILL CONSENT THEM FOR IT PREOPERATIVELY (as
above). Then have the block cart all set up for when they come out. When they come out of the OR help get
them settled in and listen to report. Then get all set up for your block and then call the attending.
 There is paperwork that needs to be filled out for blocks. It is located on the side of the block cart. Fill out
this paper, have your attending sign it, and attach it to the OR packet that the OR team fills out and turns in.
MAKE SURE YOU FILL OUT A BILLING SHEET FOR THE BLOCK (this is the same white sheet you
fill out when in the OR). You can either fill out a brand new one or just add what you did to the one the OR
team has already filled out. Make sure to check “ultrasound” if you used ultrasound.
 It is good practice to take a sticker and get a contact number for each patient you block. Call them 2 days
after you block them to see how the block worked and see you they are doing.
Pre-Op:
 In the pre-op clinic, your goal is to evaluate patients preoperatively and determine if they need any further
work up/labs/testing and answering any questions the patient may have regarding anesthesia. You will also
be ordering any meds or lab tests you think will be beneficial the morning of.
 Also, you will be filling out the anesthesia H&Ps and consents. Write down any issues you may anticipate
very clearly on the H&P so the OR team will be aware.
Daily Work Flow:
 A few days before the start of your pre-op rotation call up Kathy Goldsmith (303/436-5995), the NP (stands
for both nurse practitioner and nicest person alive) that runs the pre-op clinic. Go down to the pre-op clinic
and she will give you a little orientation. She will also go over a lot of the following information with you.
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To get to the pre-op clinic enter through the main entrance you normally do. Walk straight in and go
straight (towards the Urgent Care center). When you reach the entrance to the Urgent Care center just look
to the left you will see a sign that says anesthesia clinic and there you have it.
You usually arrive about 8am and you likely will not be able to get in if you get there earlier. You are not
expected to attend the morning lectures while on the pre-op clinic rotation. There is a workroom in the back
of the clinic that is your “home base.” Kathy or one of the MA’s will print you out a list of patients who are
coming in that day. Look over the list and if there are any really sick patients, patients getting big surgeries,
or patients with big-time medical problems and let Kathy know – she will let you see the “more
complicated” patients.
When the patients arrive they will get their vitals taken and usually an EKG (if appropriate) and then the
nurse/MA will put them in a room.
There is a yellow room and a blue room. The color of the file folder the nurse gives you with their files in it
will either be yellow or blue and this is how you know what room they are in. The paperwork included in
this file contains basically everything from their computer file printed out for you, the surgical H&P and
consent, and the day of surgery order form.
Go through all the papers before you see the patient and start filling out their green H&P form from the
papers. As you are going through the papers make 3 piles:
1) Can be thrown away/not important papers (50 pages of EKG from a stress test or Holter monitor,
duplicate med rec sheets, etc.)
2) Important papers that should be stapled to the anesthesia H&P (notes from the PCP, most recent
med list, copies of echo results)
3) Surgery’s papers (their consent form and H&P will also be in the packet) and the yellow day of
surgery order sheet.
Discard all the useless sheets into the paper shredder. Leave the other 2 piles and you will deal with them
after you see the patient.
Then go see the patient. Do an H&P and focused physical exam (i.e. heart, lungs, airway and anything else
relevant to that particular patient). Fill out the H&P form as completely as possible. Then, go through the
anesthesia consent form with them and have them sign it. Answer any questions they may have. Also
consent them for blocks if they may be candidates. Then they can leave UNLESS you think they need labs.
If they need labs you must fill out a lab sheet and send them to the Wellington-Webb Building to get labs
drawn (they don’t need to come back to the pre-op clinic afterwards). You should follow up on those labs
later that day or the next to make sure there is nothing of concern or nothing that will delay their surgery.
RIP OFF THE YELLOW CARBON COPY FROM THE BACK OF THE H&P AND STAPLE IT TO THE
PILE OF IMPORTANT PAPERS YOU GATHERED FROM THEIR FILE. So, you have the yellow carbon
copy of the H&P and the important papers pile stapled together – you then take this up to the front of the
office and put it in the slot designated to go up to the anesthesia bull pen. The nurse will take these upstairs
and file them later on. This should be all the paperwork (as far as pre-op workup) for the anesthesia provider
taking care of the patient on the day of surgery.
You are then left with the green anesthesia H&P, the blue anesthesia consent form you just did, the surgical
H&P/consent, and the yellow day of surgery order form. If you want to order any meds or labs for the
morning of surgery (albuterol neb, pepcid, bicitra, UPT, FSBS, type and screen) there is place on the yellow
form for this. Look under “anesthesia” and write your orders there and sign them. Once you are completely
done, paper clip them all together, and PUT THESE BACK IN THE BLUE OR YELLOW FILE FOLDER
YOU WERE GIVEN AND PUT THE FILE INTO THE FILE CABINET UNDER THE DATE OF THEIR
SURGERY. The file cabinet is right next to your workroom.
Then you fill out a billing sheet and drop it off in the basket in the front of the office.
Repeat this process for all patients until all patients have been seen. Patients are usually scheduled up to 34pm so you can get out of there around 4-5pm. If you have any questions about how to do anything just ask
Kathy. She knows all.
If you see any very complicated patients that you think may need to be cancelled or may need further testing
review them with Dr. Chandler THE DAY YOU SEE THEM. If Dr. Chandler is not there then just grab any
attending. It looks very bad if a patient was seen in pre-op clinic and then gets cancelled the day of surgery for
insufficient workup or because they are not medically optimized for surgery.
SICU Rotation
JAY HACKING, MD; JAMES SEDERBERG, MD; MATTHEW MALONEY, MD, BETHANY BENISH, MD, SARENA TENG,
MD
Important People:
Anesthesia Attendings: Breandan Sullivan, MD; Jason Brainard, MD; Fareed Azam, MD; Paul
Wischmeyer, MD; Pierre Moine, MD, Ben Scott, MD. Various other medicine and surgical attendings also
rotate through the SICU.
SICU Resident Phone: 85916
Schedule and Call:
 Call- come in and round, stay all day and overnight. That day the call person’s job is to get the other
resident home as quickly after rounds as possible.
 Post call- after rounding, your fellow resident should get you out of there ASAP (DO NOT VIOLATE
WORK HRS—if you are nearing 28hrs, let your attending know so they can get you out!!!!)
 Short day- this is the day the other resident is on call, and you should leave quickly after rounds.
 Long day- This is the other resident is post call day so you get them out ASAP, and stay until admissions
come out of the OR. Usually 5 PM or so but it is variable.
 This rotation can approach 70-80hrs a week, therefore, make the effort to get the non-call resident out
ASAP after morning rounds.
 You don’t come in on the weekends except the days you’re on call.
Daily Work Flow:
 Pre-Rounds: Arrive around 6 AM or earlier depending on the census. Since we are cross-covering CT
(more on that later), you must round with the CT team each morning at 6:30. First, talk to the resident on
call to see if anything 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. Next review patient data (labs, I/Os) in EPIC, start the daily progress
note (see EPIC instructions below) and write any urgent orders (transfuse, replace ‘lytes, etc…).
 If time permits, write/review orders for the next day’s labs, films, etc. (the surgical team may have already
done daily AM lab orders so just confirm this)
 Make sure everyone is seen by the time rounds start.
 Rounds: CT rounds start at 6:30 AM (8am weekends) at the CT lowest numbered patient’s room. SICU
rounds usually start at 8 AM (9 AM on Mondays). Meet in the PACS viewing room on the west side of the
SICU to look over CXRs. 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. Once rounds finish, get the postcall/short resident out and the remaining resident does any work that still needs to be done.
 Presentations: Most Attgs (esp CT) prefer system-based presentation. Start with Name, POD# s/p surgery.
Followed by significant 24hr events. Then jump to Assessment/Plan by system (Neuro-including
sedation/pain, CV, Pulm, Renal, ID, FEN. Finish with review of invasive lines and dispo.
 Rest of the day: Check the OR board for expected ICU admits and if time permits read about them briefly.
 Check the Code/Airway Tackle box every day to make sure that it is stocked with appropriate drugs
(sux/etomidate), ETTs, LMAs, and an eschmann bougie.
 You will carry the code pager/badge & elevator key when you’re on call, and usually during the day (key
can be used for tower elevators on West end of hospital to get to codes quickly)
New admits:
 When a Pt is admitted to SICU, the primary team writes the admit orders. They also should talk to you
either in person or over the phone to give you report (reason for admit, OR events, plans). Then 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…). Do a SICU 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.
CT ICU (See below for full rotation information):
 Cross-Cover: We cross-cover on the CT patients while on-call overnight. Round with the CT service
everyday so that you are familiar with the patients & the daily concerns. 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. They do not
like to be surprised in the AM.
