INDIANA UNIVERSITY DEPARTMENT OF ANESTHESIOLOGY
CORE--Neurosurgical Anesthesia
Goals and Objectives
GOALS and OBJECTIVES:
The goal of the Neurosurgical Anesthesia Rotation at the Indiana University School of Medicine
is to train physicians to be competent and compassionate practitioners of neurosurgical
anesthesia. This Core-Neurosurgical Anesthesia rotation is designed to establish a core of
knowledge, understanding and application of neurosurgical anesthesia principles. This differs
from the advance rotation in neurosurgical anesthesia where emphasis is placed in the areas of
analysis, synthesis and evaluation of patient care needs.
Basic Neurosurgical Anesthesia Resident Duties:
1. Preoperatively evaluate and develop an anesthetic plan for the administration of a safe
neuroanesthetic
2. Inter-operatively maintain safe anesthetic care for the patient with specific
consideration of the impact of neurologic disease upon the delivery of anesthesia
3. Post-operatively understand potential complications associated with the
administration of anesthesia and potential sequelae of neuroanesthesia intervention
4. Attend didactic conferences
5. Take night call on a rotating schedule
6. Respond to requests for anesthesia consults in a timely fashion
7. Maintain a personal program of self-study and professional growth
8. Complete medical records promptly
9. Document all duty hours
10. Document all procedures
11. Monitor self for fatigue
12. Dress appropriately
13. Act in a professional and ethical manner
14. Complete the appropriate evaluation instruments used by the department, including
QA forms
Educational Strategy:
The Neurosurgical Anesthesia Rotation is a one-month (4 week) block. During the
Neurosurgical Anesthesia Rotation residents will be will be supervised by various members of
the anesthesia teaching faculty. The Director of Neuroanesthesia is Stephen Rosenfeld. In his
absence, Dr. Mike Miller is assigned to cover these responsibilities. During the rotation in
neurosurgical anesthesia, residents are expected to participate in journal clubs, and morbidity and
mortality conferences (QA).
When rotating at an institution which is not the primary site of practice of the above mentioned
faculty, please contact the below listed individuals:
Dr. Scott Walker—Riley
Dr. John Hasewinkel—Wishard
Dr. Ken Gwirtz—VA
During the rotation in chronic pain, residents are expected to participate in journal club, and
morbidity and mortality conferences (QA).
Core Competencies:
The six core competencies are used as a template to evaluate residents during all Anesthesia
rotations. The terms used to define these competencies are similar to those used for other
rotations. The Goals and Objectives that follow have been specifically modified to meet the
needs of the specific teaching rotation in which you are to participate. These Goals and
Objectives are not intended to be comprehensive but have been developed to help you acquire
the core competencies in the area of Clinical Anesthesia. These core rotations should serve as
the foundation upon which the subspecialty anesthesia rotations are based. We ask you as the
learner to consider how each of the subcategories within these six competencies might relate to
cognitive, motor and affective characteristics of your education and your professional behavior.
If while reading this document you discover an area that requires revision or improvement please
bring these issues to the attention of either the Course Director or the Program Director. We seek
changes that will improve your educational experience.
EDUCATIONAL OBJECTIVES
Medical Knowledge:
After completing this rotation, residents will have gained knowledge and practical experience in
the care of neurosurgical patients by:
1. Understanding the determinants of intracranial pressure
2. Understanding the effects of drugs used in neuroanesthesia on cerebral metabolic rate
(CMR), cerebral blood flow (CBF), and intracranial pressure (ICP)
