Cardiothoracic and Vascular Anesthesia Rotation

Transcription

1 Cardithracic and Vascular Anesthesia Rtatin Gals and Objectives Department f Anesthesilgy and Periperative Medicine AU Medical Cllege f Gergia Intrductin Residents shuld prep their assigned in-huse patients themselves a day prir t the scheduled case. Fr utpatients, residents shuld review the pre-anesthesia evaluatin and ther relevant patient infrmatin including cardiac wrk up. Residents shuld call the assigned attending the night prir t surgery preferably befre 7 pm t discuss the case and address any issues. A line frm shuld be cmpleted and signed by the resident. The last few sets f vital signs and filling pressures befre leaving the OR shuld be dcumented and handed ver t the ICU nurse wh will assume care f the patient n arrival in the ICU. On arrival t ICU, the immediate pririty is t make sure that mnitring is transferred t ICU mnitr. Once stability is established, a detailed reprt shuld be given t the ICU nurse and ICU resident taking care f the patient befre leaving the ICU. N resident shuld clse the anesthesia recrd withut first infrming the attending. Please remember t print TEE reprt in additin t Anesthesia recrd Please refer t the cheat sheet fr cardiac OR develped by previus residents t set up a cardiac OR. A cpy will als be in the cardiac OR Expectatins All residents will have a CT ICU rtatin prir t the CT rtatin in the OR. Attending CT anesthesilgists will determine when residents wuld be cnsidered ready t be assigned t the CT rtatin. Fr instance, sme residents will be assigned t the CT mnths at the end f their CA-2 year t allw them t acquire the basic knwledge and skills needed in the CT rms. Residents wh fail t meet the fllwing criteria will have their CT rtatin terminated. This will give these residents time t acquire the necessary knwledge and skills needed t return t the CT rms. Critical errrs in dcumentatin Critical errrs in medical judgment Deficiencies in basic knwledge Critical errrs in technical skills Evaluatin at the end f the CT rtatin Mandatry presentatin f at least ne keywrd n Tuesdays at 06:30 am. Residents shuld meet at least a 75% attendance n these keywrd sessins. CT and Vascular Anesthesia Gals & Objectives May 19, 2014 Page 1

2 Satisfactry pass will depend n the cnsensus f attending Residents are encuraged t ask fr daily feedback frm attendings at the end f day At the discretin f the attending, residents will be given tw attempts at line placement and intubatins after which the attending will decide whether t take ver frm the resident. Orientatin fr residents starting first time CT rtatin Every effrt will be made t give a minute perating rm rientatin by ne f the CT attendings t help understand prgraming pump, clsed lp cmmunicatin with surgens and perfusinists, key events during cardiac case, safety during transprt, etc. Every effrt shall be made t pair up a new resident with a senir resident n rtatin fr the first cardiac case s that mre time will be spent t bserve and rient. Gals At the end f the 2-mnth rtatin, the resident shuld be able t Reliably perfrm a preperative evaluatin (including histry, physical exam and understanding special investigatins) fr the patient underging cardithracic and majr vascular surgery. Interpret labratry tests and imaging studies, and relate the data t surgical and anesthesia risk. List medical prblems, in rder f pririty, and frmulate an anesthetic plan tailred t the needs f the individual patient. Cunsel and educate patient and families as t the prcedures, risks and benefits f anesthesia care. Manage c-existing medical disease pre-, intra-, and pst-peratively. Select, apply, and cnsider the efficacy and accuracy f mnitring techniques. Execute the anesthetic plan in a well-prepared and skilled manner, including inductin and maintenance f simple cardithracic and majr vascular surgical prcedures.. Recgnize and respnd t significant changes in the patient s cnditin. Perfrm basic prcedures including: airway management, lung islatin techniques, peripheral and central lines, fltatin f Pulmnary Artery catheters, arterial catheters, spinal, epidural and intercstal nerve blcks. Fr the CA-3 year: In additin t the abve the resident shuld Objectives Be able t manage inductin and maintenance f medically cmplex cases underging cmplex cardithracic and vascular prcedures Demnstrate independent judgment in the management f patients underging surgery and anesthesia. Perfrm advanced prcedures Educatinal: The resident physician is expected t have a thrugh understanding f the pathphysilgy and current anesthetic management f patients that are abut t underg cardiac r thracic prcedures. At the end f the three-mnth rtatin he/she will be expected t have becme familiar with the fllwing cgnitive and prcedural skills. Cgnitive Skills: CT and Vascular Anesthesia Gals & Objectives May 19, 2014 Page 2