EPIC for SICU:
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”
1. From the “patient summary” button use the wrench function to add parameters to your toolbar.
a. ip comprehensive flow sheet
b. ip pain management
c. ip microbiology
d. ip vitals last day
e. ip mar
2. Add order sets to your favorite list by right clicking on “order sets” Useful ones are:
a. Adult insulin infusion
b. Sedation management for Mechanically ventilated patient
c. Blood administration
d. Heparin Continuous Infusion
e. SQ insulin: Glargine and Lispro for PO, NPO and Bolus Tube Feeds
f. IV PCA
g. Enteral tube feeds
3. To get to the SICU Patient listsPatient lists at topShared Patient listsSICU… 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 SICU list as they are admitted and discharged.
(Remember to also add the patient to the SICU Sign-Out Report)
4. To add templates for SICU notes:
EPIC-ToolsSmartphase Managerchange USER to Anesthesia, Resident, click GO. This will
automatically import SICU progress note, SICU accept note, SICU 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 myphases” (.my?) to
the left of the green plus sign (little dude in purple shirt). Pick SICU progress note (or SICU 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.
SICU Pearls:
1. Never transfuse a transplant patient without talking to their team first.
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.
3. Talk to the nurses about what they might need BEFORE you lay down, if you get the chance.
4. There is ALWAYS an in-house intensivist (MICU) to call if you need help with a line or if there
are any questions.
5. Call CT fellow with any questions, but gather information about hemodynamics and ins/outs first,
get specific numbers from nurse (i.e. chest tube 2 put out 100 in the last hour etc.).
6. When extubating, get ABG on CPAP, weaning parameters, and then text page the attending with
your plan and give them a way to call back if they have questions. Then wait a few minutes and
extubate.
7. Ask for help if you need it, from nurses, CT residents, other anesthesia residents or
attendings.
Door Codes:
Call Room 0158
Store/Pyxis Room 642
Storage Room (Site Rite ultrasound for line placement) 2229
CTICU ROTATION
SARENA TENG, MD
Important People:
Cardiac Attendings: David Fullerton, MD; Joseph Cleveland, MD; Brett Reece, MD
Thoracic Attendings: John Mitchell, MD; Michael Weyant, MD
CT Fellows: Ashok Babu, MD; Sagar Dahmle, MD, Elizabeth Marshall, MD
CT Nurse Practitioner: Jennye Colantoni, NP
The CT ICU rotation works a bit differently from the SICU rotation, though a lot of the EPIC stuff is
similar to the SICU rotation. You are rounding on the patients with a surgical R2 and the surgical
attendings, fellows and the NP. Occasionally, the SICU anesthesiology attending will round with the CT
team. The SICU residents also round with the CT team because they will be cross-covering on call. CT
rounds are BRIEF and typically take 2- 5 minutes per patient!
Daily Work Flow:
 Pre-Rounds: Arrive around 5 AM or earlier depending on the census. You round at 6:30AM SHARP! You
will usually split the cardiac and thoracic patients with the surgery R2.
o There is a CT SICU 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.
 First, talk to the resident on call to see if anything 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. Next review patient data (labs, I/Os)
in EPIC, start the daily progress note (see EPIC instructions above) and write any urgent orders (transfuse,
replace ‘lytes, etc…).
 Make sure everyone is seen by the time rounds start.
 Rounds: CT rounds start at 6:30 AM (8am wkends) at the CT lowest numbered patient’s room. CT Rounds
are BRIEF.
o 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, 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. Jennye, the NP will
typically write admit orders for patients coming out of the OR during the week, but you should know which
order sets to have on your favorites list because you will be responsible for writing orders on the weekends.
These can be added by typing in the name of the order set and right-clicking “add to favorites.”
Helpful order sets:
Adult Central Line Flushing Protocol
Adult IV Insulin Infusion
Blood Administration: Inpatient and Emergency Department
Cardiac ICU Transfer to IMCU / Floor
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
Enteral Tube Feeding
General Thoracic Post-Op
Heparin Continuous Infusion
ICU Electrolyte Replacement Guideline
Interventional Radiology Pre-Procedure Orders
Intrathecal Morphine Injection (Non OB)
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
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Jennye can also be a very helpful resource and knows the system quite well. She can also help you pull
lines and drains if the unit is busy and you are dealing with a sick patient.
On CT we typically don’t have the luxury of leaving early as consistently as when on the SICU rotation.
However, if you establish with the surgical resident at the beginning of the month that you will try to get
them out early on their pre and post call days and that you are going to try to do the same on your pre
and post call days, it seems to work well. They may not leave early on their pre-call days, but at least
they know what your plans are. You and the other CT resident will take turns staying late until the CT
patients are out of the OR, usually around 5pm.
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.
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 thoracic conference across the street in the Academic Office 1 in the 6th floor
surgical boardroom at 6:30AM. You will do sit-rounds with the team, then return to the ICU after and
start working.
 On Fridays, at 6:30AM there is the anesthesia CT conference in the 1st floor of the critical care wing
room CCW1.2317
New admits:
 When a patient is admitted to the CT ICU 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 SICU 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, if Jennye hasn’t done so already.
 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.
WEEKENDS:
 We are Q5 call in the ICU. Rounds start at 8AM on the weekends. On any given weekend day, there is
an anesthesia resident and a surgical resident. An oncoming surgical resident will always follow our
calls. They pull their CT floor resident into the call pool so that this consistently happens. This also
means that the surgical resident also has to cover the floor patients on the weekends, which occasionally
comes up in conversation when splitting the patients on the weekends. Since you and the surgical
resident cover both the SICU and the CT ICU patients on the weekend, you split ALL the ICU patients
evenly. This is especially important when there are 3 CT patients and 15 SICU patients or vice versa.
Splitting the patients by service usually leaves one or the other resident with way too many ICU patients
to cover.
Cardiothoracic Service
PRAIRIE ROBINSON, MD; SARA S. CHENG, MD, PHD; GREG WOLFF, MD; JIM RYAN, MD
The cardiothoracic month is pretty tiring but you sure learn a lot! There is always a lot going on around you in
the heart room and a lot of people can be in your way; however, always keep in mind that your most important
role is to always take care of the patient and pay attention to the surgery. Your attending and fellow might be in
the room reviewing the TEE images, talking to the surgeon, etc., but it is your responsibility to respond to
changes in the patient’s condition and vital signs. This includes when you’re putting in lines.
Before you start: (highly recommended to reduce start-up pain)
 Get handouts and the book "Cardiac Anesthesia" from the Anesthesia library.
 Get a 15 minute lowdown from Russ Ingram (head anesthesia tech) on the Swan box.
 Get a tour of the heart room set-up from a resident who's done CT.
 Read cardiopulmonary physiology and anesthesia chapters in Morgan and Mikhail
 Look over the website written by Dr. Seres:
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/Anesthesiology/Education/fellows
hips/cardiacfellowship/Pages/syllabus.aspx. There are a couple of things that need updating (i.e. aprotinin is
no longer used), but otherwise it's very good and exactly the way he wants things.
 Read part of Cardiac Anesthesia (Hensley/Martin/Gravlee: NOTE THE LAST AUTHOR). The one part I
think is really useful beforehand is the 1 page section in the Chapter "Anesthetic Management during CPB"
entitled "The CPB Sequence," so you know what the heck they are doing over there.
Heart Room set-up checklist:
(I kept this exact list on a little card in my pocket and never got caught missing something big even if it was
emergent and everyone was going crazy.)
 Equipment: ETT (#8,9), Alaris pumps x 2, Level 1 primed with Plasmalyte, pacing box (batteries
working?), oximetric swan box, TEE machine/probe, BIS, triple transducer, aline supplies (be prepared
to start aline in pre-op), 2nd IV supplies, cordis, swan, ultrasound, ABG syringes (heparinized), ACT
syringes (not heparinized)
 Drips: Normal saline 500mL bag (this will be your carrier; you will add Amicar to this bag after heparin
administration – if not on shortage), epinephrine (pharmacy will make for you during day M-F;
otherwise 4 mg into a 250mL bag equals 16 mcg/ml, start at 0.01 mcg/kg/min), vasopressin (pharmacy
will make, start at 0.1 units/min), nitroglycerin (don’t spike bottle, but have handy; start at 0.1
mcg/kg/min), insulin drip (if diabetic).
 Drugs: FastTrack box and Heart Resuscitation box from Pyxis, fentanyl 3 x 20mL, midazolam 2 x
10mL, phenylephrine 5 x 10mL, ephedrine 10mL, epinephrine 2 x 10mL (16 mcg/ml pulled from drip
bag, or can double dilute glass vial in drawer to 10mcg/ml), nitroglycerin 2 x 10mL (1mL from bottle
diluted into 10 ml to make 20mcg/mL), atropine, glycopyrrolate, vecuronium, sux, etomidate, esmolol,
HEPARIN 2x30mL, protamine (do not draw up until nearing the end of bypass), calcium 1 gram,
lidocaine 2 x 10mL, magnesium 2 gm.