3. Understanding the determinants of cerebral perfusion pressure (CPP)
4. Understanding the effects of blood pressure, pCO2, and paO2 on CBF
5. Describing the relationship of CBF to cerebral blood volume and ICP
6. Understanding both risks and benefits associated with hyperventilation
7. Understanding the effects of temperature on CMR and CBF.
8. Understanding clinically relevant measures associated with neuro-protection from focal
ischemia, global ischemia, and head injury
9. Defining plateau waves. Describing their significance and treatment.
10. Understanding the major anesthetic concerns associated with:
2
a. Resection of supratentorial mass
b. Posterior fossa surgery
c. Intracranial aneurysm clipping (and embolization)
d. Resection of intracranial AVM (and embolization)
e. Spinal surgery
f. Carotid endarterectomy
g. Extracranial-intracranial bypass
11. Describing the sitting position. Note cardiovascular effects and complications
12. Understanding the etiology of venous air embolism, the diagnostic modalities, prevention
and treatment
13. Describing the peri-operative management of patients with subarachnoid hemorrhage
14. Describing the prone position, understanding the cardiaovascular, pulmonary and
positioning complications
15. Understanding the factors associated with peri-operative blindness
16. Understanding the effects of anesthetic agents and intraoperative factors on SSEP and
MEP
17. Defining the Glasgow coma scale
18. Listing the major concerns in the management of head or spine trauma patients (practical
experience with neural trauma will occur on rotations at Riley and Wishard Hospitals
where trauma patients will more commonly be found)
19. Describing the management of seizures
20. Understanding the drug interactions of anti-convulsant medications
21. Understanding peri-operative concerns in pituitary surgery.
22. Understanding etiology, diagnosis and treatment: diabetes insipidus and syndrome of
inappropriate secretion of anti-diuretic hormone (SIADH).
23. Describing anesthesia techniques for awake craniotomy
24. Understanding the pharmacology and drug interactions of drugs used in the treatment of
Parkinson’s disease
25. Understanding the considerations of providing anesthesia for magnetic resonance
imaging.
26. Understand post-operative complications of neurosurgery
27. Understand the management of the patient with delayed emergence after neurosurgery
Patient Care:
Using the above medical knowledge the resident is expected to:
1. Evaluate neurosurgical patients and developing a treatment plan
2. Plan a comprehensive approach to neuroanesthesia problems
3. Plan a comprehensive plan for peri-operative assessment and management of the
neurosurgical patient
4. Demonstrate the ability to function as a consultant and specialist in neuroanesthesia
5. Analyze the administration/complications/benefits of the various pharmacologic
agents used in neuroanesthesia
6. Prepare patients for surgery and invasive neuroanesthesia procedures
3
7. Participate and performing invasive interventional procedures associated with the safe
conduct of a neuroanesthesia under attending supervision
8. Perform various techniques, including, but not limited to:
a. Placement of central venous lines
b. Placement of arterial lines
c. Managing the airway of the patient with an unstable cervical spine.
d. Managing the airway of the patient in a stereotactic frame.
e. Positioning the prone patient.
Interpersonal and Communication Skills:
After completing this rotation, residents will have gained experience and competence in:
1.
2.
3.
4.
Obtaining an accurate useful patient history appropriate for neurosurgical anesthesia
Completing an informative, legible medical record
Communicating skillfully with patients and family members
Communicating information about anesthetic procedures with other colleagues
including referring physicians, nurses, and workers on ancillary services
5. Effective counseling of patients and families regarding methods of neurosurgical
anesthesia, alternatives, and risks and benefits of treatment options
6. Obtaining informed consent for neurosurgical anesthesia procedures
7. Answering questions from the patient and or family members regarding the
neurosurgical anesthesia issues in a fashion that is readily understood
Professionalism:
After completing this rotation, residents will have gained experience and competence in:
1.
2.
3.
4.
