INDIANA UNIVERSITY DEPARTMENT OF ANESTHESIOLOGY
CA1 Clinical Anesthesia
Goals and Objectives
GOALS and OBJECTIVES:
The goal of the CA1 Clinical Anesthesia Rotations at the Indiana University School of Medicine
is to train physicians to be competent and compassionate practitioners of clinical anesthesia.
These Clinical Anesthesia rotations are designed to enhance your overall knowledge,
understanding and application of anesthesia principle. This differs from the CA2 and CA3
rotations in clinical anesthesia in which the emphasis is placed on more advanced aspects of
patient care such as analysis, synthesis and evaluation. The medical knowledge portion of your
CA1 year will focus upon basic and clinical science in anesthesia.
Expected Clinical Anesthesia Resident Duties:
1. Preoperatively evaluate patients and develop a plan for the safe administration of an
anesthetic
2. Intraoperatively maintain safe anesthetic care for the patient
3. Post-operatively understand potential complications and sequelae associated with the
administration of anesthesia
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 Clinical Anesthesia Rotations are provided in one-month (4-week) blocks. During the
Clinical Anesthesia Rotation residents may work with multiple members of the teaching faculty,
but their educational experience will be supervised by the Director of Anesthesia Services at
each of the four major teaching locations.
If concerns arise related to a rotation at a specific location, please feel free to contact the
appropriate individual listed below:
Dr. Jerry Young—University
Dr. Scott Walker—Riley
Dr. John Hasewinkel--Wishard
Dr. Ken Gwirtz—VA
During the rotation in Clinical Anesthesia, residents are expected to participate in journal clubs
and morbidity and mortality conferences (QA).
Core Competencies:
The six core competencies are used as a template to evaluate residents during all Anesthesia
rotations. The terms used to define these competencies are similar to those used for other
rotations. The Goals and Objectives that follow have been specifically modified to meet the
needs of the specific teaching rotation in which you are to participate. These Goals and
Objectives are not intended to be comprehensive but have been developed to help you acquire
the core competencies in the area of Clinical Anesthesia. These core rotations should serve as
the foundation upon which the subspecialty anesthesia rotations are based. We ask you as the
learner to consider how each of the subcategories within these six competencies might relate to
cognitive, motor and affective characteristics of your education and your professional behavior.
If while reading this document you discover an area that requires revision or improvement please
bring these issues to the attention of either the Course Director or the Program Director. We seek
changes that will improve your educational experience.
EDUCATIONAL OBJECTIVES
Medical Knowledge:
The CA1 Clinical anesthesia rotations are meant to provide you with a global understanding of
the various aspects required to provide safe anesthesia to our patients. The ABA Content
Outline in the areas of basic and clinical science acts as the framework for the Medical
Knowledge component of the CA1 goals and objectives. We stress that the following do not
define the entirety of the knowledge base that you will need to acquire but instead represent a
general overview.
BASIC SCIENCES
A. ANATOMY
1. Topographical Anatomy as Landmarks
a) Neck: Tracheotomy Site, Cricothyroid Membrane, Internal and
External Jugular Veins, Thoracic Duct, Carotid and Vertebral
Arteries, Stellate Ganglion, Cervical Spine Landmarks (Vertebra
Prominens, Chassaignac’s Tubercle)
b) Chest: Pulmonary Lobes, Cardiac Landmarks, Subclavian Vein
c) Pelvis and Back: Vertebral Level of Topographical Landmarks,
2
Caudal Space
d) Extremities: Relationship of Bones, Nerves, and Arteries
2. Radiological Anatomy
a) Chest (Including CT and MRI); heart: angiography, nuclear
imaging techniques
b) Brain and Skull (Including CT and MRI)
c) Spine (Cervical, Thoracic, Lumbar), Including CT and MRI
d) Neck (Including Doppler Ultrasound for Central Venous Access)
B. PHYSICS, MONITORING, & ANESTHESIA DELIVERY DEVICES
1. Mechanics
a) Pressure Measurement of Gases, Liquids
b) Transducers, Regulators, Medical Gas Cylinders
2. Flow Velocity
a) Viscosity-Density; Laminar-Turbulent Flow
b) Flowmeters: Rotameter
c) Principles of Doppler Ultrasound
3. Properties of Liquids, Gases, and Vapors
a) Diffusion of Gases
b) Solubility Coefficients
c) Relative and Absolute Humidity
d) Critical Temperature, Critical Pressure