 Other stuff to check: is there blood in the fridge? (need it at start of case esp with redo- they might rip
the heart open during sternotomy- it has happened!)
Coronary Bypass Case Flow:
Following is an outline of cardiac case flow and things to think about during each period. The first couple of
times you do this, the attending will be with you and show you where/how to hook up some of this stuff.
 Pre-bypass: Patient should have one large bore IV to go to sleep with, place a-line, cardiac induction
(midazolam, fentanyl, etomidate, paralytic) place another large bore IV (14 or 16g), right sided IJ cordis,
float swan if indicated, place BIS, OG to remove gastric contents, bite guard for TEE, place the bar across
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the IV poles, label all of your IV lines both at the bag and on the table. Hook your drips to the VIP port of
the cordis. Tape down the cordis once the patient is completely positioned so that it is not being pulled on,
these have been pulled out during the case or during transport. The attending or CT fellow will place the
TEE. Set foley up so that you can easily monitor urine output. Titrate your anesthesia to a BP within 20% of
initial pressures. Send baseline ACT/ABG. Also send baseline labs if patient does not have recent labs on
file. The surgeon will give you the pacing wires- hook them up to the pacer box (right side is atrial pacer,
left side is ventricular pacer), the coronary sinus line will attach to the CVP port, flush this line.
Sternotomy: give fentanyl pre-sawing 10-20mL (check with attending), hold ventilation!! At aortic
cannulation, goal of MAP around 60, SBP 90-100. This is a good time to use the nitroglycerin you have
drawn up. Prior to going on bypass, dose heparin 300-400u/kg, perfusionist will tell you the dose. 3 minutes
later draw ACT, give to perfusionist. Usual goal is >400 (CT attending dependent). You may have to give
more and recheck an ACT. Bolus 5g of Amicar after the heparin, prior to bypass initiation. Put the other 10g
of Amicar in your 500cc NS carrier and run at 100mL/hr (2g/hr). Empty the foley prior to bypass and note
the amount. Chart cross clamp and bypass times or ask perfusionist if you miss it. You may need to re-dose
your paralytic, narcotics, midazolam right at or right after bypass initiation.
Bypass: Stop ventilating when pump flows adequate, turn off inhalational and O2, re-dose paralytic,
narcotics, midazolam if you haven’t already. Labs are drawn by perfusionist, follow the hct, glucose, lytes
and treat as needed. They will transfuse blood. Start/stop drips as needed, goal MAP >40. Turn your
machine to CPB mode. Follow UOP, tell perfusionist if less than 100cc/hr. TEE on standby, no warm fluids
running.
Ending Bypass: Patient will be re-warmed, turn all monitors/alarms on, re-dose paralytic (check twitches
first!), versed if needed, when surgeon requests- give lidocaine 100mg and magnesium 2g, note when cross
clamp is removed, depending on the rhythm may have to pace, may need more lido or Mg or drips started.
Give Ca 1g when requested by surgeon-usually about 20min after cross clamp is off and the heart is beating
well. Re-expand lungs, watch the lungs come up, make sure there is no tension on the LIMA graft, turn on
vent, and send PT/PTT/CBC/Lytes to lab. Continue to follow ABG. Protamine dose will be given to you by
the perfusionist, when asked- give test dose, then give slowly through peripheral IV, tell surgeon when
half of the dose is in. After protamine is given draw ACT 3min later. Also, send TEG with and without
heparinase. Note off bypass time. Empty urine when off bypass and tell perfusionist total on bypass UOP.
Post-bypass: Follow coags/bleeding status and transfuse products as indicated. Repeat TEE exam. Remove
TEE, clean up your lines, disconnect PIVs for transport, remove BIS, empty foley, place dressing on cordis,
patient remains intubated, to SICU. Take drugs with you- phenylephrine, epi, ephedrine, atropine, paralytic,
narcotics, esmolol, NTG.
St Joes:
If you are assigned to St Joes, you should call the main desk (303-837-7640) the night before after 5pm to find
out the case time and attending. Page/call your attending the night before. This is very important because some
attendings do not work with residents. Most attendings will try to arrive a little earlier, if they know you are
coming, to help give you some direction. In the morning, you will go see the patient in pre-op and start the Aline. The circulating nurse brings the patient back to the OR. Help get the patient onto the table (the nurse will
put monitors on). You will help with induction and intubation. After the patient is asleep, turn your focus to
the TEE machine, as the surgery team will put in the necessary lines. The case will run the same as at
University, except much more quickly.
VA:
If you are assigned to the VA (which is rare as the CA-3 at the VA will usually do the heart cases there), arrive
early to set up. The main difference with running cases here is the different equipment. The pumps are from
the stone-age and are a pain to set up. If you are lucky, one of the techs over there can help you on your first try.
One more thing:
Teamwork is key on this service. There are 4 residents on service who are kind of a self-contained group (which
many times turns out to be 3 residents since a lot of people take vacation on their CT month). On any given day
you might be spread over 3 sites: UCH, VA, and St. Joe's. So helping each other out by calling around when
you're done with your cases, doing the pre-ops for the next day at your site so that your friend doesn't have to
come over from across town just to do it, relieving the higher numbered call people, keeping clearly labeled
stashes of drugs in the fridge for each other- all this stuff helps a lot and can keep you from being totally
miserable.
Attending Preferences:
Dr. Gravlee
Likes to be called for going on pump, coming off pump, ICU transport, and ANYTIME blood/FFP/Platelets are
given, call if in doubt
Likes pre-induction A Line, and big IVs
Put protamine in 100 cc bag and slowly drip in (this is a cool trick that frees your hands)
Do your Faust reading (or other daily ITE keyword, since we may be moving away from FAUST)
Likes to use morphine if possible
Likes the mask straps to be on the head donut.
Dr. Puskas
Likes pre-induction Aline usually
Put in TEE probe before central line placement and always use full body drape for central line
Think about double lumen cordis if redo/chance for lots of bleeding and poor IV access
Dr. Nasrallah
Doesn’t like ultrasound for line placement
Never use BIS
Don’t give phenylephrine if pulmonary HTN
Dr. Seres
Etomidate induction, will often use C-MAC
Have neo and glyco ready and give freely to keep SBP > 100, HR > 50, consider phenylephrine gtt esp if
CABG and it will be a long time to going on pump
Have a clear induction plan when you call to tell him about the patient
Likes to have at least one 16 g IV peripheral
Don’t use stylet in ETT if you think easy intubation
Always use BIS and always keep at least one twitch
Consider ketamine/dilaudid if really going to fast track
Put TEE probe in before central line placement and always use ultrasound for line placement
Dr. Weitzel
Usually has fellow induce while resident does art line
Induction with versed/fentanyl/sevo/muscle relaxant
Only put in 14 gauge peripheral IVs
Dr. Sullivan
Aline before induction all CT cases. Doesn’t care about a 2nd PIV
Defib pads on for all redos, Mitral Stenosis, VADs, Heart Transplants
No Etomidate for induction. Consider having a vial of Propofol available in the OR
Know medical co-morbidities - echo reports, cath lab results, etc. (goes without saying)
If pt has pacemaker have a plan (phone calls made the night before to EP or arrangement to deal with defib)
No BIS unless doing TIVA
Levophed infusion available for all CT cases, Nicardipine infusion available (don’t have to make it up)
Phenylephrine infusion started in the room for all Aortic Stenosis cases prior to induction
No paralysis after induction (“if the patient breathes or moves put them to sleep” – Dr. Sullivan)
Acute Pain Service (APS)
PRAIRIE ROBINSON, MD; ESTEE PIEHL, MD; KELLIE HANCOCK, MD; JESSICA YANOSIK, MD ANDREA ZATLIN,
MD
Important people:
Director, Acute Pain Service: Dr. Matt Fiegel
APS advanced practice nurses: Robert Montgomery and Lynn Hornick
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 also be managing patients with epidurals
and nerve block catheters on the floor. 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!
Before you start:
The main focus of this rotation is the placement and management of thoracic epidurals and lower extremity
blocks. Upper extremity blocks are rare on APS, but you will do them. Cater your initial reading to local
anesthetics, lower extremity blocks, and neuraxial anesthesia. As always, try to invest some time in getting an
orientation tour from the previous resident. It is helpful to familiarize yourself with the block cart, basic set-up
for a nerve block, and paperwork prior to starting.
Resources:
At the beginning of the rotation, you will get a notebook that has your reading schedule for the month and
several informative articles. Books that are referenced are available to you at your desk in the pre-op area.
There are also guides on epidural and spinal dosing of narcotics and local anesthetics that you will use daily.
Useful adjunctive websites are: www.nysora.com and www.usra.ca. Both websites include detailed directions,
pictures, and videos on how to do the different blocks. Dr. Fiegel is another important resource, especially when
it comes to ultrasound-guided blocks.