3 Cardiac: Preperative evaluatin ability t determine periperative risk and anesthetic management. Mnitring the cardithracic surgical patient, including but nt limited t; ECG, bld pressure (invasive and nninvasive), central venus pressure, pulmnary artery pressure, cardiac utput, mixed venus xygen saturatin, pulse xymetry, ABG analysis, capngraphy, temperature and basic TEE mnitring. vaspresing agnist), antiarrhythmias (B Blckers, CA channel blckers, Amidarne, etc.), diuretics. Anesthetic management: including inductin f anesthesia and management f the precardipulmnary bypass, cardipulmnary bypass and pst-cardipulmnary bypass perids. Pstperative care f the cardiac surgical patient: including but nt limited t ventilatry management, pain and sedatin cntrl, hemdynamic and cagulatin management. The resident will be expected t have a clear understanding f the pathphysilgy f cardipulmnary bypass, circulatry assist devices (IABP) and intraperative mycardial and brain prtectin. Thracic Preperative assessment: including risk stratificatin based n lung and cardiac functins. Mnitring with emphasis n ABG analysis and ventilatry mechanics. Lung separatin techniques, physilgy f ne lung ventilatin. Psitining Fiberptic brnchscpy and anesthetic techniques. Treatment f hypxemia during ne lung ventilatin. Pain and pstperative ventilatry management Prcedural Skills Insertin f invasive hemdynamic mnitring lines Pulmnary artery catheters Central venus lines Arterial catheters Endtracheal intubatin and ventilatry management Duble lumen endtracheal tubes (DLT) Brnchial blckers (BB) Tube exchangers Mdes f mechanical ventilatin: VC, PC, HFJO Fiberptic brnchscpy (awake fiberptic intubatins, fiberptic cnfirmatin f prper placement f DLTs and BBs) Basic transesphageal echcardigraphy (insertin f TEE prbe, indicatins and cntraindicatins fr periperative TEE, understanding basic TEE views) Pain management (thracic epidural, intercstal blcks, PCA) Cmmunicatins The resident physician will be evaluated n his ability t cmmunicate and interact with his/her peers, including: CT and Vascular Anesthesia Gals & Objectives May 19, 2014 Page 3

4 Patients and families Physicians, including anesthesilgists, residents, surgens and ther cnsultants Nurses, OR and anesthesia technicians, perfusinists, respiratry therapists, and ther supprt staff Prfessinal Behavir Cmpassinate care f patients Respect fr cwrkers Desire t learn (attendance t didactic sessins, case reviews, in-services, etc.) Willingness t wrk (arrives n time, desire t help member f the CT team, etc.) Cntinuity f care - Willingness t prvide cntinuus care intra- and pstperatively. CA-2 Duratin 2 mnths Residents may request additinal mnths in their CA-3 year fr mre expsure Educatin Objectives 1. Medical Knwledge: The resident physician is expected t have a thrugh understanding f the pathphysilgy and current anesthetic management f patients that are abut t underg cardiac, thracic and majr vascular prcedures. At the end f the tw-mnth rtatin he/she will be expected t have becme familiar with the fllwing cgnitive and prcedural skills. Cgnitive Skills: Cardiac: Thracic: Preperative evaluatin ability t determine periperative risk and frmulate a plan fr the anesthetic management. Mnitring the cardiac surgical patient, including but nt limited t; ECG, bld pressure (invasive and nninvasive), central venus pressure, pulmnary artery pressure, cardiac utput, mixed venus xygen saturatin, pulse xymetry, ABG analysis, capngraphy, temperature and basic TEE mnitring. Cardivascular drugs: Understanding the pharmaclgy f intrpes, vasdilatrs, vaspressrs, antiarrhythmics, and diuretics. The resident will be expected t have a clear understanding f the pathphysilgy f cardipulmnary bypass, circulatry assist devices (IABP) and intraperative mycardial and brain prtectin. Anesthetic management: including inductin f anesthesia and management f the precardipulmnary bypass, cardipulmnary bypass and pst-cardipulmnary bypass perids. Pst-perative care f the cardiac surgical patient: including but nt limited t ventilatry management, pain and sedatin cntrl, hemdynamic and cagulatin management. Understand the principles f bld transfusin practices and periperative bld cnservatin Pre-perative assessment: including risk stratificatin based n lung and cardiac functins Mnitring with emphasis n ABG analysis and ventilatry mechanics Lung separatin techniques, physilgy f ne-lung ventilatin CT and Vascular Anesthesia Gals & Objectives May 19, 2014 Page 4

