Beth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine Rotation: Post Anesthesia Care Unit (CA-1, CA-2, CA-3) Goals GOALS AND OBJECTIVES To analyze and interpret various components of the anesthesia record and the anesthesiologist s report so as to facilitate optimal care for the patient recovering from anesthesia and surgery To observe, diagnose and manage commonly occurring medical problems arising in post operative patients To acquire management skills necessary to work with nursing and administrative personnel and to get patients as quickly as possible to their long term recovery sites (home, floor, ICU) thereby allowing efficient, continuing care in the operating room To communicate with anesthesia faculty, surgical team and other consultants, if warranted by change in patient condition Objectives by Core Competency Patient Care A. Acute pain management Be able to provide appropriate safe pain relief in the PACU using various pharmacologic measures including opioids, NSAIDS, intravenous PCA Pain management skills Develop in conjunction with pain service and the primary team the ability to place, test and use thoracic and lumbar epidural catheters In conjunction with the pain service and the primary team develop the ability to place and test common regional blocks in the postoperative patient when indicated B. Respiratory and pulmonary dysfunction Recognize and manage the obstructed airway, hypoxic or hypercarbic respiratory failure Diagnose aspiration pneumonia and institute adequate therapy Evaluate and manage patient with bronchospasm or stridor Diagnose and manage patient with postobstructive pulmonary edema Diagnose and manage patient with pneumothorax 1
Diagnose and manage post operative atelectasis Respiratory skills The resident should be able to maintain the airway and ventilate with mask and adjunctive airway devices, perform endotracheal intubation in either the sedated or awake patient The resident must be able to apply the ASA difficult airway algorithm The resident should be able provide mechanical ventilation The resident should utilize appropriate extubation criteria The resident will follow patients with chest x-rays and treat complications such as pneumothorax or hemothorax which could include placement of chest tubes C. Cardiovascular dysfunction Diagnose and manage cardiogenic, hypovolemic, septic and neurogenic shock Treat common perioperative arrhythmias and know when to consult specialists outside anesthesiology Diagnose and manage postoperative hypertension and hypotension Diagnose and treat myocardial ischemia Learn the judicious use of diuretics in patients who are fluid overloaded Vascular skills The resident should be able to manage basic and advanced cardiac life support and demonstrate leadership in the running of a code in the PACU The resident should be able to utilize invasive monitoring including arterial lines, central venous pressure and pulmonary artery catheters The resident should be adept at placement of arterial catheters and central venous catheters via internal jugular, subclavian or femoral route D. Renal dysfunction Assess volume status in patients Diagnose electrolyte abnormalities and correct them if appropriate E. Gastrointestinal dysfunction Identify causes of postoperative nausea and vomiting and treat appropriately GI skills The resident should be adept in the placement of nasogastric tubes in the awake patient F. Neurological dysfunction Identify, recognize and initiate appropriate therapy for delayed awakening Recognize and treat emergence related delirium 2
Recognize and treat acute postoperative neurological deficits in conjunction with the primary team and other specialists Recognize the common causes of motor block after neuraxial anesthesia and initiate diagnostic measures and consults if an epidural hematoma is suspected Recognize and treat inadequate return of neuromuscular function after general anesthesia G. Temperature dysfunction Diagnose and institute therapy for hypothermia Identify and treat appropriately patients with malignant hyperthermia H. Miscellaneous Problems Appropriately manage postoperative shivering Possess sufficient basic knowledge of common surgical procedures to be able to anticipate, recognize and appropriately treat postoperative problems and complications associated with each operation I. Apply criteria for safe discharge from PACU to the following: Home Inpatient Ward Intensive Care Unit Medical Knowledge A. Acute pain management Assess and develop strategies for postoperative pain management on the patient s arrival in the PACU Pain management skills Understand the theory behind multimodal analgesia and it's application in the perioperative period B. Respiratory and pulmonary dysfunction Understand the respiratory consequences of anesthesia and surgical incisions Generate a differential diagnosis of shortness of breath Respiratory skills The resident must understand the ASA difficult airway algorithm The resident should be familiar with various respiratory therapies The resident should know how to interpret blood gases The resident should know appropriate extubation criteria 3
C. Cardiovascular dysfunction Differentiate cardiogenic, hypovolemic, septic and neurogenic shock Develop differential diagnoses for common perioperative arrhythmias Generate a differential diagnosis for hypertension and hypotension Understand the causes and treatments for myocardial ischemia Understand the mechanisms of action of diuretics Vascular skills The resident should know the protocols for basic and advanced cardiac life support All residents must have current ACLS certification The resident should be able to select modalities of invasive monitoring including arterial lines, central venous pressure and pulmonary artery catheters D. Renal dysfunction Develop differential diagnosis for postoperative decrease in urine output and differentiate between pre-renal, renal and post-renal causes Identify causes of high urine output E. Gastrointestinal dysfunction Understand the mechanisms of action of anti-emetic agents GI skills The resident should be adept in the placement of nasogastric tubes in the awake patient F. Neurological dysfunction Identify the causes of delayed awakening and emergence related delirium Generate a differential diagnosis of postoperative neurological deficits Discuss the symptoms of an epidural hematoma and its implications Understand the implications of inadequate return of neuromuscular function after general anesthesia G. Temperature dysfunction Understand the implications of postoperative hypothermia Explain the management approach to patients with malignant hyperthermia H. Miscellaneous Problems Discuss the management of postoperative shivering and its implications I. Define criteria for safe discharge from PACU to the following: 4
Home Inpatient Ward Intensive Care Unit Practice-based Learning and Improvement Use down-time between patient arrivals from the operating room for independent self study or discuss with nursing and or the PACU attending, system based issues that occur at the workplace Prepare and present one 10 min. talk during the rotation to PACU nursing staff Critically evaluate intraoperative management of patients and how this impacts PACU course Interpersonal and Communication Skills Ability to communicate with anesthesia faculty and other consultants when significant changes in patient status occur Ability to communicate postoperative information to the surgical team accurately and efficiently, particularly when postoperative problems may be related to surgical complications Develop the ability to dialogue with nursing and resolve differences of opinion in the care of the patient Professionalism Coordinate postoperative care between surgical and nursing services in a way that is patient-centered Demonstrate sensitivity and responsiveness to patients culture, age, gender and disabilities Systems-based Practice Acquire management skills by working with nursing, surgical and administrative personnel to transfer patients from PACU to long term recovery sites (home, floor, ICU) Be able to discuss the concepts of Fast Tracking, Phase I and Phase II, Aldrete score and home readiness Have an understanding of the cost implications and impact on staffing on longer PACU stays 5
Have a basic understanding of the various anesthesia and surgery related factors, such as PONV, pain, urinary retention, etc and how they impact PACU length of stay and health care costs Advocate for quality patient care Miscellaneous Responsibilities At the discretion of the floor manager, on call attending or PACU attending, be available to help out with IV starts in the holding area, lunch breaks and urgent preops. These duties are expected to be very rare and should not be a frequent occurrence. Be responsible for cleaning up epidural carts in the holding area on a periodical basis. If the PACU is not busy the resident is welcomed to attend the daily afternoon resident lectures within the building. However the resident is still expected to field calls from the PACU nursing and be available to return if the situation warrants. Evaluation Residents will be evaluated by randomly chosen nursing staff towards the end of each rotation. Residents will be evaluated in the following competency areas and scores entered into the online resident evaluation program: o Professionalism and Honesty o Interpersonal skills and Communication o Availability and Responsiveness o Patient Care o Practice based Learning and Improvement The PACU director will also evaluate the residents that have rotated through PACU every month as will other PACU attendings as they encounter the PACU resident on a day to day basis. 6