Daily Workflow:
For the first several days, Rob and Lynn (the advanced practice nurses on the service) will be around a lot to
show you how to write notes and orders on EPIC, help with set-up, and talk about acute pain management. You
will find that Rob and Lynn are extremely helpful and knowledgeable. If you have questions and your attending
is not available, they will usually have the answer. They have loads of experience in pain management, so don’t
forget to use them as a resource. They are also often available by pager if you have questions over your first call
weekend (they will volunteer this information if they want to make themselves available). Their pager numbers
are listed on the APS census sheet. They will round daily on APS patients, Rob on M/T/F, Lynn on W/Th.
As in everything, your days are often attending dependent. You are expected to look at the OR schedule when it
comes out (usually around noon each day) with the pain attending or a pain nurse. Mark "block" next to each
patient that is a likely candidate for a block or epidural. Note the number of first case blocks. If there are
multiple procedures, the regional nerve blocks are your priority. (The order of priority is lower extremity block,
upper extremity block, thoracic epidural, and finally lumbar epidural.) If you are unable to do all of the
blocks/epidurals, you should touch base with the anesthesia resident that will be doing the case to make sure
they are planning on doing the block/epidural. When others do place blocks for their patients, be sure to ask
about the specifics of their placement, i.e. epidural catheter loss of resistance and distance at the skin. You'll
need this for our APS list and for rounding. If you are working with Dr. Fiegel, you will be able to do multiple
first case blocks, because he helps with the consent and set-up.
The residents on the CT and Transplant services are now expected to do the epidurals for their patients so you
are no longer responsible for these. It is helpful, however, to touch base with the residents on these services to
make sure that someone is prepared to put the epidural in.
In addition to all this, I recommend making a "block grid" with blocks in the order of which you will perform
them in the morning. This will help you stay organized and prevent you from potentially delaying rooms.
Moreover, you can use this as a check-box system to make sure you have placed all your notes/orders (you can
do upwards of 15 blocks on busy days!) Columns I would include on your grid: Patient name, procedure/block
(including information on loss of resistance, catheter placement for epidurals), sedation/meds (documented in
EPIC), block note, post-op orders, APS list, EPIC list (you need to place patients on each list so you remember
to round on them the following day, see below for instructions).
AM Set-up: BLOCKS
It is helpful, especially on busy days, to have syringes ready to use. Prepare the day before by having a bag of
premade 20cc syringes, because you will go through them quickly. A total knee uses 4-20cc syringes, and
bilateral knees use 8-20cc syringes (or a lumbar epidural), so you can go through your bag quickly. It is also
helpful to have premade syringes ready to draw up fentanyl and versed as well (at least 2mg versed, 100mcg
fentanyl). When you arrive (usually around 6-6:30 depending on work load), you can draw up your local
anesthetic for your first few cases. See anesthesia attending preference below for the local anesthetic of choice.
To make a 1:400,000 epi concentration (which you will use for most blocks), add 0.07ml (yes, less than 0.1cc)
epi with the TB syringe to a 30ml vial.
Epidurals: Helpful info
 Refer to the block card you are given at the beginning of the rotation for helpful hints on epidural
dosing. The handbook also has a helpful guide for troubleshooting epidurals!
 Materials needed: Epidural kit, tegaderm, loss of resistance tubing, gloves, saline flushes, tape, statlock
 Typically patients can have their epidural for a max of 6 days. If they epidural does not work, it's almost
always okay to put them on a PCA to achieve more satisfactory pain control.
 Read up on the ASRA guidelines regarding anticoagulants and placement/removal of epidurals. If you
aren't sure, ask or read up on it before manipulating your epidural catheters.
 Check an INR on anyone that has been on coumadin recently PRIOR to performing the block. We do
not place these in people with an INR.1.5.
Intrathecal narcotics: most commonly used in GYN/ONC surgeries
 IT duramorph is the narcotic most typically used for these blocks.
 As with epidurals, check the coag status of these patients prior to blocking them.
 We typically follow these patients until POD#1, 24 hours after they received their duramorph
Pre-procedure workup:
In the morning, see your patient and do a targeted H&P. You are NOT expected to do the full pre-op H&P in
EPIC, but you need enough information to do a safe regional anesthetic. I would recommend looking up most
of this information the night before to save yourself time. Major things to assess:
 Surgical site—where is the incision?
 Cardiopulmonary status.
 Allergies.
 Is the patient on any medications that affect coagulation or does the patient have any existing
diseases that might affect coagulation status (i.e. liver disease)? Is there any reason to order
coags? Make sure you know your patient’s platelet count!
 Any history of pre-existing neuropathy?
 Any previous history of regional anesthesia?


Is there unusual anatomy that might make regional anesthetic difficult or unsafe (i.e. it may be
difficult to place an epidural in a patient with multiple back surgeries)?
Assess preop labs that are available, including coags and bmp
Obtain consent for your regional technique plus the surgical anesthetic. Ask your attending for the appropriate
facts to convey to the patient regarding risks. Things that should always be covered—risk of bleeding, infection,
nerve injury, new or worse pain, reaction to local anesthetic. For total joints, Dr. Fiegel likes you to order preop
lyrica (150mg for pts <70yo, 75mg >70), celebrex (200mg; consider holding for Cr >1.5), and oxycontin (10mg
pts <70 yo, 5mg >70). Obviously use your judgment if you feel any of these medications are not safe or
indicated. It's helpful to order these the evening before to save yourself time and an added responsibility in the
morning!
Procedures:
The patient needs to have monitors on prior to starting the procedure, including pulse ox, EKG, BP, and
supplemental O2 if you're planning to give versed/fentanyl. The pre-op nurse needs to be present and a time-out
done. Do not give sedation unless ALL consents are done. Get your block entirely set up before calling your
attending. For the first 2 weeks, Dr. Fiegel will ask you to perform blocks using the nerve stimulator,
ultrasound the last 2 weeks. After the block, make sure to assess and record vitals. Don't forget to document
sedation meds on the intraop record. You also need to place a block/epidural note (see below) for each patient
as well as place post-op or intraop orders (such as local and narcotics for epidurals). It will take a few days to
learn which pharmacy orders and post-op orders are needed for which type of block. Remember, Dr. Fiegel,
Rob and Lynn can always help you with this.
Orders:
 Pre-op orders: use the "pre-op order set" under the "orders" tab on EPIC to place any preop meds.
Meds for total joints mentioned above can also be found here.
 Epidurals: There are preset PCEA orders that also include PCA orders (search order sets for "PCEA").
I recommend ordering plenty of prns (including fentanyl, benadryl, ativan) when appropriate for the
patient to avoid calls later.
o Also remember to order local anesthetic and preservative free hydromorphone for intraop use on
these patients. Order set is titled
 IT narcotics: there is a preset order set titled "IT duramorph non-OB"- use this! Typically these patients
are also placed on a PCA for additional post-op pain control
 Peripheral blocks: Each joint patient should also be placed on the "post-op joint protocol" (specific
order set) for after surgery, which typically includes celebrex, acetaminophen, oxycontin and oxycodone
as well as options for toradol, percocet prn in the PACU. There are specific doses of oxycodone for
those >70, and it's typical to avoid oxycontin in this case (unless they have chronic pain, etc.)
o If that patient takes narcotics at home, we typically place them back on their home regimen
POD#1 if taking PO
o Use the "continuous nerve block infusion and single shot nerve block" order set. Most joints
also receive a dilaudid PCA (no bolus, no basal, demand usually 0.2-0.4 with an 8 min lockout),
which will automatically be discontinued POD#1 unless you specify otherwise. This is
contained on the total joint protocol order set. Nerve catheters: typically order ropivicaine 0.1%
infusion at ~7ml/hr
Consults:
 The APS is often consulted to manage post-operative pain, especially in patients with known chronic pain
issues. Rob and Lynn may do the consult but if you end up doing it, they will help you come up with a plan.
 Once you have a plan, see the patient with either Rob and Lynn and your Attending.
 If called with a pain consult after you have left the hospital, you can make recommendations over the phone,
but remember to place a formal note with Lynn/Rob in the morning.
Call/Weekends:
 Call nights can be busy, especially if you are managing multiple epidurals. The handbook that you receive
at the beginning of the rotation is excellent in helping you trouble shoot as well as the epidural pocket card.
Don’t forget that there are other anesthesia people available in the hospital to help if you have questions (the
C1 resident and attending, SICU, and OB residents) or an epidural needs to be placed! Each of them will be
carrying their respective Cisco phone (you will also have one with everyone's contact info).
 For weekend call, remember that you do not have to see a consult for 24 hours but always offer some
recommendations until you can see the consult. You need to round on and place notes for every patient on
the service, every day of the weekend and check your plan out with the C1 attending.
Rounding:
 Rob and Lynn would like you to round with them when you can (but remember that your first priority is to
get experience with blocks). Rob rounds once a day and Lynn rounds twice a day.
 On rounds, they expect you to take the lead in examining your post op block patients and writing their notes.