Acting in a professional manner while providing patient care
Demonstrating reliability and dependability
Exemplifying compassionate and appropriate patient care
Acquiring teaching skills essential for creating a positive learning environment,
including involvement in the education of medical students
5. Showing respect for patients
6. Providing for the emotional needs of patients
Systems-Based Practice
After completing this rotation, residents will have gained experience and competence in:
1. Understanding their role as a patient care advocate
2. Becoming familiar with the costs associated with the delivery of anesthesia care
4
3. Incorporating the concepts of cost-benefit analysis when considering therapeutic
options
4. Interpreting the constraints associated with management of the operating room and be
able to integrate this understanding into best patient care practices
5. Emphasizing safety for the patient as well as operating room personal
6. Obtaining a better understanding of the tools that are being utilized to assess best
practices in anesthesia by organizations such as Magnet and Leapfrog
7. Working towards developing team building skills
Practice Based Learning and Improvement:
After completing this rotation, residents will have gained experience and competence in:
1. Self-directed learning
2. Becoming more efficient at locating medical information associated with
neuroanesthesia.
3. Reviewing the medical literature related to the field of neuroanesthesia and
integrating this information with the care of the patient
4. Learning to better utilize information technology to access on-line medical
information pertaining to innovative diagnostic and therapeutic modalities in the area
of neuroanesthesia.
5. Transferring knowledge about neuroanesthesia to other members of the healthcare
team (medical students, ancillary care personal and nursing staff)
Trainee Evaluations:
The Clinical Competency Committee (CCC) meets every other month to evaluate the progress of
the trainees. Specifically addressed are the six basic competencies and the neurosurgical
anesthesia specific competencies outlined above. The instruments used to assess their progress
include an evaluation form which utilizes a scaled five point Likert scoring system which
assesses each of the six competencies. In house testing is also performed twice yearly to insure
that the trainees are acquiring the knowledge associated with the provision of a safe anesthetic.
Residents are expected to take the in-training examination administered by the American Society
of Anesthesiologists/American Board of Anesthesiology (ASA/ABA).
On a more informal (and potentially more important) level, members of the teaching faculty
evaluate our trainees daily and are provide them real-time feedback concerning their
performance in the delivery of anesthesia services. Informal discussions with the neurosurgical
anesthesia residents address any deficiencies in patient care or knowledge base. Additionally,
we try to know our trainees personally to better understand and/or address underlying stressors or
personal issues that may interfere with learning and performance.
5
Every six months, the American Board of Anesthesiology requires that the Clinical Competency
Committee submit a Resident Training and Evaluation Report. In addition to the basic
competencies, we submit our evaluation of a trainee’s progress in the following areas:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Demonstrates ethical/moral behavior
Is reliable, conscientious, responsible and honest
Learns from experience; knows limits
Reacts to stressful situations appropriately
Has no documented abuse of alcohol or illegal use of drugs during this report
period
Has no cognitive, physical, sensory or motor impairment that precludes individual
responsibility for any aspect of anesthetic management
Demonstrates respect for the dignity of patients and colleagues
Has no restriction, condition, limitation or revocation of license to practice
medicine
Understands anatomical, physiological, and pathophysiological concepts of organ
disease that culminates in the need for solid organ transplant
Collects and uses clinical data
Recognizes the psychological factors modifying pain experience
Communicates/works effectively with patients/colleagues
Demonstrates appropriate concern for patients
Demonstrates commitment to life long learning
Adapts and is flexible
Is careful and thorough
Generates complete, legible, and accurate medical record
Possesses business skills for effective practice management
Uses information technology to optimize patient care
Is an advocate for quality care
Recognizes gaps in knowledge and expertise
Demonstrates continuous practice improvement
Uses appropriate technical skills in diagnostic and therapeutic procedures
Completes study of management of acute pain, cancer pain, and chronic pain
Readings:
Reading assignments to establish knowledge, understanding and application of neuroanesthesia
principles for patient care in this rotation are:




Miller’s Anesthesia, 6th edition. Chapters 21 and 53.also pages 2955-68
Principals and Practice of Anesthesiology (Longnecker) pages 1618-1629
Positioning in Anesthesia and Surgery (Warner) :chapters on prone and sitting
position.
Recent review articles on SSEP and MEP will be provided.
6