5 Psitining Fiberptic brnchscpy. Treatment f hypxemia during ne lung ventilatin. Pst-perative pain and ventilatr management Majr Vascular: Preperative assessment: including risk stratificatin Understanding the pathphysilgy f majr vascular cases such as abdminal artic aneurysm repair and cartid endarterectmies Understanding the physilgy f artic crss clamping Understanding the cmplicatins f crss clamping Understanding the varius mnitring mdalities fr majr vascular as well as cartid endartectmies Pstperative care f the majr vascular patient Prcedural skills: Insertin f invasive hemdynamic mnitring lines Pulmnary artery catheters Central venus lines Arterial catheters Pacemakers Cardiversin Endtracheal intubatin and ventilatry management Duble lumen endtracheal tubes Brnchial blckers Tube exchangers Mdes f mechanical ventilatin: VC, PC, PS. Fiberptic brnchscpy (awake fiberptic intubatins, fiberptic cnfirmatin f prper placement DLTs and BBs) Basic TEE (insertin f TEE prbe, btaining basic TEE views) Pain management (thracic and lumbar epidural placement and management, Intraspinal narctics, Intercstal blcks, PCA) Methds f Evaluatin Glbal evaluatin 360 evaluatins by nurses, peers, surgens and medical students Daily feedback frm attendings 2. Patient Care: Cardiac: Residents will learn the principles f caring fr the cardiac patient t include Inductin f anesthesia Management f anesthesia during the prebypass perid Management f anesthesia during the bypass perid CT and Vascular Anesthesia Gals & Objectives May 19, 2014 Page 5

6 Thracic: Majr vascular: Weaning frm cardipulmnary bypass Management during the pst bypass perid Management f patients underging ff pump CABG Transfer f patient t the ICU Inductin f anesthesia Management f thracic epidural during case Psitining Lung islatin techniques Fiberptic laryngtrachebrnchscpy Truble sht hypxemia during ne lung ventilatin Emergence f anesthesia Transprt f patient Inductin f anesthesia Maintenance f anesthesia Management f lumbar epidural Management f the pathphysilgy f crss clamping Interpreting filling pressures and hemdynamic prfiles Emergence Transprt f patient Methds f Evaluatin Glbal evaluatin Daily evaluatins filled by each attending Interpersnal and Cmmunicatin skills Residents must be able t demnstrate interpersnal and cmmunicatin skills that result in effective infrmatin exchange with patients and their families as well as prfessinal assciates. Residents are expected t Explain the prcess f cardiac thracic and majr vascular anesthesia Discuss the risks f general and reginal anesthesia Cmmunicate with OR nurses, perfusinist, OR techs and ther supprt staff cncerning the care f the patient Cmmunicate with surgens abut the anesthetic plan as well as the intraperative management f the patient Cmmunicate with faculty and develp a plan fr the anesthetic management f the patient Cmmunicate with the ICU care team and give reprt cncerning the intraperative curse f the patent as well as pst perative management. Wrk effectively with ther members f the health care team Methds f Evaluatin: Glbal evaluatin Daily evaluatins filled by each attending 360 evaluatins by nurses, peers, surgens and medical students CT and Vascular Anesthesia Gals & Objectives May 19, 2014 Page 6

7 4. Prfessinalism: Residents must demnstrate A cmmitment t carry ut prfessinal respnsibilities, i.e., willingness t wrk (arrives n time, desire t help members f the CT team, etc.) Adherence t ethical principles Sensitivity and respnsiveness t a patient s culture age gender and disabilities. Desire t learn (attendance t didactic sessins, case reviews, in-services, etc.) Cntinuity f care: Willingness t prvide cntinuus care intra and pstperatively. Methds f Evaluatin Glbal evaluatin 360 evaluatins by nurses, peers, surgens and medical students 5. Practice Based Learning: Residents are expected t Lcate appraise and assimilate evidence frm scientific studies related t their patients health Able t access n line medical infrmatin t manage patients as well as supprt their wn educatin Able t use hspital based cmputerized recrd system as well as efficiently use the cmputerize recrd. Analyze practice experience and perfrm practice based imprvement activities using a systematic methdlgy facilitate the learning f students and ther health care prviders Recgnize limitatins and ask fr help when apprpriate Learn frm experience Methds f Evaluatin Glbal evaluatin CT/CTICU Key wrd presentatin during the rtatin 65% attendance fr Key wrd presentatin required 6. Systems Based Practice Residents are expected t Practice cst effective health care and resurce allcatin that d nt cmprmise the health f the patient Advcate fr quality patient care Partner with health care managers and health care prviders t assess crdinate and imprve health f their patients Suggested Reading Authr: Kaplan s Cardiac Anesthesia A Practical Apprach t Cardiac Anesthesia (Hensley) Cardithracic jurnals (e.g., Cardithracic and Vascular Anesthesia) The guidelines n hw t perfrm basic TEE exam (intranet) Cheat sheet fr OR rm set up CT and Vascular Anesthesia Gals & Objectives May 19, 2014 Page 7