They will help with all other notes and orders. The attendings rarely participate in rounds.
 You are not expected to round if you have blocks!
 How long do we follow these people?
o Epidurals: 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.
Place an order to hold a given dose of heparin/etc. to help your efficiency. 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 the "tip was intact". Moreover, always discuss your
plans with the surgical team before pulling your epidural (especially CT)!!
o IT duramorph: 24 hrs post-block. primary team can manage PCA from that point on.
o Peripheral blocks: POD#1 if single-shot block performed. POD#2 if catheter placed for TKA.
Attendings:
 Dr. Fiegel - goes out of his way to help you, and does a lot of teaching. He will help you keep up with the
paperwork and procedure notes and will help you get set up and get consent.
 He usually prefers 30cc 0.5% bupivicaine or 0.5% ropivacaine for the femoral and lumbar plexus. He
prefers 30 cc 0.25% bupivacaine or 0.25% ropivacaine for the sciatic block. He likes you to also use epi for
blocks you are performing without ultrasound (i.e. lumbar plexus blocks). Dr. Fiegel is very liberal with
sedation and often uses up to 5 cc of fentanyl, so you will probably want to check out 4 of versed and 5 of
fentanyl when working with him. He will want you to work on doing the blocks with nerve stimulation and
will move on to ultrasound once you are comfortable with stimulation techniques (usually week 3).
 Dr. Hendrickse, Dr. Brainard, Dr. Shindell – These attending are flexible. They usually don’t have strong
opinions on the local anesthetic used. Dr. Shindell does like the paramedian, hanging drop technique for
epidurals- it's pretty sweet. Read up on it before you do this with her.
 Dr. Lace- he likes for you to anesthetize the block site with local. Give it time to set in before attempting
the block, including for epidurals!
 Ortho attending preferences for blocks:
Eckhoff: No preferences
Dayton: No preferences
D'Ambrosia and Hogan: No sciatic blocks for their TKAs
Lindeque: No sciatic block for TKAs. Ask about any upper extremity block and blocks for tibial
surgery.
Stoneback: Ask for pretty much every case.
Tips on Meds:
It’s important to remember that you will be checking out a lot of narcotics for multiple patients in rapid
sequence or at the same time. You have to turn in empty bags with the patient’s name even if you give all of
your drugs, so make sure you put a patient sticker on a pharmacy bag when you take out a controlled substance
from Pyxis. It can be a couple hours between when you give the med and when you do the procedure note, so
it’s easy to forget what you gave to which patient on a busy day. Pick a system that will help you keep track.
You can write on the OR schedule what meds were checked out and given for each patient. Alternatively, you
can record it on each individual bag as you go.
Another word about meds: You will often have multiple blocks in rapid sequence, especially on Mon, Tues and
Fri. On those days, you will need to draw up several doses of local for blocks prior to the start of the day. You
need to get all these vials out of the Pyxis without overcharging someone at the beginning of the day. The
easiest way to do this is to charge one vial of local (i.e. ropivicaine) to the first patient, but when the door opens
take out 4-5 vials and draw these up into syringes. Then, charge the vials to each individual patient as you go
along during the day when you take out narcotics. That way you charge everyone for the appropriate drugs but
can still be ready to go before the first patient.
Charting/Documentation:
Each day, it is your responsibility to place each patient on both the APS and EPIC lists:
 APS 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.
 Ex: T8-9, PCEA B0.1 H7 8/4/15 (bupivicaine 0.1%, hydromorphone 7, basal 8ml,
demand 4ml, 15 min lockout)
 EPIC list: find "patient lists" tab on the top of the EPIC screen. Find "shared patient list" on the L hand
side and click the "+" sign. APS should pop up. To find your patient, find the "units" tab below the
shared patient list tab and click the "+"- your patient should be under preop or OR. Drag and drop into
the APS shared list folder.
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- Dr. Fiegel will help you with this your first day.
Chronic Pain Service
SARA CHENG, MD, PHD; ESTEE PIEHL, MD; ANDREW SULLIVAN, MD
Important people:
Rotation director and Director of University of Colorado Hospital Pain Clinic: Jason Krutsch, MD
VA attendings: Mohammed Javed, MD (VA), Peter Rowe, MD (VA)
Phone numbers:
Chronic pain pager: 303-266-7291
University Clinic phone: 720-848-1970
Before you start:
Try to come into clinic to learn about the EPIC pain clinic environment as it is different than the OR
environment. All clinic notes are created using this software. If you cannot get going on your first day, you
will have to stay very late to finish all those notes.
Schedule:
Dr. Krutsch is the director of the rotation. He is a great teacher, lots of fun, and will give you free advice on
spiffy dressing and progressive/house/trance musical trends. He decides at the beginning of each week which
days you will be at the University and which days you will go to the VA. Email him the week before you start
your rotation to ask where you should show up on the first day. The two residents on the rotation and the
chronic pain fellow will take turns carrying the chronic pain pager for overnight and weekend call. The fellow
usually makes this schedule and will arrange this with you prior to the start of the rotation. For one weekend,
you will take acute pain service call and have to come in to round on all the APS inpatients.
Daily Work Flow:
 Learning how to blow it up with Dr. Krutsch is key. He’ll show you how.
 Clinic hours are 0730 to about 1630. They vary every day. Dr. Krutsch will send you an email the night
before to tell you when to come in.
 Check-in: After patients check-in at the front desk, they are then are brought back to an exam room by the
nurse for clinical visit note. The staff will bring you the paperwork or place it in the file holder in the
provider back office. The nurse will print you the assessment sheet with the room number on the back.
New patients fill out a health history form on their first day, which helps you with their assessment. You
will then see the patient and report your assessment to the attending. Procedures: If the staff is aware of
the procedure to be done, insurance authorization and teaching will be completed in advance. Only
procedures that have been preauthorized are performed. Notify a nurse when you have completed the
consent and are ready to go to the procedure room. The nurse will take the patient back. This gives you time
to set up your meds and review the procedure. Reminder: Consents must be dated and times filled in by
both the provider and the patient.
 Sedation: The nurse will sedate the patients as ordered. They will want to know about the order as soon as
possible. Please allow 15-30 minutes to give a PO valium or to start an IV. If you are administering a
sedative, please inform the nurse. Orders must also be written and signed by the provider. The nurses will
work with you on these forms. Afterwards the patient will be recovered and monitored according to the
amount of sedation received.
 Check-out: When a patient is ready to be discharged, a gold Return Appointment Scheduling form is
required. This is used to allow the front desk staff to schedule the patient’s next visit, please fill it out
completely. RPV= return visit, FLU= procedure that requires fluoroscopy. PRO- Procedure but no Fluoro
required. Future sedation needs are marked, if it will be needed.
 Notes: After seeing the patient and discussing the diagnosis, workup and plan with Dr. Krutsch, you will
type your note into EPIC. Every note needs to have several elements for billing and Dr. Krutsch will make


sure that you have completed these. Notes, as you will see, are a time-consuming, bone-crushing reason
why most of us will never, ever be clinic physicians. So, a few pointers: Type the HPI and ROS while in
the room with the patient. Then type the PE and Plan after discussion with Dr. Krutsch. There are a few
required elements in the notes, and there are two templates “pain consult” for new patients and “pain
procedure” for…procedures. There is a copy forward function that is quite useful for the frequent fliers. The
fellow should help you with all of this.
Spinal Cord Stimulators: If a stimulator is going to be considered, give the patient a video and booklet to
review. These can be found in the metal cabinet in the physician’s room. The patient will need a
psychological consult with a MMPI. Ask the patient to make an appointment to come back for a preop visit
after the psych eval is done. When the patient comes back for the preop visit, they will arrange the surgical
dates and postop appointments at that time. You will need to fill out the preop surgery packet, found in the
nurse station.
If a patient has a pump or implanted SCS, the nurse or attending can show you how to interrogate them.
After reprogramming, a printout is made for the patient, the nurse and one to be scanned into the computer.
However, Dr. Krutsch usually does the reprogramming without us as their learning benefit to us is
negligible.
VA Pain Clinic tips:
 Hours are from 0730 to about 1600, usually. You will need your badge and working computer codes to
write your notes. Make sure that you contact Carrie (contact info in VA section) if you haven’t been there in
a while to make sure everything still works. Don’t forget your parking hang tag (also, remember this
expires, so check it out)
 The VA clinic is awesome in that it is entirely procedure based- you will be doing only new patient
evaluations and blocks. No pain medicine management at all- that is done by the PCP. The pace is slower
than at the U, so you won’t be running around like a chicken with its head cut off. The attendings will show
you what CPRS templates are useful to use. They will also show you the set-up and the location of meds in
the block room, how to consent the patients on the computer, etc. If you do a good job, you can end up
doing all of the blocks with attending supervision, since the fellow is not there if you are. Sometimes you
might get to do some OR procedures with Dr. Rowe- always an interesting experience to be on the other
side of the drape for us- try not to yell at anesthesia, ‘kay? (e.g. What’s the hold up? Where’s my patient?)