4. Gas Laws
5. Vaporizers
a) Vapor Pressure and Calculation of Anesthetic Concentrations
b) Vaporizer Types and Safety Features
6. Uptake and Distribution of Inhalation Agents
a) Uptake and Elimination Curves; Effect of Ventilation, Circulation,
Anesthetic Systems
b) Concentration Effect
c) Second Gas Effect
d) Nitrous Oxide and Closed Spaces
7. Physics of Anesthesia Machine/ Breathing System
a) Principles: Resistance, Turbulent Flow, Mechanical Deadspace,
Rebreathing, Dilution, Leaks, Gas Mixtures, Humidity, Heat
b) Components: Connectors, Adaptors, Mask, Endotracheal Tube,
Reservoir Bag, Unidirectional Valves, Corrugated Breathing Tubes, Laryngeal
Mask Airways, Airway Pressure Relief Valve
c) Characteristics
1) circle systems: closed and semi-closed; adult; pediatric
2) non-circle systems: insufflation; open; semi-open
3) portable ventilation devices (self-reinflating, non
selfreinflating), non-rebreathing valves
4) CO2 absorption: principles, canisters, efficiency
5) toxicity: Compound A, carbon monoxide
d) Oxygen Supply Systems: FiO2
e) Waste Gas Evacuation Systems
3
f) Safety Features (Proportioning Devices, Rotameter Configuration,
Pressure Fail-Safe)
g) Design/Ergonomics of Anesthesia Machines
8. Monitoring Methods
a) Vascular Pressures: Arterial (Invasive/Noninvasive Differences),
Central Venous (CVP), Pulmonary Arterial (PAP), Pulmonary Artery
Occlusion (PAOP), Left Atrial (LAP), Left Ventricular EndDiastolic (LVEDP)
b) Heart Function: Heart Tones, Electrocardiogram (ECG), Echocardiography,
Doppler, Cardiac Output
c) Brain and Spinal Cord Function: Electroencephalogram (EEG) (Raw and
Processed), Depth of Anesthesia Monitors (Bispectral, Other), Evoked
Potentials, Wake-Up Test, Intracranial Pressure (ICP), Jugular Venous
Oxygen Saturation, Near Infrared Spectroscopy (Cerebral Oximetry),
Transcranial Doppler
d) Neuromuscular Function: Nerve Stimulators, Electromyography (EMG)
e) Ventilation: Respirometers, Inspiratory Force, Spirometry, FlowVolume Loops
f) Gas Concentrations: O2, CO2, Nitrogen, Anesthetic Gases
and Vapors
g) Temperature
h) Oxygen: Oximetry, CO-oximetry, Pulse Oximetry, Mixed Venous Oxygen
Saturation (SvO2)
9. Instrumentation
a) Blood Gases: Electrodes for pH, PO2, PCO2, Calibration,
Temperature Corrections, Errors
b) Gas Concentrations: Infrared Absorption, Mass Spectrometry, Raman Scatter
Analysis
c) Cardiac Output: Fick, Dye Dilution, Thermodilution, Doppler,
Impedance
d) Pressure Transducers: Resonance, Damping
e) Non-Invasive Blood Pressure (BP) Measurement: Doppler,
Oscillometry, Korotkoff Sounds, Palpation
f) Blood Warmers, Autotransfusion Devices
g) Echocardiography: Technical Aspects, Complications
h) Coagulation Monitors
i) Ultrasound-Guided Placement of Invasive Catheters (Arterial,
Central Venous) and Nerve Blocks
j) Body Warming Devices: Forced Air, Heating Lamps, Insulation
Devices, Warming Blankets, Water-Flow “Second Skin” Devices
10.Ventilators
a) Classifications: Flow Generation vs. Pressure Generation
b) Principles of Action: Assistors, Controllers, Assist-Control;
Pressure-Limited, Volume-Limited; FIO2 Control; Periodic Sigh,
Inverse Ratio, High Frequency Ventilation, Intermitten Mandatory Ventilation
(IMV), Synchronized IMV, Pressure Support, Airway Pressure Release
4
Ventilation (APRV), Pediatric Adaptation, Non-Invasive Techniques:
Biphasic Positive Airway Pressure (BIPAP), Others
c) Monitors; Pressure (Plateau, Peak), Oxygen, Apnea,
Inspiratory/Expiratory Ratio, Dynamic Compliance, Static
Compliance
d) Continuous Positive Airway Pressure (CPAP) and Positive Endexpiratory
Pressure (PEEP); Nasal CPAP and BIPAP
e) Nebulizers, Humidifiers, Drug Delivery Systems (Nitric Oxide, Others)
11. Alarms: Operating Room, Electrical, Anesthesia Machine,
Ventilators, Capnometer, Oxygen
12. Defibrillators:Automatic Internal, External, Implantable; Energy,
Cardioversion, Types of Waveforms (Monophasic, Biphasic); Paddle
Size and Position; Automated External Defibrillators (AEDs)
13. Pacemakers
a) Temporary Transvenous; Permanent (Epicardial, Endocardial),
Transcutaneous
b) Types: Fixed Rate, Biventricular Synchronized, Ventricular, Atrial,
Atrio-ventricular (A-V) Sequential
c) Standard Nomenclature
d) Reasons for Failure or Malfunction
14. Electrical; Fire and Explosion Hazards; Basic Electronics
a) Source of Ignition; Static
b) Prevention: Grounding, Isolation Transformers
c) Macro and Micro Current Hazards
d) Safety Regulations; National Fire Protection Association (NFPA)
Standards
e) Lasers, Laser Safety, Laser-safe Endotracheal Tubes
f) Airway Fires
15. Drug Delivery Devices: Patient-Controlled Intravenous and Epidural
Analgesia, Epidural and Subarachnoid Continuous Drug Delivery
Devices
C. MATHEMATICS
1. Simple Math: Logarithms; Graph of Simple Equations; Exponential
Function, Analysis of Biologic Curves
2. Statistics: Sample and Population; Probability; Mean, Median, and
Mode; Standard Deviation and Error; T-Test; Chi-Square;
Regression Analysis/Correlation; Analysis of Variance, Power
Analysis, Meta-Analysis, Confidence Limits, Odds Ratio, Risk Ratio
3. Computer: Data Handling, Processing, and Analysis
a) Basic Computer Knowledge: Programs vs. Operating System,
Computer Virus, Disk or Central Processing Unit (CPU) Failure,
Amplifiers, Microprocessors
D. PHARMACOLOGY
1. General Concepts
a) Pharmacokinetics and Pharmacodynamics, Protein Binding;
Partition Coefficients; pKa; Ionization; Tissue Uptake;
5
Compartmentalization and Exponential Models
1) pharmacokinetics of neuraxial drug administration: epidural and
subarachnoid
2) tolerance and tachyphylaxis
b) Termination of Action
1) elimination, biotransformation; context-sensitive half-time
2) impact of renal disease
3) impact of hepatic disease
c) Drug Interactions: Enzyme Induction and Inhibition, Hepatic Blood Flow,
Drug-Drug Binding
1) alternative and herbal medicines: perioperative implications
d) Drug Reactions (Anaphylactoid, Anaphylaxis, Idiosyncratic)
e) Pharmacogenetics
1) malignant hyperthermia (including diagnosis and therapy)
2) pseudocholinesterase deficiency
3) prolonged QT syndrome
4) genetic factors in drug dose-response relationships
f) Addiction
1) physiology and pharmacology
2) patient addiction: anesthetic implications
3) addiction among health care workers and anesthesiologists
2. Anesthetics-Gases and Vapors
a) Physical Properties
b) Mechanism of Action
c) Effects on Central Nervous System (CNS)
d) Effects on Cardiovascular System
e) Effects on Respiration
f) Effects on Neuromuscular Function
g) Effects on Renal Function
h) Effects on Hepatic Function
i) Effects on Hematologic and Immune Systems
j) Biotransformation and Toxicity
k) Minimum Alveolar Concentration (MAC), Factors Affecting MAC
l) Trace Concentrations, OR Pollution, Personnel Hazards
m) Comparative Pharmacodynamics
3. Anesthetics-Intravenous (Opioid and Non-Opioid Induction and
Anesthetic Agents)
a) Opioids
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
(a) intravenous
(b) epidural and intrathecal
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
6
7) side effects and toxicity
8) indications and contraindications
b) Barbiturates
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
c) Propofol
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
d) Etomidate
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
e) Benzodiazepines
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
4. Anesthetics - Local
a) Uptake, Mechanism of Action
b) Biotransformation and Excretion
c) Comparison of Drugs and Chemical Groups
d) Prolongation of Action
e) Side Effects and Toxicity
1) CNS : seizures, cauda equina syndrome, transient
neurological symptoms
7
2) cardiac
3) allergy
4) preservatives/additives
5) maternal-fetal
5. Muscle Relaxants (Depolarizing, Non-Depolarizing)
a) Mechanism of Action
b) Pharmacokinetics and Pharmacodynamics, Abnormal Responses
c) Prolongation of Action; Synergism
d) Metabolism and Excretion
e) Side Effects and Toxicity
f) Indications and Contraindications
g) Antagonism of Blockade
h) Drug Interactions (Antibiotics, Antiepileptics, Lithium, Magnesium,
Inhalational Anesthetics)
CLINICAL SCIENCES
A. ANESTHESIA PROCEDURES, METHODS,AND TECHNIQUES
1. Evaluation of the Patient and Preoperative Preparation
a) Laboratory Evaluation
1) American Society of Anesthesiologists (ASA) Preoperative
Testing Guidelines
2) American College of Cardiology/American Heart Association
Guidelines for Perioperative Cardiovascular Evaluation
b) Premedication
1) interaction with chronic drug therapy; interaction with
anesthetic agents
2) adverse reactions to premedications; patient variability, dose
response curves, side effects
3) specific problems in disease states: hyperthyroidism and
hypothyroidism, drug abuse, glaucoma, uremia, increased CSF pressure,
chronic steroid ingestion, obesity, depression, COPD, hypertension
4) pediatric and geriatric doses, routes of administration
5) role in patients with allergies
6) alteration of gastric fluid volume and pH, gastroesophageal and pyloric
gastroesophageal reflux disease (GERD), sphincter tone
7) continuation vs. discontinuation of chronic medications: antihypertensives,
anti-anginal, antihyperglycemics, antidepressants, platelet inhibitors, etc.
8) prophylactic cardiac risk reduction: beta-adrenergic
blockers, etc.
c) Physical Examination, Airway Evaluation
d) NPO Status, Full Stomach and Induction of Anesthesia
e) ASA Physical Status Classification
2. Regional Anesthesia
a) General Topics: Premedication, Patient Position, Equipment,
Monitoring and Sedation
b) Spinal, Epidural, Caudal, Combined Spinal/Epidural
8
1) indications, contraindications, techniques, complications,
comparison of techniques
2) sites of actions
3) factors influencing onset, duration, and termination of action
4) systemic toxicity, test dose
5) complications: precipitating factors, prevention, therapy,
implications of anticoagulants and platelet inhibitors:
American Society of Regional Anesthesia and Pain Medicine (ASRA)
guidelines
c) Peripheral and Autonomic Nerve Blocks: Indications,
Contraindications, Techniques, Clinical Assessment, Complications, Use of
Nerve Stimulators
1) head and neck
2) upper extremity/brachial plexus
3) trunk and perineum extremity
d) IV Regional: Mechanism, Agents, Indications, Contraindications, Techniques,
Complications
3. General Anesthesia
a) Stages and Signs of Anesthesia; Awareness Under Anesthesia
b) Techniques: Inhalational, Total Intravenous, Combined
Inhalational/Intravenous
c) Airway Management
1) assessment/identification of difficult airway: anatomic
correlates, Mallampati classification, range of motion
2) techniques for managing airway: awake vs. asleep, use vs.
avoidance of muscle relaxants, drug selection, retrograde
intubation techniques, ASA Difficult Airway Algorithm
3) devices: flexible fiberoptic, rigid fiberoptic, transillumination,
laryngoscope blades, Bullard laryngoscope
4) alternatives and adjuncts: laryngeal mask airway (traditional and
modified), esophageal obturator airways, occlusive pharyngeal airways
5) transcutaneous or surgical airway: tracheostomy, cricothyroidotomy,
translaryngeal or transtracheal jet ventilation
6) endobronchial intubation: double-lumen endobronchial tubes; bronchial
blockers (integral to endotracheal tube or separate), placement and
positioning considerations, postoperative considerations
7) intubation and tube change adjuncts: gum-elastic bougies, jet stylettes,
soft and rigid tube change devices; complications
4. Monitored Anesthesia Care and Sedation: ASA Guidelines for
Sedation, Sedation Guidelines for Non-Anesthesiologists
5. Intravenous Fluid Therapy During Anesthesia:Water, Electrolyte,
Glucose Requirements and Disposition, Crystalloid Vs. Colloid
6. Complications (Etiology, Prevention, Treatment)
a) Trauma
1) upper airway, epistaxis
2) larynx, trachea, and esophagus
9
3) eyes: corneal abrasions, blindness
4) vascular; arterial and venous thrombosis; thrombophlebitis;
sheared catheter, intra-arterial injections, air embolism, cardiac/vascular
perforations, pulmonary artery rupture
5) neurological: pressure injuries of mask, tourniquet, body position,
intraneural injections, retractors, peripheral neuropathies, ASA Patient
Positioning Guidelines
6) burns
b) Chronic Environmental Exposure; Fertility, Teratogenicity,
Carcinogenicity, Scavenging
c) Temperature
1) hypothermia: etiology, prevention, treatment, complications (shivering,
O2 consumption), prognosis
2) nonmalignant hyperthermia; complications, treatment
d) Bronchospasm; Anaphylaxis
1) latex allergy
e) Laryngospasm
f) Postobstructive Pulmonary Edema
7. Special Techniques
a) Controlled Hypotension; Choice of Drugs, Use of Posture, Ventilation
b) Controlled Hypothermia; Techniques, Systemic Effects, Shivering,
Rewarming, Complications
c) Hyperbaric Oxygen and Anesthesia Care
d) High Altitude Anesthesia
8. Postoperative Period
a) Pain Relief
1) pharmacologic
(a) drugs: opioids, agonist-antagonists, local anesthetics, alpha-2
agonists, nonsteroidal anti-inflammatory drugs (NSAIDs), NMethyl-D-Aspartate (NMDA) receptor blockers
(b) routes: oral, rectal, subcutaneous (SC), transcutaneous,
transmucosal, intramuscular (IM), intravenous (IV),
including patient-controlled analgesia (PCA), epidural,
spinal, intrapleural, other regional techniques
(c) risks and benefits, complications
2) other techniques; Transcutaneous Electrical Nerve Stimulation (TENS);
cryotherapy; acupuncture, hypnosis
b) Respiratory Consequences of Anesthesia and of Surgical
Incisions
c) Cardiovascular Consequences of General and Regional
Anesthesia: Differential Diagnosis and Treatment of
Postoperative Hypertension and Hypotension
d) Neurologic Consequences of Anesthesia: Confusion, Delirium,
Cognitive Dysfunction
e) Nausea and Vomiting; Aspiration
10
1) Prevention and treatment: use of antacids, Histamine 2 (H2) blockers,
metoclopramide, transdermal scopolamine, droperidol, serotonin
antagonists, proton inhibitors, dexamethasone, multimodal therapy,
acupressure/acupuncture
2) pulmonary aspiration of gastric contents
BASIC SCIENCES
A. ANATOMY
1.
Topographical Anatomy as Landmarks
a)
Neck: Cricothyroid Membrane, Internal and External Jugular Veins, Thoracic
Duct, Carotid and Vertebral Arteries, Stellate Ganglion, Cervical Spine
Landmarks (Vertebra Prominens, Chassaig nac’s Tubercle)
2.
b)
Chest: Pulmonary Lobes, Cardiac Landmarks, Subclavian Vein
c)
Pelvis and Back: Vertebral Level of Topographical Landmarks, Caudal Space
d)
Extremities: Relationship of Bones, Nerves, and Arteries
Radiological Anatomy
a)
Chest (Including CT and MRI)
b)
Brain and Skull (Including CT and MRI)
c)
Spine (Cervical, Thoracic, Lumbar), Including CT and MRI
d)
Neck (Including Doppler Ultrasound for Central Venous Access)
B. PHYSICS, MONITORING, AND ANESTHESIA DELIVERY DEVICES
1. Mechanics
a)
Pressure Measurement of Gases, Liquids
b)
Transducers, Regulators, Medical Gas Cylinders
2. Flow Velocity
a)
Viscosity—Density; Laminar-Turbulent Flow
b)
Flowmeters: Rotameter
c)
Principles of Doppler Ultrasound
3. Properties of Liquids, Gases, and Vapors
a)
Diffusion of Gases
b)
Solubility Coefficients
c)
Relative and Absolute Humidity
d)
Critical Temperature, Critical Pressure
11
4 Gas Laws
5. Vaporizers
a)
Vapor Pressure and Calculation of Anesthetic Concentrations
b)
Vaporizer Types and Safety Features
6. Uptake and Distribution of Inhalation Agents
a) Uptake and Elimination Curves; Effect of Ventilation, Circulation, Anesthetic
Systems
b) Concentration Effect
c) Second Gas Effect
d) Nitrous Oxide and Closed Spaces
7. Physics of Anesthesia Machine! Breathing System
a) Principles: Resistance, Turbulent Flow, Mechanical Deadspace, Rebreathing,
Dilution, Leaks, Gas Mixtures, Humidity, Heat
b) Components: Connectors, Adaptors, Mask, Endotracheal Tube, Reservoir Bag,
Unidirectional Valves, Corrugated Breathing Tubes, Laryngeal Mask Airways,
Airway Pressure Relief Valve
c) Characteristics
1) circle systems: closed and semi-closed; adult; pediatric
2) non-circle systems: insufflation; open; semi-open
3) portable ventilation devices (self-reinflating, non-self-reinflating), nonrebreathing valves
4) CO2 absorption: principles, canisters, efficiency
5) toxicity: compound A, carbon monoxide
d) Oxygen Supply Systems: FxO2
e) Waste Gas Evacuation Systems
f) Safety Features (Proportioning Devices, Rotameter Configuration, Pressure
Fail-Safe)
g) Design/Ergonomics of Anesthesia Machines
8. Monitoring Methods
a) Vascular Pressures: Arterial (Invasive/Noninvasive Differences), Central
Venous (CVP), Pulmonary Arterial (PAP), Pulmonary Artery Occlusion
12
(PAOP), Left Atrial (LAP), Left Ventricular End-Diastolic (LVEDP)
b) Heart Function: Heart Tones, Electrocardiogram (ECG), Echocardiography,
Doppler, Cardiac Output
c) Brain and Spinal Cord Function: Electroencephalogram (EEG) (Raw and
Processed), Depth of Anesthesia Monitors (Bispectral, Other), Evoked
Potentials, Wake-Up Test, Intracranial Pressure (ICP), Jugular Venous
Oxygen Saturation, Near Infrared Spectroscopy (Cerebral Oximetry),
Transcranial Doppler
d) Neuromuscular Function: Nerve Stimulators, Electromyography (EMG)
e) Ventilation: Respirometers, Inspiratory Force, Spirometry, Flow-Volume
Loops
f) Gas Concentrations: 02, CO2, Nitrogen, Anesthetic Gases and Vapors
g) Temperature
h) Oxygen: Oximetry, Co—oximetry, Pulse Oximetry, Mixed Venous Oxygen
Saturation (SvO2)
9. Instrumentation
a) Blood Gases: Electrodes for pH, P02, PCO2, Calibration, Temperature
Corrections, Errors
b) Gas Concentrations: Infrared Absorption, Mass Spectrometry, Raman Scatter
Analysis
c) Cardiac Output: Fick, Dye Dilution, Thermodilution, Doppler, Impedance,
Pulse Wave Analysis
d) Pressure Transducers: Resonance, Damping
e) Non-Invasive Blood Pressure (BP) Measurement: Doppler, Oscillometry,
Korotkoff Sounds, Palpation
f) Blood Warmers, Autotransfusion Devices
g) Echocardiography: Technical Aspects, Complications
h) Coagulation Monitors
i) Ultrasound-Guided Placement of Invasive Catheters (Arterial, Central
Venous) and Nerve Blocks
j) Body Warming Devices: Forced Air, Heating Lamps, Insulation Devices,
13
Warming Blankets, Water-Flow “Second Skin” Devices
10. Ventilators
a) Classifications: Flow Generation Vs. Pressure Generation
b) Principles of Action: Assistors, Controllers, Assist-Control; Pressure-Limited,
Volume-Limited; FIO2 Control; Periodic Sigh, Inverse Ratio, High Frequency
Ventilation, Intermittent Mandatory Ventilation (IMV), Synchronized IMV,
Pressure Support, Airway Pressure Release Ventilation (APRV), Pediatric
Adaptation, Non-Invasive Techniques: Biphasic Positive Airway Pressure
(BIPAP), Others
c) Monitors; Pressure (Plateau, Peak), Oxygen, Apnea, Inspiratory/Expiratory
Ratio, Dynamic Compliance, Static Compliance
d) Continuous Positive Airway Pressure (CPAP) and Positive End-expiratory
Pressure (PEEP); Nasal CPAP
e) Nebulizers, Humidifiers, Drug Delivery Systems (Nitric Oxide, Others)
11. Alarms and Safety Features: Operating Room, Electrical, Anesthesia machine,
Ventilators, Ca pnometer, Oxygen, Hemodynamic monitors
12. Defubrillators: Automatic Internal, External, Implantable; Energy, Cardioversion,
Types of Waveforms (Monophasic, Biphasic); Paddle Size and Position;
Automated External Defibrillators (AEDs)
13. Pacemakers
a) Temporary Transvenous; Permanent (Epicardial, Endoca rd ial), Transcuta
neous
b) Types: Fixed Rate, Biventricular Synchronized, Ventricular, Atrial, Atrioventricular (A-V) Sequential
c) Standard Nomenclature
d) Reasons for Failure or Malfunction
14. Electrical; Fire and Explosion Hazards; Basic Electronics
a)
Source of Ignition; Static
b)
Prevention: Grounding, Isolation Transformers
c)
Macro and Micro Current Hazards
d)
Safety Regulations; National Fire Protection Association (NFPA)
14
standards
e)
Lasers, Laser Safety, Laser-Safe Endotracheal Tubes
15. Drug Delivery Devices: Patient-Controlled Intravenous and Epidural Analgesia,
Epidural and Subarachnoid Continuous Drug Delivery Devices
C.
MATHEMATICS
1. Simple Math: Logarithms; Graph of Simple Equations; Exponential Function,
Analysis of Biologic Curves
2. Statistics: Sample and Population; Probability; Mean, Median, and Mode; Standard
Deviation and Error; T-Test; Chi-Square; Regression Analysis/Correlation; Analysis
of Variance, Power Analysis, Mete-Analysis, Confidence Intervals, Odds Ratio, Risk
Ratio
3. Computer: Data Handling, Processing, and Analysis
a) Basic Computer Knowledge: Programs vs. Operating System, Computer Virus,
Disk Or Central Processing Unit (CPU) Failure, Amplifiers, Microprocessors
D.
PHARMACOLOGY
1. GeneralConcepts
a) Pharmacokinetics and Pharmacodynamics, Protein Binding; Partition
Coefficients; pka; Ionization; Tissue Uptake; Compartmentalization and
Exponential Models
1) pharmacokinetics of neuraxial drug administration: epidural and suba rachnoid
2) tolerance and tachyphylaxis
b) Termination of Action
1) elimination; biotransformation; context-sensitive half-time
2) impact of renal disease
3) impact of hepatic disease
c) Drug Interactions: Enzyme Induction and Inhibition, Hepatic Blood Flow, DrugDrug Binding
1) alternative and herbal medicines: perioperative implications
d) Drug Reactions (Anaphylactoid, Ana phylaxis, Idiosyncratic)
e) Pharmacogenetics
1) malignant hyperthermia (including diagnosis and therapy)
15
2) butyrylcholinesterase (pseudocholinesterase) deficiency
3) prolonged QT syndrome
4) genetic factors in drug dose-response relationships
f) Addiction
1) physiology and pharmacology
2) patient addiction: anesthetic implications
2. Anesthetics-Gases and Vapors
a) Physical Properties
b) Mechanism of Action
c) Effects on Central Nervous System (CNS)
d) Effects on Cardiovascular System
e) Effects on Respiration
f) Effects on Neuromuscular Function
g) Effects on Renal Function
h) Effects on Hepatic Function
i) Effects on Hematologic and Immune Systems
j) Biotransformation and Toxicity
k) Minimum Alveolar Concentration (MAC), Factors Affecting MAC
I) Trace Concentrations, OR Pollution, Personnel Hazards
m) Comparative Pha rmacodynamics
3. Anesthetics-Intravenous (Opioid and Non-Opioid Induction and Anesthetic
Agents)
a) Opioids
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
(a) intravenous
(b) epidural and intrathecal
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
16
7) side effects and toxicity
8) indications and contraindications
b) Barbiturates
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
c) Propofol
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
d) Etomidate
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
e) Benzodiazepines
1) mechanism of action
17
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
f) Ketamine
1) mechanism of action
2) pharmacokinetics and pharmacodynamics
3) metabolism and excretion
4) effect on circulation
5) effect on respiration
6) effect on other organs
7) side effects and toxicity
8) indications and contraindications
4. Anesthetics - Local
a) Uptake, Mechanism of Action
b) Biotransformation and Excretion
c) Comparison of Drugs and Chemical Groups
d) Prolongation of Action
e) Side Effects and Toxicity
1) CNS : seizures, cauda equina syndrome, transient neurological symptoms
2) cardiac
3) allergy
4) preservatives/additives
5) methemoglobinemia
5. Muscle Relaxants (Depolarizing, Non-Depolarizing)
a) Mechanism of Action
b) Pharmacokinetics and Pharmacodynamics, Abnormal Responses
c) Prolongation of Action; Synergism
18
d) Metabolism and Excretion
e) Side Effects and Toxicity
f) Indications and Contraindications
g) Antagonism of Blockade
h) Drug Interactions (Antibiotics, Antiepileptics, Lithium, Magnesium,
Inhalational Anesthetics)
II. CLINICAL SCIENCES
A.
ANESTHESIA PROCEDURES, METHODS, AND TECHNIQUES
1. Evaluation of the Patient and Preoperative Preparation
a) Laboratory Evaluation
1)American Society of Anesthesiologists (ASA) Preoperative Testing
Guidelines
2)American College of Cardiology/American Heart Association Guidelines
for Perioperative Cardiovascular Evaluation
b) Premedication
1) interaction with chronic drug therapy; interaction with anesthetic agents
2) adverse reactions to premedications; patient variability, dose response
curves, side effects
3) specific problems in disease states: hyperthyroidism and hypothyroidism,
drug abuse, glaucoma, uremia, increased CSF pressure, chronic steroid
ingestion, obesity, depression, COPD, hypertension
4) pediatric and geriatric doses, routes of administration
5) role in patients with allergies
6) alteration of gastric fluid volume and pH, sphincter tone
7) continuation vs. discontinuation of chronic medications:
antihypertensives, anti-anginal, antihyperglycemics, antidepressants,
platelet inhibitors, etc.
8) prophylactic cardiac risk reduction: beta-adrenergic blockers, etc.
(a) physical examination, airway evaluation
(b) NPO and full stomach status; implications for airway management,
choice of anesthesia technique and induction of anesthesia; gastric
19
emptying time; preoperative; full stomach and induction of anesthesia
(c) ASA Physical Status classification
2. Regional Anesthesia
a) General Topics: Premedication, Patient Position, Equipment, Monitoring and
Sedation
b) Spinal, Epidural, Caudal, Combined Spinal/Epidural
1) indications, contraindications
2) sites of actions
3) factors influencing onset, duration, and termination of action
4) systemic toxicity, test dose
5) complications (see also IIIC2f): precipitating factors, prevention, therapy,
implications of anticoagulants and platelet inhibitors: American Society of
Regional Anesthesia and Pain Medicine (ASRA) guidelines
c) Peripheral and Autonomic Nerve Blocks: Indications, Contraindications,
Techniques, Clinical Assessment, Complications, Use of Nerve Stimulators
1) head and neck
2) upper extremity/brachial plexus
3) trunk and perineum
4) lower extremity
d) IV Regional: Mechanism, Agents, Indications, Contraindications, Techniques,
Complications
3. General Anesthesia
a) Stages and Signs of Anesthesia; Awareness Under Anesthesia
b) Techniques: Inhalational, Total Intravenous, Combined
Inhalational/Intravenous
c) Airway Management
1) assessment/identification of difficult airway: anatomic correlates,
Mallampati classification, range of motion
2) techniques for managing airway: awake vs. asleep, use vs. avoidance of
muscle relaxants, drug selection, retrograde intubation techniques, ASA
Difficult Airway Algorithm
20
3) devices: flexible fiberoptic, rigid fiberoptic, transillumination,
laryngoscope blades, alternative intubating devices
4) alternatives and adjuncts: laryngeal mask airway (traditional and
modified), esophageal obturator airways, occlusive pharyngeal airways
5) transcutaneous or surgical airway: tracheostomy, cricothyroidotomy,
translaryngeal or transtracheal jet ventilation
6) endobronchial intubation: double-lumen endobronchial tubes; bronchial
blockers (integral to endotracheal tube or separate), placement and
positioning considerations, postoperative considerations
7) intubation and tube change adjuncts: bougies, jet stylettes, soft and rigid
tube change devices; complications
d) ASA monitoring standards
4. Monitored Anesthesia Care and Sedation: ASA Guidelines for Sedation, Sedation
Guidelines for Non-Anesthesiologists
5. Intravenous Fluid Therapy During Anesthesia: Water, Electrolyte, Glucose
Requirements and Disposition, Crystalloid vs. Colloid
6. Complications (Etiology, Prevention, Treatment)
a) Trauma
1) upper airway, epistaxis
2) larynx, trachea, and esophagus
3) eyes: corneal abrasions, blindness
4) vascular; arterial and venous thrombosis; thrombophlebitis; sheared
catheter, intra-arterial injections, air embolism, cardiac/vascular
perforations, pulmonary artery rupture
5) neurological: pressure injuries of mask, tourniquet, body position, intra
neural injections, retractors, peripheral neuropathies
6) burns
b) Chronic Environmental Exposure; Fertility, Teratogenicity, Carcinogen icily,
Scavenging
c) Temperature
1) hypothermia: etiology, prevention, treatment, complications (shivering, 02
21
consumption), prognosis
2) nonmalignant hyperthermia; complications, treatment
d) Bronchospasm
e) Anaphylaxis
1) latex allergy
2) other
f) Laryngospasm
g) Postobstructive Pulmonary Edema h) Aspiration of Gastric Contents
7. Special Techniques
a) Controlled Hypotension; Choice of Drugs, Use of Posture, Ventilation
b) Controlled Hypothermia; Techniques, Systemic Effects, Shivering,
Rewarming, Complications
c) Hyperbaric Oxygen and Anesthesia Care
d) High Altitude Anesthesia
8. Postoperative Period
a) Pain Relief
1) pharmacologic
(a) drugs: opioids, agonist-antagonists, local anesthetics, alpha-2
agonists, nonsteroidal anti-inflammatory drugs (NSAIDs), N-MethylD-Aspartate (NMDA) receptor blockers
(b) routes: oral, subcutaneous (SC), transcutaneous, transmucosal,
intramuscular (IM), intravenous (IV), including patient-controlled
analgesia (PCA), epidural, spinal, interpleural, other regional
techniques
2) other techniques; Transcutaneous Electrical Nerve Stimulation (TENS);
cryotherapy; acupuncture, hypnosis
b) Respiratory Consequences of Anesthesia and of Surgical Incisions
c) Cardiovascular Consequences of General and Regional Anesthesia:
Differential Diagnosis and Treatment of Postoperative Hypertension and
Hypotension
d) Neurologic Consequences of Anesthesia: Confusion, Delirium, Cognitive
22
Dysfunction, Failure to awaken
e) Nausea and Vomiting
1) physiology; etiology; risk factors, preventive strategies
2) use of antacids, histamine-2 (H2) blockers, metoclopramide, transdermal
scopolamine, droperidol, serotonin antagonists, proton pump inhibitors,
dexamethasone, multimodal therapy, acupressure/acupuncture
f) Neuromuscular consequences: residual paralysis, muscle soreness, recovery of
airway reflexes
Patient Care:
Using the above medical knowledge the resident is expected (after completion of the Clinical
anesthesia rotations) to:
1. Evaluate patients and develop a treatment plan
2. Anticipate and manage problems commonly encountered during anesthesia
3. Formulate a comprehensive plan for peri-operative assessment and management of
the patients undergoing anesthesia
4. Demonstrate the ability to function as a member of the global healthcare team
5. Understand the administration/complications/benefits of the various pharmacologic
agents sufficiently to make sound medical judgments appropriate for providing a safe
anesthetic
6. Skillfully perform procedures, including, but not limited to:
a. Obtaining intravenous access
b. Placement of intra-operative monitors
c. Induction of Anesthesia
d. Endotracheal intubation
e. Placement of arterial lines
f. Placement of pulmonary artery catheters
g. Placement of spinal/ epidurals for post-operative analgesia Pre-operative
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 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 anesthesia,
alternatives, and risks and benefits of treatment options
23
6. Obtaining informed consent for anesthetic procedures
7. Answering questions from patient and or family members regarding 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
3. Incorporating the concepts of cost-benefit analysis when considering therapeutic
options
4. Interpreting the constraints associated with management of the operating room and be
able to integrate this understanding into best patient care practices
5. Emphasizing safety for the patient as well as operating room personal
6. Obtaining a better understanding of the tools that are being utilized to assess best
practices in anesthesia by organizations such as Magnet and Leapfrog
7. Working towards developing team building skills
Practice Based Learning and Improvement:
After completing this rotation, residents will have gained experience and competence in:
1. Self-directed learning
2. Becoming more efficient at locating medical information associated with acute pain
3. Reviewing the medical literature related to the field of acute pain and integrating this
information with the care of the patient
4. Learning to better utilize information technology to access on-line medical
information pertaining to innovative diagnostic and therapeutic modalities in the area
of acute pain
24
5. Transferring knowledge about acute pain 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 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 provide them real-time feedback concerning their performance in
the delivery of anesthesia services. Informal discussions with the anesthesia residents address
any deficiencies in patient care or knowledge base. Additionally, we try to know our trainees
personally to better understand and/or address underlying stressors or personal issues that may
interfere with learning and performance.
Every six months, the American Board of Anesthesiology requires that the Clinical Competency
Committee submit a Resident Training and Evaluation Report. In addition to the basic
competencies, we submit our evaluation of a trainee’s progress in the following areas:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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
25
17.
18.
19.
20.
21.
22.
23.
24.
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
Suggested Readings:
Suggested reading assignments to expand knowledge and patient care for this rotation include
but are not limited to the most recent editions of the following textbooks:









Anesthesia-Miller
Atlas of Regional Anesthesia – Brown
Clinical Anesthesia-Barash, Cullen, Stoelting
Clinical Anesthesiology-Morgan, Mikhail, Murray
Peripheral Nerve Blocks-Hadzic, Vloka
Pharmacology and Physiology in Anesthetic Practice – Stoelting, Dierdorf
Principles and Practice of Anesthesiology-Longnecker, Tinker, Morgan
Understanding Anesthesia Equipment-Dorsch, Dorsch
Annual Refresher Course Lectures and Basic Science Reviews of the ASA
(published annually)
Review articles in the following peer-reviewed journals provide useful reading:



Anesthesiology
Anesthesia and Analgesia
British Journal of Anesthesia
26