CA-1 NEUROANESTHESIA ROTATION Medical Center Rotation Site Director: Dr. Thomas Kozhimannil Rotation Duration: 4 weeks Introduction: The goal of the Neurosurgical Anesthesia Rotation at the is to train physicians to be competent and compassionate practitioners of neurosurgical anesthesia. This Core-Neurosurgical Anesthesia rotation will introduce and concentrate on the basic practices of neuroanesthesia for patients with normal or abnormal intracranial, neuraxial, cerebrovascular, and peripheral nerve conditions. The basic sciences of anatomy, physiology, and physics as they relate to the pre- anesthetic assessment, intraoperative management, and post-operative care of the neurosurgical patient will be emphasized. Patients with intracranial pathology represent a significant proportion of the population requiring operative intervention. The physiology of intracranial dynamics and the pharmacologic results of anesthetic intervention constitute a specialty field of knowledge within that of general anesthesiology. Vascular malformations, trauma, and tumors all require an understanding concerning their origin, natural clinical course and potential for therapeutic intervention. Patients with chronic neurologic disorders represent a patient subgroup who benefit from the applied pharmacologic understanding of the neuroanesthesiologist. The goal of this rotation is proficiency in the administration of anesthesia and perioperative care of the patient undergoing a neurosurgical procedure. GOALS: Gain the skills, knowledge and attitudes during CA-1 to be able to care for a neurosurgery patient: o To train residents who are capable of providing high quality anesthesia care based on principles of teamwork and collaboration for neurosurgery procedures; o To train residents who use the bio-psychosocial model and life-long learning principles in providing high quality care to patients with vascular and non-vascular intracranial processes, physiology of intracranial conditions with and without increased ICP, spinal procedures, methods of cerebral and spinal protection and monitoring of neurosurgical patient. Page 1 of 6
Approximate Training Level Assessment Methods/Tools OBJECTIVES (by ACGME Competency) Patient Care Clinical Skills and Reasoning: o Performs a thorough preoperative assessment of neurosurgical patient (perception to mechanism or complex overt response) o Formulates a safe anesthetic management and monitoring plan for a neurosurgical patient, including consideration of anesthetic medication and gases effects on neuro-monitoring modalities (perception to complex overt response) o Formulates safe postoperative management plan for a neurosurgery patient (perception to complex overt response) o Interprets value of information provided by different monitoring modalities, such as electroencephalography and evoked potentials for the management of neurosurgical patient (perception to mechanism) Technical/Device Related Skills o Demonstrates skill in management and use of cerebral spinal fluid pressure monitoring devices (perception to mechanism) o Direct Observation o Simulation o Chart- review o Case logs o Observes neuromonitoring technicians prepare patient for neuromonitoring (perception, set) Patient Management o Skillfully places arterial, central line (perception to complex overt response) o Skillfully manages anesthetic induction, maintenance and emergence from anesthesia for patients undergoing procedures such as craniotomy, posterior fossa surgery, stereotactic surgery, head trauma, intracranial aneurysm and arteriovenous malformations, spinal surgery (perception to mechanism or complex overt response) o Direct Observation o Simulation o Chart- review o Case logs Page 2 of 6
o Demonstrates ability to manage neurosurgery patients with increased intracranial pressure, and/or at risk of air embolism, significant bleeding, intraoperative brain stem injury, patients with ruptured or un-ruptured intracranial aneurysm (perception to mechanism) o Demonstrates ability to manage anesthetic for a patient undergoing spinal surgery including safe and protective positioning of the patient, providing anesthetic that does not interfere with neuromonitoring (perception to mechanism or complex overt response) o Independently transports and transfers care to a secondary provider (complex overt response) Medical Knowledge o Discusses neuro-physiology including cerebral perfusion pressure, cerebral autoregulation, external effects on cerebral blood flow, cerebrospinal fluid physiology, blood-brain barrier physiology and pharmacology, effects of anesthetic medications and gases on cerebral blood flow and metabolism (knowledge to application) o Discusses neuropharmacology and different medications used in neurosurgery (knowledge to application) o Discusses protective effects of hypothermia on cerebral metabolic rate and oxygen consumption, discusses other brain protection strategies (knowledge to application) o Discuses anesthesia for intracranial and spinal surgical procedures (knowledge to application) o Discusses pathophysiologic mechanisms underlying the anesthetic management of a patient with increase intracranial pressure (knowledge to application) o Discusses risk factors, precautions and actions needed in patients with venous air embolism and significant bleeding during neurosurgical procedures (knowledge, application) o Discusses considerations specific to intracranial vascular surgery, o Introductory lecture series test o Anesthesia knowledge test o Annual in-training examination o Informal oral questioning o Simulation o Oral case presentations Page 3 of 6
such a vasospasm, re-rupture of aneurysm, arteriovenous malformation specific complications hydrocephalus (knowledge to application) o Discusses anesthetic considerations specific to cervical, thoracic and lumbar spinal surgery, including physiology of neuromonitoring (knowledge to application) Practice Based Learning and Improvement o Identify own learning deficits, develop a learning plan and carry it out (receiving to valuing) o Respond appropriately to constructive feedback (receiving to o Written essay describing an analysis of patient valuing) o Demonstrate ability to effectively search for literature (perception to management (areas of deficiencies, room for complex overt response) o Read, analyze and interpret the scientific literature improvement) o Immediate formative o Analyze own practice and determine ways in which you can improve your comprehensive anesthetic plan (analysis, valuing) feedback from attending o Direct observation o Journal club presentations and case presentations Interpersonal and Communication Skills o Teaches use of effective listening, questioning, and explanatory skills in gathering information from patients and in providing information to patients, families, the public, and other health care providers (valuing to internalizing) o Effectively and efficiently communicates pertinent patient information to a secondary care provider (valuing to internalizing) o Skill in working as a member of a patient care team including other physicians, nurses, neuromonitoring personnel, other health care professionals (valuing to internalizing) o Direct observation with patient o Direct observation in simulation o 360 global rating o Learner classroom presentation Page 4 of 6
o Maintain comprehensive, timely, and legible medical records (internalizing) Professionalism o Awareness and management of his/her own values and attitudes, which might interfere with appropriate patient care specific to management of cardiac and vascular patient (organizing, internalizing) o Responsiveness to and management of issues that relate to sociocultural aspects of family life, and social adjustment related to ethnicity, religion, culture, gender or sexual preference (internalizing) o Consistent compassion, honesty, integrity and respect for others in all professional activities (internalizing) System Based Practice o direct observation o 360 o Work in inter-professional teams to increase patient safety and quality of care (perception to complex overt response) o Coordinate patient care in the settings of cardiac surgery (perception o direct observation o 360 o M&M conference to complex overt response) o Discuss system-based problems as they pertain to patient care at M&M conferences (knowledge to analysis) presentation with system analysis Page 5 of 6
Scholarly/Research Activities Reading Requirements The resident should read the following chapters in Miller s Anesthesia prior to taking the rotation: Chapter 21 Cerebral Physiology and the Effects of Anesthetic Techniques Chapter 53 (Vol 2) Neurosurgical Anesthesia The resident should read the following chapters in Miller s Anesthesia while taking the rotation: Chapter 38 Neurologic Monitoring Chapter 28 Patient Positioning, especially the sections on Lateral Oblique Position (pp.1160-2) Prone (pp. 1162-3) Sitting (pp. 1164-6) Chapter 16 The Autonomic Nervous System Chapter 82 (Vol 2) Postoperative Blindness Chapter 79 (Vol 2) Brain Death Suggested Reading For additional references, the textbook ANESTHESIA AND NEUROSURGERY, 4 th edition, by Cottrell and Smith, 2001 by Mosby is suggested. The book is available in the library, and you may check out a second copy during your rotation. Please also see the list of Journal articles on https://wiki.umn.edu Assessments The resident will receive a summative written evaluation form at the end of the rotation from the Site Director, as well as verbal feedback informally throughout the rotation. The case-logs of the resident will also be evaluated periodically by the clinical competency committee for the number and type of procedures and anesthetic techniques entered to ensure they are obtaining adequate experience. Notes Page 6 of 6