All in all, this rotation is quite a lot of fun and good learning. Enjoy not having to wake up at 5am and go stomp
out some chronic pain.
Children’s Hospital Colorado
GILLIAN JOHNSON, MBBCHIR; CRISTINA WOOD, MD; JOEL WILSON, MD, ALLISON LOSEY, MD
Important people:
Program Coordinator: Morris Dressler MD 74820
Administrative Assistant: Lindsay Johnson 76226
Codes:
Call Room: 8642 (inner and outer door)
Phone Numbers:
Main CHC Hospital: 720-777-1234
Anesthesia Charge: 720-777-8339
OR Charge Desk: 720-777-6492
On Day One:
You will be scheduled for orientation. This will include a morning of EPIC (computer medical record) training,
badge collection and parking information and access. 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) When you complete orientation please go to the OR and call the charge
phone to find out if you are needed. Often you may leave, but you are expected to ask. Please take this
opportunity to get a tour!!
General Info:
 Mail boxes are located behind the desk of Lindsay Johnson in the faculty office area (across bridge to admin
area and take first right). You will receive meal tickets etc. here.
 Attendings will sometimes run their own room, sometimes work one on one with residents and other times
have 2 residents to supervise. New to CHC: there are some anesthesia assistants (AAs) and some CRNAs.
Weekday Daily Work Flow:
 Do H&Ps on patients coming into the hospital as best you can using EPIC. Give yourself 30 minutes to setup your OR before any morning conferences (Mondays 7:00 then daily at 6:30 in the Pikes Peak conference
room on 2nd flr).
 All patient information is on electronic boards in pre-op, post-op and ORs. Check this board before you set
up anything!
 . Narcotics are located in omnicells in each OR like Denver Health. Specific to this hospital ephedrine is
considered a monitored substance. At the end of each case, the unused medications will be returned to the
bin on the right side of the omnicell. It is usually easiest to wait until you discuss with your attending what
specific narcotics they like to use. Otherwise, you may be returning a lot of drugs.
 Arrive in Pre-op around 7:00(8:00 on Mondays).
 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).
 Complete questions for pre-op H&P.
 Consent the patient/parents, nothing to sign but discussion must be had with the family.
 Remember to talk about who is coming back to the OR with the child. (Emergent cases or children under 12
months – NO parents back to OR; attending dependent). Tell the parents what they are likely to see as the
child goes to sleep. Toddlers may fight and it may be upsetting to parents. Most children will wriggle
during stage II, so let the parent know that after their eyes are closed and the child is asleep the body will
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move but they are NOT conscious. The parents do best when fully informed.
If doing an inhalation induction ask the child which smell he/she wants for her mask.
Versed premed is available as a PO order from you. Ask the parents how they think the child is doing with
the process and if they feel that some sedation would be helpful. Most parents will know, especially if this
kid is a frequent flyer. Premed requires 10-20min to be effective PO so it needs to be ordered as soon as
possible and discussed with the nurse directly.
If the child is a teen and almost adult size then you may chose IV induction vs. Inhalational. Discuss this
with patient and family and prepare child for either method.
Go back to the room and do a final check and put pre-op into EPIC 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)
Call your attending to tell them the nurse is coming back with the patient/has arrived with the patient.
Get patient up on the OR bed. Use your skills to keep the child engaged and happy while you pre-oxygenate
and give a little nitrous oxide. This is an odorless way of getting the induction started. NOTE – if the
patient is a small baby and is asleep then leave the pacifier in and induce before the baby wakes up. This is
a very slick way of a no fuss induction. Some kids do better if sat up when induction begins – wrap a warm
blanket around their shoulders and hug their arms to their sides as they drift off.
Once the child is asleep the circulator will take parents out of the room. Then 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 e.g. snake light to help you. Saphenous sticks are
common in babies and those getting caudals for urological procedures.
PACU orders are done in EPIC and should be complete before leaving the room for the PACU.
Many attendings like deep extubations. There are a few medical/attending specific exceptions.
Take sux/atropine, narcotics, propofol and the mask with you to the PACU, you will be a hit with the nurses
if you can quiet a “wild” child, so they can chart and get them on the monitor before the child is trying to get
out of bed and pull out their IV.
In PACU, handoff follows a specific flowchart that the nurses will have. There is nothing for you to fill out
or enter into EPIC, you just speak with the nurse. After it is complete, there is a handoff button that the
nurse must click.
OR schedule with anesthesia assignments comes out around 5pm. 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 attending the night before to discuss
plans. Attendings may not answer, but it is good to call if you have any questions regarding the plan.
Call Nights/Weekend Call:
 Weekday call NOON – 7am. I have never heard of anyone being called in early, but keep your pager on.
Attending also starts at 12pm.
 Saturday call is 3pm to 7am. You should plan to arrive around 2pm in order to receive handoff from the APS
nurse. Call the APS phone when you arrive.
 Call room: located on the 2nd floor, past the bridge and conference room and through the double doors. There
is a bank of call rooms found through a door on the right, labeled, code 8642. Our call room is labeled and
the code is 8642.
 Pain service phone: You will be paged by the pain service RN at about 5pm on call days. They will give you
sign out and a Spectralink phone. Now that the residents have their own phones, you may forward the APS
phone to yours so you don’t have to carry two phones and your pager. Ask plenty of questions especially
about the plan for problems overnight. Keep track of any patients added overnight/changes made. Give
report after conference in am.
 Morning after call: Pain phone and pain service sign-out to RN coming on. Code pager goes to the person
taking care of the PACU during the week and C1 on weekends.
 Pain nurse rounds all days. This did not used to be the case and is a HUGE benefit to us.
Codes: Your responsibility is the same as in all codes.
 Level One Trauma – MUST attend. Sign in when you arrive.
 Level Two Trauma – do NOT need to attend.
 Core – MUST attend.
 Airway Box – 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 on the units, so bring those with you if you know they
are needed. Frequently, you will secure the airway on your own, but do not hesitate to call the attending
if you are concerned about the airway or would like a second pair of hands. When called to the ER,
occasionally the ED fellow will ask to place the airway. Use your discretion and do what is best for the
safety of the patient.
Phones:
Attendings, fellows, AAs, CRNAs and nursing staff carry PCD phones for easy communication on campus.
They work like a regular hospital extension, so you only need to dial 5 numbers.
Call the PCD during the day to contact your attending (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 with all the attendings’ home phone numbers and pager
numbers for calling your attending the night before cases.
Helpful PCD numbersAnes Tech
73939
Anes in Charge
78339
Pain Service
75433
OR Front Desk
76492
Obstetrics (Labor and Delivery)
ESTEE PIEHL, MD, ALLISON LOSEY, MD, MATTHEW ROWAN, MD
Codes:
4th Floor Work Room: 11153; 5th Floor Work Room: 11153
All Med Rooms: 84111; Nutrition Rooms: 11153
Women’s Locker Room: 84111/ 23985
Men’s Locker Room: 6667/0404
Call Room: 0404
OR carts: 1+2 together then 3
Phone Numbers:
OB Charge Phone: 8-5973
OB Resident Phone: 8-5972
OB CRNA Phone: 8-5911
Scheduled Meetings:
7am T-F: Team Meeting/ OB sign-out (we go to Grand Rounds on Mondays)
5pm M-F: OB evening sign-out (try to make it if you can)
12:30pm on Tuesday: MFM Clinic Meeting
One Friday (or more) a month: Care Conference (you will be emailed a time)
Reading:
Dr. Hawkins will send you an email before your rotation starts with five 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. The reading list
books are located in the OB anesthesia work room, but no one checks to see if you are reading it. 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 7am – 7pm or vice
versa. Please try to arrive with enough time to get hand off from the on call resident before 7 so the resident can leave on
time (about 15 minutes early). The usual schedule is three days, then three nights then three days off. However, this is
changed around for any number of reasons and may be way more random than that. It is nice to arrive at 7am in the
morning, no doubt, but the schedule is not as nice as it sounds so beware the pitfalls:
 If this is your first OB month, CHECK YOUR SCHEDULE TO MAKE SURE YOUR FIRST 1-2 SHIFTS ARE
DAY SHIFTS. The chiefs work very hard to ensure this is the case but it is in your best interest to double-check.
Doing your first OB shift at night is hard because you will less supervision and teaching than during the day.
 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 get woken up
all 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. However, it can be downright rough on your fourth overnight. So, it goes without saying, the first day
of your three days off, you will probably sleep the whole day.
 You will be tired by the end of the month. Changing from days to nights and back is really hard on your sleep cycle.
So, do what you have to do to get some sleep on your off time: melatonin, Benadryl, Ambien, whatever. Granted,
your neighbors might look at you funny if you are drinking wine on your porch at 8am. So keep it in the closet! Just
kidding.
 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 6:30am and getting home around 8pm 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 actually like to teach and a good syllabus. The OB attendings are: Joy Hawkins,
Brenda Bucklin, Andi Fuller, Matt Fiegel, Marina Shindell, Estee Piehl. They all like to teach and will happily discuss
any OB topic that you pick for the day provided that there is time. They are usually on service during the days. That
is especially helpful in the first month when you have no idea what you are doing. Most of the attendings that cover
nights have no particular interest in OB so they let you run the show. They will come help with all C-sections, if
possible, but frequently will not come for epidurals in the middle of the night. However, if you have any problems 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!!! This, of course, makes any real anesthesiologist’s heart go pitter-pat-pat. The OB attendings
have worked very hard to make sure that we get called before the CRNAs for procedures (oh, yeah, BTW there is also
a CRNA in house 24-7) so that we can get experience. Again, tough in the middle of the night sometimes, but that is
what we are here for.
 We get every Saturday 7a-7p off. Entirely. As in no resident is in house. Cool, huh? The CRNAs cover the
Saturday day shift by themselves so we get it off. Baseball games in the summer, skiing in the winter – you can plan
it now!
 We are given a laminated “cookbook” card with drug dosing for most OB situations. It is VERY helpful, so make sure
you get one and put it in your pocket. (I don’t think they give these out anymore, might need to make it yourself, if
you want)
Pearls:
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ALWAYS CHECK YOUR ORs ASAP. By this I mean to check your 4th floor ORs when you come on shift or as
soon as you possibly can. This is especially important at night when there is a lot less help. The ORs should
always be set up for an emergent (Oh god mom and baby are going to die if we can’t get baby out now) 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 and make sure you have pitocin/hemabate/methergine available. (It is second year, you should have
some idea and you should also have one of the CRNAs walk you through what they have set up.)
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 isn’t available
or you don’t trust them because they only cover OB once every other month. 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.
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 and make up charting packets 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.
We use EPIC charting on the OB floors as well. It is best to login and open a case immediately when you get to
the patients room. There is a macro listed for OB epidurals, C/S, and General for C/S. This is really helpful.
When going to do 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 30min of vitals, unlink
the device. If you forget to unlink, the nurses will call you because they cannot do their charting. Billing requires
30min of vital signs, which also happens to be the time period when most unpleasant events happen following
epidural placement. You should remain in the room monitoring the patient for these 30 min. After placing an
epidural or performing a C/S add the patient to the shared OB patient list with any pertinent information regarding
the patient.
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
SARA CHENG, MD, PHD; AARON MURRAY, MD; ANDREW SULLIVAN, MD
The main focus of this month is doing liver transplants. You will also spend some time doing kidney, pancreas,
and rarely multi-visceral transplants as well. The liver recipients may have major derangements in multiple
organ systems, and the liver transplantations often involve major hemorrhage, coagulopathy, and hemodynamic
instability. These are big cases, but very satisfying. The teaching on this rotation is excellent, as your attending
will rarely leave the room for very long.
Important people:
Susan Mandell, MD- Head of Transplant Anesthesia. Other attendings: Drs. Fareed Azam, Matthew Fiegel,
Adrian Hendrickse, Sara Cheng and Marina Shindell.
Reading:
A 3 ring-binder will be given to you by Kathy Riggs. Get it early and take a look at the OR setup beforehand.
Also check out the DVDs of Sara Cheng’s Grand Rounds on Liver Transplants- it is a good overview/summary.
(available in the library in the anesthesia office)
Schedule:
Deceased-donor liver transplantation is generally a semi-emergency due to the limited ability of the donor organ
to tolerate cold ischemia (<10hrs). Occasionally a live donor case will be done here, but it’s rare. Thus, you’ll
be on 24-7 call for all but 2 weekends of this month. The rest of the time you will be working in the OR on
days. Try to be proactive and ask the charge attending to put you on good cases for the next day’s schedule. It
is also good to 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 each night. Keep your eye on the boardyou’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 you are a super gunner
When the OR desk calls you on nights/weekends for a liver transplant, they will usually give you at least 3-4
hours notice, if not more. Always call the desk again before you head into the hospital, as plans may have
changed. Remember to ask the patient’s name, MR #, and whether the attending and fellow have been
informed. If not, you need to call them. To make your life easier, go on EPIC and pre-order your drips before
you leave your house. The inpatient pharmacy (when the OR pharmacy is closed after 5pm or on weekends) is
as slow as frozen molasses. Order your drips (magnesium, vasopressin, and phenylephrine) to be tubed to the
OR desk. Also, I always order an insulin gtt if the OR pharmacy won’t be open.
Transplant Setup:
Suggest 1-1.5 hrs for setup and looking over patient in EPIC pre-op. Calculate a MELD at
(http://www.unos.org/resources/meldpeldcalculator.asp), determine the risk category for bleeding, and for
antibiotics so that you know what you’re up against. Eventually you will need to document UNOS transplant
number, pt blood type and donor blood type in EPIC (circulator will have this paperwork, and in theory it
should be covered in the timeout).
 Infusions:
 Mannitol (20%) 30-50 cc/hr,
 Magnesium (1g/hr),
 Dopamine (2 mcg/kg/min),
 Vasopressin (0.04 units/min),
 Phenylephrine (200mcg/mL, put on roller ball microdripper or for Dr. Azam place on
infusion pump),
o You may also eventually need to order an insulin infusion from pharmacy. Surgeons may also
request a thymoglobulin infusion in special liver transplant situations and in any “high PRA” kidney
transplant. “Thymo” is ordered from pharmacy, you will need to know patients weight, and
remember to give it after dose of steroids for concerns of serum sickness.
o Drugs from Pyxis: Check out transplant box, dopamine, lorazepam as it doesn’t have the hepatic
metabolism that midazolam does, and cisatracurium.
o Infusion set-up: place phenylephrine on right (with level one) on roller ball microdripper tubing
[unless with Azam, then goes on a pump and attached to manifold]. All other infusions on left on
pumps. Connect all to multi infusion manifold. Manifold can be found in anesthesia work room or
OR#3 back cart. Use the Mannitol infusion as “carrier” and plug in to the central luer lock at 3050cc/hr.
o An antibiotic infusion list should be available at the beginning of your month but usually it boils
down to running Cefoxitin 2gm and Unasyn 3gm over 8 and 6 hrs respectively with a loading dose.
o A few house keeping things- I like to put a silk tape over the top of all my infusion pumps to write
drug names on them and then when you have the whole octopus plugged in, rip a long piece of
plastic tape in half lengthwise. I use 2’’ strands of this to make the whole thing one big bundle of
cables that I can still rip apart if I need an individual line.
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Belmont in room – don't wet down just yet: ask attending what wet down fluids to use (albumin 5%, appears
a safe choice, other attendings use normal saline).
Wet down Level 1.
Get ultrasound [Azam doesn't usually use this, unless you want to].
Dual transducers for CVP, arterial line.
Drugs to draw up.
o Induction
 Fentanyl
 Lorazepam
 Propofol
 Etomidate (if really tenuous CV status)
 Cisatracurium
 Succinylcholine
o Poppers
 Atropine
 Glycopyrrolate
 Phenylephrine
 Ephedrine
 NTG (50mcg/ml)
 Calcium chloride (have multiple prefilled vial/syringes available)
 Sodium bicarbonate (have multiple prefilled vial/syringes available)
 Epinephrine (10 mcg/mL, and 100 mcg/mL)
o Lasix (10 mg/mL, 10 mL syringe. From transplant box)
o Methylprednisolone (from transplant box, ask attending if they want 500 mg, or 1 g. Needs
reconstitution)
THAM
Albumin
Extra fluids, RIC's, manifolds, central lines, pumplines.
Before taking the patient back:
See patient, consent for GA, A-line, CVP and TEE. Mention risk of leaving intubated overnight in the ICU.
WARM the room to at least 80deg. Check to make sure attending has called in blood (“is this patient, medium
or high risk?”) and that blood is available and is in the room, or at least on the way to the OR.
Patient in OR:
 You will do a RSI, they are all considered full stomachs, with propofol and sux. Maintenance NMB will be
cisatracurium. No lidocaine in liver patients!!
 Place arterial line.
 Now try and get two short 14 gauge IV's. Belmont to one, Level One to another. One of these lines could
also be a 18 gauge changed over a wire to a RIC, then attached to the Belmont.
 If 2 short 14's are placed, you can use triple lumen for CVP. (Mandell always places cordis, regardless). If
vascular access in PIV isn't great, consider Cordis. Consider FFP through the PIV's prior to placing central
line if major coagulopathy. Attach infusion manifold to one central port. CVP to second port,
phenylephrine on roller ball line to infusion manifold.
 Bair hugger, OG (usually comes out at end, but some surgeons prefer an NG), Esophageal temp, BIS if
working with Fiegel.
 Fiegel likes FFP on the Level One and PRBCs in the Belmont, but the others just dump a 1:1 ratio in the
Belmont.
Surgery:
 Phase 1: Dissection
o Big issue is blood loss. Try to keep up and stay ahead, often using 1:1 PRBC:FFP.
o Have infusions going at above concentrations, adjust as necessary. Send ABG's q 30-60 minutes,
watch base deficit, pH, Hgb, and calcium in particular.
 Phase 2: Anhepatic
o Vessels clamped. Phase of reduced preload and hypotension while the gut begins to get
hyperkalemic and acidotic (this will be released to heart in phase 3). Titrate phenylephrine and
vasopressin as needed because the issue isn't necessarily volume at this point as major bleeding is
controlled. THAM is a buffer that is lower in sodium than sodium bicarb and may be used at this
time as an infusion.
 Phase 3: Reperfusion
o Unclamping. Starts with Cava. CVP and BP will come up. Administer sodium bicarb or THAM in
prep for release of acids, especially with the next vessel to be unclamped. Have atropine, epi,
calcium, stick of phenylephrine and phenylephrine infusion hooked up and ready for portal vein
unclamping. Consider half an amp of calcium and some atropine prophylactically [Azam will use
glycopyrrolate]. The release of K, cold blood and acids into circulation will increase your risk of
hypotension and bradyarrhythmias. Usually, you can expect short period of cardiac instability, but
these instabilities can include asystole and HR’s in the 30’s. The hepatic artery is released last and
there is not much physiologic derangement from this.
 Surgeons will then pack the liver, place a Yankauer into the abdominal cavity and step out for 30-45
minutes. This is a chance to catch up on blood loss and send ABG's, TEG's. Also a good time to send a
CBC, coags, fibrinogen. Have FFP and blood trickling in to match the rate of blood loss from any leaky
anastomosis or chewed up liver surface. Then they will come back to re-inspect, control any minor
bleeding, anastamose the bile ducts and close. Keep sending ABG's to match blood loss.
 If liver is working, won't need as much calcium when administering FFP, citrate will go down; liver will
begin to make bile for surgeon.
 Try to get patient back to breathing once fascial closure complete, prepare for extubation and transport to
PACU. On occasion may go direct to ICU +/- intubation.
 Coagulopathy
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o May consider using amicar and factor 7 if field remains without clot and all of the TEG numbers
appear adequate after product has been repleted.
Variations
o Live Liver Recipient: Same setup, usually not as sick as has much lower MELD score and could not
get on the cadaveric list.
o Live Liver Donor: Young and healthy by definition. Only need central line, and epidural, and a
couple of peripherals in these patients. Be very cautious with them though as we have had a bad
outcome and these are things that make the national news.
Outpatient Anesthesia (AOP) - University of Colorado Hospital
MATTHEW COLEMAN, MD; ANH DANG, MD; JIM RYAN, MD
This is typically a fun month with lots of opportunities to do peripheral nerve blocks. You also learn different
techniques for induction and learn that you actually can intubate without neuromuscular blockers. Dr.
Armstrong and Dr. Shiffrin rarely use NMBs for intubation unless specifically indicated, and prefer to use LTA.
Important people:
AOP charge: John Armstrong, MD and Jeff Shiffrin, MD (when Dr. Armstrong is not there)
Pharmacy: Mary Cousins, Carol McKinney, Liz Lyke
Anesthesia Techs: Johnny Lawerence, Roland Coop
Before you start:
Know the lay of the land; Preop and PACU, ORs, GI, Pharmacy, Anesthesia workroom, Locker rooms, Storage
room where block equipment is stored, and lounge. Your Pyxis codes will work the same as the AIP. ORs
include AOP 8, 9, 11-17, GI (except 13). Make sure to get a key to the OR carts! Unlike AIP, carts in the
AOP are locked, so without a key, you will not be able to access syringes, drugs, etc. Also unlike AIP, you get
narcotics for all your cases in the morning at the pharmacy – keep them locked in the cart in between cases.
Schedule and Call:
 Schedule: Tuesday – Friday 6:30 to 3-5 pm (rarely there past 5 pm). Mondays you’ll be scheduled at the
AIP, usually covering 12 hours.
 Call: Expect to be on call 1 Saturday night during the month, 2 if they are strapped for people, or if there
are 5 weekends in the month.
 Cases: Most of the time you’ll be doing Ortho cases that require blocks, with a few days in the month doing
ENT, gyn, dental, etc. You will not likely do any GI or eyeballs.
 The current agreement is that the residents in the AOP start and finish their rooms (almost all of the time).
You are not expected to take over CRNA rooms if you finish early, and they will not take over your room
unless it is well past 5 pm.
 If you are out before noon, you should help give some lunches and make sure there are no potential add-ons.
Call the charge before taking off.
Daily Work Flow:
Arrive in Pre-op around 7:00, unless you will block the first patient, shoot for 6:45. If you would like a locker
at the AOP, there are usually a few empty ones you could claim for the day. 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.
Pharmacy: Get patient’s narcotics bag from the pharmacy. You can pick up your entire day of narcotic bags at
once. 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, ketorolac, local for blocks, and phenylephrine sticks (in the
pharmacy refrigerator). Pharmacy hours are 6:30 am – 5:00 pm.
Anesthesia Techs and Workroom: The workroom is located on the southwest side of the AOP near OR 16.
Call Russ Ingram prior to starting to make sure you have a code to the workroom. Anesthesia techs arrive later
than at the AIP and are usually not available to help get ready for your first cases. So, be ready to get in the
workroom, get LMAs, pumps, etc. Also, 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 U/S 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 sterile block trays and U/S
covers in the bottom drawer. The block tray contains the drape, syringes, three-way stopcock, tubing, epi,
sterile gauze, and chloroprep. In preparation for a block, pull out a tray, U/S cover, the drugs (usually 0.5%
Bupiv or 1.5% Mepiv or a combo of both for the actual block and Lido 2% for the skin), your sterile gloves and
the needle. Note: Drs. Armstrong and Shiffrin typically like to drape for all blocks regardless of whether or not
you’re leaving a catheter (this is different than how it’s done on APS or at DH). 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 (often times your attending will do this for you). 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.
Important AOP Numbers:
Anes Charge Attg
84439
Anes 2nd Charge
81507
RN charge
81508
Pre-op
81350
PACU
86203
AOP pharmacy
81391
Anes Tech 1
84459
Anes Tech 2
85918
AOP Front Desk
88130
OR
8
9
11
12
14
15
16
17
RN phone
83208
83209
82511
81412
81414
81415
81416
81417
Anes phone
82201
81375
81342
81422
81419
81423
81421
81159
Blood gas lab
Blood Bank
85309
84444
Door Codes
Anes Workroom
AOP Hallway
00701*
0608
Sample Notes
There are many different ways to do your documentation on paper charting. Just be sure it is legible and that
you document attention to key points. These are just a few examples, be sure to check with your attending or
senior resident.
Bier block:
Pt ID, H&P, Q&A. Consented. Bilat hand 20 g PIV. Abx. To OR6. ASA monitors. NC O2. Sedation. RUE
Esmarck. RUE tourniquet up to 250 mmHg @0745. 50 cc 0.5% lidocaine injected smoothly with good venous
distention. VSS, no sx of local anes tox. Blankets on upper/lower body. Patient comfy for procedure.
ICU transport of intubated patient:
Pt ID’d, chart reviewed, IC from power of attorney. Report received from nurse. To OR10 with ambu+O2,
aline, EKG, pulse ox. VSS. In situ ETT to machine circuit. ASA monitors. OGT to suction. Eyes taped. Foley to
grav. Arms < 90º. All PPP. UBBH. Esoph temp probe.
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/
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 zero to highest of 5):
Big Blue
Editors’
reputation(s)
Authors’
reputations
Level of peer
review
Thoroughness
0
Morgan/Mikhail/ Miller or
Murray
Barash
2
4
0-1
2
4
5
0
2
3-4
5
3
2
5
Conciseness
(inv prop to
thoroughness)
Use as Exam
source material
Accuracy of
info
Readability (but
different folks
like different
styles)
2-3
4
1
2 (limited by #
of articles,
individual
articles are @
5)
2
0
1
5
2-3
1-2
3
4
5
3
4
3
2




Anes or A&A
Review Articles
5
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 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 Anschutz Medical Campus
Anschutz Inpatient Pavilion, 12605 E. 16th Avenue, Aurora, CO 80045
CRITICAL
VA Map
1055 Clermont Street, Denver, CO 80220
Parking is across the street from the VA hospital (across Bellaire street; directly across from the parking
structure). You cannot park in the building labeled parking structure.
Denver Health Medical Center
777 Bannock Street, M.C. 0218, Denver, CO 80204-4507
Parking is in the structure on the bottom left corner of the map labeled “public parking garage”. Park
above level 2 after passing the badge-access gate.
NOTES: