| General Anesthesia |
| What is the formula for calculating ETT size? |
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Preoperative Evaluation Intraoperative Care The Postanesthesia Care Unit (PACU) or “Recovery Room” Critical Care and Trauma Medicine Anesthesia Outside the Operating Room Obstetric Anesthesia Ambulatory and Office-Based Anesthesia Operating Room Management |
| What questions should a medical doctor or surgeon ask an anesthetist? |
| Critical care |
| Medical Equipment |
| Postoperative care is the management of a patient after surgery. |
| Pre-Anaesthetic Check-Up (PAC) OPD |
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What is anesthesia? What is an anesthesiologist? What is a nurse anesthetist? How is anesthesia practiced in the _________? Do I need to see an anesthesiologist prior to my admission for surgery? Do I need to fast before surgery? I am taking medications. Should I continue to take them prior to surgery? What about premedication? What will happen to me in the operating room? What drugs are used to administer an anesthetic? What are the complications of anesthesia? What about postoperative pain relief? What does an anesthesiologist do? What is the difference between an anesthesiologist and a nurse anesthetist? Do I need a preoperative medical exam? Why must I not eat or drink prior to surgery? What about my medications? What is General Anesthesia? Will I need a breathing tube during surgery? What is spinal and epidural anesthesia? What are the advantages/disadvantages of spinal vs. epidural anesthesia? If I have an epidural/spinal will I be awake during my surgery? What is a spinal headache and how is it treated? Will anesthesia make me nauseous? How does my anesthesiologist know everything is OK during my surgery? I have a "bad heart" - should I worry? I am a smoker - is this a problem? Could I be allergic to the anesthetic? Do I really need an IV? When can the IV come out? I have a loose tooth - is that a problem? What happens when I "go to sleep"(general anesthesia)? Could I wake up during the surgery? How will my pain be treated after the surgery? If I'm given morphine after the anesthetic will I get addicted? Will I have a sore throat after the surgery? Will I experience nausea and vomiting after the surgery? Will I receive blood during my surgery? A relative of mine had a bad reaction to anesthesia. Could it happen to me? 50 Pediatric Anesthesia Questions 1. How is cardiac output different between an infant and an adult, and what are the anesthetic implications of these differences? 2. For a 900 gm premature infant, how would you specifically treat the following intraoperative events? 1. Increased HR, Increased BP 2. Increased HR, Decreased BP 3. Decreased HR, Decreased BP 3. What are normal vital signs for a newborn, 6 month old, 1 year old, and 6 year old? 4. Why are children predisposed to intra-operative bradycardia, and what is the treatment (mg/kg)? 5. Is there an absolute minimum dose for atropine? If so, what is it and why? 6. Why are children predisposed to hypothermia? What are the effects of volatile anesthetics on nonshivering (brown fat) thermogenesis? 7. What is the dose/kg of the following drugs: 1. Ondansetron 2. Metoclopramide 3. Ketorolac 4. Atropine 5. Neostigmine 6. Cefazolin 7. Ampicillin 8. Dexamethasone 9. Naloxone 8. What is the formula for calculating ETT size? 9. What laryngoscope blade type(s) and size(s) is/are appropriate for: 1. Newborns 2. 1-6 months 3. 6 months-6 years 4. 6 years-10 years 10. At what age do you use a cuffed ETT, and why? 11. What is your detailed algorithm for treating laryngospasm? 12. How are the physical characteristics of a child’s airway different from an adult’s? 13. Why does a child desaturate quickly during induction of general anesthesia? 14. Why is prevention of air bubbles in the IV especially important in children? 15. Explain why some anesthesiologists will NOT use succinylcholine in children, and others WILL use it. 16. What patient population is at risk for MH? List examples of disorders and operations associated with MH. What is the phone number for MHAUS? 17. What is the treatment of MH in detail? What is masseter spasm, and what would you do if you saw it during induction of a child? 18. What are NPO guidelines for a child? Differentiate between formula, breast milk, and clear liquids. 19. Describe the anesthetic implications of the following syndromes: 1. Osteogenesis Imperfecta 2. Cerebral Palsy 3. Pierre Robin Syndrome 20. What are the appropriate LMA sizes for a child? List by weight and/or age. 21. What are the different types of tracheo-esophageal fistula, and what are the airway management implications? Any other anesthetic implications? 22. What birth history questions should be asked in a preop interview for a neonate? 23. A 1 month old, ex-35 week premie is brought for elective outpatient surgery. Do you let the baby go home postoperatively, or observe him for 24 hours? Why? 24. What is your choice of anesthetic induction technique for a child with severe asthma? 25. Which intravenous agents (including induction agents, paralytics, opiates, etc) are associated with histamine release? 26. What is your airway management plan for a child with: 1. Choanal atresia 2. Cleft lip and palate 3. Micrognathia 27. What is the formula for estimating weight of a child if all you know is the age? 28. What are the anesthetic implications of pyloric stenosis? 29. What is the significance of a past history of a viral upper respiratory infection within the past 2-4 weeks? Would you cancel an elective case if a child had a history of infection 1 week ago, but seems fine now? Is there a difference in these children between LMA placement and intubation? 30. What is the oxygen consumption in ml/kg/min of a child vs. an adult? What are the anesthetic implications? 31. What is the hemoglobin in ml/kg of a neonate, a 6 month old, and a 6 year old? 32. How are the oxygen-hemoglobin curve and oxygen affinity affected by fetal hemoglobin? What are the anesthetic implications? 33. Would you use 100% oxygen on a 1 month old baby having an elective procedure? Why or why not? What if the child were 6 months old? 34. What is your maintenance fluid of choice for neonates? 35. On what part of the body would a branchial cleft cyst excision take place? What are the anesthetic implications of this surgery? 36. What are the differences between an omphalocele and gastroschesis? 37. What is VATER (or VACTERL) syndrome? 38. A nervous, crying mother of a calm 2 year old asks if she can come back for induction of anesthesia. How do you respond, in detail? 39. A mother tells you that her 6 yo child is a Jehovah’s Witness, and that she wants him to receive no blood products no matter what. His Hgb is 7, and he is having an extensive bowel resection. In detail, how do you respond? 40. Describe in detail how you would perform a caudal block on a 6kg infant having hypospadias repair, including medications and doses. 41. Describe in detail how you would intubate a child with severe epiglottitis. 3 days later, you are again consulted to extubate the child. Describe your plan. 42. A 5yo has just undergone exploratory laparotomy. What are your postoperative pain orders, and would you write for a PCA? If so, how would you dose it? 43. What are the anesthetic implications for a neonate with a large diaphragmatic hernia? How would you plan your anesthetic? 44. In detail, what is ECMO? 45. What are the advantages and disadvantages of preoperative midazolam for tonsillectomy in children? What is the dose? 46. Describe the differences between halothane and sevoflurane for children. Specifically comment on potency, pungency, MAC, side effects, and induction/emergence characteristics. 47. Describe the renal and hepatic function of a neonate. What are the anesthetic implications? When do they normalize? 48. At what age is MAC requirement highest? Draw the age vs. MAC curve. 49. What are the anesthetic implications of a child with Downs Syndrome? 50. What are the anesthetic implications of a child with Cystic Fibrosis? 1. Are there different kinds of anesthesia? 2. What are the risks of anesthesia? 3. What about eating or drinking before my anesthesia? 4. Should I take my usual medicines? 5. Could herbal medicines and other dietary supplements affect my anesthesia if I need surgery? 6. What makes office-based anesthesia different? 7. How is the epidural block performed for labor and delivery? 8. Should I stop smoking before my surgery? 9. Is there anything the anesthesiologist can do to prevent urinary retention? 10. Are anesthetic risks increased with long surgeries? 11. Are spinal anesthetics safe? 12. Should all of my muscles be sore for a day and a half after breast surgery? 13. I’m having problems swallowing and speaking long after surgery. What advice do you offer to help improve my problems? 14. Should my throat be sore five weeks after surgery? 15. Should my IV site continue to be sore and swollen three weeks after surgery? Excerpt from the Anesthesia and You section of the ASA Web site www.asahq.org/patientEducation/anesandyou.htm Q 1: Are there different kinds of anesthesia? A 1: There are three main categories of anesthesia: local, regional, and general. Each has many forms and uses. In local anesthesia, the anesthetic drug is usually injected into the tissue to numb just the specific location of your body requiring minor surgery, for example, on the hand or foot. In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery. You may remain awake, or you may be given a sedative. You do not see or feel the actual surgery take place. There are several kinds of regional anesthesia. Two of the most frequently used are spinal anesthesia and epidural anesthesia, which are produced by injections made with great exactness in the appropriate areas of the back. They are frequently preferred for childbirth and prostate surgery. In general anesthesia, you are unconscious and have no awareness or other sensations. There are a number of general anesthetic drugs. Some are gases or vapors inhaled through a breathing mask or tube and others are medications introduced through a vein. During anesthesia, you are carefully monitored, controlled and treated by your anesthesiologist, who uses sophisticated equipment to track all your major bodily functions. A breathing tube may be inserted through your mouth and frequently into the windpipe to maintain proper breathing during this period. The length and level of anesthesia is calculated and constantly adjusted with great precision. At the conclusion of surgery, your anesthesiologist will reverse the process and you will regain awareness in the recovery room. Q 2: What are the risks of anesthesia? A 2: All operations and all anesthesia have some risks, and they are dependent upon many factors including the type of surgery and the medical condition of the patient. Fortunately, adverse events are very rare. Your anesthesiologist takes precautions to prevent an accident from occurring just as you do when driving a car or crossing the street. The specific risks of anesthesia vary with the particular procedure and the condition of the patient. You should ask your anesthesiologist about any risks that may be associated with your anesthesia. Excerpt from the Anesthesia for Ambulatory Surgery Q 3: What about eating or drinking before my anesthesia? A 3: As a general rule, you should not eat or drink anything after midnight before your surgery. Under some circumstances, you may be given permission by your anesthesiologist to drink clear liquids up to a few hours before your anesthesia. Q 4: Should I take my usual medicines? A 4: Some medications should be taken and others should not. It is important to discuss this with your anesthesiologists. Do not interrupt medications unless your anesthesiologist or surgeon recommends it. Q 5: Could herbal medicines and other dietary supplements affect my anesthesia if I need surgery A 5: Anesthesiologists are conducting research to determine exactly how certain herbs and dietary supplements interact with certain anesthetics. They are finding that certain herbal medicines may prolong the effects of anesthesia. Others may increase the risks of bleeding or raise blood pressure. Some effects may be subtle and less critical, but for anesthesiologists anticipating a possible reaction is better than reacting to an unexpected condition. So it is very important to tell your doctor about everything you take before surgery. Q 6: What makes office-based anesthesia different? A 6: There is one fundamental and very important difference between office-based anesthesia and receiving anesthesia in a hospital or ambulatory surgical center. The strict, well-defined standards and regulations that keep surgery and anesthesia very safe in hospitals and ambulatory surgical centers do not uniformly apply to physicians offices in the United States. Q 7: How is the epidural block performed for labor and delivery? A 7: An epidural block is given in the lower back. You will either be sitting up or lying on your side. The block is administered below the level of the spinal cord. The anesthesiologist will use a local anesthesia to numb an area of your lower back. A special needle is placed in the epidural space just outside the spinal sac. Q 8: Should I stop smoking before my surgery? I am a long term smoker over 50 yrs. I will be having a inguinal hernia repair in about 2 weeks. I have been told that my lungs may get worse before they get better if I quit smoking now and it may interfere with my breathing during my anesthetic and after surgery. Is this true? What do you suggest? A 8: The bottom line is - quit smoking now! Your surgery represents a golden opportunity to do so. There is evidence that smokers who quit at or before surgery experience fewer symptoms of nicotine withdrawal and are more likely to succeed in their attempt to stop smoking long term. Although it may take 3 - 6 weeks for the lungs to recover from some of the effects of smoking, and you have only 2 weeks to go, there is still, on balance, benefit to you if you stop. As always, you have to look at the benefits and the risks. During the first few days after stopping, some people will experience an increase in mucus production in the air passages of the lungs. Some people think this might increase the possibility of a lung complication but there is no published evidence that this is true. On the other hand, the risks of a lung complication after a relatively minor operation such as inguinal hernia repair are rather low anyway. This is an operation that can be done without general anesthesia and intubation, which are associated with the lung complications you want to avoid. And there are also immediate physiologic benefits from stopping smoking, such as increased oxygen carried in the blood, and improvement in wound healing. Some authorities, the most prominent of whom is Dr David Warner from the Mayo Clinic, believe that this is an important public health issue. Dr Warner heads a new American Society of Anesthesiologists task force which is looking at how to help people quit smoking at the time of surgery. It's hard to do it on your own entirely, and the use of nicotine replacement therapy (NRT) - that is the nicotine patch or gum - can definitely help keep you off the cigarettes. Dr Warner concludes that NRT is safe, and probably effective for people trying to stop smoking around the time of surgery. Ask your primary care doctor to assist you with this. Q 9: Is there anything the anesthesiologist can do to prevent urinary retention? I am 75 year-old man. I have had surgeries for replaced knees, bladder tumors, and others, all with GA. After all the work is done and I am back home or in the hospital room I can never pee. A catheter has to be put in always. A lot of hospital and Dr. office people have told me that the anesthesia has affected my bladder muscle and it won’t squeeze the pee out. After 4-5 days when the catheter is taken out, I can pee again, but even then it takes a few days to get back to normal. Is there anything the anesthesiologist can do so my bladder will not be so affected? It is not a blockage like an enlarged prostate or anything (my urologist has confirmed that) but just the inability of the bladder to empty itself. A 9: Thanks for your interesting question. Studies have shown that anesthesia is only one of several factors that can cause your problem, which is known as “urinary retention”. But there is a perhaps understandable tendency among some doctors to blame anesthesia for anything that goes wrong after surgery! As anesthesiologists, we are accustomed to this phenomenon and usually are able to make light of it with our surgical colleagues. Spinal or epidural anesthesia is a well known cause of urinary retention – in these cases, the retention usually lasts only a few hours and can be remedied by emptying the bladder with a catheter during that short period of time while the anesthetic wears off. However, specific anesthetic agents used in premedication and in general anesthesia seem to have little to do with urinary retention. Similarly, analgesic (pain) medications probably have little effect. Surgery of the pelvis or urinary tract can cause urinary retention through inhibition of bladder reflexes caused by surgical manipulation. Another factor that can prevent the bladder from emptying normally is excess fluid administration resulting in bladder distension. Pain and anxiety can also contribute to the problem. The effects of non-anesthetic medications can play a part – the medications that do this, such as anticholinergic medications, have effects on parts of the autonomic nervous system which control bladder emptying. Inability to stand or sit after surgery has been found to be a common cause of retention. In older men, enlargement of the prostate gland frequently leads to urinary retention. Unfortunately, patients who have had urinary retention, like yourself, are at particularly high risk of having this happen again. Individuals with this problem often have an abnormal voiding history before the surgery, which may indicate the presence of an “occult” (silent) neuropathic (nerve) or obstructive bladder disorder. The fact that you have previously had surgery on your bladder makes me suspect that this is case – however this is only speculation, and you should discuss this in detail with your urologist. Your urologist may be able to do special tests to determine whether there is a subtle bladder problem which is your predisposing factor for postoperative urinary retention. Regrettably therefore, there is probably not much your anesthesiologist can do to prevent this from happening again. However, you should definitely discuss this problem with both your surgeon and your anesthesiologist before any subsequent surgery to try and address correctable factors, such as those I’ve mentioned, before, during and after the surgery. Q 10: Are anesthetic risks increased with long surgeries? I will be having breast surgery and reconstruction soon. My HMO has plastic surgeons who can do a bilateral mastectomy with a Deep Interior Epigastric Perforator (DIEP) flap reconstruction in 12-18 hours. An outside physician can do the same surgery in 6-8 hours. Can you tell me what greater risks would be involved in being under anesthesia for 12-18 hours versus 6-8 hours? I am 52 years old. Thank you. A 10: Thanks for your question. If you are a healthy individual without other medical problems, your risk of an anesthesia complication from a mastectomy and reconstructive surgery is rather low. I cannot comment on the risk of the surgical procedure itself, which is probably the most important issue in your case. I would advise you first of all to get some clarification from your surgeons as to why there is such a big time difference between the two procedures you describe. It is possible that the shorter procedure (6-8 hrs) is actually a different operation in some way. For that kind of information you should speak directly with your surgeons. The best person with whom to discuss the risks of anesthesia is an anesthesiologist who has had the opportunity to review your medical records, take a full medical history and examine you, and who is aware of the nature and extent of the planned operation. Having said all that, I am not aware of any evidence that the duration of general anesthesia by itself increases the risks of anesthesia complications. Studies of anesthesia-related risk have shown correlation with other factors, like: 1. Your general medical condition especially problems like diabetes, heart or lung disease, malnutrition or obesity, 2. Your functional status, that is your ability to tolerate at least moderate levels of physical activity. Obviously, anesthetic outcomes are also related to the skill and experience of the anesthesiologist or anesthesiology team that is taking care of you. The anesthetic needs to be tailored to your medical condition, to the surgery itself, and wherever possible, to your individual preferences. As with other medical outcomes, having your surgery in a center that performs larger numbers of the procedure is more likely to result in a good outcome than having it in a hospital does only a small number each year. Q 11: Are spinal anesthetics safe? I need a total hip replacement and the surgeon I’ve seen says he uses spinals for surgery. I’ve heard bad things about this and wonder how safe that kind of anesthesia is. A 11: Thanks for your question. You can rest assured that spinal anesthesia is a safe choice for hip surgery. Many patients when offered this type of anesthesia are concerned about serious side effects, such as paralysis, and also about troubling but less dangerous side effects, such as headache. There seems to be a common, although false, perception that these complications occur often. In fact, spinal anesthesia has a long track record of safety, with a rate of serious complications (low!) about equal to the rate of major problems with general anesthesia (also low!). Studies that have looked at the overall outcome of spinal and general anesthesia for hip surgery have not found a completely convincing advantage of one over the other, and therefore both types of anesthesia are commonly used. In our hospital, at least half of the hip replacement surgery is done with spinal anesthesia. Among the reasons it is favored, include: (1) more rapid recovery of mental function, (2) the lack of need for insertion of breathing tubes, (3) the lower incidence of nausea or vomiting, and (4) the prolongation of anesthesia after completion of surgery, which means a longer pain free period. Paralysis after spinal anesthesia is very rare. The number of patients who develop a headache is also quite low – in expert hands and using appropriately sized (small) needles, fewer than 1% or so of patients should have a headache. Although a “spinal headache” is troublesome, it is not life-threatening. Not all patients are candidates for spinal anesthesia. We do not offer this technique to patients who are at risk for internal bleeding problems or to patients with infection in the area where the needle is inserted. In our hospital, we try to offer a realistic explanation of the different anesthetic techniques, their risks and benefits. Assuming there is not an absolutely compelling reason to choose a particular technique, we usually allow the patient to make a choice. It is best for you to have this discussion with your anesthesiologist, the physician who will be responsible for this aspect of your care. Q 12: Should all of my muscles be sore for a day and a half after breast surgery? I had breast surgery a few years ago and will have to undergo a similar procedure again. I experienced severe muscle and joint pain 8 to 10 hours after the surgery and the pain lasted for about 36 hours. I had never experienced anything so painful before, and I am more than a little concerned about this happening again. What accounts for this pain? A 12: Thanks for your question. The severe muscle and joint discomfort you experienced after breast surgery is known as "postoperative myalgia". This is a fairly common, quite distressing, but rather interesting condition. It usually appears on the first day after surgery, is often described as feeling similar to the pain one might suffer after unaccustomed physical exercise, and is usually located in the neck, shoulder and upper abdominal muscles. There are a few theories about the cause of postoperative myalgia, but it is usually attributed to the use of a muscle relaxant drug called succinylcholine. Hence this is sometimes referred to as "scoline pain". Although the problem of postoperative myalgia has been recognized for many years, the exact way in which succinylcholine causes this muscle pain is not fully understood. Most believe that it is due to uncoordinated contraction of muscles that occurs a few seconds before the muscle relaxation that is the desired effect of the drug. It is also not clear how best to prevent scoline pain, short of avoiding the use of this drug altogether. It is natural to ask then why we continue to use this medication, and the reason is that succinylcholine, despite a few significant side-effects, is a very reliable and quick-acting muscle relaxant that helps the anesthesiologist "secure" the airway (place a breathing tube). Myalgia from succinylcholine is most common in young female patients, especially those undergoing ambulatory surgery (going home the same day as the surgery). The incidence of myalgia with succinylcholine ranges widely - in some reports it's as low as 1.5% but can be as high as 80 - 90%. To add to the mystery, some patients experience myalgia even when they are not given succinylcholine at all! Naturally you would like to avoid this very unpleasant experience at your forthcoming surgery. The good news is that there are other muscle relaxant drugs than can almost always be used instead of succinylcholine. This will not guarantee that you do not have the myalgia again but probably makes it much less likely. If the use of succinylcholine cannot be avoided, (this is rare), there are methods for decreasing the incidence and severity of the muscle pain, such as giving a very small dose of another muscle relaxant before the succinylcholine, or by giving a local anesthetic medication called lidocaine. Typically the pain lasts 2 or 3 days and it can be quite severe, as you've described. Fortunately it does go away without specific treatment. Standard pain medicines, such as acetaminophen can be prescribed. You or your anesthesiologist may be able to obtain the records of your previous anesthetic and hospital stay. This will supply clues about what happened to you during your last surgery. Be sure to discuss your concerns with your anesthesiologist, whose job is to evaluate you thoroughly and come up with a plan to provide you with a safe anesthetic, with minimum side-effects. Good luck! Q 13: I’m having problems swallowing and speaking long after surgery. What advice do you offer to help improve my problems? Over a period of 10 yrs., I’ve had 3 long cervical and 1 long lumbar spinal fusion. My voice has changed; sounds rasping when I’m tired; I have problems swallowing; learned to Heimlich myself when food gets stuck, and even have sudden muscle spasms trying to swallow saliva and think I’m going to choke to death. One surgeon said all the tubes put in during surgery could affect vocal chords, muscles, and nerves. What advice or help is there to relieve these problems? Does any of this also cause me to slur my words when I’m tired? I’d truly appreciate your insight. Many thanks. A 13: I’m sorry to hear of your difficulties. Recent studies are showing that endotracheal intubation – that is, the insertion of a plastic breathing tube into the windpipe – can cause minor damage to the vocal cords in a surprisingly high number of patients. This can occur even when the intubation is performed by an expert and appears to go absolutely smoothly. When the larynx (voice box) is examined with special instruments after apparently routine intubation, bruising or swelling of the vocal cord structures is often seen. This minor damage causes hoarseness which, fortunately, almost always improves over a few days. Unfortunately, endotracheal intubation is necessary for most surgeries on the spine, and we have not yet discovered ways to protect our patients from these minor injuries. More severe or permanent damage to the larynx (voice box) from endotracheal intubation is quite rare. Risk factors may include rheumatoid arthritis and the use of steroid medications. It is not clear whether damage to the voice box increases with the duration of the surgical procedure, but in someone who has had several long procedures, the chances of injury are probably higher. The symptoms other than hoarseness that you mention – problems swallowing, food obstruction, muscle spasms and slurred speech, do not sound like they are connected to the tubes you’ve had placed during surgery. They raise the possibility of a neurologic (nerve) problem, or a throat disorder, that might possibly be related to your previous surgical procedures but may also have nothing at all to do with them. I would strongly advise that you seek a specialist referral to an appropriate professional, such as an ear, nose and throat doctor or a neurologist. Q 14: Should my throat be sore five weeks after surgery? I had laparoscopic surgery 5 weeks ago for a hernia. Since that time, I had some minor nausea with severe hoarseness in my voice with a sore throat. The surgery itself went fine. The voice hoarseness and sore throat is still there and now I have vomited a small amount of blood one time. I had not eaten that day, and the blood was pink with saliva only. Could this be something caused from the anesthesia during surgery? I am not taking any medications at this time. Thank you for any help. A 14: A sore throat after general anesthesia is not uncommon, occurring about 20-30% of the time. In most cases it is mild, and gets better without treatment over a couple of days. Similarly, nausea after general anesthesia is quite common, especially if you are young, female, have had postoperative nausea or motion sickness before, a long anesthetic, and if you have had certain types of surgery, such as breast operations, eye or ear procedures, shoulder operations and others. It is certainly unusual that you would have your sore throat, or nausea, 5 weeks after the anesthetic. Coughing or vomiting blood is quite an alarming symptom so I'm sure you're worried. It doesn't necessarily represent something nasty but should definitely be investigated. Recent studies have shown that even when the intubation goes very smoothly, the passage of the breathing tube into the larynx (voice-box) and through the vocal cords often causes minor trauma - bruising. In rare cases, the small cartilages of the larynx can be significantly damaged, and this can take quite a long time to recover. The main symptom in this case is hoarseness. More serious injury to the voice box, or to the nerves that supply it, is also possible. Very rarely, the sore throat can be a sign of something even more ominous - a tear in the lining of the throat that if extensive can lead to severe infection, called mediastinitis. This can happen if the intubation (insertion of breathing tube) is traumatic for some reason, and if the lining of the throat is abnormally thin (e.g. elderly people, or those taking steroids) but this will usually happen over the few days immediately after the operation, not 5 weeks later. It is possible that your larynx was injured during the intubation or the course of the anesthetic. For this reason you should call your doctor and ask for a referral to an ENT (Ear, Nose and Throat) doctor who can do a thorough examination of your throat. It would also be a good idea if possible to make contact with your anesthesiologist. He or she will be keen to know that something has happened that might be related to anesthesia care and I imagine will be interested in helping you get diagnosed and appropriately treated. Q 15: Should my IV site continue to be sore and swollen three weeks after surgery? Three weeks ago today I had a tooth pulled by an Oral Surgeon and they ended up having to give me an IV to knock me out. The Oral Surgeon put the IV in the back of my hand. I have been having pain in my hand ever since I had the IV. Two week after the IV I noticed that the vein in my hand was swollen and it hurt up into my wrist. I did call the Oral Surgeons office and I did go see her. She said that there could be a possibility that it could be phlebitis or a blood clot. She told me to use an anti-inflammatory and to put warm compresses on my hand and to come back to see her in 3 days. I have another appointment with her today. I would like to know if something like this normal after having an IV. I did contact my Internal Medicine doctors office and they told me to see the Oral Surgeon today and see what she says and then to call their office back. Is this something that is normal or could it be a serious problem. A 15: Thanks for your question. Phlebitis is a term that means inflammation of a blood vessel. Phlebitis occurs quite commonly after the insertion of intravenous catheters ("IV"). The exact frequency of phlebitis is anywhere from 2.5 to 45% or more. There is a wide variation because it depends on how phlebitis is defined, as well as the place the IV is inserted, the duration that the IV has been in place, the type of material that the IV is made of, the length of the IV catheter, and on the existence of other disorders as diabetes. Phlebitis can also be associated with the formation of a blood clot in the vein. In more serious cases the site can become infected. If infection develops, the infection can be spread throughout the body. It would be very unusual for an IV placed in a hand, for a short period as you describe, to develop a serious infection. One sign of infection is the presence of enlarged lymph nodes under the arm on the affected side. Because of the risk (though small) of serious complications, you should definitely make sure to see your surgeon for the follow-up appointment. Hopefully the standard conservative treatment you mention will be successful. What is a Pediatric Anesthesiologist? A pediatric anesthesiologist is a doctor who specializes in taking care of children during surgery and other procedures. Many different types of procedures require your child to stay still or may cause them discomfort if no anesthesia is used. An anesthesiologist can combine the right types of medicine to make sure your child is comfortable during the procedure. They may or may not need to be all the way "asleep" for some procedures done outside the operating room. Your child will need to be asleep for most surgery done in the operating room. A pediatric anesthesiologist can evaluate you child and make the best decision for their care. A pediatric anesthesiologist is an anesthesiologist who has either a special interest in children and/or has received special training in pediatrics. Most anesthesiologist will go to college for 4 years, medical school for 4 years, and then do their internship and residency for 4 years. Pediatric anesthesiologists may have also done a pediatrics residency or an additional Pediatric Anesthesiology Fellowship. For more information please go to http://www.aap.org/sections/sap/he3003.pdf . Pediatric anesthesiologists take care of children of all ages from newborn to teenagers and are experienced in the special needs of children (and their families) at different ages. Their goal is to make the hospital experience as pleasant as they can, to help manage your child's anxiety before surgery and pain after surgery. Do Pediatric Anesthesiologists only work in the Operating Room (OR)? No. Pediatric anesthesiologists may be involved in sedating or anesthetizing your child for many different procedures outside of the OR. Many children can't lie still or cooperate enough to have a CT Scan or MRI. Bone marrow biopsies and lumbar punctures are procedures that young cancer patients may have to endure. The right kind of anesthesia can make these procedures much more bearable. Pediatric anesthesiologist may also be involved with helping preparing your child for surgery if they have complex medical problems. Many pediatric anesthesiologists will be involved with the pain service and will be experienced in different techniques and therapies to best manage your child's pain General Questions 1. Who’s in charge of my anesthetic? 2. What does my anesthesiologist do during surgery? 3. How risky is anesthesia? 4. Why can’t I eat and drink before anesthesia? 5. What kind of anesthesia will I have? 6. What is a general anesthetic? What are the side effects and possible complications? 7. What is a spinal anesthetic? What are the side effects and possible complications? 8. What is an epidural anesthetic? What are the side effects and possible complications? 9. What is a local anesthetic? What are the side effects and possible complications? 10. Can I get a preoperative sedative before I go to surgery? Commonly Asked Questions About Pain Relief in Labor and Delivery 11. What are my possible options for pain relief during labor and delivery? 12. Who performs spinal and epidural anesthesia? 13. What is an epidural anesthetic? 14. How is an epidural catheter placed? 15. What kind of pain relief can I expect from an epidural anesthetic? 16. Will an epidural slow my labor? 17. Will an epidural increase my chances of needing a C-section? 18. What is a spinal anesthetic? 19. What are the most common side-effects of epidural and spinal anesthesia? 20. What are the possible complications of epidural and spinal anesthesia? 1. Who’s in charge of my anesthetic? Your ASMG anesthesiologist is a physician who is board certified (or board eligible) in anesthesia, either by the American Board of Anesthesiology or the Royal College of Physicians and Surgeons in Canada. To become eligible to take these board exams, a physician must successfully complete four years of medical school, an internship and at least three years of intensive training in anesthesia. Many of the ASMG anesthesiologists have additional specialty training. You will meet your anesthesiologist prior to going into surgery. Your anesthesiologist will ask some questions about your health and/or ask you to fill out an anesthesia questionnaire. Your anesthesiologist will discuss the planned anesthetic with you. Please feel free to ask as many questions necessary for you to feel comfortable with the anesthetic plan. Other Questions 2. What does my anesthesiologist do during surgery? An anesthesiologist is with you the entire time you are in surgery. He/ she will be monitoring your vital signs and adjusting the anesthetic. Your anesthesiologist may also monitor your fluid and blood volume, and the functioning of your heart, lungs and kidneys with special monitors. Along with the anesthetic, your anesthesiologist may also administer IV fluids, blood, antibiotics and other necessary medications. Your anesthesiologist will accompany you to the recovery room or intensive care unit when surgery is done. He/she will stay with you until you are stable and the anesthetic is wearing off. 3. How risky is anesthesia? In general, the risk of serious injury or death during anesthesia is about the same as the risk when going for a car ride. Because you are in a car almost every day, you may not consider driving particularly risky. However, you probably rarely undergo an anesthetic so you may find yourself anxious before surgery. Remember that it is extremely unusual for healthy patients to have serious complications from anesthesia. However, a number of health problems may increase the risk of complications such as smoking, lung disease, heart disease, kidney failure, diabetes, and obesity. If you have any of these health problems, be sure to discuss them with your anesthesiologist. 4. Why can’t I eat and drink before anesthesia? While under anesthesia, you loose your protective reflexes such as coughing. However, it is possible to throw up during an anesthetic and easily aspirate gastric contents (in other words, whatever was in your stomach can end up in your lungs). If you have eaten or had fluids recently, there is more acid and particles in your stomach. Aspiration of this could cause extensive damage to your lungs. This "aspiration pneumonia" was one reason many people died under anesthesia many years ago before NPO ("fasting", or nothing by mouth) guidelines were instituted. During emergency surgery, many precautions are taken to limit the risk of aspiration pneumonia in patients with a "full stomach". However, it is best to follow the fasting guidelines set by your anesthesiologist for elective surgery. You may be asked to take some or all of your usual medications with a few sips of water before surgery - these are usually dissolved and out of your stomach by the time anesthesia starts. Your anesthesiologist may also recommend that you take certain antacids prior to your anesthetic if you are at risk for aspiration. 5. What kind of anesthesia will I have? The kind of anesthetics possible for surgery are: 1. General Anesthesia (completely asleep); 2. Regional Anesthesia (a region of your body is numbed by the use of a spinal, epidural or other type of injection); 3. Local Anesthesia (a numbing medicine is injected around the area of surgery.) The type of anesthesia you receive will depend on the type of surgery, your medical condition, your surgeon’s preferences, and your wishes. Your anesthesiologist will discuss all options available to you and make a suggestion for the type(s) of anesthetic. If you have any questions or concerns, please feel free to discuss the anesthetic with your anesthesiologist. 6. What is a general anesthetic? What are the side effects and possible complications? A general anesthetic usually starts with the IV injection of a medication that causes rapid loss of consciousness. Occasionally, anesthesia starts with the use of an inhaled anesthetic gas. This is usually easier and more comfortable for children. After the anesthetic has started, the anesthesiologist will use a combination of IV medications and anesthetic gases to keep you asleep during surgery. The anesthetic gas is turned off at the end of surgery when it’s time to wake up. Frequently, patients feel only moments have gone by when in reality, several hours may have passed. Anesthetics, like alcohol, affect everyone differently. Below are some of the more common side effects noted by patients recovering from general anesthesia: 1. Drowsy and tired feelings for hours after surgery. Anesthetics wear off at different rates in different people. Most people are awake enough to answer simple questions within 5-10 minutes after surgery, although many have short term memory loss, so that hours after surgery you may feel as though it took a long time to wake up. Many people also feel tired enough to sleep for long periods of time after surgery even though they can easily be awakened. The pain medications you get after surgery may also prolong these feelings of sleepiness. 2. Nausea. Approximately one third of people undergoing general anesthesia experience some nausea. If nausea has been a problem with past anesthetics, let your anesthesiologist know — there are a few things that can be done to help. Nausea can usually be treated quickly with medications, but a few people experience marked nausea despite our best efforts. If you have had problems with nausea after general anesthesia you might consider a regional or local anesthetic if these are options. 3. Headache. This occurs in approximately 10% of patients and is more common in patients prone to headaches and in patients who drink coffee (due to caffeine withdrawal). 4. Sore throat. While you are asleep you may have a soft plastic device in your throat to make sure your airway is open and air is moving in and out easily. Even when placed very carefully and delicately, you may experience a sore throat. This usually resolves in a day, but if there has been some difficulty in placing the plastic airway device, sore throat and hoarseness may persist for longer. Permanent damage to your throat or vocal cords is very unusual. 5. Damage to teeth. This is also usually due to the plastic airway device. Damage to teeth can happen during placement (even if the anesthesiologist is very careful) or on awakening if you bite down very hard on the plastic. Be sure to let your anesthesiologist know if you have loose teeth or delicate dental work. 6. Many people ask about the possibility of being awake and aware during surgery when they are supposed to be unconscious. This is exceedingly uncommon but may happen under unusual circumstances such as emergency surgery for a patient in shock - the patient’s vital signs may be so weak that they cannot tolerate much anesthetic. Remember that during a local or regional anesthetic you may be awake during all or part of the procedure depending on the amount of sedation given. 7. There are also a number of very rare but severe complications of general anesthesia such as injury to nerves, organs and possibly death. Some health problems may increase your risk of complications — please thoroughly discuss your health with your anesthesiologist. 7. What is a spinal anesthetic? What are the side effects and possible complications? A spinal anesthetic is an injection of medication in the lower part of the back. The medication is injected by a very small needle into the spinal fluid where it spreads out to numb the nerves that go to the lower half of your body. You may feel a tingling sensation or warmth spread over your legs as the medication begins to work. However, most people won’t feel any unusual sensations, but will notice that it is impossible to move their legs when the spinal anesthetic is working. Your anesthesiologist may test the level of anesthesia a few minutes after the injection to make sure it is working well. Many patients want to know if the spinal injection hurts. In general, the spinal anesthetic is no more painful than having an IV started. Usually an injection of local anesthetic is given at the skin level so that the placement of the spinal needle is not felt. Occasionally, you may feel an electric sensation down one leg — let the anesthesiologist know immediately so he or she may adjust the angle of the needle to make it more comfortable for you. The spinal injection may be difficult due to anatomic abnormalities such as scoliosis or unusual bone formation around the vertebra in the lower back. Your anesthesiologist may ask you to curl up and push you lower back out toward them. This straightens your back and increases the size of the small openings the spinal needle must go through. If you feel anxious about the spinal injection, your anesthesiologist may give you a sedative to help you relax. It’s best not to have you fully unconscious during the spinal injection since your anesthesiologist will probably need your assistance with positioning. Side effects of spinal anesthesia are uncommon, but the following are seen most often: 1. Spinal headache: Approximately 1% of patients will develop a headache within 24 hours after the spinal anesthetic. The cause of the headache is a slow leak of spinal fluid out the hole left by the needle. Changes in the shape and size of the needle have greatly reduced the incidence of this problem. Although a spinal headache is not life threatening, it can be quite uncomfortable. It is almost always more painful in the sitting or standing position than lying down. For many years, it was assumed that lying flat for 24 hours after a spinal injection would reduce the risk of spinal headache. We know now that position does not increase the risk. The headache will resolve spontaneously but this may take weeks. If the headache is mild, it may resolve quickly by drinking more fluids and taking caffeine. If the headache is severe and incapacitating, an alternative treatment is the "blood patch", which can usually resolve the headache within an hour. The blood patch is about 99% effective in relieving the headache, but often causes a pressure feeling in the lower back for a day. Serious complications from the blood patch are very rare and include infection or irritation of spinal nerves. 2. Difficulty urinating after the spinal anesthetic. Even when the spinal anesthetic appears completely resolved, it may be difficult to urinate for up to 24 hours. This problem is most common with older men (especially with prostate enlargement). If a bladder catheter is planned for surgery and postoperative care, difficulty urinating is not an issue. However, inability to urinate may delay your discharge from the hospital for "same day" surgeries. 3. Low blood pressure. A spinal anesthetic normally lowers blood pressure about 10 to 20 percent, and blood pressure returns to normal when the spinal anesthetic resolves. Occasionally, blood pressure falls more that expected, but can be treated quickly with IV fluids and medication. Low blood pressure may make some feel dizzy and nauseated. On some occasions the blood pressure may be slow to return to normal even after the spinal anesthetic has resolved. These patients are kept in the recovery room and treated until their blood pressure has returned to a normal range. Certain blood pressure medications are more likely to increase the possibility of these problems. Thankfully, serious complications of spinal anesthesia are very rare. The possible complications include infection, nerve damage, and death. Although many people fear nerve damage from a spinal anesthetic, the incidence of nerve injury from a spinal anesthetic is no greater than the incidence of nerve injury from general anesthesia. 8. What is an epidural anesthetic? What are the side effects and possible complications? An epidural anesthetic is very similar to a spinal anesthetic except the epidural needle does not puncture the sac that holds the spinal fluid. Instead, a tiny tube or catheter is inserted through the needle and comes to rest just outside the sac. Numbing medication is given through this tube that gradually gets absorbed through the sac and into the spinal fluid. The epidural anesthetic therefore takes longer to provide pain relief.. The benefit of an epidural anesthetic is that it can last much longer than a spinal anesthetic by leaving the soft epidural catheter in place and continually giving medication. This flexibility is what makes epidural anesthesia the choice for relief of pain during labor. Many times the epidural catheter is left in place after surgery in order to give medication through the tube to help manage postoperative pain. Many patients ask if the placement of the epidural catheter is painful. In general, the placement of an epidural catheter is no more painful than placement of an IV catheter. Usually an injection of local anesthetic is given at the skin level so that the placement of the epidural needle is not felt. Occasionally, you may feel an electric sensation down one leg — let the anesthesiologist know immediately so he or she may adjust the angle of the needle to make it more comfortable for you. Epidural placement may be difficult due to anatomic abnormalities such as scoliosis or unusual bone formation around the vertebra. Your anesthesiologist may ask you to curl up and push you lower back out toward them. This straightens your back and increases the size of the small openings the epidural needle must go through. If you feel anxious about the epidural, your anesthesiologist may give you a sedative to help you relax while the epidural is being placed. It’s best not to have you fully unconscious during the epidural placement since your anesthesiologist will probably need your assistance with positioning. Possible complications from epidurals are very similar to those from spinal anesthetic (see question 7). Side effects can also occur when the catheter does not end up in the correct position. Epidural catheters are placed by feel so even a very experienced anesthesiologist cannot know exactly where the end of the catheter lays. When the anesthesiologist places an epidural, they will give a small amount of medication called a "test dose" to help them determine the position of the catheter tip. If the catheter is not is the correct position, the catheter is usually removed and replaced. Sometimes the catheter can end up in a place where the numbing medicine cannot get into the spinal fluid sac and the epidural fails to work or makes only a few nerves numb. Occasionally the catheter ends up in a blood vessel and the numbing medicine gets into the blood circulation. If the epidural is in a blood vessel, you would experience dizziness, ringing in the ears and /or an increase in heart rate when the "test dose" is given. If the epidural needle or catheter ends up puncturing the spinal fluid sac, a spinal headache is possible and treatment is the same as for spinal headache. The administration of numbing medication intended for an epidural but given directly into the spinal fluid may result in the rapid onset of a high spinal anesthetic, a sharp drop in blood pressure and difficulty breathing. Again the small "test dose" helps the anesthesiologist determine the location of the catheter tip and usually prevents these problems from occurring. Other major complications from an epidural anesthetic are extremely rare and include infection, bleeding, seizures, nerve damage and death. Although many people fear nerve damage from epidural anesthesia, the incidence of nerve damage from epidurals is no greater than the incidence of nerve damage during a general anesthetic. 9. What is a local anesthetic? What are the side effects and possible complications? During a local anesthetic, a numbing medicine is injected around the surgical area. This injection may be done either by the surgeon or the anesthesiologist. Often, the anesthesiologist will give a sedative prior to the injection to make the procedure more comfortable for you. Many times the sedative causes a brief lapse of memory, and you may feel as though you have been asleep for part or all of the surgery. There may be moments during the surgery when you feel a pressure sensation where the surgeon is working. The anesthesiologist will be with you the entire surgery. Let them know if anything feels uncomfortable and they will make you more comfortable. The benefit of local anesthesia is that there are very few side effects or complications, and recovery time is usually faster than for other types of anesthesia. If the sedation becomes very heavy, the possible complications are similar to those of a general anesthetic. If a large amount of local anesthetic gets into the blood circulation, you may feel dizziness, ringing in your ears, and/or an increase in heart rate. Very rarely, a seizure may occur. 10. Can I get a preoperative sedative before I go to surgery? After speaking with your anesthesiologist and signing all consents you may usually have a sedative to relax before going into the operating room. 11. What are my possible options for pain relief during labor and delivery? 1. Some women prefer natural methods such as Lamaze. These techniques are usually taught outside the hospital prior to labor. 2. Your obstetrician may prescribe intravenous (IV) or intramuscular medication for pain. These usually relieve pain for a few hours, but may make both you and your baby sleepy. 3. Your obstetrician may request an anesthesia consult for spinal or epidural pain medication (more information below). 4. You may also combine techniques. For instance, you may start out in labor using natural relaxation techniques, but later choose intravenous medication. If the IV pain medication wears off before delivery, you may decide to request an epidural or spinal anesthetic. 12. Who performs spinal and epidural anesthesia? Spinal and epidural anesthetics are performed by anesthesiologists (medical doctors with training in anesthesia). Anesthesiologists are present in labor and delivery area of the hospital to provide pain relief, anesthesia for C-sections, and to assist the obstetrician with complex medical problems that may present during labor and delivery. 13. What is an epidural anesthetic? Epidural anesthesia is a type of regional anesthesia (i.e. it affects the lower region of your body). This is accomplished by the placement of a very small plastic tube into the lower back. One end of the tube rests just outside the sack that holds spinal fluid. A dilute solution of numbing medicine and narcotic is placed through the tube and gradually bathes the nerves going to your lower body to relieve pain. Medication can be given through the tube continuously and either increased or decreased as needed to keep you comfortable during labor. These medications stay in this area of your back and do not enter your blood stream in significant amounts. Because of this, you and your baby are not sedated. However, the epidural anesthetic may be started at a time in labor when you are very tired and you may naturally fall asleep when the pain goes away. Epidural anesthesia works quite well and about three-quarters of women delivering in hospitals request this type of pain relief. 14. How is an epidural catheter placed? If you choose to have an epidural anesthetic, the anesthesiologist will ask you to curl up on your side or sit up with your knees bent and head down. These positions curve your lower back and separate the bones in your spine. The anesthesiologist will wash your back off with antiseptic and then inject a local anesthetic to numb the small area where the epidural will be placed. The anesthesiologist will ask you to do your best not to move at this point. A needle is placed in your lower back (between the bones) and the catheter is inserted through the needle. You may feel a brief tingling sensation down one leg during this process. The needle is then removed and the epidural catheter is taped to your back. After delivery, the epidural catheter is removed and the numbness wears off over a few hours. 15. What kind of pain relief can I expect from an epidural anesthetic? The goal of a labor epidural anesthetic is to significantly reduce the pain while leaving enough sensation to feel pressure and push during delivery. The epidural medication generally begins to work within 5 minutes, but can take up to 15 minutes to achieve its full effect. Sometimes your pain relief may not be complete, or it may be one sided. In most cases, changing your position, changing the dose of medication, and/or repositioning the catheter in your back resolves this. On occasion, the catheter may need to be replaced. Be sure to talk to your nurse or anesthesiologist if you have concerns about the amount of pain you feel. 16. Will an epidural slow my labor? There has been much debate and research on this topic. Generally, epidural anesthesia does not dramatically effect the progress of labor and delivery. Sometimes there is a brief slowing of contractions thought to be due to the extra IV fluids given around the time of epidural placement. Occasionally, labor progresses more rapidly after the epidural anesthetic is working and you are more relaxed. One factor important for a good labor pattern is the placement of the epidural only after labor is regular and your cervix is dilating. 17. Will an epidural increase my chances of needing a C-section? Statistically, there is a higher rate of C-sections in laboring women with epidural anesthesia. However, this is due to the fact that women who have more difficult labor (due to multiple factors including the size and position of the baby) and intolerable pain are more likely to ask for epidural anesthesia. This same group of women are more likely to require C-section for delivery because of factors unrelated to the anesthetic. 18. What is a spinal anesthetic? A spinal anesthetic is a single injection of medication in the lower back. The medication is injected by a very small needle directly into the spinal fluid where it spreads out to affect the nerves that go to your lower body. A spinal anesthetic is often used as a complete anesthetic for C-sections. However, the dose and type of medication can be changed to act as a pain reliever during labor. Labor spinal anesthesia provides almost immediate pain relief, but only last about two hours. A spinal anesthetic may be a good choice for you if you are almost ready to deliver and need urgent pain relief. A combined spinal/epidural anesthetic is another option. The initial dose of medication is given through the spinal needle for fast pain relief and then an epidural catheter is inserted for extended pain management. 19. What are the most common side-effects of epidural and spinal anesthesia? The most common side effects from epidural and spinal anesthesia are: 1. Itching — this is not an allergy, but a common side effect of some of the medication. 2. A decrease in blood pressure — this is due to the medications and relief of pain. This is usually counteracted with increased IV fluids and occasionally, medication. For this reason, an IV is placed prior to the epidural. Vital signs of you and your baby will be followed during the epidural anesthetic. 3. Shaking — this is a side effect of the epidural medication, rapid infusion of relatively cold IV fluid, and labor itself. 20. What are the possible complications of epidural and spinal anesthesia? 1. Infrequently, once the anesthetic takes effect, the mother’s uterus contracts very hard. This may cause the baby’s heart rate to decline briefly, but does not harm the baby. 2. Approximately one in every four hundred patients receiving spinal or epidural anesthesia gets a spinal headache. Spinal headaches usually start the day after the anesthetic. These headaches can be painful, but are not life threatening and can be treated. 3. On rare occasions, the epidural medication may go into a blood vessel. A very large dose could cause a loss of consciousness or a seizure. Small doses are normally used for labor. 4. Occasionally, the anesthetic can be too strong and breathing assistance may be required. 5. Very rarely, back or nerve damage can occur. 6. While extremely rare, major organ damage or death may result from any anesthetic. What anesthetics do you use? What are these? What is induction? What drugs do you use for this? Are patients intubated? How do you know you are not giving too much anesthesia? What is the medical history of Anesthesia? nitrous oxide as an anesthetic when in 1844 he performed tooth extractions using this gas. in 1846 (a simple glass globe housing an ether-soaked sponge so that patients could inhale the vapor through one of two outlets). On October 16, 1846, ______ invention was tested in the surgical amphitheater of _____ Hospital when a 20-year old man was successfully anesthetized so a tumor could be painlessly removed. This signaled the birth of the modern medical use of Anesthetics. Why does the anesthesiologist need my medical history? In order to achieve a clear understanding of your needs and to determine the best anesthetic for you, information regarding your medical conditions must be obtained by your anesthesiologist. It is important to bring a list of all medications that you take on a regular basis or have taken recently. Please remember to include over-the-counter drugs as well as herbal remedies. Smoking and drinking also impact the effect of anesthesia throughout your system. Why are patients not allowed to eat or drink before surgery? For most procedures it is necessary for you to have an empty stomach so that the chances of regurgitating any undigested food or liquids are greatly reduced. What are local, regional and general anesthetics? Local: In local anesthesia, the anesthetic drug is usually injected into the tissue to numb just the specific location of your requiring minor surgery. Regional: In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery. You may remain awake, or you may be given a sedative. Two of the most frequently used are spinal anesthesia and epidural anesthesia. General: In general anesthesia you have no awareness or other sensations. Some general anesthetic drugs are gases or vapors inhaled through a breathing mask or tube, and others are medications introduced through a vein. During anesthesia, you are carefully monitored, and your anesthesiologist tracks all your major bodily functions. At the conclusion of your surgery, your anesthesiologist will reverse the process and you will regain awareness in the recovery room. Who will give the anesthetic? What type of anesthesia will be used and what are the risks associated with it? Is the anesthesia provider qualified and trained in Advanced-Cardiac Life Support? Who will help me during recovery from the anesthesia? Are they qualified to recognize medical emergencies? What type of monitoring will be used? Is the anesthesia provider trained to use the monitoring equipment? Does the anesthesia equipment have the latest safety features? Is the equipment tested regularly to make sure it works properly? (New technology, including pulse oximetry and capnography should, in our opinion, be readily available.) What emergency preparations and procedures will be in place? If a child is having anesthetic, is the office equipped with resuscitation equipment suitable for a child? Is the anesthesia provider qualified and trained in Pediatric Advanced-Cardiac Life Support? No matter what type of anesthetic is used, is the OT equipped with: * a defibrillator * extra oxygen * a fully stocked crash cart * an IV that will be in place in case of an emergency * C02 monitor * EKG With respect to post-operative pain, who gives the prescription? Who do you call with pain problems? Planning for anesthesia: * What do I need to know about anesthesia? * Who will be caring for me when I receive anesthesia? * What factors affect the choice of anesthesia? Types of anesthesia: * What are the major types of anesthesia? Anesthesia - Types of Anesthesia Anesthesia involves the use of medicines to block pain sensations (analgesia) during surgery and other medical procedures. Anesthesia also reduces many of your body's normal stress reactions to surgery. The type of anesthesia used for your surgery depends on: * Your medical history, including other surgeries you have had and any conditions you have (such as diabetes). You will also be asked whether you have had any allergic reactions to any anesthetics or medicines or whether any family members have had reactions to anesthetics. * The results of your physical examination. A physical exam will be done to evaluate your current health and identify any potential risks or complications that may affect your anesthesia care. * Tests such as blood tests or an electrocardiogram (EKG, ECG), if needed. * The type of surgery that you are having. o You need to be able to lie still and remain calm during surgery done with local or regional anesthesia. o Young children usually cannot stay still during surgery and need general anesthesia. o Adults who are extremely anxious, in pain, or have muscle disorders also may have difficulty remaining relaxed and cooperative. o Some surgical procedures require specific positions that may be uncomfortable for long periods if you are awake. o Some procedures require the use of medicines that cause muscle relaxation and affect your ability to breathe on your own. In such cases, your breathing can best be supported if general anesthesia is used. Based on your medical condition, your anesthesia specialist may prefer one type of anesthesia over another for your surgery. When the risks and benefits of different anesthesia options are equal, your anesthesia specialist may let you choose the type of anesthesia. Anesthesia methods There are several ways that anesthesia can be given. * Local anesthesia involves injection of a local anesthetic (numbing agent) directly into the surgical area to block pain sensations. It is used only for minor procedures on a limited part of the body. You may remain awake, though you will likely receive medicine to help you relax or sleep during the surgery. * Regional anesthesia involves injection of a local anesthetic (numbing agent) around major nerves or the spinal cord to block pain from a larger but still limited part of the body. You will likely receive medicine to help you relax or sleep during surgery. Major types of regional anesthesia include: o Peripheral nerve blocks. A local anesthetic is injected near a specific nerve or group of nerves to block pain from the area of the body supplied by the nerve. Nerve blocks are most commonly used for procedures on the hands, arms, feet, legs, or face. o Epidural and spinal anesthesia. A local anesthetic is injected near the spinal cord and nerves that connect to the spinal cord to block pain from an entire region of the body, such as the abdomen, hips, or legs. * General anesthesia is given into a vein (intravenously) or is inhaled. It affects the brain as well as the entire body. You are completely unaware and do not feel pain during the surgery. In addition, general anesthesia often causes forgetfulness (amnesia) right after surgery (postoperative period). For some minor procedures, a qualified health professional who is not an anesthesia specialist may give some limited types of anesthesia, such as procedural sedation. Procedural sedation combines the use of local anesthesia with small doses of sedative or analgesic agents (painkillers) to relax you. Medicines used for anesthesia A wide variety of medicines are used to provide anesthesia. Their effects can be complex, and they can interact with other medicines to cause different effects than when they are used alone. Anyone receiving anesthesia-even procedural sedation-must be monitored continuously to protect and maintain vital body functions. The complex task of managing the delivery of anesthesia medicines as well as monitoring your vital functions is done by anesthesia specialists. Medicines used for anesthesia help you relax, help relieve pain, induce sleepiness or forgetfulness, or make you unconscious. Anesthesia medicines include: * Local anesthetics, such as lidocaine (Xylocaine) or bupivacaine (Marcaine), that are injected directly into the body area involved in the surgery. * Intravenous (IV) anesthetics, such as sodium thiopental (Pentothal), midazolam (Versed), propofol (Diprivan), or fentanyl (Sublimaze), that are given through a vein. * Inhalation anesthetics, such as isoflurane and nitrous oxide, that you breathe through a mask. Other medicines that are often used during anesthesia include: * Muscle relaxants, which block transmission of nerve impulses to the muscles. They are used during anesthesia to temporarily relax muscle tone as needed. * Reversal agents, which are given to counteract or reverse the effects of other medicines such as muscle relaxants or sedatives given during anesthesia. Reversal agents may be used to reduce the time it takes to recover from anesthesia. Anesthesia - Risks and Complications Although all types of anesthesia involve some risk, major side effects and complications from anesthesia are uncommon. Your specific risks depend on your health, the type of anesthesia used, and your response to anesthesia. Personal risk factors Your age may be a risk factor. In general, the risks associated with anesthesia and surgery increase in older people. Certain medical conditions, such as heart, circulation, or nervous system problems, increase your risk of complications from anesthesia. Complications from local anesthesia When used properly, local anesthetics are safe and have few major side effects. But in high doses local anesthetics can have toxic effects caused by being absorbed through the bloodstream into the rest of the body (systemic toxicity). This may significantly affect your breathing, heartbeat, blood pressure, and other body functions. Because of these potential toxic effects, equipment for emergency care must be immediately available when local anesthetics are used. Complications from regional anesthesia For regional anesthesia, an anesthetic is injected close to a nerve, a bundle of nerves, or the spinal cord. In rare cases, nerve damage can cause persistent numbness, weakness, or pain. Regional anesthesia (regional nerve blocks, epidural and spinal anesthesia) also carries the risk of systemic toxicity if the anesthetic is absorbed through the bloodstream into the body. Other complications include heart or lung problems, and infection, swelling, or bruising (hematoma) at the injection site. Spinal anesthesia medicine is injected into the fluid that surrounds the spinal cord (cerebrospinal fluid). The most common complication of spinal anesthesia is a headache caused by leaking of this fluid. With current techniques of giving spinal anesthesia, this occurs in about 1% to 2% of all people who have spinal anesthesia and is more common in younger people. A spinal headache may be treated quickly with a blood patch to prevent further complications. A blood patch involves injecting a small amount of the person's own blood into the area where the leak is most likely occurring to seal the hole and to increase pressure in the spinal canal and relieve the pull on the membranes surrounding the canal. Complications from general anesthesia Serious side effects of general anesthesia are uncommon in people who are otherwise healthy. But because general anesthesia affects the whole body, it is more likely to cause side effects than local or regional anesthesia. Fortunately, most side effects of general anesthesia are minor and can be easily managed. General anesthesia suppresses the normal throat reflexes that prevent aspiration, such as swallowing, coughing, or gagging. Aspiration occurs when an object or liquid is inhaled into the respiratory tract (the windpipe or the lungs). To help prevent aspiration, an endotracheal (ET) tube may be inserted during general anesthesia. When an ET tube is in place, the lungs are protected so stomach contents cannot enter the lungs. Aspiration during anesthesia and surgery is very uncommon. To reduce this risk, people are usually instructed not to eat or drink anything for a specific number of hours before anesthesia so that the stomach is empty. Anesthesia specialists use many safety measures to minimize the risk of aspiration. Insertion or removal of airways may cause respiratory problems such as coughing; gagging; or muscle spasms in the voice box, or larynx (laryngospasm), or in the bronchial tubes in the lungs (bronchospasm). Insertion of airways also may cause an increase in blood pressure (hypertension) and heart rate (tachycardia). Other complications may include damage to teeth and lips, swelling in the larynx, sore throat, and hoarseness caused by injury or irritation of the larynx. Other serious risks of general anesthesia include changes in blood pressure or heart rate or rhythm, heart attack, or stroke. Death or serious illness or injury due solely to anesthesia is rare and is usually also related to complications from the surgery. Death occurs in about 1 in 250,000 people receiving general anesthesia, although risks are greater for those people with serious medical conditions.1 Some people who are going to have general anesthesia express concern that they will not be completely unconscious but will "wake up" and have some awareness during the surgical procedure. But awareness during general anesthesia is very rare because anesthesia specialists devote careful attention and use many methods to prevent this. Risks from reactions to anesthetic medicines Some anesthetic medicines may cause allergic or other abnormal reactions in some people, but these are rare. If you suspect you may have such a problem, you should tell both your surgeon and anesthesia specialist well before your surgery. Testing will then be arranged as necessary. A rare, potentially fatal condition called malignant hyperthermia (MH) may be triggered by some anesthetics. The anesthetics most commonly associated with malignant hyperthermia include the potent inhalation anesthetics and the muscle relaxant succinylcholine. For more information, see the listing for the Malignant Hyperthermia Association of the United States (MHAUS) in the Other Places to Get Help section of this topic. * What kinds of medicines are used for anesthesia? Risks and possible problems: * What are the potential risks or complications of anesthetic medicines? * What medical conditions may increase my risk of complications during anesthesia? Preparing for anesthesia: * How do I prepare for anesthesia? * Do I need to fast before my procedure? * How can I reduce anxiety before my procedure? What happens during anesthesia: * What happens while I am being given anesthesia? You likely will be given anesthesia by an anesthesia specialist. Final preparations before your surgery may include: * Attaching monitoring instruments to check your breathing, oxygen level, heart rate, blood pressure, and other body functions. * Positioning your body for surgery. You will be placed in a position that allows your surgeon access to the appropriate body area and avoids unnecessary pressure on any parts of your body. The three main phases of anesthesia are induction, maintenance, and emergence. Induction The first phase of anesthesia, when you first begin receiving an anesthetic, is called induction. For local anesthesia and many types of regional anesthesia, induction occurs when a local anesthetic is injected into the part of your body that needs to be anesthetized. Local and regional anesthesia often are given with other medicines that make you relaxed or sleepy (sedatives) or relieve pain (analgesics). These medicines are often given through a vein (intravenously, IV) before the local anesthetic is given. Induction of epidural and spinal anesthesia may require the insertion of a needle into the space around the spinal nerves in the lower back. You will receive an injection of local anesthetic to reduce discomfort before the needle is inserted. General anesthesia is often induced with intravenous anesthetics, but inhalation anesthetics also may be used. * Because they enter directly into the bloodstream, intravenous anesthetics usually cause unconsciousness in less than 1 minute. * Inhalation anesthetics also act quickly, but you must inhale them for a short time before they cause unconsciousness. Inhalation anesthetics are usually given through a mask that covers your nose and mouth. Induction with inhalation agents is mainly used for small children and adults who do not yet have an intravenous (IV) catheter. Maintenance and monitoring The second phase of anesthesia is called maintenance. During maintenance, the anesthesia specialist maintains a balance of medicines while carefully monitoring your breathing, heart rate, blood pressure, and other vital functions. Anesthesia is adjusted based on your responses during the procedure. With local anesthesia and regional nerve blocks, maintenance frequently requires additional injections of sedatives to prolong the effects for more lengthy procedures. For general anesthesia, after you are unconscious, anesthesia may be maintained with an inhalation anesthetic alone, with intravenous anesthetics, or most commonly with a combination of the two. Very often, inhalation anesthetics are given through an endotracheal (ET) tube or a laryngeal mask airway (LMA), which is an airway placed at the back of your throat but not in your windpipe like an ET tube. The airway is inserted after you become unconscious. It also is common during general anesthesia for you to be given other medicines intravenously to maintain stable vital functions and to help prevent or decrease pain or nausea after the procedure. The final phase of anesthesia is called emergence. When your procedure is completed, the anesthesia specialist will stop giving the anesthetic. As your body clears the anesthetic medicines from your system, the effects begin to wear off, and your body functions begin to return. How quickly you emerge from anesthesia depends on the anesthetics and other medicines used and on your response to the medicines. With local and regional anesthesia, emergence occurs as the effect of the injected anesthetic wears off and sensation returns. How long it takes for sensation to return depends on the type of anesthetic used, how much you were given, and the area of your body that was affected. Local anesthesia and some regional nerve blocks may wear off within 1 to 2 hours. Emergence from epidural or spinal blocks may take longer. Emergence from general anesthesia begins when the intravenous or inhalation anesthetic is stopped. It may take a short time before your body clears the anesthetic from your system. You will be closely monitored during emergence to make sure that you are breathing well on your own; your heartbeat, blood pressure, and other vital functions stay at normal levels; and your muscle control has returned. If an endotracheal tube (ET) or laryngeal mask airway (LMA) was used, it will be removed as soon as you are breathing on your own. In some cases, to help speed emergence, reversal agents are used to counteract, or reverse, the effects of certain anesthetics. These agents may help reduce the time it takes for you to recover from anesthesia. Emergence does not mean you will have completely recovered from all the effects of anesthesia. Some effects may persist for many hours after anesthesia has ended. For example, you may have some numbness or reduced sensation in the part of your body that was anesthetized until the anesthetic wears off completely. Even if you feel alert and normal, your judgment and reflexes may still be affected for some time after your procedure, especially if you continue to take medicines, such as those to control pain or nausea. But if you experience numbness or reduced sensation longer than expected, contact your anesthesia specialist. Recovering from anesthesia: * How long will it take for me to recover from anesthesia? * Are there any side effects after anesthesia? Recovery from anesthesia occurs as the effects of the anesthetic medicines wear off and your body functions begin to return. Immediately after surgery, you will be taken to a post-anesthesia care unit (PACU), often called the recovery room, where nurses will care for and observe you. A nurse will check your vital signs and bandages and ask about your pain level. How quickly you recover from anesthesia depends on the type of anesthesia you received, your response to the anesthesia, and whether you received other medicines that may prolong your recovery. As you begin to awaken from general anesthesia, you may experience some confusion, disorientation, or difficulty thinking clearly. This is normal. It may take some time before the effects of the anesthesia are completely gone. Your age and general health also may affect how quickly you recover. Younger people usually recover more quickly from the effects of anesthesia than older people. People with certain medical conditions may have difficulty clearing anesthetics from the body, which can delay recovery. After anesthesia Some of the effects of anesthesia may persist for many hours after the procedure. For example, you may have some numbness or reduced sensation in the part of your body that was anesthetized until the anesthetic wears off completely. Your muscle control and coordination may also be affected for many hours following your procedure. Other effects may include: * Pain. As the anesthesia wears off, you can expect to feel some pain and discomfort from your surgery. In some cases, additional doses of local or regional anesthesia are given to block pain during initial recovery. Pain following surgery can cause restlessness as well as increased heart rate and blood pressure. If you experience pain during your recovery, tell the nurse who is monitoring you so that your pain can be relieved. * Nausea and vomiting. You may experience a dry mouth and/or nausea. Nausea and vomiting are common after any type of anesthesia. It is a common cause of an unplanned overnight hospital stay and delayed discharge. Vomiting may be a serious problem if it causes pain and stress or affects surgical incisions. Nausea and vomiting are more likely with general anesthesia and lengthy procedures, such as surgery on the abdomen, the middle ear, or the eyes. In most cases, nausea after anesthesia does not last long and can be treated with medicines called antiemetics. * Low body temperature (hypothermia). You may feel cold and shiver when you are waking up. A mild drop in body temperature is common during general anesthesia because the anesthetic reduces your body's heat production and affects the way your body regulates its temperature. Special measures are often taken during surgery to keep a person’s body temperature from dropping too much (hypothermia). * When do I meet my anesthesiologist? * What are the risks of anesthesia? * What are some side effects of anesthesia? * Why do I need to fast the night before surgery? * What if I get a cold, fever or cough before surgery? * What should I do if I have a pacemaker? * Should I take my regular medications? * What are options for blood transfusions? * Where will I go after surgery? * Can I have visitors in the recovery room? * What are my options for pain control after surgery? * Let us know how we are doing! When do I meet my anesthesiologist? Your anesthesiologist will talk with you and examine you in the pre-operative holding area. Your anesthesiologist will be happy to answer any anesthesiology questions that you or your family may have. Back to top What are the risks of anesthesia? With the extensive knowledge and training of anesthesiologists and sophisticated monitoring equipment, anesthesia is safer today than ever. Serious and potentially fatal complications are now very rare. However, the specific risks depend on the type of surgery and overall health of the patient. You should discuss with your anesthesiologist any questions you have about your specific risks. Back to top What are some side effects of anesthesia? The most common side effects are sore throat, nausea and headache. Children are often disoriented and may be temporarily delirious in the recovery room when they wake up. With spinal and epidural anesthetics, temporary difficulty with urination is common. Some pain medications may cause itching and nausea. These are common and temporary conditions. Back to top Why do I need to fast the night before surgery? The night before surgery, patients are not allowed to eat or drink. This is in order to empty the stomach, because there is always a small risk of stomach contents injuring the lungs when a patient receives anesthesia or sedation ("light anesthesia"). Empty stomachs reduce this potentially life-threatening risk. For your safety, your surgery may be postponed if you eat or drink after midnight (unless directed to do so). The general guideline is: NOTHING after midnight prior to surgery. If you are taking medications, consult your doctor about whether to take them. Depending on your particular condition, your anesthesiologist may have adjustments to the orders. If you have any questions or concerns, please consult your anesthesiologist. Back to top What if I get a cold, fever or cough before surgery? You should call your anesthesiologist or surgeon to determine what should be done. You should be as healthy as possible before surgery. Call 650-321-4121 if you do not know your doctor's number. Back to top What should I do if I have a pacemaker? Please bring any information regarding your pacemaker into the operating room. The type of pacemaker and the last time it was checked are very important. If you can, ask your cardiologist or pacemaker technician what the "magnet mode" is for your pacemaker. Back to top Should I take my regular medications? You should check with your surgeon or anesthesiologist about whether or not to take your medications. You may have medications that are important to continue taking even the morning of the surgery. There are also medications that are important NOT to take the night before or the morning of surgery. You should not hesitate to contact your doctor if you have any questions about your medications. Back to top What are options for blood transfusions? With sophisticated biological tests, blood transfusions today are safer than ever. You can donate blood for yourself several weeks in advance of your surgery if you are healthy and meet the weight requirement. This is called "autologous" blood. If relatives or friends donate blood for you, this is called "designated donor" blood. Blood must be donated at least three to four days prior to surgery to allow for appropriate testing of the blood. Barring clerical error, autologous blood has the lowest infection and transfusion-reaction risks. Any other type of blood has a risk of about one in 60,000 for hepatitis and about one in 500,000-1,000,000 for HIV. Back to top Where will I go after surgery? You will be watched closely in the recovery room until your anesthesiologist and nurse feel you are stable enough to go either to your hospital room or home. For some surgeries, you may go directly from the operating room to the intensive care unit. Back to top Can I have visitors in the recovery room? In general, visitors are not allowed in the recovery room. Children may have a limited number of visitors once their recovery-room nurse has made sure everything is stable. Back to top What are my options for pain control after surgery? Your surgeon and anesthesiologist can discuss possible pain-control options. 1. What is an anesthesiologist? 2. Is there anything else that anesthesiologists do? 3. What are the pre-surgical appointments for? Why are there so many questions? 4. What is informed consent? 5. What do I need to tell the anesthesiologist? 6. What kind of anesthesia will I have? 7. What does the anesthesiologist do during the surgery? 8. Will I need to receive blood for the surgery? 9. Can you give me more information about general anesthesia? 10. Do I have to have a breathing tube? 11. What is regional anesthesia? 12. Can I request the specific type of anesthesia that I want? 13. What are the common risks of anesthesia? 1. What is an anesthesiologist? Anesthesiologists are physicians who have specialized training that allows them to provide pain control, pain relief and care for the general well-being of the patient in the operating room. They are able to regulate changes in breathing, heart rate, blood pressure, etc. that are important to your condition while undergoind surgery. The anesthesiologist acts as the advocate for the patient when the patient is under anesthesia and unable to perform that role themselves. Anesthesiologists have completed college, four years of medical school, an medical or surgical internship and three years of anesthesiology residency. 2. Is there anything else that anesthesiologists do? Anesthesiologists also fulfill a role outside of the operating room with their knowledge of pre-operative assessment and planning, analgesia for labor and delivery, critical care in the intensive care unit and recovery room, postoperative pain management and management of chronic pain syndromes. 3. What are the pre-surgical appointments for? Why are there so many questions? The pre-surgical appointments serve a dual purpose. First, they are a chance to gather important information about you and your medical condition in order to ensure yor safety and your comfort. In addition, it is a chance for you to ask any questions you might have about what is going to happen, make decisions about your options and give informed consent. 4. What is informed consent? Informed consent means that you, the patient, has been presented with the options for treatment, the commone and serious risks and expected benefits of each option and what the likely outcomes of the treatment (or of no treatment) are. In addition, you should be given a chance to ask questiosn. Informed consent is usually given in writing and requires a signature (exceptions are extreme emergencies). 5. What do I need to tell the anesthesiologist? It is important that you are complete and honest when answering questions prior to surgery. These questions relate to your general health and any specific medical conditions that may present a risk to you. You should be prepared to discuss your health history, the history of your blood relatives (if known), any medications including over the counter products, smoking, drug use, past experiences with surgery and anesthesia, etc. 6. What kind of anesthesia will I have? The type of anesthesia will be chosen based on the type of surgery, your medical condition and your preferences. There are four types of anesthesia commonly employed - general, regional, monitored anesthesia care (MAC) and local. In very broad terms: general affects your entire body and may be given intravenously or as an inhaled gas. These medications make you dizzy or drowsy and cause you to lose consciousness. As a result of these medications, you might stop breathing on your own and therefore you might have breaths given to you through a mask or a small tube gently inserted into your lungs through your mouth. Regional anesthesia only affects a section of your body, making it numb. You may remain awake or be sedated. Monitored anesthesia care (MAC) involved medications given to make you drowsy and to relive pain. Local anesthesia affects only the location of surgery. It is usually injected, but can sometimes be given as a ointment, cream or spray. You may remain awake or be sedated for this as well 7. What does the anesthesiologist do during the surgery? In short, the anesthesiologist is responsible for your comfort and your safety. In addition to giving you the medications needed for the anesthesia, the anesthesiologist monitors your vital signs (such things as heart rate, blood pressure, oxygen content, body temperature, breathing...) and alters them as necessary. He or she is also in charge of fluids that you might receive and, if necessary, blood transfusions. Lastly, any other medical conditions that you might have (diabetes, asthma, hypertension, heart problems) will be treated by the anesthesiologist while you are in their care. 8. Will I need to receive blood for the surgery? Whether you will need a blood transfusion will depend on your medical condition, the type of surgery you are having, your personal beliefs and preferences, etc. This should be a topic of discussion with your surgeon and anesthesiologist. 9. Can you give me more information on general anesthesia? General anesthesia is given either intravenously or through the inhalation of certain gases. Sometimes, the two are combined to achieve general anesthesia. When you are under general anesthesia you are unconscious - and thus unaware of what is happening to you and around you. Your vital signs such as heart rate, blood pressure and heart rate are carefully monitored and controlled. You may cease breathing on your own during general anesthesia and the anesthesiologist may assume control of your breathing. Sometimes this requires a breathing tube to be inserted - it goes through your lungs and into your lungs. 10. Do I have to have a breathing tube? General anesthesia often results in the loss of the ability to breathe on your own. There are different ways to assist your breathing - one of which is the breathing tube (known as an endotracheal tube). There are many situations when the placement of the tube is the safest and most reliable method to assure adequate breathing. There are alternatives in other cases including breathing through mask or other devices. You can discuss this issue with your anesthesiologist to see if these other alternatives are applicable to your specific situations. 11. What is regional anesthesia? Regional anesthesia refers to the process by which an injection of local anesthesia is given near your nerves and results in numbness of the area of surgery. You may remain awake or be sedated. Spinal and epidural anesthesia are the most commonly known of the regional techniques and involve injections in the back that result in numbness of the lower half of your body. There are, however, other types of regional anesthesia that can numb an arm, a single leg, etc. 12. Can I request the specific type of anesthesia that I want? To some degree you can. Some operations can be performed with different types of anesthesia while some require one technique. Your anesthesiologist will review your planned surgery and your medical condition. Then they will be able to discuss your options with you and allow you to make your preferences known. 13. What are the common risks of anesthesia? Luckily the common complications of anesthesia are not particularly dangerous and the dangerous complications of anesthesia are very rare. The most common complications include nausea, vomiting, sore throat, blood pressure changes, and pain. These are usually mild, not dangerous and easily treated with medication. The more serious complications include such things as allergic reactions, genetic conditions, stroke, heart attack, etc. which can lead to serious disability or death. These more serious complications are very rare. With the application of new technologies to the field of anesthesia and the careful monitoring of the anesthesia provider anesthesia is extremely safe. 50 General Anesthesia Questions 1. What is transpulmonary pressure? How about FRC and VC? Can you draw the lung capacities/volumes diagram? What is normal FRC and VC in cc/kg? 2. What happens to FRC with GA? Why is low FRC bad? What conditions lower FRC? 3. What part of the lung is usually ventilated best, the apex or the base? What happens with GA? 4. What is the alveolar gas equation? What are the formulas for calculating oxygen content/delivery/consumption? What is the formula for calculating shunt fraction? 5. What is the difference between shunt and V/Q mismatch? Is hypoxemia from a PE due to shunt or dead space? 6. How would you assess a Pt’s COPD? How do you assess its severity? Are preoperative PFTs required for COPD patients? 7. What risk factor predispose to postop pulmonary dysfunction? How does the presence of COPD affect your choice of anesthetics? How would you ventilate a patient with COPD? 8. How would the presence of a difficult airway affect your induction in a Pt with asthma? Would you use ketamine? Why or why not? 9. Is deep extubation indicated for a Pt with a history of severe brochospasm? 10. How can COPD be distinguished from restrictive lung disease by spirometry? What type of infiltrative disorders cause restrictive lung disease? Draw the flow/volume loops for each disorder. 11. What are the different causes of pulmonary edema? How can you distinguish between cardiogenic and noncardiogenic pulmonary edema? 12. A Pt develops stridor after extubation, and then desaturates after reintubation. What is your differential diagnosis and treatment plan? 13. How would you induce anesthesia for a Pt with a large anterior mediastinal mass causing significant tracheal compression? 14. A 57 year old male who had an MI seven months ago is scheduled for cataract Sx. Do you need an extensive (or any) cardiac workup? 15. After a retrobulbar block, a Pt become unresponsive, what is your differential diagnosis and response? 16. A Pt complains of postop eye pain following a prone operation. What is your differential diagnosis? What if he complains of blindness? What are the risk factors, if any? 17. What would you tell a Pt if a corneal abrasion occurred? How do you treat it acutely? 18. What is the significance of cervical involvement with rheumatoid arthritis? 19. Is regional anesthesia a good or bad idea in a patient with a difficult airway? 20. During insertion of an artificial prosthesis in an orthopedics case, the Pt becomes hypotensive, what is your differential diagnosis, and what would you do? 21. Thirty minutes after inflation of a tourniquet during an orthopedics case, the Pt develops unexplained HTN. What is your differential diagnosis and management? 22. Is postop pulmonary function and outcome definitely improved with regional versus general anesthesia? 23. What is your plan for perioperative pain control for a total knee or total hip replacement? 24. How is electrical shock in the OR quantitatively classified? 25. What safety measures are available to reduce the chances of electric shock in the OR? 26. What is an isolation transformer and how does it work? 27. The line isolation monitor alarms during a code situation when the defibrillator is plugged in for emergency cardioversion. What do you do? 28. What features on the anesthetic machine prevent the delivery of a hypoxic mixture? 29. How much N2O is left in a cylinder if it reads 745 PSIG? 30. What is a fail-safe device on an anesthetic machine? 31. What is the problem with repeated use of the O2 flush valve? 32. How does use of a vaporizer at higher altitude affect output? Are there differences between agents/vaporizers? 33. Are there any toxic substances produced in CO2 canisters? How does the choice of Baralyme or soda lime affect production? Is Baralyme still available? Are there differences between volatile agents and substance production? 34. How do you check the low pressure system on an anesthesia machine? 35. The PEEP reads 15 cm H2O when none was intended, what would you do? 36. A postop Pt is oliguric and this is blamed on fluoride nephrotoxicity because isoflurance was used. What is your response? Any difference if they blamed it on Sevoflurane? 37. Should you avoid succinylcholine in a patient with dialysis-dependent renal failure? What potassium level is your cut-off for succinylcholine? 38. Can you safely reverse neuromuscular blockade in a patient with renal or hepatic failure? 39. Who is at risk for acute renal failure? What is the FeNa? How do you differentiate between pre-renal, renal, and post-renal drop in urine output? 40. What is TURP syndrome? What is the best anesthetic technique for TURP and why? How would you diagnose and treat a suspected case? What is central pontine myelinolysis? 41. How can you preserve hepatic blood flow intraop? What factors determine hepatic blood flow? What blood pressure considerations should you have when anesthetizing a patient for liver resection? 42. What LFTs, if any, would you order for a Pt undergoing a laparoscopic cholecystectomy? What would you say if a patient’s postoperative LFT elevation were blamed on the volatile anesthetic? 43. What are your concerns in a Pt with chronic alcoholism? How would you manage the anesthetic for a drunk trauma patient that was a chronic drinker versus one that was not? 44. How would you manage the airway of a drunk and combative patient with a suspected C-spine injury and oral trauma? 45. Is a rapid sequence induction a good idea for severe liver cirrhosis Pt? Why? Which agents would you avoid, if any? What preop labs/tests would you order in a liver cirrhosis Pt? Is gastroparesis a risk in patients with end-stage liver and/or renal disease? 46. What tests for coagulation are normally available? What are D-dimers? 47. Should all Pts with VWD receive DDAVP preop? How long does it take DDAVP to work? How long does it take vitamin K to work? How much FFP would you need to give someone with a coumadin-induced coagulopathy? Let’s say their INR was 1.9. 48. After 10 units of “emergency” type O PRBCs, would you administer type-specific blood if it becomes available? Why or why not? How about after 4 units? How about FFP? 49. What are the chances of a hemolytic transfusion reaction if type specific blood is given? If T/S’d blood is given? If T/C’d blood is given? 50. How would you decide whether the Pt with sickle cell anemia requires transfusion preop? What are your goals for the transfusion? What is "awareness" under anesthesia? Awareness under general anesthesia means becoming conscious – or awake – during some part of your operation and remembering things that happened. Awareness is an uncommon complication that may or may not be accompanied by pain. When using local or regional anesthesia with sedation, it is expected that patients may have some recollection of the procedure. The remote possibility of awareness should not deter you from having needed surgery. Your anesthesia professional can help you to feel comfortable and informed about your upcoming experience with anesthesia. What causes anesthesia awareness? Awareness occurs when you are not receiving enough anesthetic medication to keep you unconscious. Some people may react differently to the same level or type of anesthesia. Sometimes different medications can mask important signs that anesthesia professionals monitor to help assess the depth of anesthesia. In some situations, such as emergency, trauma and cardiac surgery, or in situations involving patients whose condition is unstable, the medical condition of the patient may prevent the anesthesia professional from using sufficient anesthesia to prevent awareness. Because anesthesia has certain effects on the body, including lowering blood pressure and slowing breathing, a deep anesthetic may not be in the best interest of the patient. In these and other situations – such as emergency cesarean delivery - awareness may not be completely avoidable. Awareness also may happen if the equipment that delivers the anesthetic to your body malfunctions, or if your anesthesia professional misjudges the amount of medication needed to keep you unconscious. Adobe Acrobat PDF LEARN MORE ABOUT AWARENESS Can anesthesia awareness be prevented? Before surgery, you should meet with your anesthesia professional to discuss anesthesia options and determine the plan for your operation. You should describe any problems you may have experienced with previous anesthetics, and also discuss any prescription medications or over-the-counter medications you are taking. Should you have concerns regarding awareness, before surgery is the ideal time to express them and to ask questions. Your anesthesia professional cares for you during surgery by relying on his or her clinical experience, training and judgment combined with safe medications and continuous monitoring. During general anesthesia, your anesthesia professional will use multiple ways to determine if you are getting sufficient amount of anesthetic medication to keep you unconscious. This can be difficult in some patients. Recently, the introduction of brain monitors – like the BIS monitor – has provided anesthesia professionals with another method to help care for their patients. What do I do if I had awareness under anesthesia? If you have distinct recollections of your surgery after general anesthesia, you should discuss it with one of the people involved in your care. Any of the nurses who care for you, your surgeon or your anesthesia professional will be a good place to start. Sometimes, patients will not remember being awake during surgery for several days. If this happens to you, be sure to mention it to your surgeon at next appointment or if the hospital calls you for follow-up check. Regardless of whom you first mention your experience to, it is important to try to speak directly with the anesthesia professional who was involved in your surgery. Your anesthesia professional can best explain to you the events that took place in the operating room at any stage of your surgery and why you might have been aware at certain times. If your recollections of surgery or the awareness episode distresses you, your anesthesia professional can help you or refer you to a counselor or to other appropriate resources. What is the Purpose of the Preoperative Anesthesiology Clinic? How Do I Contact the Preop Clinic? What is the Purpose of Preoperative Assessment? What are the Surgery or Primary Care Clinics' Responsibilities? Why do Surgeries get Postponed? What is a "Current" Work-up? Which Patients are Usually Poor Candidates for Outpatient Surgery? What is the Purpose of the Preoperative Anesthesiology Clinic? The PAC mission is to be responsible for preparing the patient for anesthesia. This includes: 1. Evaluating each patient to identify problems which may be of a particular concern when performing an anesthetic. 2. Alerting the O.R. with regard to specific patient problems which may best be managed by particular anesthesiologists. 3. Acting as a resource for surgical services to consult when unsure of the appropriate evaluation for certain types of patients. 4. Educating patients about issues such as: NPO requirements, medications to be taken on the morning of surgery, and anesthesia options. By performing these tasks, the PAC can be expected to improve patient care and satisfaction, as well as reducing cancellations or delays on the day of surgery. On the other hand, however, the PAC cannot (with current resources and mandate) be responsible for: * scheduling patients for the O.R. (use OutPatient scheduling: 2-0403, Beth; or InPatient O.R. scheduling: 3-8957, Perry), * performing the full pre-surgical H&P, * doing routine vital signs, * arranging medical consultations (except as a courtesy), * hunting down patient records or calling the local MD for general information, * checking that all ordered tests are actually done, * following-up to see whether tests results are abnormal if the test results are not available at the time of the PAC visit. [top] | PAC Home How Do I Contact the Preoperative Anesthesiology Clinic? Preoperative Anesthesiology Clinic (PAC) Hours: 9:00 a.m. to 5 p.m. Monday thru Friday. @ F6/2 in the Outpatient Surgery Center Scott Springman, MD "srspring" + "@wisc.edu" (The two elements are separated to thwart spam email gathering programs- put them together without the quotes, spaces, or the plus sign) Director of Anesthesia Preoperative Clinic (page 6310) Irene Boris, RN, MS "ijboris" + "@uwhealth.org" 608-262-0870 (page 4763) Kathy Justinger, RN, MS "kfjustin" + "@wisc.edu" 608-263-9483 (page 8456) Lori Mainguth, RN, NP "lmainguth" + "@uwhealth.org" 608-263-1307 (pager: 6566) Jane Noyes, RN, NP "jmnoyes" + "@wisc.edu" 608-263-8008 [page 6827] PAC FAX # 608-262-7192 PAC e-mail address: "anesClinic" + "@anesthesia.wisc.edu" (The two elements are separated to thwart spam email gathering programs- put them together without the quotes, spaces, or the plus sign) Web: http://www.anesthesia.wisc.edu/Clinic/index.html [top] | PAC Home What is the Purpose of Preoperative Assessment? * The primary aims of preoperative assessment and preparation: 1. Documenting the condition(s) for which the procedure is needed. 2. Identifying other conditions in a timely fashion (at least 2 to 3 days before surgery) which can be improved to reduce the patient's surgical and anesthetic perioperative morbidity or mortality. 3. Obtaining consultations, when necessary, with appropriate medical services to optimize the patient's health. These consultations should ideally not be done in a "last second" fashion. 4. Allowing time for the Anesthesia Team to anticipate potential problems and to modify the anesthetic technique, the medications, and/or monitoring. 5. Educating and informing the patient about the surgical - anesthetic process, risks, and alternatives. 6. Reducing economic loss or inconvenience to patients, physicians, nursing and hospital staff by avoiding delays and cancellations. * Secondary aims include: Satisfying review agencies regulations (such as JCAHO, CMS), including having a full preoperative/preanesthesia H&P current within 30 days. This may be secondary to the medical aims, but it is still essential to comply with these regulations. * Other potential benefits, but which are not justified without other primary or secondary needs: Health screening for asymptomatic conditions needing primary care follow-up. [top] | PAC Home What is Necessary from the Surgery/Primary Care Clinics for a Work-up? First of all, the Surgery Clinic is responsible for explaining the surgical procedure to the patient. The Clinic should also explain the ABSOLUTE necessity of an escort home for Outpatients (who have ANY sedation, G/A, Bier block or other regional anesthesia), as well as the usual need for a caretaker overnight post-op (except for minor procedures in healthy patients when approved ahead of time). The Clinics should NEVER promise that a procedure will be done at a certain time on the day of surgery since schedules always change up to the last day before surgery. Any such unfulfilled promise is a recipe for patient dissatisfaction! For a patient to be properly evaluated in the Anesthesiology Preoperative Clinic, the following basic information should be assembled and available to the PAC at the time of the visit: 1. The proposed procedure and the surgeon's name. 2. Whether the procedure is planned as FDS or OP , and the requested/suggested type of anesthesia (either local + sedation & monitoring: "Monitored Anesthesia Care"--also called "MAC," or regional/general anesthesia) 3. The planned date of the procedure. 4. The patient's complete chart, which includes: the old records, a medical history , an adequate review of systems , a physical exam , and available test results. The cancellation rate is, and will continue to be, increased for patients coming to the APC without a chart and/or without an H&P. Without adequate information, it is impossible to do a complete evaluation. 5. An adequate History and Review of Systems. Significant positives in the assessment should be explored, e.g.: it is not very helpful to state only that the patient has "heart disease." What kind of disease? The nature, extent, and treatment of each problem have different implications for preparing the patient for anesthesia and surgery. Inadequate evaluation of the cardiovascular system is the main cause of procedure delays or cancellations. The history, which includes medications currently taken, allergies to medications, and a pertinent review of systems continues to be the most important aspect of the preoperative assessment. This cannot be overemphasized! Omissions in the medical history continue to be an important cause of delays and cancellations. 6. The patient's vital signs (especially BP) are recorded. 7. The work-up is signed legibly by the person who performed it. Preferably, the evaluator's name is printed next to the signature. If we cannot read the signature, we won't know who to call with questions. 8. When possible, the pertinent laboratory data, the ECG, and the CXR (when appropriate) should accompany the patient to the PAC. Having immediate access to these tests will speed the evaluation process. This, we realize, is not always possible. (However, see next below) 9. If test results are not available to the PAC, each surgical clinic must have a mechanism to follow-up on abnormal tests before the day of surgery. IMPORTANT! If patients are first seen in the PAC the day before surgery (or even worse - late in the day before surgery) it will be difficult to arrange medical consultation or obtain outside records. Please bear this in mind when surgery clinic staff arrange for the pre-surgical visit or transfer of records! Last minute evaluation of patients with significant medical problems greatly increases the likelihood of postponement and patient dissatisfaction. For these patients, an evaluation at least 3 days before surgery will greatly reduce delays and smooth the preoperative process. (Please note that there is a specific "Phone Triage" form available to be used at the time of the phone call to patient's to schedule the surgery clinic preop visit. Call us for details.) Another important point to remember is that the patient's primary care physician or specialist is an excellent source of medical information needed in the preoperative evaluation. A patient's cardiologist or pulmonologist should always be notified of a patient's impending procedure. In addition to finding important medical information, it is important for professional courtesy, (as well as for future referrals) that the patient's primary physician and/or specialists know that the patient is scheduled for surgery. [Top] | PAC Home Why do Surgeries get Postponed? In studying the problem of avoidable preoperative cancellations or postponements, it is clear that certain factors appear again and again: 1. Last minute attempts to evaluate patients with complex medical problems. 2. Lack of generally accepted clinical guidelines for adequate preoperative assessment .This produces inconsistencies, misunderstandings, and (at times) unnecessary arguments between surgeons, anesthesiologists, and internists. That is what these guidelines seek to avoid. 3. Misunderstanding about what constitutes the important aspects of preoperative assessment. 4. Missing or unavailable old records at the time of the anesthesia work-up process. 5. Missing or incomplete portions of the preoperative history or physical exam (e.g. no recorded blood pressure). 6. Lack of follow-up of ordered tests, prior to day of surgery. Obviously, all cancellations can not be avoided. Some patients will have a change in their medical condition on the day of surgery which can not be foreseen. Most problems, however, are the result of a lack of adequate preparation and can be prevented with a little initiative. For example, in the work-up of CHEST PAIN, the following simple questions will usually resolve the issue of how to proceed: 1. How long have these episodes been going on? 2. What kind of pain: sharp, heaviness or pressure, stabbing? 3. How severe is it? (scale of 1-10) 4. How long does it last? Seconds, minutes, hours? 5. Location(s) of pain? Radiation of pain to other areas? arm, jaw, back? 6. What brings it on and what makes it worse: Activity or at rest? Food affect? Position? Deep breath, moving, anxiety? Can patient walk 2 blocks at a normal pace? Climb 1 flight of stairs? What makes it better: rest, antacid, NTG (how many per day)? 7. Associated symptoms: SOB, sweating, palpitations? Other: nocturnal dyspnea, orthopnea, edema, dizziness. 8. Has the patient seen a doctor about this? Any work-up or tests? When? How can we get these records? 9. Does primary physician or cardiologist know that patient is having surgery? [top] | PAC Home What is a "Current" Work-up? When does a work-up or laboratory testing become "outdated?" There is, of course, no absolute answer in the strict medical sense. In a way, it becomes outdated the day after the preoperative visit. However, JC & CMS requires a H&P within 30 days of the procedure. For testing, see our current recommendations: "Basic testing Issues", "Suggested Preoperative Tests", and "Specific Disease Testing." The other question is: "when is another comprehensive H&P necessary?" Rather than give a fixed time limit to this, it makes more sense to say that patients need an evaluation directed toward the involved organ systems in a time frame commensurate with the severity and stability of the disease. For some patients with complex medical problems (especially cardiovascular ones), this may mean a week or less. For some patients who are perfectly healthy, this means up to 30 days. An "Update" note is required by CMS and JC for any H&P that is more than 24 hoursold. However, every patient needs to be briefly reevaluated on the day of surgery. This ensures that a previously stable condition has not changed, and that a new condition has not suddenly appeared. Which Patients are Usually Poor Candidates for Outpatient Surgery? We are often asked to comment on which patients are not appropriate candidates for outpatient surgery. These criteria are continuously evolving. Below is a table of those patients usually regarded as "poor" candidates for OP status. You must consult with us at the Anesthesiology Preoperative Clinic if you wish to book these patients as outpatients. WHO SHOULD MONITOR sedation? Because patients can slip into a deep sleep, proper monitoring of conscious sedation is necessary. Healthcare providers monitor patient heart rate, blood pressure, breathing, oxygen level, carbon dioxide exhalation, and alertness throughout and after the procedure. The provider who monitors the patient receiving conscious sedation should have no other responsibilities during the procedure and should remain with the patient at all times during the procedure. The level of sedation will be determined by the nature of your operative procedure. Some procedures require only minimal to moderate sedation. Others will require a deeper level. Your anesthetist will determine the appropriate level of sedation for your particular procedure. This will be discussed on the phone for your pre-operative interview. Return to Top What are the SIDE EFFECTS of sedation? A brief period of amnesia after the procedure may follow the administration of sedation. Occasional side effects include headache, hangover, nausea and vomiting or unpleasant memories of the surgical experience. Medications will be administered to prevent side effects, to the extent that they can be controlled. You may also receive prescriptions from your doctor for post-procedure comfort. Return to Top What should PATIENTS EXPECT immediately following the procedure? A qualified provider monitors the patient immediately following the procedure. Written postoperative care instructions should be given to the patient to take home. Patients should not drive a vehicle, operate dangerous equipment or make any important decisions for at least 24 hours after receiving conscious sedation. A follow-up phone call usually is made by the healthcare provider to check on the patient's condition and answer any remaining questions. What is the ROLE OF THE CAREGIVER after the anesthesia? The person caring for an individual post Intravenous Sedation must be alert to the possibilities of oversedation, drowsiness, unsteady gait, low blood sugar, faulty reasoning and decision making in the patient. The caregiver must check on the patient every 10-15 minutes for approximately two hours. During this time the patient needs assistance in usual, routine activities. Medications should be noted on a pad of paper as to the time and amount taken. Talking on the phone is usually not a good idea after sedation. Return to Top What is intravenous sedation? What Patients Should Expect Sedation provides a safe and effective option for patients undergoing minor surgeries, dental work, or diagnostic procedures. The number and type of procedures that can be performed using intravenous sedation have increased significantly as a result of new technology and state of the art medications. conscious sedation allows patients to recover quickly and resume normal activities in a short period of time. QUESTIONS to ask about intravenous sedation The following is a list of questions that patients should ask prior to the surgical or diagnostic procedure: * Will a trained and skilled provider be dedicated to monitoring me during conscious sedation? * Will my provider monitor my breathing, heart rate, and blood pressure? * Will oxygen be available and will the oxygen content of my blood be monitored? * Are personnel trained to perform advanced cardiac life support? * Is emergency resuscitation equipment available on-site and immediately accessible in the event of an emergency? * Will a trained and skilled provider stay with me during my recovery period and for how long? * Should a friend or family member take me home? Return to Top What is CONSCIOUS SEDATION? This type of sedation induces an altered state of consciousness that minimizes pain and discomfort through the use of pain relievers and sedatives. Patients, who receive conscious sedation usually are able to speak and respond to verbal cues throughout the procedure, communicating any discomfort they experience to the provider. Other types of sedation (see below) produce a deeper level of unconsciousness. A brief period of amnesia may erase any memory of the procedure. Return to Top Are there other LEVELS OF SEDATION? The depth of sedation can range from minimal to deep sedation. Minimal sedation (anxiolysis): A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Moderate Sedation/analgesia (conscious sedation): A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Deep Sedation/analgesia: A drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. Anesthesia: Consists of general anesthesia and spinal or regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. # List 3 symptoms of poor ventricular function (history). # List 3 signs of poor ventricular function (physical). # What information can be derived from exercise electrocardiography? # What information can be derived from echocardiography? # What information can be derived from cardiac catheterization? # List 5 conditions that are detrimental to myocardial oxygen balance in patients with coronary artery disease. # a. What are the branches of the right and left coronary arteries? b. What is the blood supply of the AV node? c. What is the blood supply of the SA node? d. List 3 manifestations of myocardial ischemia in a patient under general anesthesia. # What are the determinants of blood pressure? # What are the determinants of cardiac output? # What are the determinants of oxygen content? # a. What are the determinants of oxygen delivery? b. What are the determinants of oxygen consumption? # What coronary artery and territory of the heart is monitored by leads II, III and AVF? # What coronary artery and territory of the heart is monitored by leads V4 and V5? # What coronary artery and territory of the heart is monitored by lead I and AVL? # List 3 important considerations for anesthesia in patients with mitral stenosis. # List 3 important considerations for anesthesia in patients aortic stenosis. # List 3 advantages of using opioids such as fentanyl for cardiac anesthesia. # List 3 disadvantages of using opioids such as fentanyl for cardiac anesthesia. # What is the mechanism of action of nitroglycerin in patients with myocardial ischemia? # What are the main indications for inserting a pulmonary artery catheter (PAC)? # What parameters can be measured and calculated from a pulmonary artery catheter? # a. List 5 clinical situations which might lead you to not insert a PAC in a patient meeting the criteria in questions #20, assuming easy cannulation of a central venous route. b. List 5 clinical situations which might lead you to not insert a right internal jugular cannula in a patient meeting the criteria in question #20. # Describe the anatomical location of the internal jugular vein. # What is the mechanism of action of heparin? # What is the mechanism of action of protamine? # List 3 side effects of protamine. # What does the ACT measure? # What does the PT measure? # What does the PTT measure? # List 5 essential components of the cardiopulmonary bypass circuit. # List 5 essential tasks to perform before and immediately after initiating bypass. # List 5 causes of hypotension during initiation of bypass. # What is the significance of cardiopulmonary bypass time. # What is significance of aortic cross clamp time. # List 5 essential tasks to perform before discontinuing cardiopulmonary bypass (besides ventilation, oxygenation and ensuring adequate HR and rhythm) # What is the therapy of low BP, CVP, PAP and CO? # What is the therapy of low BP, high PAP, low CO? # What is the therapy of high BP, low CO, normal PAP? # List 3 advantages and 2 disadvantages of dobutamine. # List 2 advantages and 2 disadvantages of epinephrine. # List 2 advantages and 2 disadvantages of norepinephrine. # List 2 advantages and 2 disadvantages of milrinone. # List 2 advantages and 2 disadvantages of calcium chloride. # List 2 advantages and 2 disadvantages of using volatile inhalational anesthetics during cardiac anesthesia. # List 2 advantages and 2 disadvantages of using benzodiazepines for cardiac anesthesia # List 2 advantages and 2 disadvantages of hypothermia during cardiopulmonary bypass. # a. What is significance of acute hypokalemia after cardiopulmonary bypass? b. What level of hypokalemia requires treatment after bypass? c. List 3 ECG signs of hyperkalemia d. List 3 methods to treat acute hyperkalemia (drugs and dose, in order of onset time from fastest to slowest). # List conditions that decrease Sv02. # List conditions that may predispose to pulmonary artery rupture in a patient with a PAC. # List conditions that may predispose to massive air embolism during and after bypass. # a. List conditions that may mimic severe bronchospasm after bypass. b. List methods to treat confirmed severe bronchospasm after bypass. Defining Clinical Competence in Anesthesiology Essential Attributes The physician must possess those abilities, traits and skills that are essential to the safe practice of anesthesiology, critical care and pain management. The physician who lacks one or more of the following attributes is not competent to practice anesthesiology safely. 1. Is honest and ethical 2. Is reliable, conscientious and responsible 3. Learns from experience 4. Reacts to stressful situations in an appropriate manner 5. Has no current documented abuse of alcohol or illegal use of drugs 6. Has ability to acquire and process information in an independent and timely manner and adequate physical, sensory and motor faculties to function independently as an anesthesiologist Acquired Character Skills The physician should demonstrate the following acquired character skills that are important to the practice of anesthesiology and which develop and evolve during the anesthesiology continuum. 1. Communicates effectively with patients, their families and members of the health care team 2. Has a commitment to continuing education 3. Is adaptable and flexible 4. Is careful and thorough 5. Is complete and accurate in record keeping 6. Has breadth of thinking 7. Is appropriately self-confident Knowledge Committees on Clinical Competence judge residents' knowledge in arriving at their evaluations. The written and oral examinations of the ABA also measure the adequacy of knowledge. The scope of this knowledge is currently defined in the Content Outline of the In-Training Examination. Judgment The physician must possess the ability to elicit the essential information from patients and physicians and to integrate it with a fund of knowledge and cinical skills that permits diagnosis and understanding of conditions and prescriptions for appropriate and safe anesthetic management. 1. Demonstrates use of a sound background in general medicine in the management of problems relevant to the specialty of anesthesiology 2. Recognizes the adequacy of preoperative preparation of patients for anesthesia and surgery and recommends appropriate steps when preparation is inadequate 3. Selects anesthetic and adjuvant drugs and techniques for rational and safe anesthetic management 4. Recognizes and responds appropriately to significant changes in anesthetic course 5. Prescribes and advises appropriate postanesthetic care 6. Provides appropriate consultative support for patients who are critically ill 7. Evaluates, diagnoses, and selects appropriate therapy for acute and chronic pain disorders Clinical Skills The physician must demonstrate the facility to organize and expedite safe anesthetic procedures. The following contains examples that aid the evaluation of psychomotor performance. 1. General Preparation a. Adequacy and speed of preparation b. Indicated vascular cannulations including venous, arterial, central venous and pulmonary arterial catheter insertions c. Appropriate application and use of current technology for efficient and safe anesthesia care and life support of patients. Examples include direct and indirect blood pressure measurements, ventilation and respiratory gas monitoring, assessment of neuromuscular function, eletrocardiographic, electroencephalographic, and evoked-potential monitoring, and evaluation of laboratory results (chemistry, radiographs, etc.) d. Instrument and anesthesia machine testing and calibration e. Operating room safety procedures for oxygen delivery, electrical safety, and waste gas evacuation f. Proper patient positioning during anesthesia 2. General anesthesia a. Airway management: head position, ventilation by mask, appropriate use of oral and nasal airways b. Tracheal intubation: oral and nasal intubation by various techniques, appropriate and adequate tracheal and airway local anesthesia, fiberoptic techniques c. Maintenance of respiration and gas exchange including management of various types of mechanical ventilation d. Support of the circulation during the perioperative period, including management of all types of shock e. Support of renal function perioperatively f. Management of the patient with increased intracranial pressure g. Appropriate administration of fluids and maintenance of fluid, electrolyte and acid-base balance h. Judicious use of blood products 3. Regional anesthesia and pain (including postoperative) management a. Spinal and epidural anesthesia and analgesia b. IV regional anesthesia c. Nerve blocks for diagnostic, therapeutic and surgical procedures 4. Special procedures a. Management of cardiopulmonary resuscitation b. Anesthetic management of cardiopulmonary bypass c. One-lung ventilation d. Deliberate hypotension Overall Clinical Competence The competent physician must possess each of the Essential Attributes necessary to the safe practice of anesthesiology and demonstrate adequate Acquired Character Skills, Knowledge, Judgment and Clinical Skills for assuming independent responsibility for patient care. Core Competencies 1. Patient Care Physician must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: * communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families * gather essential and accurate information about their patients * make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment * develop and carry out patient management plans * counsel and educate patients and their families * use information technology to support patient care decisions and patient education * perform competently all medical and invasive procedures considered essential for the area of practice * provide health care services aimed at preventing health problems or maintaining health * work with health care professionals, including those from other disciplines, to provide patient-focused care 2. Medical Knowledge Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to: * demonstrate an investigatory and analytic thinking approach to clinical situations * know and apply the basic and clinically supportive sciences which are appropriate to their discipline 3. Practiced-Based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: * analyze practice experience and perform practice-based improvement activities using a systematic methodology * locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems * obtain and use information about their own population of patients and the larger population from which their patients are drawn * apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness * use information technology to manage information, access on-line medical information; and support their own education * facilitate the learning of students and other health care professionals 4. Interpersonal and Communication Skills Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to: * create and sustain a therapeutic and ethically sound relationship with patients * use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills * work effectively with others as a member or leader of a health care team or other professional group 5. Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: * demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development * demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices * demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities 6. Systems-Based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: * understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice * know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources * practice cost-effective health care and resource allocation that does not compromise quality of care * advocate for quality patient care and assist patients in dealing with system complexities * know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance Cardiothoracic Anesthesia Neuro Anesthesia Obstetrical Anesthesia Pain Management Critical Care Pediatric Anesthesia Burn and Trauma Anesthesia Recovery Room Care Management Clinical anesthesia experience Total cases Intrathoracic with CPB Intrathoracic without CPB Major vascular Intracranial vascular Intracranial nonvascular Vaginal delivery C-section Ambulatory, same day Trauma Spinal anesthesia Epidural anesthesia Nerve block anesthesia Deliberate hypotension Insertion of A-line Insertion of PA catheter Insertion of CVP line Fiberoptic intubation TEE Double lumen ETT LMA EEG monitoring Evoked potential monitor Age < 45 weeks PCA 45 weeks PCA to 1 year Age 1 to 12 years Age > 65 years Acute pain management Chronic pain management Cancer pain management Total pain procedures Spinal procedure for pain Epidural for pain Nerve block for pain Daily Anesthesiology Resident Evaluations I. Room Preparation Unsatisfactory: Critical equipment not ready or missing (e.g., machine not checked, no larygoscope or suction, etc.) Average: All equipment present Outstanding: Room well-prepared and organized, nothing extraneous II. Preop Evaluation Unsatisfactory: Important information missing or overlooked (e.g., recent MI, previous history of anesthetic problems, difficult airway, etc.) Average: No important information lacking Outstanding: Complete problem-oriented preop done - well documented and well organized IV. Technical Skills Unsatisfactory: Unable to do straightforward procedures Average: Does routine procedures well, has difficulty with harder procedures Outstanding: Technically very adept V. Case Management Unsatisfactory: Fails to recognize or appropriately treat significant problems (BP, decreased SpO2, etc.) or fails to call for help when appropriate Average: Does well with routine problems, some difficulty with more complex issues Outstanding: Correctly and expeditiously recognizes and treats problems, major and minor VI. Knowledge Unsatisfactory: Major gaps in essential knowledge base, or inability to apply knowledge to the clinical situation Average Outstanding: Excellent knowledge base, appropriately applied VII. Essential Character Traits Unsatisfactory: Lacking one or more of: honesty, reliability, responsibility, ethics Average Outstanding: Extremely reliable, dependable, ethical and responsible Goals and Objectives for Cardiothoracic Anesthesia Goals and Objectives for Anesthesia for CA-1 and 2 Residents in Cardiothoracic Surgery I. Define the Rotation Anesthesia for cardiothoracic is a two month rotation. The first month occurs during the CA-1 year, and the second during the CA-2 year. II. Primary Area of Knowledge and Goals The overall goal of this rotation is to provide an introduction and a broad understanding for the sub-specialty of anesthesia for cardiothoracic surgery. The areas of knowledge to be covered will include: 1. an introduction to the preoperative assessment, intraoperative management and postoperative management of patients presenting for cardiac, aortic and/or thoracic surgery. 2. an introduction to one lung ventilation and fiberoptic bronchoscopy. 3. an introduction to invasive monitoring including arterial, central venous and pulmonary artery catheters III. Cognitive Objectives The resident will be able to: 1. describe the normal anatomy and physiology of the heart. 2. discuss pharmacology pertinent to the cardiovascular system. 3. describe coronary artery and valvular heart disease. 4. explain anesthesia implications of these diseases. 5. discuss and explain the rationale of induction and maintenance of anesthesia techniques for cardiothoracic surgery. 6. discuss the mechanism and anesthesia implications of cardiopulmonary bypass. 7. describe the pathophysiology and the anesthesia implications of anesthesia for aortic surgery. 8. describe the pathophysiology , and discuss the anesthesia implications of pulmonary surgery. 9. explain the sequential steps in cardiopulmonary resuscitation. 10. list the indications, and potential complications of : a. arterial catherization b. central venous catherization c. pulmonary artery catherization d. bronchoscopy e. double lumen tube placement f. epidural catheters 11. describe the expected postoperative recovery of the uncomplicated cardiac surgery patient. 12. list common problems and their treatments of this uncomplicated surgery patient. 13. describe the expected postoperative recovery of the uncomplicated thoracic surgery patient. 14. list common problems and their treatment of this uncomplicated surgery patient. 15. describe the management of ventilation of the uncomplicated cardiac/thoracic surgery patients. IV. Skill Objectives: The resident will be able to: 1. insert, manage, and interpret the results of arterial catherization, central venous catherization, and pulmonary artery catherization with minimal staff assistance. 2. perform fiberoptic bronchosopy with minimal staff assistance. 3. insert and manage double lumen endotracheal tubes with minimal staff assistance. 4. place and manage epidural catheters for patients having thoracic surgery. V. Conference and Literature Assignments The CA-1 or 2 rotating resident will attend the weekly conferences held by the Department of Anesthesiology. The annual curriculum is expected to fully cover the subject for cardiothoracic surgery, and include such specialty items such as journal club, and quality assurance issues. Reading and active participation is expected of these residents. Goals and Objectives for Anesthesia for CA-3 Residents in Cardiothoracic Surgery I. Definition Rotations for CA-3 residents in anesthesia for cardiothoracic surgery are provided for a duration of 1 to 6 months. II. Goals and Primary Area of Knowledge The overall goals to be attained will relate directly to the duration of training elected in this subspecialty by the CA-3 resident, but in general is intended to provide advanced training in anesthesia for cardiothoracic surgery. The area of knowledge includes a preoperative assessment, and the intraoperative and postoperative management of patients presented for cardiac, aortic, and/or thoracic surgery. Also included will be training in one lung ventilation, fiberoptic bronchoscopy, invasive monitoring, and introduction to transesophageal echocardiography. Some of these areas such as transesophageal echocardiography will be intended for those residents spending at least 6 months training in the subspecialty. III. Cognitive Objectives: The resident will be able to: 1. demonstrate mastery of all cognitive objectives expected of the CA-1 and 2 resident. 2. describe anesthesia implications of transesophageal echocardiographic monitoring. 3. describe the anatomy and pathophysiology of congenital heart abnormalities. IV. Skill Objectives: The resident will be able to: 1. demonstrate mastery of all skill objectives expected of a CA-1 and 2 resident with essentially no staff supervision. 2. Demonstrate the basic use and interpretation of transesophageal echocardiography. V. Conference and Literature Assignments The CA-3 rotating resident will attend the conferences held by the Department of Anesthesiology. The annual curriculum is expected to fully cover the subject for cardiothoracic surgery, and include such specialty items such as echocardiography, journal club and quality assurance issues. Reading and active participation is expected of these residents. There will be greater expectation of the CA-3 resident in reading, participation, and presentations at these sessions. Division of Neuroanesthesiology Clinical Training CA-1 and CA-2 Advanced Clinical Training CA-3 The Neuroanesthesia clinical rotation at MetroHealth Medical Center offers the resident experiences in a wide range of neurosurgical cases including: extra and intracranial (aneurysms and arteriovenous malformations) vascular surgery, benign and malignant intracranial tumors, craniobasal and craniofacial surgery, transsphenoidal pituitary surgery, posterior fossa craniotomies, head trauma, pediatric neurosurgery, stereotactic and brain biopsy procedures and spinal surgery involving Evoked Potential Monitoring. The objectives for the Clinical Training for CA-1 and CA-2 include: Didatic 1. Knowledge of cerebal, cerebrovascular and spinal cord physiology including blood flow dynamics, metabolism and causes/consequences of altered physiology. 2. Becoming familiar with the physiopathlology of intracranial pressure and cerebral edema, causes and treatment. 3. The effect of coexisting disease on cerebral pathophysiology. 4. Knowledge of cerebrovascular pharmacology of anesthetic agents and other drugs used on the neurosurgical patient; effects on physiology and metabolism. Clinical 1. Being familiar with various neurosurgical techniques and approaches of neurosurgery including sitting craniotomies, Evoked Potential Monitoring and electrostimulation implants. 2. Preoperative, intraoperative and postoperative care of the routine and emergency patients with neurological problems. 3. Patient evaluation, induction and maintenance of anesthesia, invasive and noninvasive monitoring. 4. Neuroanesthesia techniques such as induced hypothermia, reduction of increased intracranial pressure and the use of techniques that might attenuate sequelae of focal ischemia. 5. Satisfactory completion of neuroanesthesia clinical rotation exam. The objectives of the Advanced Clinical Training for the CA-3 include: 1. Review of the basic clinical objectives for CA-1 and CA-2. 2. Focusing on preoperative evaluation of the neurosurgical patient and clinical decision making. 3. Impact of coexisting disease on clinical decision making for the neurosurgical patient involving further preoperative testing, intraoperative monitors and postoperative pain management. 4. Evaluation of clinical involving choice of induction agent, neuromuscular blocking agents, maintenance anesthesia and postoperative planning. 5. Satisfactory completion of neuroanesthesia mock oral exam by staff attending anesthesiologist. Goals and Objectives for CA-1/2 and CA-3 Residents in Obstetrical Anesthesia 1. The rotation Anesthesia residents at the MetroHealth Medical center will be required to participate in a minimum of 2 one-month rotations in L&D learning Obstetrical Anesthesia. One rotation to be scheduled in the latter half of their CA-1 year, and one month in the CA-II year. In the CA-III year, one or more elective months may be selected. 2. Academic Objectives and Goals For the new resident, it is important to recognize that there is a core of knowledge that must be mastered to become a competent consultant in Obstetrical Anesthesia. The acquisition of this knowledge is vital for not only board certification, but for optimal patient care. The resident will be expected to gain an understanding of the basic principals of perinatal anesthetic delivery in both the normal parturient as well as those with complex medical requirements. They will develop the necessary skills in pre-anesthetic assessment and preparation, intra anesthetic management, and post- operative care including assessment of complications, care and prevention strategies. Additionally, residents in the CA III year will attain additional proficiency in all these areas allowing them to assist in junior resident training, act with more independence in both normal and high risk parturient care, and participate in optional research projects to advance knowledge in this field. 3. Knowledge objectives At the conclusion of the resident’s two months of rotation in Obstetrical Anesthesia, the resident will: a. Have a thorough knowledge of the physiologic changes in pregnancy. b. Understand maternal uptake/distribution, placental transfer, and perinatal effects of volatile anesthetics, barbiturates, ketamine, narcotics, sedatives, tranquilizers, neuromuscular blocking agents, local anesthetics, antihypertensive agents, anticoagulants, Tocolytic, as well as glucose/hypoglycemic agents. c. Understand uterine blood flow it’s changes in pregnancy, how regional and general anesthetics effect it, and the effects of vasopressors/antihypertensive agents on it. d. Understand the physiology of labor, it’s stages, how anesthesia effects labor, and how agents used in labor and delivery (like tocolytic’s, ergot alkaloids, pitocin, prostaglandin’s, etc.) can effect maternal physiology and anesthetic management. e. Understand and be able to discuss the advantages, disadvantages, and risks of sedation, inhalation, epidural, spinal, and pudendial anesthesia for labor. f. Understand and be able to discuss the advantages, disadvantages, and risks of local, regional and general anesthesia for the patient undergoing cesarean section. g. Understand and manage induction, maintenance, and emergence from general anesthesia, the effects of volatile anesthetics on the uterus and fetus, the pros/cons of Nitrous Oxide, and the management of complications such as failed intubation, aspiration, hypotension, hypertension, etc. h. Understand and be able to discuss the advantages, disadvantages, and risks of anesthesia for the patient undergoing non-obstetric surgery during pregnancy. i. Understand how agents/ procedures in the induction/augmentation of labor can effect maternal anesthetic care such as amniotomy and the use of oxytocin. j. Understand the pharmacokinetics / pharmacodynamics of local anesthetics as well as complications/toxicity in the parturient and neonate. k. Understand the options for post-partum anesthesia care the advantages, disadvantages and risks. l. Understand and be able to describe the anatomic features and appropriate landmarks necessary to administer a regional anesthetic block including spinal dermatomes and pain pathways. m. Be able to identify and assess the relative and absolute contraindications to regional anesthesia related to coagulopathy, neurologic disease, hypovolemia, drug allergy, fever/sepsis, backache, scoliosis, etc. n. Understand, recognize, and manage patients with medical conditions in pregnancy such as: 1) pregnancy inducted hypertension 2) cardiac disease (congenital/ischemic/valvular/cardiomyopathy) 3) respiratory disease (restrictive/obstructive) 4) bleeding disorders in pregnancy ( placenta previa, abruption, accreta, etc.) 5) diabetes 6) morbid obesity 7) difficult airways 8) the causes of cardio- respiratory arrest 9) misc. disorders ( thyroid, NM disorders, MH, coagulopathies) 10) the patient with PDPH o. Describe/manage complications of regional anesthesia in pregnancy hemodynamic, backache, bladder dysfunction, neurologic sequela, infection, headache, etc. p. Understand and discuss obstetric and neonatal indications for cesarean section both elective and emergent and be able to discuss the risk/benefits of the various options for anesthetic management. q. Be able to discuss the obstetrical considerations/management of labor complications such as breech delivery, cord prolapse, transverse lie, multiple gestation, brow presentation, premature rupture of membranes, and premature delivery. r. Understand the management of maternal hemorrhage and the risks associated with such conditions as: previa, abruption, accreta, uterine rupture, uterine atony, retained placenta, uterine inversion, DIC. s. Understand the basic anatomy and physiology of the feto-placental unit, ante-partum fetal monitoring and assessment including non stress testing, oxytocin stress testing, biophysical profile, fetal lung maturity testing, fetal heart rate monitoring, and fetal pH monitoring. t. Understand, be able to discuss peripartum fetal asphyxia diagnosis/management of neonatal disorders such as meconium aspiration, diaphragmatic hernia, T-E fistula, sepsis, RDS of the newborn. 4. Skill Objectives a. To be able to safely and thoroughly prepare an operating room to be ready to administer an anesthetic for vaginal/cesarean delivery. b. To be proficient in the placement and management of regional anesthesia (both spinal and epidural anesthetics) in all clinical setting for labor, cesarean delivery, D&C, postpartum tubal ligation, cerclage, etc. The goal is to do a minimum of 50 regional anesthetics per month. c. To be able to select appropriate monitoring for the various clinical settings that occur in the parturient. d. To be able to safely administer general anesthesia to the parturient in both the non- emergent and emergent setting for both vaginal and cesarean delivery. e. To be able to pre-operatively evaluate and design a safe anesthetic plan for the anesthetic management of: 1) The healthy parturient for vaginal delivery with or w/o the use of forceps. 2) The healthy parturient presenting for elective cesarean section 3) The healthy parturient presenting for emergency cesarean section. 4) The parturient with Preeclampsia/Eclampsia for either vaginal/cesarean section 5) The parturient with antepartum/intrapartum/postpartum hemorrhage f. To be familiar with the diagnosis and management of the fetal/neonatal distress. g. Learn to interact/communicate effectively with all allied personnel in the obstetric care team, to lead in the pre-anesthetic evaluation, labor, intra-operative and post-operative care as well as maternal/fetal resuscitation. h. Learn to function as a consultant to patients, families, colleagues in anesthesia, obstetrics and other specialties. 5. Literature Conference Obligations a. Attendance at Tuesday morning 7 AM grand rounds. b. Attendance at Wednesday afternoon 1 PM resident lecture. c. Attendance at Friday afternoon 1 PM resident lecture. d. The resident is to read all 16 chapters of the Obstetrical Anesthesia handbook that is supplied by the secretarial staff. They are to be able to answer the questions provided in each chapter of the manual. They are then to present each chapter to the attending staff to demonstrate their command of the information. The attending will then sign off on each chapter the resident presents. At the end of each rotation 8 chapters are to be completed and the resident is to give the signature sheet to the secretary at the end of the month. e. Shnider, S MD and Levinson, G. Anesthesia for Obstetrics f. Ostheimer, Gerald, MD Manual of Obstetric Anesthesia g. Gambling DR, Douglas J, Obstetric Anesthesia and Uncommon Disorders Anesthesia Resident Pain Management Rotation Goals and Objectives The Anesthesiology Department at MetroHealth Medical Center established the Pain Management Program in 1983. This program addresses the needs of our community in the treatment of Acute, Chronic and Cancer Pain. The program works hard to provide a significant educational experience to our Anesthesiology Residents during their rotation in Pain Management. We are proud that our Pain Management Program provides educational information and training opportunities to other interested residents or active physicians at MetroHealth Medical Center. Goals and objectives of CA-2 Resident Pain Rotation: Define rotation: 1. Two month rotation in pain management. The rotation will provide basic experience in acute, chronic and cancer pain. 2. The residents are fully committed to pain management during this rotation without any operating room coverage. 3. The residents are responsible along with their CA-3 colleagues, to operate and provide 24 hour pain coverage under the supervision of the Pain Management Specialist. Cognitive Objectives: To enable our Residents to reach the following goals: 1. Understand the anatomy, physiology and patho-physiology of pain, e.g., nociceptors, pathways, mechanisms and spinal or central modulations. 2. Understand the pharmacology and pharmacodynamics of oral, I.V., cutaneous and spinal opiates. 3. Understand the importance of post-operative and post-trauma pain management. 4. Understand the multiple acute pain management modalities, e.g., I.V. PCA, peripheral nerve blocks, neuro-axial blocks, the role of NSAID’s and neurolytic drugs, TENS units, and psychotherapies. 5. Understand the complex pathways and mechanisms in chronic pain patients. 6. Understand the nature of neuropathic pain and the mechanisms, e.g., CRPS type I & II, post-herpetic neuralgia, diabetic neuropathy, and trigeminal neuralgia. 7. Understand the complex mechanisms involved in back and neck pain. 8. Understand the role of nerve blocks and the neuro-axial implants in the treatment of chronic pain e.g., dorsal column stimulators and intra-thecal drug delivery systems 9. Understand the principles of diagnostic testing. 10. Understand the human aspect of pain and suffering and the possibility of failure to relieve the pain of some chronic pain sufferers. Skill Objectives: 1. Order and manage PCA pumps and provide the necessary documentation. 2. Perform peripheral or neuro-axial nerve blocks in accordance with their level of training. 3. Recognize and treat the side effects of these treatments. 4. Conduct a full history taking and physical examination including neuro-muscular exam. 5. Assist and perform some chronic pain management therapies. 6. Conduct Acute and Chronic Pain Management service rounds and respond to in-house consults. 7. Assist in all intrathecal pump refills and drug refill orders. Conference and Literature Assignments: 1. Attendance at Anesthesiology Grand Rounds(Online). 2. Attendance at _________ lectures series(Online). 3. Attendance at the Journal Clubs. 4. Prepare and read about the procedures prior to performing them. Discuss cases with the attending. 5. Read the entire pain management handout prior to the rotation. Make use of the pain reference textbooks and journals during the rotation. Goals and Objectives for CA-3 Resident Pain Rotation: Define Rotation: 1. A two to six month rotation in pain management. The rotation will enhance their knowledge and skills in acute and chronic pain management. 2. The ______ resident has the same commitments and the responsibilities of the _______ resident, in addition the responsibility to be a leader and a teacher for CA-2 resident. (Online) Cognitive Objectives: To enable our residents to attain the following goals: 1. Demonstrate mastery of all cognitive objectives expected of CA-2 resident. 2. Discuss in depth the acute pain management modalities and their complications. 3. List the indication and contraindications for each acute pain management modality. 4. Describe the effect of centrally acting drugs. 5. Understand the difference between tolerance and addiction to narcotics. 6. Demonstrate mastery in evaluating pain patients and formulating a plan of treatment. 7. Describe the benefit of additional testing and consults. 8. Discuss the measurement and assessment of pain and function. 9. Discuss the role of nerve blocks in pain management. 10. Discuss the indications and contraindications of advanced implantable therapies. 11. Discuss the indications and contraindications for radio-frequency therapy. 12. Discuss the importance of a multidisciplinary approach to pain management, and the contributions of other specialties to the success of the treatment. Skill objectives: 1. Demonstrate mastery of all skill objectives of _____ residents. 2. Perform thoracic epidurals and neuro-axial blocks. 3. Perform peripheral continuous nerve blocks. 4. Perform a full history and physical examination. 5. Perform a wide range of chronic pain blocks. 6. Assist in the insertion of implantable therapies. 7. Refill and manage the pumps. Conference and Literature Assignments: 1. Attendance at Anesthesiology Grand Rounds. 2. Attendance at _______ lectures series. 3. Attendance at the Journal Clubs. 4. Current Review of Pain, by ________ 5. The Pain Clinic Manual, by ________ 6. Cancer Pain, by _______ 7. The Clinical Journal of Pain. 8. The Journal of Regional Anesthesia. Department of _______ Resident Advanced Rotation Curriculum Define Rotation: 1. Two to six months rotation in pain management. The rotation will enhance their knowledge and skills in acute and chronic pain management. 2. CA-3 resident has the commitment and the responsibility of a CA-2 resident, in addition to the responsibility to be a leader and a teacher for CA-2 resident. Cognitive Objectives: To enable our residents reach their goals in: 1. Demonstrate mastery of all cognitive objectives expected of CA-2resident. 2. Discuss in depth the acute pain management modalities and their complications. 3. List the indication and contra-indications to each acute pain management modalities. 4. Describe the effect of centrally acting drugs. 5. Understand the difference between tolerance and addiction to narcotics. 6. Demonstrate mastery in evaluating pain patients and formulating a plan of treatment. 7. Describe the benefit of additional testing and consults. 8. Discuss the measurement of and assessment of pain and function. 9. Discuss the role of nerve blocks in pain management. 10. Discuss the indications and contraindications of advanced implantable therapies. 11. Discuss the indications and contraindications for Radio-frequency therapy. 12. Discuss the importance of a multidisciplinary approach to pain management, and the contributions of other specialties to the success of the treatment. Skill objectives: 1. Demonstrate mastery of all skill objectives of the CA-2 resident. 2. Perform thoracic epidurals and neuro-axial blocks. 3. Perform peripheral continuous nerve blocks. 4. Perform a full history and physical examination. 5. Perform a wide range of chronic pain blocks. 6. Assist in the insertion of implantable therapies. 7. Refill and manage pumps. Anesthesiology Resident Education/Training Goals and Objectives The overall general objectives of resident education and training in Pediatric Anesthesiology are to develop consultant-level knowledge in all areas of the subspecialty and to develop the knowledge and skill, based especially on hands-on clinical experience, to provide state-of-the-art pediatric anesthesia care in most situations likely to be encountered in future practice. Residents may also be encouraged, though not required, to participate in clinical research projects under the direction of the attending staff. Our two to three month Pediatric Anesthesia Rotation is focused on facilitating the achievement of these and the following more specific goals and objectives. Pediatric Anesthesia Rotation CA1/2/3. Duration: 2-3 months (Online) Description The rotation is designed as two separate months during the CA1 and/or CA2 years, plus an elective third month during the CA3 year. Pediatric anesthsia information for preview and concurrent study is available online. Suggested reading list follows. During the three months residents are directly supervised by faculty members of the MHMC Department of Anesthesia in the provision of anesthesia and post-anesthetic care for newborns, infants, children and adolescents to age 18 undergoing therapeutic, diagnostic and surgical procedures. This care is inclusive of general anesthesia, regional anesthesia, intravenous sedation as well as appropriate regimes for analgesia in this population. A core curriculum of topics in Pediatric Anesthesia is presented throughout the year as part of the regular Tuesday morning, Wednesday afternoon and Thursday afternoon lecture series. This didactic material emphasizes the anatomy, physiology and pharmacology as it pertains to the practice of pediatric anesthesiology. A syllabus of regularly updated study material is available online. Each resident is expected to begin study of the relevant material prior to the first month of the rotation. Goals Specifically, residents will be able to demonstrate: * Essential Character Attributes o Be punctual o Be honest and ethical o Learn from experience o React appropriately in stressful situations * Good judgment (including recognition of personal limitations) * Understanding and application of: 1. Special pediatric considerations in temperature regulation 2. Malignant hyperthermia 3. Resuscitation of the newborn 4. Pediatric apparatus, including breathing circuits, humidifying methods, thermal control 5. Appropriate thorough preoperative evaluation and development of positive rapport with the pediatric patient and family. 6. Appropriate preparation of the operating room and equipment for the pediatric patient. 7. Premedication: drugs, dosage, routes, vehicles 8. Agents and technics o Anesthetic: actions different from adults o Neuromuscular blockers (sensitivity, congenital diseases) o Selection of and demonstrate skillful application of technics of pediatric anesthetic induction: intravenous (IV) inhalational rectal intramuscular (IM) o Skillful management of the pediatric airway by hand and mask o Achievement of IV access in the pediatric patient o Performance of efficient atraumatic endotracheal intubation of the pediatric patient o Appropriate selection and performance of basic pediatric regional anesthetic technics including + Caudal epidural block + Spinal + Ilioinguinal-hypogastric nerve block + Penile block + Peripheral nerve blocks 9. Fluid therapy and blood replacement, physiologic anemia 10. Problems in intubation (full stomach, diaphragmatic hernia, T-E fistula, Pierre-Robin, awake intubation) 11. Proficiency in the anesthetic management of routine pediatric cases (tympanotomy tubes, adenoidectomy and tonsillectomy, herniorrhaphy,...) explaining the selection of airway, fluid type and rate, agents and adjuvants 12. Anesthetic implications of common and critical pediatric conditions o Asthma o Upper respiratory infection (URI) o Tonsillar and adenoidal hypertrophy/tonsillitis o Serous otitis media (SOM) o Croup o Epiglottitis o Obstructive sleep apnea (OSA) 13. Neonatal physiology o Respiratory + Development, anatomy, surfactant + Pulmonary oxygen toxicity + Pulmonary function + Lung volumes vs. adult + Airway differences, infant vs. adult o Cardiovascular + Transition, fetal to adult + Persistent fetal circulation o Metabolism, fluid distribution and renal function o Thermal regulation (neutral temperature, brown fat) o Fetal hemoglobin o Clinical problems of prematurity + Respiratory distress syndrome (RDS) + Bronchopulmonary dysplasia (BPD) + Apnea of prematurity + Retinopathy of prematurity (ROP): anesthetic implications + Necrotizing enterocolitis (NEC) 14. Congenital heart disease o Cyanotic defects, primary pulmonary hypertension o Acyanotic defects o Altered uptake/distribution of IV and inhalation anesthetics o Other anesthetic considerations o Anesthetic considerations of specific lesions + Patient ductus arteriosus (PDA) + Atrial septal defect (ASD) + Ventricular septal defect (VSD) + Tetralogy of Fallot (TOF) + Transposition of the great arteries (TGA) + Persistent pulmonary hypertension of the newborn ("PFC") 15. Emergencies in the newborn o Diaphragmatic hernia o T-E fistula o Neonatal lobar emphysema o Pyloric stenosis o Necrotizing enterocolitis o Omphalocele/gastroschisis o RDS: etiology, management, ventilation technics o Myelomeningocele 16. Management of the anesthetic recovery of pediatric patients 17. Postoperative analgesia CA3 Residents completing the third month of Pediatric Anesthesia will additionally be able to 1. Supervise junior residents and medical students in performing pediatric anesthesia care 2. Appropriately manage anesthesia for complex and/or difficult cases (diaphragmatic hernia, T-E fistula, omphalocele/gastroschisis, Pierre-Robin syndrome, epiglottitis, ...) 3. Lead discussions with junior residents on principles of pediatric anesthesia 4. Assume role of consultant anesthesiologist Pediatric Anesthesia Educational Objectives The following serves as a guide to the education and evaluation of residents rotating in Pediatric Anesthesia. 1. MEDICAL KNOWLEDGE: * Cognitive ability: residents will learn the principles of anesthesia for pediatric patients including the anatomy and physiology of neonates and children; the pathophysiological process involved in pediatric surgical conditions; the pharmacology of anesthetic agents as it effects neonates, infants and children; the principles of temperature regulation for neonates, infants and children; the principles of equipment and monitoring devises used in pediatric anesthesia; * Psychomotor ability: residents will develop a working knowledge and understanding of the indications and contraindications, risks and benefits of the various procedures they learn; residents will develop technical skill with procedures such as intravenous, intraarterial and central venous catheter insertion in infants and children, neuroaxial and other regional procedures in infants and children. * Affective ability: residents will begin to develop behavior patterns related to working with pediatric patients and their parents in the preparation and administration of anesthesia, including the need for careful assessment, the ability to respond to rapidly changing patient conditions and the team approach to pediatric anesthesia.. 2. PATIENT CARE: * Cognitive ability: residents will learn the basic principles of caring for pediatric patients undergoing surgery for general, urological, orthopedic, ENT, cardiac, neurosurgical, ambulatory and other surgical procedures; residents will also understand the principles of sedation and monitoring for pediatric patients having procedures outside the operating room such as radiological procedures; the recognition, treatment and prevention of postoperative pain in children and infants. * Psychomotor ability: residents will have the opportunity to anesthetize at least 100 patients aged between 2 to 12 years and at least 15 under 2 years, including neonates and premature babies; residents will learn how to perform invasive procedures with appropriate concern for patient safety such as epidural, caudal and spinal anesthesia; sedation and monitoring techniques; * Affective ability: residents will develop a behavioral approach that pays attention to all aspects of caring for pediatric patients and their parents in the perioperative period; residents will pay particular attention to patient safety; residents will be expected to work at the appropriate level of supervision for their training and for the condition of their patients; residents should demonstrate independent thinking but also show appropriate judgment and decision making including knowing when to ask for help from their supervising attendings. 3. INTERPERSONAL & COMMUNICATION SKILLS: * Cognitive ability: residents will learn techniques for effective communication with pediatric patients and their parents concerning pre-operative assessment, explaining the process of anesthesia and discussing risks of general and regional anesthesia. * Psychomotor ability: residents will be able to demonstrate skills for making a thorough preoperative assessment of each patient, they will also develop effective communication skills for explaining the process of anesthesia and discussing risks of general anesthesia to patients and their parents; residents will develop effective listening skills and show effective communication with patients, their parents and families and other members of the pediatric care team. * Affective ability: residents will demonstrate behaviors that show commitment to effective communication with patients, their families and other members of the pediatric surgical team; residents should be able to communicate pertinent data about the patient to their attending in a precise and efficient manner. 4. PROFESSIONALISM: * Cognitive ability: residents will learn the basic definitions of professional conduct as it applies to the practice of anesthesia for pediatric surgery and basic ethical principles. * Psychomotor ability: residents will act in a way that shows commitment to professional practice in their interactions with patients, their parents and families, colleagues and other members of the pediatric health care team; residents will be expected to contribute to the smooth running of the pediatric operating rooms; residents will be expected to complete all pre, intraoperative and post operative documentation in accordance with departmental requirements. * Affective ability: residents will demonstrate commitment to professional practice in their interactions with patients, their families, colleagues and other members of the pediatric health care team. 5. PRACTICE-BASED LEARNING: * Cognitive ability: residents will learn the practice of reflection on their performance and how to learn from expereince; they will understand the principles of life-longer learning and evidence – based medicine as it relates to pediatric anesthesia. * Psychomotor ability: residents will demonstrate reflective practice and develop skills to enhance learning from various sources including the use of web-based learning; residents will participate in feedback with their tutors to help improve their practice of pediatric anesthesia. * Affective ability: residents will demonstrate commitment to continually trying to improve their performance and take an active role in furthering their knowledge by attending organized educational activities especially the pediatric didactic lecture schedule and by preparing a 20 minute presentation for the end of the rotation. 6. SYSTEMS BASED PRACTICE: * Cognitive ability: residents will understand the team approach to how pediatric patients present, are investigated and assessed and optimized for their surgical procedures and how their management impacts on this team approach; residents will understand how the pediatricians, surgeons, nurses and intensive care departments interact with the pediatric surgical patients. * Psychomotor ability: residents will take part in practices and initiatives such as quality improvement programs that interact with other areas of the health care system; residents will be expected to function as a team member and work with nurses, surgeons and operating room staff to improve the care they offer their patients and their own understanding of the broader aspects of the health care system. * Affective ability: residents will develop behaviors that show an appreciation for the impact of their practices on the whole system caring for pediatric patients undergoing surgery. Syllabus for _______ Anesthesia Rotation in the Surgical Intensive Care Unit Airway Management * Indications for an endotracheal tube * The compromised airway * Intrathoracic vs extrathoracic airway obstruction * Evaluation for airway protection and edema * Management of post-extubation stridor * Intubation techniques in unstable patients * Medicating the hemodynamically unstable patient * Intubating the patient with closed head or cervical spine injury * Cuff leaks - evaluation and management * Timing of tracheostomy Respiratory Management Respiratory physiology * Ventilation perfusion relationships * Causes of hypoxemia * Postoperative changes in respiratory function * PaO2/FIO2 relationships * Oxygen delivery and consumption Mechanical ventilation * Modes of mechanical ventilation - volume vs pressure * PEEP - indications, systemic effects, contraindications * Non-invasive mechanical ventilation Weaning from mechanical ventilation * Determining patients who are candidates for ventilator weaning * Use of weaning parameters * Controversies in weaning modes - AC/SIMV, T-piece trials Respiratory issues in trauma * Pulmonary contusion - physiology, management * Flail chest * Fat embolism ARDS * Diagnostic criteria * Management - fluid balance, ventilator strategies, steroids * Oxygen toxicity * Barotrauma Fluid Balance in the Surgical Patient Perioperative fluid management * Intraoperative fluid balance * Sources of intraoperative fluid loss * Postoperative fluid balance – patterns of third spacing and mobilization * Crystalloid vs colloids Transfusion therapy * Optimal hematocrit * Indications for blood products * Albumin controversies Electrolyte and Acid-base disorders * Acid base balance, compensatory mechanisms * Renal failure- diagnostic criteria, management, indications for dialysis, renal replacement techniques Hemodynamic monitoring Pulmonary artery catheters * Use of hemodynamic monitoring data, limitations of data, waveform recognition * Complications of catheters Hemodynamic mangement * Management of hypertension * Management of tachyarrhythmias * Inotropic agents * Vasopressor agents * Recognition and management of shock states Infectious diseases * Sources of infection in the ICU patient * Management of fever in the ICU * Sinusitis * Preventive measures * Antibiotic management, empiric coverage, rotation of antibiotics * Management of central lines in the ICU patient Nutritional support * Enteral vs parenteral nutritionv * Uses of indirect calorimetry Neurosurgical concepts Closed head injury, intracranial pressure * Basic concepts of cerebral hemodynamics * Management of elevated intracranial pressure * Concepts of cerebral perfusion pressure Cerebral aneurysms * Complications of aneurysmal rupture * Management of cerebral vasospasm * Timing of aneurysmal clipping Cervical spine injuries * Respiratory pathophysiology * Hemodynamic management * Steroids in spinal cord injury * Timing of spine stabilization Radiology in the ICU * Limitations of plain films * Proper placement of tubes, central lines * Recognition of pulmonary collapse * Use of CT scans in the ICU patient Recommended reading: * Anesthesiology Resident’s Guide to Learning in the Intensive Care Unit, ______ * The ICU Book, ______ 1. All of the strategies for definitive airway management are acceptable in patients with Angioedema EXCEPT: 1. Awake fiberoptic intubation 2. Awake Direct Laryngoscopy 3. Rapid Sequence Intubation 4. Cricothyrotomy 5. Tracheotomy Answer: C. Rapid Sequence Intubation 2. Which of the following statements concerning the head-injured patient is TRUE? 1. Improved neurological outcome is associated with the avoidance of direct laryngoscopy for intubation in this population. 2. The unconscious head-injured patient (GCS<8) has a three-fold chance of cervical spine injury. 3. Avoidance of cervical spine movement during airway management is more important than avoiding transient hypoxia and hypotension. 4. The safest way of proceeding with intubation is proven to be the flexible fiberoptic bronchoscope. 5. The use of muscle relaxants for intubation of these patients is contraindicated because they will interfere with subsequent neurological evaluation. Answer: B. The unconscious head-injured patient (GCS<8) has a three-fold chance of cervical spine injury. Which behavior results in the most airway management negligence law suits? See the answer Question 1 1. All of the strategies for definitive airway management are acceptable in patients with Angioedema EXCEPT: 1. Awake fiberoptic intubation 2. Awake Direct Laryngoscopy 3. Rapid Sequence Intubation 4. Cricothyrotomy 5. Tracheotomy Answer: C. Rapid Sequence Intubation See the answer Question 2 2. Which of the following statements concerning the head-injured patient is TRUE? 1. Improved neurological outcome is associated with the avoidance of direct laryngoscopy for intubation in this population. 2. The unconscious head-injured patient (GCS<8) has a three-fold chance of cervical spine injury. 3. Avoidance of cervical spine movement during airway management is more important than avoiding transient hypoxia and hypotension. 4. The safest way of proceeding with intubation is proven to be the flexible fiberoptic bronchoscope. 5. The use of muscle relaxants for intubation of these patients is contraindicated because they will interfere with subsequent neurological evaluation. 1. When do I talk to an Anesthesiologist? The anesthesia interview is conducted prior to your surgery by an anesthesiologist.See the answer 2. What are the risks of anesthesia? The risk of complications is present any time you undergo anesthesia and surgery. Fortunately, serious or debilitating complications are extremely rare in healthy patients. However, the extremes of age, the seriously ill, and those undergoing major or emergency operations share an increased risk profile. Some major risks routinely discussed include death, myocardial infarction, stroke, allergic reactions, arrhythmias, aspiration, asphyxiation, awareness, bronchospasm, nerve damage, vocal cord damage, dental damage and corneal abrasions. Minor postoperative side effects include grogginess, muscle aches, nausea/vomiting, sore throat, hoarseness, or bruised lip. Generally, these are self-limited problems that resolve early in the postoperative period. Please alert us if you had any of these problems in the past, so that we can plan a better anesthetic experience for you. 3. What are the side effects of anesthesia? Although we are constantly improving our techniques, certain side effects from anesthesia and surgery are common, such as sore throat, dizziness, grogginess, muscle pain and nausea/vomiting. These problems generally respond to treatment or resolve with time. Please let us know if you had these problems or any other problems in the past, as that can help us plan a better anesthetic experience. Pain relief after you leave the recovery area is under the control of your surgeon. It is a good idea to obtain and fill your prescription before your surgery or as soon as possible after your surgery. Nausea and vomiting are not uncommon with narcotic-based pain medicines, so be sure to ask your surgeon about this possible problem before going home. 4. What is a spinal? A spinal anesthetic is a form of regional anesthesia, most often utilized for operations on the legs, lower abdomen, perineum, or back, and occasionally for upper abdominal operations. A delicate needle is inserted between the bones of the lower spine (below the level of the spinal cord) into a sac containing cerebrospinal fluid (CSF) and exiting nerve roots. A local anesthetic is then injected, “numbing” these nerves and providing surgical anesthesia. 5. What is an epidural? An epidural anesthetic is another form of regional anesthesia used for many of the same operations as a spinal. Unlike a spinal in which a onetime dose of local anesthetic is administered, providing a fixed time period of “numbing,” a small epidural catheter is left in place just outside the fluid sac. This catheter can be reinjected during a surgical procedure or childbirth to prolong the anesthetic effect. Epidurals are frequently placed prior to major abdominal and thoracic procedures. After your surgery, these epidural catheters can be infused with a narcotic and/or local anesthetic to provide pain relief. This service is managed by the Anesthesia Department and typically runs for several days after your surgery. * Before your surgery * During your surgery * After your surgery Before your surgery Preanesthesia Testing (PAT) process Once you know you are having surgery, you should schedule an appointment with an Anesthesiologist by calling 541-984-4158. As part of the preadmission testing process you will have an anesthesia interview, diagnostic testing such as blood tests or electrocardiogram as indicated, and an opportunity to discuss any questions you have about anesthesia with one of our physicians. Anesthesia interview Anesthesia interview The anesthesia interview is conducted prior to your surgery by an anesthesiologist, either as part of the preadmission testing (8:30 a.m. – 4 p.m. in the Patient Registration area of the hospital) or after admission to the hospital. The Anesthesiologist who interviews you may not be the one who administers your anesthetic; however, all the information obtained during your interview is available to your anesthesia care provider. During the preoperative interview, your medical health and anesthetic plan for your surgery will be discussed with you. You will have an opportunity to have your questions/concerns addressed. Patient Interview Office: Food and drink (NPO=Nothing by Mouth) With anesthesia, you may lose the ability to protect your lungs should stomach contents be vomited up into your throat. These contents can then be inhaled into your lungs, causing severe damage. This risk can be minimized by not eating or drinking prior to your anesthesia and surgery . You should not have solid food for at least 8 hours before surgery. Depending upon your age, medical history and the time your surgery is scheduled, you may be able to drink clear liquids, (e.g. water, apple juice, soda, coffee or tea without cream) the morning of surgery. You may also be asked to take some of your regular medications with a sip of water the morning of surgery. Remember: Adults NO solids after midnight ; this also means NO solids the day of your surgery. Clear liquids only as instructed by Anesthesiologist. Infants and children You will receive specific age-appropriate eating and drinking instructions from your surgeon or Anesthesiologist. Smoking Cigarette smoking is a risk factor for many postoperative complications. Healing of surgical wounds and bones may also be impaired in smokers. While it may take several months to achieve the maximum benefits of being a nonsmoker, even a brief period of abstinence before surgery can help you. For these reasons we recommend that you remain smoke free before and after surgery, and that you strongly consider quitting for life. Why quit smoking now? * It will help you heal faster. * It improves your chances of recovering without complications. What should you do? * Stop smoking for at least 12 hours before surgery. * Stay smoke free for at least one week after surgery. * Consider staying smoke free for life. How to get help? * Chew nicotine gum the morning of surgery instead of smoking. * Ask your surgeon about nicotine replacement therapy if needed. * Use the Web During your surgery Your anesthesiologist is responsible for your comfort and well being while you are having surgery. A member of the anesthesia staff will be monitoring you the entire time you are having surgery. Monitoring during anesthesia The most frequently used monitoring techniques at Sacred Heart Medical Center include: 1. Blood pressure 2. Electrocardiogram (EKG) 3. Oxygen content of inhaled gases when general anesthesia is administered 4. Stethoscope monitoring of heart and breath sounds 5. Temperature 6. Pulse oximetry: Measuring the amount of oxygen saturation in the patient’s blood 7. Airway gas analysis: Using an instrument that precisely measures the inhaled and exhaled amounts of oxygen, carbon dioxide, nitrogen, as well as different anesthetic gases Sophisticated surgical procedures on patients with severe heart or lung disease often require more sophisticated monitoring techniques: 1. Direct arterial blood pressure 2. Central venous pressure 3. Pulmonary artery pressure 4. Transesophageal Echocardiography After your surgery Post anesthesia care unit (Recovery room) Immediately after surgery you will be transferred to the recovery room where you will be closely monitored by skilled nurses while you emerge fully from the anesthetic. An Anesthesiologist is immediately available for consultation if needed. Any pain or side effects will be aggressively addressed during this period. Side effects Although we are constantly improving our techniques, certain side effects from anesthesia and surgery are common, such as sore throat, dizziness, grogginess, muscle pain and nausea/vomiting. These problems generally respond to treatment or resolve with time. Please let us know if you had these problems or any other problems in the past, as that can help us plan a better anesthetic experience. Pain relief after you leave the recovery area is under the control of your surgeon. It is a good idea to obtain and fill your prescription before your surgery or as soon as possible after your surgery. Nausea and vomiting are not uncommon with narcotic-based pain medicines, so be sure to ask your surgeon about this possible problem before going home. Next day follow-up Next day follow-up Next day follow-up We do our best to follow up on all patients in the hospital the day after surgery. All Short Stay patients also are contacted by telephone as feasible. Should we miss you and you have any concerns or questions after your discharge, please contact us through the Anesthesia Patient Interview Office at 541-686-7065. We will return your call as soon as possible. Please be patient as we are engaged in the operating room for the major portion of the day. What is the name of the drug given I.V. that makes you go to sleep before surgery? Is anesthesia the medicine that makes you sleep or does it reduce the pain? What kind of operation is appropriate for ambulatory surgery? Where does ambulatory anesthesia take place? What is the name of the drug given I.V. that makes you go to sleep before surgery? Intravenous drugs which produce "sleep" are called hypnotics. There are a variety of drugs that can be used. However, the two most commonly used drugs are sodium pentothal and propofol. Is anesthesia the medicine that makes you sleep or does it reduce the pain? What is the name of the drug given I.V. that makes you go to sleep before surgery? Is anesthesia the medicine that makes you sleep or does it reduce the pain? What kind of operation is appropriate for ambulatory surgery? Where does ambulatory anesthesia take place? |
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What is anesthesia? Almost everybody understands what is meant by the term anesthesia, although it is difficult to define formally. The term was originally coined to describe the state of unconsciousness that occurred after administration of ether or chloroform. Nowadays, anesthesia is generally divided into three types: general anesthesia, regional anesthesia and local anesthesia. General anesthesia is a reversible state of unconsciousness and insensibility to pain. It can well be described as a reversible state of oblivion. Regional anesthesia is when an injection of local anesthetic is used to anesthetize specific nerves leading to regions of the body. Examples of this include an injection into the brachial plexus to render the arm numb, an injection into the cerebrospinal fluid to anesthetize the lower limbs, etc. Local anesthesia is used to describe an injection of local anesthetic around an area, without blocking specific nerve trunks. An example of this would be an injection in the skin to numb it before suturing up a cut. What is an anesthesiologist? An anesthesiologist is a physician who, after completing medical school, has undertaken an additional four years of postgraduate training in order to become an anesthesiologist. The American Board of Anesthesiology offers board certification for anesthesiologists. What is a nurse anesthetist? A nurse anesthetist is a registered nurse who has undertaken two years of additional training in anesthesia and has passed a certification examination. How is anesthesia practiced in the _________? There are three common modes of practice. Firstly, physicians may practice anesthesia on their own. Secondly, they may practice in a care team situation where one physician may direct the activities of two (or possibly 3) nurse anesthetists. Thirdly, a nurse anesthetist may work under the supervision of another responsible physician, such as the surgeon. It is the opinion of this author that the first two modes of practice are preferable to the third. Do I need to see an anesthesiologist prior to my admission for surgery? Generally, if you are healthy (apart from your spine problem), it is not necessary to have a preoperative consultation with an anesthesiologist prior to admission for surgery. However, many practices will conduct preoperative assessments of all patients prior to surgery. If you have other illnesses apart from your spine problem or have an unstable spine, a preanesthetic consultation should be arranged. Do I need to fast before surgery? It is generally considered preferable to have no food or drink (including water) for at least six hours prior to surgery. This is so that the stomach will most likely be empty during the anesthetic. This reduces the risk of patient vomiting during surgery and having postoperative nausea and/or vomiting. I am taking medications. Should I continue to take them prior to surgery? This obviously depends on what medications you are taking! Generally, most medications are continued right up to the time of surgery. One exception is the group of drugs that interfere with blood coagulation. Diabetic patients also require specific management strategies for surgery. If you are taking medications, you should consult with your anesthesiologist prior to surgery and find out which medications should be continued and which should be discontinued. An exception to the above comment about not eating and drinking prior to surgery is that it is normally considered acceptable to take your morning medications with a sip of water prior to coming into hospital for surgery. What about premedication? Over the last few years, anesthetic practice has changed somewhat, in that patients are not routinely receiving sedative premedication. If you are particularly anxious, discuss this in advance with your anesthesiologist and arrangements can normally be made to administer a drug such as versed (Midazolam) which will help calm your nerves prior to surgery. Often, anesthesiologists will administer versed just before you go to the operating room. What will happen to me in the operating room? In the preoperative area, it is normal to start an IV. In the operating room, you will be connected to all of the anesthesia monitors (electrocardiogram, blood pressure monitor, pulse oximeter, neuromuscular transmission monitor and maybe a BIS monitor). You will normally be given oxygen to breathe through a mask and generally, anesthesia is induced with an intravenous induction agent. What drugs are used to administer an anesthetic? A balanced anesthetic consists of several different agents. Generally, anesthesia is induced with a short-acting intravenous anesthetic such as propofol or thiopental. These drugs have a duration of action of about five minutes. After the intravenous induction, a neuromuscular blocking agent is normally used to decrease the function of the muscles of breathing. An endotracheal tube is then placed in the trachea. Anesthesia is normally maintained with a mixture of a volatile anesthetic (administered from the anesthetic machine via the endotracheal tube) as well as nitrous oxide and oxygen. A very potent opioid such as fentanyl is commonly used, as are neuromuscular blocking agents. What are the complications of anesthesia? Minor complications include postoperative sore throat and nausea and vomiting. These are not normally very troublesome and resolve quickly. Serious complications from anesthesia are very rare. What about postoperative pain relief? Often, after spine surgery, patients receive postoperative pain relief via a patient-controlled analgesic pump. With this technology, the patient is presented with a button to push, which they push whenever they are hurting. The system is preset so that they cannot administer an excessive quantity of narcotic medication. Alternatively, intravenous or intramuscular pain killing medications may be prescribed by your surgeon or anesthesiologist. If you are nauseated or feeling sick after your surgery, drugs can be used which can stop those feelings. What does an anesthesiologist do? An anesthesiologist is a physician specialist formally trained in the use of anesthetic drugs and techniques, pain management, and critical care medicine. Your anesthesiologist will formulate an anesthetic plan based on the type of surgery you are having and with consideration given to your concomitant medical problems. As always, our goal is to minimize the potential risks associated with anesthesia and surgery and to ensure that each patient has a positive experience. Whenever possible (i.e. safe), the wishes and desires of the patient and surgeon regarding the anesthetic plan will be respected. Before surgery, your anesthesiologist will review your medical condition and explain your options for anesthesia. During surgery, the anesthesiologist will monitor you closely and make any necessary interventions to ensure your safety and comfort. Your surgeon and anesthesiologist will discuss any special needs you may have for postoperative care. What is the difference between an anesthesiologist and a nurse anesthetist? An anesthesiologist is a medical doctor who has completed a minimum of four years of residency training in anesthesiology (including internship) after graduation from medical school. A Certified Registered Nurse Anesthetist (CRNA) is a nurse who has earned a Bachelors degree in nursing (RN) and attended a two year nurse anesthesia training program. A CRNA must, by law, work under the supervision of a qualified licensed physician. At GBMC all surgical patients are cared for by a board certified anesthesiologist and may also have a CRNA assisting in their care. An anesthesia team member will be present in the operating room at all times. The attending anesthesiologist does not leave the proximity of the OR suites when a patient is in his/her care. Do I need a preoperative medical exam? You may be asked by your surgeon to be evaluated by your internist or family practitioner prior to surgery. This evaluation will determine if you are in optimal physical condition to undergo anesthesia and surgery. It will also provide important information which will help your anesthesiologist to determine the best type of anesthetic to offer you and to assess the need for any special monitoring techniques during surgery. If you have heart disease, please ask your doctor to forward the results of any recent studies (stress test, cardiac catheterization, echocardiogram, etc.) in addition to their pre-op evaluation for review by the anesthesiologist. Occasionally, a visit to the cardiologist may be necessary. Other specialist consultations or tests may be requested to ensure that you are in the best possible condition for surgery. Appropriate blood tests will be determined individually for each patient. Women of child bearing age will need a pregnancy test before elective surgery. Try to reduce caffeine intake before surgery to avoid withdrawal headaches. Cutting down on cigarette use will help reduce your risk of pulmonary complications. Ideally, one should quit smoking 6 weeks before surgery but even 48 hours of smoking cessation has been shown to be beneficial. Why must I not eat or drink prior to surgery? Patients undergoing procedures with any type of anesthesia should arrive in the operating room with an empty stomach. Anesthetic medications may depress the cough reflex and allow any regurgitated material to enter the lungs where it may cause a severe reaction known as "aspiration pneumonia." If you are scheduled for afternoon surgery it is still advisable to stop all food and drink after midnight since the operating room schedule is occasionally changed and your procedure may be moved to an earlier time. Water is acceptable in small amounts up to 3 hours prior to surgery. No food or thick liquids (juice with pulp, milk, etc.) should be consumed for at least 8 hours prior to surgery. Any intake of non-clear liquid or food may cause your surgery to be delayed or rescheduled. Please call your anesthesiologist for guidelines concerning infants and children. What about my medications? Most medications can be taken the morning of surgery with a sip of water only. Non-clear liquids (such as orange juice, coffee with milk) take longer to pass out of the stomach and can cause greater damage if they should enter the lungs. Any intake of non-clear liquid may cause your surgery to be delayed or rescheduled. The following are broad guidelines for some common medications. If you have specific questions, please call your doctor or call the hospital and ask for the Department of Anesthesia or the anesthesiologist on-call. * Blood pressure medication- should be taken as usual the morning of surgery except for diuretics (fluid pills). Diuretic medications should be skipped the morning of surgery. These include Lasix (furosemide), Hydrochlorthiazide (HCTZ) and others. * Insulin - consult your doctor. * Oral diabetes medication - do NOT take on the morning of surgery. * GLUCOPHAGE, a diabetes medicine, must be stopped 24 hours before surgery. * Thyroid medication - can be taken * Heartburn or ulcer medicine - acid blockers (Zantac, Prevacid, Pepcid, Axid, Prilosec, Propulsid, Reglan) should be taken on the morning of surgery to reduce the risk of aspiration pneumonia (see question #2). However, antacids like Maalox, Tums, or Carafate should NOT be taken because they contain particulate material that may damage the lungs if aspirated. * Aspirin - consult your doctor * Asthma inhalers- should be used the morning of surgery and bring them to the hospital with you. What is General Anesthesia? Will I need a breathing tube during surgery? General anesthesia means you will be completely unconscious during surgery. Since general anesthesia can impair normal breathing, some assistance with respiration is necessary. Most often a breathing tube is placed through the mouth into the windpipe (intubation) after the patient is asleep. This is removed as the patient is awakening and most patients will not remember having this tube in place. A mild sore throat lasting one to two days is, unfortunately, very common. In rare circumstances, tooth or airway damage may occur during airway management. Dentures should be removed before surgery. If you have loose teeth or a history of previously difficult intubation please tell your anesthesiologist. Special intubation techniques may be required for your specific situation. What is spinal and epidural anesthesia? Spinal or epidural anesthesia is most often used for procedures below the belly button. The nerves to the operative area are anesthetized with a combination of local anesthetic and narcotic. Both procedures start with a sterile preparation of the back using iodine or alcohol solutions. A small area of skin, about the size of a quarter, is anesthetized with local anesthetic (numbing medicine). Then: Epidural - a thin flexible plastic tube is inserted into the epidural space and taped along the back. Medications are continuously or intermittently injected to anesthetize the lower portion of the body. No metal or needles are left in the patient. This tube can remain in place as long as required and can be used to deliver pain medicine after surgery. Spinal - a small hair-like needle is placed into the spinal fluid and medicine is injected. The needle is immediately removed and nothing remains in the patient. The anesthesia will last for a given amount of time (depending on the medication used) and then will wear off. Most people report that spinal or epidural placement hurts less than starting an IV. In many cases sedation may be given before the spinal/epidural is placed and the patient will neither feel nor remember the placement. What are the advantages/disadvantages of spinal vs. epidural anesthesia? Spinal: Advantages - highly reliable, easier to place, very quick onset Disadvantages - finite length of action, cannot be re-dosed if procedure takes longer then expected, not useful for post-operative pain management. Epidural: Advantages - can be re-dosed for long procedures and used for post-operative pain management Disadvantages - harder to place and therefore less reliable, slower onset of numbness Either technique may be combined with general anesthesia and in some cases combined spinal-epidural can be done for the quick onset of a spinal with the post-operative pain relief of an epidural. If I have an epidural/spinal will I be awake during my surgery? Sedation is often used during regional anesthesia so that patients essentially sleep throughout most of the procedure. The level of sedation is determined by the procedure and the patient's medical condition and desires. What is a spinal headache and how is it treated? The hallmark of a spinal headache is a headache that becomes very intense when an upright posture is assumed and abates significantly when lying down. It may occur after a spinal or epidural anesthetic or after a diagnostic lumbar puncture (spinal tap). A spinal headache is related to leakage of spinal fluid through a puncture site in the sac (known as the dura) surrounding the spinal cord and spinal nerves. The brain and spinal cord "float" in a fluid filled sac. When that fluid is lost, the brain will "sag" due to gravity when in an upright posture. The traction created on surrounding structures results in headache. Lying down provides symptomatic improvement but has not been shown effective in preventing the occurrence of a spinal headache. During a spinal anesthetic, this sac is purposely punctured to inject medicine into the spinal fluid. Significant leakage leading to headache is rare because the spinal needle used is very small and the tiny puncture site heals quickly and doesn't allow much leakage. During an epidural, this sac is usually not punctured, so a spinal headache is usually not possible. However, since the sac is essentially the "back wall" of the epidural space it can accidentally be punctured during epidural placement (~1%). Since the epidural needle is larger then the spinal needle (to accommodate placement of the epidural catheter), significant leakage leading to headache is more likely (~50% when accidental puncture occurs). The overall risk of a spinal headache after spinal or epidural anesthesia is about one in a hundred or less. Most are mild and short lived requiring no specific treatment. Conservative measures include bed rest, increased fluid intake, caffeine, and an abdominal binder. For severe headaches, an autologous blood patch can be performed. An autologous blood patch is a highly effective treatment for a spinal headache. About 90% of spinal headaches will be relieved within 5 to 30 minutes and will require no further treatment. The remaining 10% will require a second patch. The patient is usually given a dose of IV antibiotics prior to the procedure. The patient is placed in the sitting position and the back is sterilely prepared with iodine or alcohol solutions. A needle or catheter is placed in the epidural space exactly as it would be for an epidural anesthetic. Then a small amount of blood is sterilely withdrawn from the patient's arm and injected into the epidural space. This blood will clot and "patch" the hole in the dural sac, preventing any further leakage of spinal fluid. It also slightly compresses the sac, "buoying" up the brain, thereby quickly relieving the headache. The patient can then resume usual activities. There is no risk of introducing blood borne infections, such as AIDS and hepatitis, since the patients' own blood is used. A blood patch is not without risk. There is a risk of infection occurring in the epidural space, a rare but serious complication. In some cases there may be transient back pain. This back pain may last minutes to hours. In rare instances it can last longer. Will anesthesia make me nauseous? There are many factors that contribute to post-operative nausea and vomiting. The type of surgery (abdominal and ear-nose-throat procedures), anesthetic medications (narcotics), changes in physiologic status (low blood pressure, irritation of internal structures, etc) and patient factors (more likely in patients prone to motion sickness) all interact and may contribute to nausea. In recent years, the armamentarium of anti-nausea drugs has improved significantly and has reduced the occurrence of post-op nausea. If this has been a problem for you in the past, please tell your anesthesiologist and prophylactic (preventive) medications can be given to reduce your risk. 1. How does my anesthesiologist know everything is OK during my surgery? 2. I have a "bad heart" - should I worry? 3. I am a smoker - is this a problem? 4. Could I be allergic to the anesthetic? 5. Do I really need an IV? When can the IV come out? 6. I have a loose tooth - is that a problem? 7. What happens when I "go to sleep"(general anesthesia)? 8. Could I wake up during the surgery? 9. How will my pain be treated after the surgery? 10. If I'm given morphine after the anesthetic will I get addicted? 11. Will I have a sore throat after the surgery? 12. Will I experience nausea and vomiting after the surgery? 13. Will I receive blood during my surgery? 14. A relative of mine had a bad reaction to anesthesia. Could it happen to me? How will my anesthesiologist know everything is OK during my surgery? During surgery you will be monitored very intensively. Advanced medical instruments are used to keep an eye on the function of the heart, lungs, brain and other vital organs, as well as to make sure you are receiving just the right amount of anesthesia. Of course, the presence of a skilled and vigilant anesthesia provider is the best monitor of all! I have a "bad heart" - should I worry? Aneshesiologists very frequently take care of patients with heart disease, lung disease, kidney failure, and all sorts of other serious medical conditions. Your anesthesiologist will ask you a number of questions about your illness and will have a plan to minimize the risk associated with your condition. Tests or consultations may be arranged to learn more or even to improve your condition before surgery. I am a smoker - is this a problem? If you are a smoker, our advice is to quit smoking as soon as you can! Smokers are more likely to experience breathing complications during and after anesthesia. Fortunately, these problems are usually managed without great difficulty. Smokers must also be especially careful to carry out deep breathing exercises after their surgery to prevent chest infection, pneumonia or even collapse of the lungs. The use of a so-called incentive spirometer can be very helpful during recovery from surgery. Could I be allergic to the anesthetic? Allergic reactions can occur with any medicine. Allergies to anesthetic agents can occur, but fortunately are very rare. From time to time, people get skin rashes such as hives. Shock-type reactions are, luckily, rather rare. Should such a reaction occur, your anesthesiologist is trained to recognize this kind of problems and knows how to deal with it. Do I really need an IV? When can the IV come out? In almost all cases of surgery, one or more intravenous lines are necessary. Frequently, the intravenous is started in the back of the hand, using a small amount of local anesthesia to minimize the discomfort. Other sites can be used as well. The IV is used not only to provide analgesics (pain killers), and anesthetic agents, but also as a route for fluids. The IV also serves as a "lifeline" for the administration of emergency drugs if needed. The IV is usually removed when you are able to drink well and when there is no further need for intravenous medications. I have a loose tooth - is that a problem? Your anesthesiologist will want to know about any dental prostheses (false teeth, bridges, implants), tooth or gum disease, or cosmetic dentistry. This information is needed because of the risk of trauma or damage to teeth during the insertion of breathing tubes or other instruments. Obviously the danger is increased if a tooth is actually loose. If you inform your anesthesiologist about dental prostheses, tooth or gum disease, or cosmetic dentistry, it will help us avoid tooth damage. Special anesthesia techniques may be necessary. Sometimes, if a tooth is very loose or fragile, it is wise just to have it removed by a dentist before your surgery. What happens when I "go to sleep"(general anesthesia)? The process begins once an intravenous line is started (usually with the use of some local anesthetic). In many cases, a mild sedative agent is then administered intravenously to reduce the nervousness that is common before surgery. When you are on the operating room table monitoring equipment is attached. For major surgery, special monitors, such as tubes going into the heart or into an artery for blood pressure measurement, are sometimes used. If a lot of blood loss is expected, more than one intravenous line may be started. In most cases you are given oxygen to breathe through a mask for a couple of minutes. After this, drugs are injected into the intravenous line to cause unconsciousness, often followed by a muscle relaxant drug. Muscle relaxant drugs make it easier to insert a breathing tube and also assist the surgeon's work. The breathing tube may then be connected to a ventilator (breathing machine) which breathes for you during the surgery. Additional medications to keep you asleep are introduced through the anesthetic breathing tube or the intravenous line. Not infrequently, morphine-like pain relievers will be given to eliminate the pain while you are asleep. The depth of anesthesia is continually monitored during the procedure and more drugs are added as necessary to keep the appropriate level of anesthesia and muscle relaxation, and to control the body's responses to the surgery. Could I wake up during the surgery? Fortunately, we monitor a variety of signs that help assess how deeply under anesthesia you are. So, in ordinary elective surgery, waking up, or what we call "awareness" under anesthesia, is very rare. Although still unusual, awareness can sometimes occur during emergency surgery, such as Cesarean sections done under general anesthesia, or during operations for major trauma. If you believe that you were awake during your procedure under general anesthesia, please let your doctors know, so that your anesthesiologist can meet to discuss this with you and provide appropriate assistance. How will my pain be treated after the surgery? There are great variations in the amount of pain a patient will experience after surgery. Some surgical procedures, such as lung surgery and bone surgery, can be very painful. Other procedures like cataract surgery can be almost painless during recovery. Pain management in the recovery room area (immediately after surgery) is usually taken care of by small doses of intravenous (IV) analgesics. A popular method, known as "patient controlled analgesia" (PCA), works very well. With PCA, you are able to control the amount of pain medication merely by pushing a button whenever pain is experienced. When the button is pushed, you get a small dose of narcotic analgesic. Following the administration of this dose, you are "locked out" from getting any more medication for a particular period, for example, 5-10 minutes. After that, you can get more medication. PCA is very safe when administered, as intended, by the patient. Family members or others should never be permitted to press the button for you. Another method of pain relief that is very effective for some big surgical procedures, such as lung surgery, is epidural analgesia. Once you are eating and drinking well, the need for intravenous or intramuscular medications is reduced, and medications taken by mouth can be helpful. Not infrequently acetaminophen (e.g. Tylenol) with codeine, or similar analgesics, are used at this stage to provide pain relief. Occasionally, Tylenol, or similar medications, are not adequate for some kinds of pain, in which case "breakthrough" medication, for example intramuscular morphine, given by injection, may be ordered. If I'm given morphine after the anesthetic will I get addicted? The simple answer is, no. There is no need to be concerned about the appropriate use of post-operative narcotic analgesics provided appropriate clinical precautions are used. Effective pain relief is important for many reasons. If you don't have adequate pain relief after surgery this interferes with recovery from surgery, and the risk of complications such as blood clots in the lung or pneumonia may increase. Will I have a sore throat after the surgery? The insertion of the endotracheal tube ("breathing tube") can result in a sore throat after the surgery. Sometimes a sore throat will occur even without intubation. This is usually not a major problem, but some people find it annoying. Throat lozenges can alleviate the symptoms. A persistent or severe sore throat should be reported to your anesthesiologist or your surgeon. Will I experience nausea and vomiting after the surgery? Certain surgical procedures are more likely to induce nausea and vomiting than others. For example, operations on the eyes, middle ear, breasts, and bowel are more likely to cause nausea. Some individuals appear to be more susceptible to this problem, including those who have had motion sickness or previously had nausea or vomiting after anesthesia. When nausea and vomiting occurs, a variety of medications are available that can alleviate the symptoms. If you had major problems with nausea or vomiting after previous surgery, please make a point of letting your anesthesiologist know, so that he or she can decide what anesthetic technique to use to minimize this possibility. Will I receive blood during my surgery? You will be given a blood transfusion only if your anesthesiologist considers it absolutely necessary to protect your life and health. All blood given is tested for presence of the AIDS virus, Hepatitis B and C viruses and other infections, so the chances of getting these serious infections is extremely low. If your religion forbids receiving blood transfusions (Jehovah's Witness), please let us know so that the risks can be explained, the issues discussed in depth, and your wishes respected. A relative of mine had a bad reaction to anesthesia. Could it happen to me? Most "bad reactions" to anesthesia are not life-threatening. There are two rare but preventable inherited problems which we will mention here. "Malignant hyperthermia" is a very rare hereditary (inherited) problem that is triggered by anesthetic agents such as halothane or succinylcholine. If this was the case, your relative might have experienced severe fever and other problems during surgery or during recovery from anesthesia. Some individuals are unable to metabolize (break down) the drug succinylcholine which is often used to relax the muscles during the surgery. As a result of their inability to metabolize this drug, the drug may last much longer than it would ordinarily. This is also a rare problem, which occurs in about 1 in 3,000 people. By providing your anesthesiologist with the details of what happened to you or your relatives, he or she will be able to decide whether or not special precautions in your case are necessary. * What kinds of medicines are used for anesthesia? Risks and possible problems: * What are the potential risks or complications of anesthetic medicines? * What medical conditions may increase my risk of complications during anesthesia? Preparing for anesthesia: * How do I prepare for anesthesia? * Do I need to fast before my procedure? * How can I reduce anxiety before my procedure? What happens during anesthesia: * What happens while I am being given anesthesia? You likely will be given anesthesia by an anesthesia specialist. Final preparations before your surgery may include: * Attaching monitoring instruments to check your breathing, oxygen level, heart rate, blood pressure, and other body functions. * Positioning your body for surgery. You will be placed in a position that allows your surgeon access to the appropriate body area and avoids unnecessary pressure on any parts of your body. The three main phases of anesthesia are induction, maintenance, and emergence. Induction The first phase of anesthesia, when you first begin receiving an anesthetic, is called induction. For local anesthesia and many types of regional anesthesia, induction occurs when a local anesthetic is injected into the part of your body that needs to be anesthetized. Local and regional anesthesia often are given with other medicines that make you relaxed or sleepy (sedatives) or relieve pain (analgesics). These medicines are often given through a vein (intravenously, IV) before the local anesthetic is given. Induction of epidural and spinal anesthesia may require the insertion of a needle into the space around the spinal nerves in the lower back. You will receive an injection of local anesthetic to reduce discomfort before the needle is inserted. General anesthesia is often induced with intravenous anesthetics, but inhalation anesthetics also may be used. * Because they enter directly into the bloodstream, intravenous anesthetics usually cause unconsciousness in less than 1 minute. * Inhalation anesthetics also act quickly, but you must inhale them for a short time before they cause unconsciousness. Inhalation anesthetics are usually given through a mask that covers your nose and mouth. Induction with inhalation agents is mainly used for small children and adults who do not yet have an intravenous (IV) catheter. Maintenance and monitoring The second phase of anesthesia is called maintenance. During maintenance, the anesthesia specialist maintains a balance of medicines while carefully monitoring your breathing, heart rate, blood pressure, and other vital functions. Anesthesia is adjusted based on your responses during the procedure. With local anesthesia and regional nerve blocks, maintenance frequently requires additional injections of sedatives to prolong the effects for more lengthy procedures. For general anesthesia, after you are unconscious, anesthesia may be maintained with an inhalation anesthetic alone, with intravenous anesthetics, or most commonly with a combination of the two. Very often, inhalation anesthetics are given through an endotracheal (ET) tube or a laryngeal mask airway (LMA), which is an airway placed at the back of your throat but not in your windpipe like an ET tube. The airway is inserted after you become unconscious. It also is common during general anesthesia for you to be given other medicines intravenously to maintain stable vital functions and to help prevent or decrease pain or nausea after the procedure. The final phase of anesthesia is called emergence. When your procedure is completed, the anesthesia specialist will stop giving the anesthetic. As your body clears the anesthetic medicines from your system, the effects begin to wear off, and your body functions begin to return. How quickly you emerge from anesthesia depends on the anesthetics and other medicines used and on your response to the medicines. With local and regional anesthesia, emergence occurs as the effect of the injected anesthetic wears off and sensation returns. How long it takes for sensation to return depends on the type of anesthetic used, how much you were given, and the area of your body that was affected. Local anesthesia and some regional nerve blocks may wear off within 1 to 2 hours. Emergence from epidural or spinal blocks may take longer. Emergence from general anesthesia begins when the intravenous or inhalation anesthetic is stopped. It may take a short time before your body clears the anesthetic from your system. You will be closely monitored during emergence to make sure that you are breathing well on your own; your heartbeat, blood pressure, and other vital functions stay at normal levels; and your muscle control has returned. If an endotracheal tube (ET) or laryngeal mask airway (LMA) was used, it will be removed as soon as you are breathing on your own. In some cases, to help speed emergence, reversal agents are used to counteract, or reverse, the effects of certain anesthetics. These agents may help reduce the time it takes for you to recover from anesthesia. Emergence does not mean you will have completely recovered from all the effects of anesthesia. Some effects may persist for many hours after anesthesia has ended. For example, you may have some numbness or reduced sensation in the part of your body that was anesthetized until the anesthetic wears off completely. Even if you feel alert and normal, your judgment and reflexes may still be affected for some time after your procedure, especially if you continue to take medicines, such as those to control pain or nausea. But if you experience numbness or reduced sensation longer than expected, contact your anesthesia specialist. Recovering from anesthesia: * How long will it take for me to recover from anesthesia? * Are there any side effects after anesthesia? Recovery from anesthesia occurs as the effects of the anesthetic medicines wear off and your body functions begin to return. Immediately after surgery, you will be taken to a post-anesthesia care unit (PACU), often called the recovery room, where nurses will care for and observe you. A nurse will check your vital signs and bandages and ask about your pain level. How quickly you recover from anesthesia depends on the type of anesthesia you received, your response to the anesthesia, and whether you received other medicines that may prolong your recovery. As you begin to awaken from general anesthesia, you may experience some confusion, disorientation, or difficulty thinking clearly. This is normal. It may take some time before the effects of the anesthesia are completely gone. Your age and general health also may affect how quickly you recover. Younger people usually recover more quickly from the effects of anesthesia than older people. People with certain medical conditions may have difficulty clearing anesthetics from the body, which can delay recovery. After anesthesia Some of the effects of anesthesia may persist for many hours after the procedure. For example, you may have some numbness or reduced sensation in the part of your body that was anesthetized until the anesthetic wears off completely. Your muscle control and coordination may also be affected for many hours following your procedure. Other effects may include: * Pain. As the anesthesia wears off, you can expect to feel some pain and discomfort from your surgery. In some cases, additional doses of local or regional anesthesia are given to block pain during initial recovery. Pain following surgery can cause restlessness as well as increased heart rate and blood pressure. If you experience pain during your recovery, tell the nurse who is monitoring you so that your pain can be relieved. * Nausea and vomiting. You may experience a dry mouth and/or nausea. Nausea and vomiting are common after any type of anesthesia. It is a common cause of an unplanned overnight hospital stay and delayed discharge. Vomiting may be a serious problem if it causes pain and stress or affects surgical incisions. Nausea and vomiting are more likely with general anesthesia and lengthy procedures, such as surgery on the abdomen, the middle ear, or the eyes. In most cases, nausea after anesthesia does not last long and can be treated with medicines called antiemetics. * Low body temperature (hypothermia). You may feel cold and shiver when you are waking up. A mild drop in body temperature is common during general anesthesia because the anesthetic reduces your body's heat production and affects the way your body regulates its temperature. Special measures are often taken during surgery to keep a person’s body temperature from dropping too much (hypothermia). * When do I meet my anesthesiologist? * What are the risks of anesthesia? * What are some side effects of anesthesia? * Why do I need to fast the night before surgery? * What if I get a cold, fever or cough before surgery? * What should I do if I have a pacemaker? * Should I take my regular medications? * What are options for blood transfusions? * Where will I go after surgery? * Can I have visitors in the recovery room? * What are my options for pain control after surgery? * Let us know how we are doing! When do I meet my anesthesiologist? Your anesthesiologist will talk with you and examine you in the pre-operative holding area. Your anesthesiologist will be happy to answer any anesthesiology questions that you or your family may have. What are the risks of anesthesia? With the extensive knowledge and training of anesthesiologists and sophisticated monitoring equipment, anesthesia is safer today than ever. Serious and potentially fatal complications are now very rare. However, the specific risks depend on the type of surgery and overall health of the patient. You should discuss with your anesthesiologist any questions you have about your specific risks. What are some side effects of anesthesia? The most common side effects are sore throat, nausea and headache. Children are often disoriented and may be temporarily delirious in the recovery room when they wake up. With spinal and epidural anesthetics, temporary difficulty with urination is common. Some pain medications may cause itching and nausea. These are common and temporary conditions. Why do I need to fast the night before surgery? The night before surgery, patients are not allowed to eat or drink. This is in order to empty the stomach, because there is always a small risk of stomach contents injuring the lungs when a patient receives anesthesia or sedation ("light anesthesia"). Empty stomachs reduce this potentially life-threatening risk. For your safety, your surgery may be postponed if you eat or drink after midnight (unless directed to do so). The general guideline is: NOTHING after midnight prior to surgery. If you are taking medications, consult your doctor about whether to take them. Depending on your particular condition, your anesthesiologist may have adjustments to the orders. If you have any questions or concerns, please consult your anesthesiologist. What if I get a cold, fever or cough before surgery? You should call your anesthesiologist or surgeon to determine what should be done. You should be as healthy as possible before surgery. Call 650-321-4121 if you do not know your doctor's number. What should I do if I have a pacemaker? Please bring any information regarding your pacemaker into the operating room. The type of pacemaker and the last time it was checked are very important. If you can, ask your cardiologist or pacemaker technician what the "magnet mode" is for your pacemaker. Should I take my regular medications? You should check with your surgeon or anesthesiologist about whether or not to take your medications. You may have medications that are important to continue taking even the morning of the surgery. There are also medications that are important NOT to take the night before or the morning of surgery. You should not hesitate to contact your doctor if you have any questions about your medications. What are options for blood transfusions? With sophisticated biological tests, blood transfusions today are safer than ever. You can donate blood for yourself several weeks in advance of your surgery if you are healthy and meet the weight requirement. This is called "autologous" blood. If relatives or friends donate blood for you, this is called "designated donor" blood. Blood must be donated at least three to four days prior to surgery to allow for appropriate testing of the blood. Barring clerical error, autologous blood has the lowest infection and transfusion-reaction risks. Where will I go after surgery? You will be watched closely in the recovery room until your anesthesiologist and nurse feel you are stable enough to go either to your hospital room or home. For some surgeries, you may go directly from the operating room to the intensive care unit. Can I have visitors in the recovery room? In general, visitors are not allowed in the recovery room. Children may have a limited number of visitors once their recovery-room nurse has made sure everything is stable. What are my options for pain control after surgery? Your surgeon and anesthesiologist can discuss possible pain-control options. 1. What is an anesthesiologist? 2. Is there anything else that anesthesiologists do? 3. What are the pre-surgical appointments for? Why are there so many questions? 4. What is informed consent? 5. What do I need to tell the anesthesiologist? 6. What kind of anesthesia will I have? 7. What does the anesthesiologist do during the surgery? 8. Will I need to receive blood for the surgery? 9. Can you give me more information about general anesthesia? 10. Do I have to have a breathing tube? 11. What is regional anesthesia? 12. Can I request the specific type of anesthesia that I want? 13. What are the common risks of anesthesia? 1. What is an anesthesiologist? Anesthesiologists are physicians who have specialized training that allows them to provide pain control, pain relief and care for the general well-being of the patient in the operating room. They are able to regulate changes in breathing, heart rate, blood pressure, etc. that are important to your condition while undergoind surgery. The anesthesiologist acts as the advocate for the patient when the patient is under anesthesia and unable to perform that role themselves. Anesthesiologists have completed college, four years of medical school, an medical or surgical internship and three years of anesthesiology residency. 2. Is there anything else that anesthesiologists do? Anesthesiologists also fulfill a role outside of the operating room with their knowledge of pre-operative assessment and planning, analgesia for labor and delivery, critical care in the intensive care unit and recovery room, postoperative pain management and management of chronic pain syndromes. 3. What are the pre-surgical appointments for? Why are there so many questions? The pre-surgical appointments serve a dual purpose. First, they are a chance to gather important information about you and your medical condition in order to ensure yor safety and your comfort. In addition, it is a chance for you to ask any questions you might have about what is going to happen, make decisions about your options and give informed consent. 4. What is informed consent? Informed consent means that you, the patient, has been presented with the options for treatment, the commone and serious risks and expected benefits of each option and what the likely outcomes of the treatment (or of no treatment) are. In addition, you should be given a chance to ask questiosn. Informed consent is usually given in writing and requires a signature (exceptions are extreme emergencies). 5. What do I need to tell the anesthesiologist? It is important that you are complete and honest when answering questions prior to surgery. These questions relate to your general health and any specific medical conditions that may present a risk to you. You should be prepared to discuss your health history, the history of your blood relatives (if known), any medications including over the counter products, smoking, drug use, past experiences with surgery and anesthesia, etc. 6. What kind of anesthesia will I have? The type of anesthesia will be chosen based on the type of surgery, your medical condition and your preferences. There are four types of anesthesia commonly employed - general, regional, monitored anesthesia care (MAC) and local. In very broad terms: general affects your entire body and may be given intravenously or as an inhaled gas. These medications make you dizzy or drowsy and cause you to lose consciousness. As a result of these medications, you might stop breathing on your own and therefore you might have breaths given to you through a mask or a small tube gently inserted into your lungs through your mouth. Regional anesthesia only affects a section of your body, making it numb. You may remain awake or be sedated. Monitored anesthesia care (MAC) involved medications given to make you drowsy and to relive pain. Local anesthesia affects only the location of surgery. It is usually injected, but can sometimes be given as a ointment, cream or spray. You may remain awake or be sedated for this as well 7. What does the anesthesiologist do during the surgery? In short, the anesthesiologist is responsible for your comfort and your safety. In addition to giving you the medications needed for the anesthesia, the anesthesiologist monitors your vital signs (such things as heart rate, blood pressure, oxygen content, body temperature, breathing...) and alters them as necessary. He or she is also in charge of fluids that you might receive and, if necessary, blood transfusions. Lastly, any other medical conditions that you might have (diabetes, asthma, hypertension, heart problems) will be treated by the anesthesiologist while you are in their care. 8. Will I need to receive blood for the surgery? Whether you will need a blood transfusion will depend on your medical condition, the type of surgery you are having, your personal beliefs and preferences, etc. This should be a topic of discussion with your surgeon and anesthesiologist. 9. Can you give me more information on general anesthesia? General anesthesia is given either intravenously or through the inhalation of certain gases. Sometimes, the two are combined to achieve general anesthesia. When you are under general anesthesia you are unconscious - and thus unaware of what is happening to you and around you. Your vital signs such as heart rate, blood pressure and heart rate are carefully monitored and controlled. You may cease breathing on your own during general anesthesia and the anesthesiologist may assume control of your breathing. Sometimes this requires a breathing tube to be inserted - it goes through your lungs and into your lungs. 10. Do I have to have a breathing tube? General anesthesia often results in the loss of the ability to breathe on your own. There are different ways to assist your breathing - one of which is the breathing tube (known as an endotracheal tube). There are many situations when the placement of the tube is the safest and most reliable method to assure adequate breathing. There are alternatives in other cases including breathing through mask or other devices. You can discuss this issue with your anesthesiologist to see if these other alternatives are applicable to your specific situations. 11. What is regional anesthesia? Regional anesthesia refers to the process by which an injection of local anesthesia is given near your nerves and results in numbness of the area of surgery. You may remain awake or be sedated. Spinal and epidural anesthesia are the most commonly known of the regional techniques and involve injections in the back that result in numbness of the lower half of your body. There are, however, other types of regional anesthesia that can numb an arm, a single leg, etc. 12. Can I request the specific type of anesthesia that I want? To some degree you can. Some operations can be performed with different types of anesthesia while some require one technique. Your anesthesiologist will review your planned surgery and your medical condition. Then they will be able to discuss your options with you and allow you to make your preferences known. 13. What are the common risks of anesthesia? Luckily the common complications of anesthesia are not particularly dangerous and the dangerous complications of anesthesia are very rare. The most common complications include nausea, vomiting, sore throat, blood pressure changes, and pain. These are usually mild, not dangerous and easily treated with medication. The more serious complications include such things as allergic reactions, genetic conditions, stroke, heart attack, etc. which can lead to serious disability or death. These more serious complications are very rare. With the application of new technologies to the field of anesthesia and the careful monitoring of the anesthesia provider anesthesia is extremely safe. 50 General Anesthesia Questions 1. What is transpulmonary pressure? How about FRC and VC? Can you draw the lung capacities/volumes diagram? What is normal FRC and VC in cc/kg? 2. What happens to FRC with GA? Why is low FRC bad? What conditions lower FRC? 3. What part of the lung is usually ventilated best, the apex or the base? What happens with GA? 4. What is the alveolar gas equation? What are the formulas for calculating oxygen content/delivery/consumption? What is the formula for calculating shunt fraction? 5. What is the difference between shunt and V/Q mismatch? Is hypoxemia from a PE due to shunt or dead space? 6. How would you assess a Pt’s COPD? How do you assess its severity? Are preoperative PFTs required for COPD patients? 7. What risk factor predispose to postop pulmonary dysfunction? How does the presence of COPD affect your choice of anesthetics? How would you ventilate a patient with COPD? 8. How would the presence of a difficult airway affect your induction in a Pt with asthma? Would you use ketamine? Why or why not? 9. Is deep extubation indicated for a Pt with a history of severe brochospasm? 10. How can COPD be distinguished from restrictive lung disease by spirometry? What type of infiltrative disorders cause restrictive lung disease? Draw the flow/volume loops for each disorder. 11. What are the different causes of pulmonary edema? How can you distinguish between cardiogenic and noncardiogenic pulmonary edema? 12. A Pt develops stridor after extubation, and then desaturates after reintubation. What is your differential diagnosis and treatment plan? 13. How would you induce anesthesia for a Pt with a large anterior mediastinal mass causing significant tracheal compression? 14. A 57 year old male who had an MI seven months ago is scheduled for cataract Sx. Do you need an extensive (or any) cardiac workup? 15. After a retrobulbar block, a Pt become unresponsive, what is your differential diagnosis and response? 16. A Pt complains of postop eye pain following a prone operation. What is your differential diagnosis? What if he complains of blindness? What are the risk factors, if any? 17. What would you tell a Pt if a corneal abrasion occurred? How do you treat it acutely? 18. What is the significance of cervical involvement with rheumatoid arthritis? 19. Is regional anesthesia a good or bad idea in a patient with a difficult airway? 20. During insertion of an artificial prosthesis in an orthopedics case, the Pt becomes hypotensive, what is your differential diagnosis, and what would you do? 21. Thirty minutes after inflation of a tourniquet during an orthopedics case, the Pt develops unexplained HTN. What is your differential diagnosis and management? 22. Is postop pulmonary function and outcome definitely improved with regional versus general anesthesia? 23. What is your plan for perioperative pain control for a total knee or total hip replacement? 24. How is electrical shock in the OR quantitatively classified? 25. What safety measures are available to reduce the chances of electric shock in the OR? 26. What is an isolation transformer and how does it work? 27. The line isolation monitor alarms during a code situation when the defibrillator is plugged in for emergency cardioversion. What do you do? 28. What features on the anesthetic machine prevent the delivery of a hypoxic mixture? 29. How much N2O is left in a cylinder if it reads 745 PSIG? 30. What is a fail-safe device on an anesthetic machine? 31. What is the problem with repeated use of the O2 flush valve? 32. How does use of a vaporizer at higher altitude affect output? Are there differences between agents/vaporizers? 33. Are there any toxic substances produced in CO2 canisters? How does the choice of Baralyme or soda lime affect production? Is Baralyme still available? Are there differences between volatile agents and substance production? 34. How do you check the low pressure system on an anesthesia machine? 35. The PEEP reads 15 cm H2O when none was intended, what would you do? 36. A postop Pt is oliguric and this is blamed on fluoride nephrotoxicity because isoflurance was used. What is your response? Any difference if they blamed it on Sevoflurane? 37. Should you avoid succinylcholine in a patient with dialysis-dependent renal failure? What potassium level is your cut-off for succinylcholine? 38. Can you safely reverse neuromuscular blockade in a patient with renal or hepatic failure? 39. Who is at risk for acute renal failure? What is the FeNa? How do you differentiate between pre-renal, renal, and post-renal drop in urine output? 40. What is TURP syndrome? What is the best anesthetic technique for TURP and why? How would you diagnose and treat a suspected case? What is central pontine myelinolysis? 41. How can you preserve hepatic blood flow intraop? What factors determine hepatic blood flow? What blood pressure considerations should you have when anesthetizing a patient for liver resection? 42. What LFTs, if any, would you order for a Pt undergoing a laparoscopic cholecystectomy? What would you say if a patient’s postoperative LFT elevation were blamed on the volatile anesthetic? 43. What are your concerns in a Pt with chronic alcoholism? How would you manage the anesthetic for a drunk trauma patient that was a chronic drinker versus one that was not? 44. How would you manage the airway of a drunk and combative patient with a suspected C-spine injury and oral trauma? 45. Is a rapid sequence induction a good idea for severe liver cirrhosis Pt? Why? Which agents would you avoid, if any? What preop labs/tests would you order in a liver cirrhosis Pt? Is gastroparesis a risk in patients with end-stage liver and/or renal disease? 46. What tests for coagulation are normally available? What are D-dimers? 47. Should all Pts with VWD receive DDAVP preop? How long does it take DDAVP to work? How long does it take vitamin K to work? How much FFP would you need to give someone with a coumadin-induced coagulopathy? Let’s say their INR was 1.9. 48. After 10 units of “emergency” type O PRBCs, would you administer type-specific blood if it becomes available? Why or why not? How about after 4 units? How about FFP? 49. What are the chances of a hemolytic transfusion reaction if type specific blood is given? If T/S’d blood is given? If T/C’d blood is given? 50. How would you decide whether the Pt with sickle cell anemia requires transfusion preop? What are your goals for the transfusion? What is "awareness" under anesthesia? Awareness under general anesthesia means becoming conscious – or awake – during some part of your operation and remembering things that happened. Awareness is an uncommon complication that may or may not be accompanied by pain. When using local or regional anesthesia with sedation, it is expected that patients may have some recollection of the procedure. The remote possibility of awareness should not deter you from having needed surgery. Your anesthesia professional can help you to feel comfortable and informed about your upcoming experience with anesthesia. What causes anesthesia awareness? Awareness occurs when you are not receiving enough anesthetic medication to keep you unconscious. Some people may react differently to the same level or type of anesthesia. Sometimes different medications can mask important signs that anesthesia professionals monitor to help assess the depth of anesthesia. In some situations, such as emergency, trauma and cardiac surgery, or in situations involving patients whose condition is unstable, the medical condition of the patient may prevent the anesthesia professional from using sufficient anesthesia to prevent awareness. Because anesthesia has certain effects on the body, including lowering blood pressure and slowing breathing, a deep anesthetic may not be in the best interest of the patient. In these and other situations – such as emergency cesarean delivery - awareness may not be completely avoidable. Awareness also may happen if the equipment that delivers the anesthetic to your body malfunctions, or if your anesthesia professional misjudges the amount of medication needed to keep you unconscious. Can anesthesia awareness be prevented? Before surgery, you should meet with your anesthesia professional to discuss anesthesia options and determine the plan for your operation. You should describe any problems you may have experienced with previous anesthetics, and also discuss any prescription medications or over-the-counter medications you are taking. Should you have concerns regarding awareness, before surgery is the ideal time to express them and to ask questions. Your anesthesia professional cares for you during surgery by relying on his or her clinical experience, training and judgment combined with safe medications and continuous monitoring. During general anesthesia, your anesthesia professional will use multiple ways to determine if you are getting sufficient amount of anesthetic medication to keep you unconscious. This can be difficult in some patients. Recently, the introduction of brain monitors – like the BIS monitor – has provided anesthesia professionals with another method to help care for their patients. What do I do if I had awareness under anesthesia? If you have distinct recollections of your surgery after general anesthesia, you should discuss it with one of the people involved in your care. Any of the nurses who care for you, your surgeon or your anesthesia professional will be a good place to start. Sometimes, patients will not remember being awake during surgery for several days. If this happens to you, be sure to mention it to your surgeon at next appointment or if the hospital calls you for follow-up check. Regardless of whom you first mention your experience to, it is important to try to speak directly with the anesthesia professional who was involved in your surgery. Your anesthesia professional can best explain to you the events that took place in the operating room at any stage of your surgery and why you might have been aware at certain times. If your recollections of surgery or the awareness episode distresses you, your anesthesia professional can help you or refer you to a counselor or to other appropriate resources. What is the Purpose of the Preoperative Anesthesiology Clinic? How Do I Contact the Preop Clinic? What is the Purpose of Preoperative Assessment? What are the Surgery or Primary Care Clinics' Responsibilities? Why do Surgeries get Postponed? What is a "Current" Work-up? Which Patients are Usually Poor Candidates for Outpatient Surgery? What is the Purpose of the Preoperative Anesthesiology Clinic? The PAC mission is to be responsible for preparing the patient for anesthesia. This includes: 1. Evaluating each patient to identify problems which may be of a particular concern when performing an anesthetic. 2. Alerting the O.R. with regard to specific patient problems which may best be managed by particular anesthesiologists. 3. Acting as a resource for surgical services to consult when unsure of the appropriate evaluation for certain types of patients. 4. Educating patients about issues such as: NPO requirements, medications to be taken on the morning of surgery, and anesthesia options. By performing these tasks, the PAC can be expected to improve patient care and satisfaction, as well as reducing cancellations or delays on the day of surgery. On the other hand, however, the PAC cannot (with current resources and mandate) be responsible for: * scheduling patients for the O.R. (use OutPatient scheduling: _______ or InPatient O.R. scheduling: ________), * performing the full pre-surgical H&P, * doing routine vital signs, * arranging medical consultations (except as a courtesy), * hunting down patient records or calling the local MD for general information, * checking that all ordered tests are actually done, * following-up to see whether tests results are abnormal if the test results are not available at the time of the PAC visit. How Do I Contact the Preoperative Anesthesiology Clinic? Preoperative Anesthesiology Clinic (PAC) What is the Purpose of Preoperative Assessment? The primary aims of preoperative assessment and preparation: 1. Documenting the condition(s) for which the procedure is needed. 2. Identifying other conditions in a timely fashion (at least 2 to 3 days before surgery) which can be improved to reduce the patient's surgical and anesthetic perioperative morbidity or mortality. 3. Obtaining consultations, when necessary, with appropriate medical services to optimize the patient's health. These consultations should ideally not be done in a "last second" fashion. 4. Allowing time for the Anesthesia Team to anticipate potential problems and to modify the anesthetic technique, the medications, and/or monitoring. 5. Educating and informing the patient about the surgical - anesthetic process, risks, and alternatives. 6. Reducing economic loss or inconvenience to patients, physicians, nursing and hospital staff by avoiding delays and cancellations. * Secondary aims include: Satisfying review agencies regulations (such as JCAHO, CMS), including having a full preoperative/preanesthesia H&P current within 30 days. This may be secondary to the medical aims, but it is still essential to comply with these regulations. * Other potential benefits, but which are not justified without other primary or secondary needs: Health screening for asymptomatic conditions needing primary care follow-up. What is Necessary from the Surgery/Primary Care Clinics for a Work-up? First of all, the Surgery Clinic is responsible for explaining the surgical procedure to the patient. The Clinic should also explain the ABSOLUTE necessity of an escort home for Outpatients (who have ANY sedation, G/A, Bier block or other regional anesthesia), as well as the usual need for a caretaker overnight post-op (except for minor procedures in healthy patients when approved ahead of time). The Clinics should NEVER promise that a procedure will be done at a certain time on the day of surgery since schedules always change up to the last day before surgery. Any such unfulfilled promise is a recipe for patient dissatisfaction! For a patient to be properly evaluated in the Anesthesiology Preoperative Clinic, the following basic information should be assembled and available to the PAC at the time of the visit:v 1. The proposed procedure and the surgeon's name. 2. Whether the procedure is planned as FDS or OP , and the requested/suggested type of anesthesia (either local + sedation & monitoring: "Monitored Anesthesia Care"--also called "MAC," or regional/general anesthesia) 3. The planned date of the procedure. 4. The patient's complete chart, which includes: the old records, a medical history , an adequate review of systems , a physical exam , and available test results. The cancellation rate is, and will continue to be, increased for patients coming to the APC without a chart and/or without an H&P. Without adequate information, it is impossible to do a complete evaluation. 5. An adequate History and Review of Systems. Significant positives in the assessment should be explored, e.g.: it is not very helpful to state only that the patient has "heart disease." What kind of disease? The nature, extent, and treatment of each problem have different implications for preparing the patient for anesthesia and surgery. Inadequate evaluation of the cardiovascular system is the main cause of procedure delays or cancellations. The history, which includes medications currently taken, allergies to medications, and a pertinent review of systems continues to be the most important aspect of the preoperative assessment. This cannot be overemphasized! Omissions in the medical history continue to be an important cause of delays and cancellations. 6. The patient's vital signs (especially BP) are recorded. 7. The work-up is signed legibly by the person who performed it. Preferably, the evaluator's name is printed next to the signature. If we cannot read the signature, we won't know who to call with questions. 8. When possible, the pertinent laboratory data, the ECG, and the CXR (when appropriate) should accompany the patient to the PAC. Having immediate access to these tests will speed the evaluation process. This, we realize, is not always possible. (However, see next below) 9. If test results are not available to the PAC, each surgical clinic must have a mechanism to follow-up on abnormal tests before the day of surgery. IMPORTANT! If patients are first seen in the PAC the day before surgery (or even worse - late in the day before surgery) it will be difficult to arrange medical consultation or obtain outside records. Please bear this in mind when surgery clinic staff arrange for the pre-surgical visit or transfer of records! Last minute evaluation of patients with significant medical problems greatly increases the likelihood of postponement and patient dissatisfaction. For these patients, an evaluation at least 3 days before surgery will greatly reduce delays and smooth the preoperative process. (Please note that there is a specific "Phone Triage" form available to be used at the time of the phone call to patient's to schedule the surgery clinic preop visit. Call us for details.) Another important point to remember is that the patient's primary care physician or specialist is an excellent source of medical information needed in the preoperative evaluation. A patient's cardiologist or pulmonologist should always be notified of a patient's impending procedure. In addition to finding important medical information, it is important for professional courtesy, (as well as for future referrals) that the patient's primary physician and/or specialists know that the patient is scheduled for surgery. Why do Surgeries get Postponed? In studying the problem of avoidable preoperative cancellations or postponements, it is clear that certain factors appear again and again: 1. Last minute attempts to evaluate patients with complex medical problems. 2. Lack of generally accepted clinical guidelines for adequate preoperative assessment .This produces inconsistencies, misunderstandings, and (at times) unnecessary arguments between surgeons, anesthesiologists, and internists. That is what these guidelines seek to avoid. 3. Misunderstanding about what constitutes the important aspects of preoperative assessment. 4. Missing or unavailable old records at the time of the anesthesia work-up process. 5. Missing or incomplete portions of the preoperative history or physical exam (e.g. no recorded blood pressure). 6. Lack of follow-up of ordered tests, prior to day of surgery. Obviously, all cancellations can not be avoided. Some patients will have a change in their medical condition on the day of surgery which can not be foreseen. Most problems, however, are the result of a lack of adequate preparation and can be prevented with a little initiative. For example, in the work-up of CHEST PAIN, the following simple questions will usually resolve the issue of how to proceed: 1. How long have these episodes been going on? 2. What kind of pain: sharp, heaviness or pressure, stabbing? 3. How severe is it? (scale of 1-10) 4. How long does it last? Seconds, minutes, hours? 5. Location(s) of pain? Radiation of pain to other areas? arm, jaw, back? 6. What brings it on and what makes it worse: Activity or at rest? Food affect? Position? Deep breath, moving, anxiety? Can patient walk 2 blocks at a normal pace? Climb 1 flight of stairs? What makes it better: rest, antacid, NTG (how many per day)? 7. Associated symptoms: SOB, sweating, palpitations? Other: nocturnal dyspnea, orthopnea, edema, dizziness. 8. Has the patient seen a doctor about this? Any work-up or tests? When? How can we get these records? 9. Does primary physician or cardiologist know that patient is having surgery? What is a "Current" Work-up? When does a work-up or laboratory testing become "outdated?" There is, of course, no absolute answer in the strict medical sense. In a way, it becomes outdated the day after the preoperative visit. However, JC & CMS requires a H&P within 30 days of the procedure. For testing, see our current recommendations: "Basic testing Issues", "Suggested Preoperative Tests", and "Specific Disease Testing." The other question is: "when is another comprehensive H&P necessary?" Rather than give a fixed time limit to this, it makes more sense to say that patients need an evaluation directed toward the involved organ systems in a time frame commensurate with the severity and stability of the disease. For some patients with complex medical problems (especially cardiovascular ones), this may mean a week or less. For some patients who are perfectly healthy, this means up to 30 days. An "Update" note is required by CMS and JC for any H&P that is more than 24 hoursold. However, every patient needs to be briefly reevaluated on the day of surgery. This ensures that a previously stable condition has not changed, and that a new condition has not suddenly appeared. Which Patients are Usually Poor Candidates for Outpatient Surgery? We are often asked to comment on which patients are not appropriate candidates for outpatient surgery. These criteria are continuously evolving. Below is a table of those patients usually regarded as "poor" candidates for OP status. You must consult with us at the Anesthesiology Preoperative Clinic if you wish to book these patients as outpatients. WHO SHOULD MONITOR sedation? Because patients can slip into a deep sleep, proper monitoring of conscious sedation is necessary. Healthcare providers monitor patient heart rate, blood pressure, breathing, oxygen level, carbon dioxide exhalation, and alertness throughout and after the procedure. The provider who monitors the patient receiving conscious sedation should have no other responsibilities during the procedure and should remain with the patient at all times during the procedure. The level of sedation will be determined by the nature of your operative procedure. Some procedures require only minimal to moderate sedation. Others will require a deeper level. Your anesthetist will determine the appropriate level of sedation for your particular procedure. This will be discussed on the phone for your pre-operative interview. What are the SIDE EFFECTS of sedation? A brief period of amnesia after the procedure may follow the administration of sedation. Occasional side effects include headache, hangover, nausea and vomiting or unpleasant memories of the surgical experience. Medications will be administered to prevent side effects, to the extent that they can be controlled. You may also receive prescriptions from your doctor for post-procedure comfort. What should PATIENTS EXPECT immediately following the procedure? A qualified provider monitors the patient immediately following the procedure. Written postoperative care instructions should be given to the patient to take home. Patients should not drive a vehicle, operate dangerous equipment or make any important decisions for at least 24 hours after receiving conscious sedation. A follow-up phone call usually is made by the healthcare provider to check on the patient's condition and answer any remaining questions. What is the ROLE OF THE CAREGIVER after the anesthesia? The person caring for an individual post Intravenous Sedation must be alert to the possibilities of oversedation, drowsiness, unsteady gait, low blood sugar, faulty reasoning and decision making in the patient. The caregiver must check on the patient every 10-15 minutes for approximately two hours. During this time the patient needs assistance in usual, routine activities. Medications should be noted on a pad of paper as to the time and amount taken. Talking on the phone is usually not a good idea after sedation. What is intravenous sedation? What Patients Should Expect Sedation provides a safe and effective option for patients undergoing minor surgeries, dental work, or diagnostic procedures. The number and type of procedures that can be performed using intravenous sedation have increased significantly as a result of new technology and state of the art medications. conscious sedation allows patients to recover quickly and resume normal activities in a short period of time. QUESTIONS to ask about intravenous sedation The following is a list of questions that patients should ask prior to the surgical or diagnostic procedure: * Will a trained and skilled provider be dedicated to monitoring me during conscious sedation? * Will my provider monitor my breathing, heart rate, and blood pressure? * Will oxygen be available and will the oxygen content of my blood be monitored? * Are personnel trained to perform advanced cardiac life support? * Is emergency resuscitation equipment available on-site and immediately accessible in the event of an emergency? * Will a trained and skilled provider stay with me during my recovery period and for how long? * Should a friend or family member take me home? What is CONSCIOUS SEDATION? This type of sedation induces an altered state of consciousness that minimizes pain and discomfort through the use of pain relievers and sedatives. Patients, who receive conscious sedation usually are able to speak and respond to verbal cues throughout the procedure, communicating any discomfort they experience to the provider. Other types of sedation (see below) produce a deeper level of unconsciousness. A brief period of amnesia may erase any memory of the procedure. Are there other LEVELS OF SEDATION? The depth of sedation can range from minimal to deep sedation. Minimal sedation (anxiolysis): A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Moderate Sedation/analgesia (conscious sedation): A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Deep Sedation/analgesia: A drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. Anesthesia: Consists of general anesthesia and spinal or regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. # List 3 symptoms of poor ventricular function (history). # List 3 signs of poor ventricular function (physical). # What information can be derived from exercise electrocardiography? # What information can be derived from echocardiography? # What information can be derived from cardiac catheterization? # List 5 conditions that are detrimental to myocardial oxygen balance in patients with coronary artery disease. # a. What are the branches of the right and left coronary arteries? b. What is the blood supply of the AV node? c. What is the blood supply of the SA node? d. List 3 manifestations of myocardial ischemia in a patient under general anesthesia. # What are the determinants of blood pressure? # What are the determinants of cardiac output? # What are the determinants of oxygen content? # a. What are the determinants of oxygen delivery? b. What are the determinants of oxygen consumption? # What coronary artery and territory of the heart is monitored by leads II, III and AVF? # What coronary artery and territory of the heart is monitored by leads V4 and V5? # What coronary artery and territory of the heart is monitored by lead I and AVL? # List 3 important considerations for anesthesia in patients with mitral stenosis. # List 3 important considerations for anesthesia in patients aortic stenosis. # List 3 advantages of using opioids such as fentanyl for cardiac anesthesia. # List 3 disadvantages of using opioids such as fentanyl for cardiac anesthesia. # What is the mechanism of action of nitroglycerin in patients with myocardial ischemia? # What are the main indications for inserting a pulmonary artery catheter (PAC)? # What parameters can be measured and calculated from a pulmonary artery catheter? # a. List 5 clinical situations which might lead you to not insert a PAC in a patient meeting the criteria in questions #20, assuming easy cannulation of a central venous route. b. List 5 clinical situations which migh t lead you to not insert a right internal jugular cannula in a patient meeting the criteria in question #20. # Describe the anatomical location of the internal jugular vein.v # What is the mechanism of action of heparin? # What is the mechanism of action of protamine? # List 3 side effects of protamine. # What does the ACT measure? # What does the PT measure? # What does the PTT measure? # List 5 essential components of the cardiopulmonary bypass circuit. # List 5 essential tasks to perform before and immediately after initiating bypass. # List 5 causes of hypotension during initiation of bypass. # What is the significance of cardiopulmonary bypass time. # What is significance of aortic cross clamp time. # List 5 essential tasks to perform before discontinuing cardiopulmonary bypass (besides ventilation, oxygenation and ensuring adequate HR and rhythm) # What is the therapy of low BP, CVP, PAP and CO? # What is the therapy of low BP, high PAP, low CO? # What is the therapy of high BP, low CO, normal PAP? # List 3 advantages and 2 disadvantages of dobutamine. # List 2 advantages and 2 disadvantages of epinephrine. # List 2 advantages and 2 disadvantages of norepinephrine. # List 2 advantages and 2 disadvantages of milrinone. # List 2 advantages and 2 disadvantages of calcium chloride. # List 2 advantages and 2 disadvantages of using volatile inhalational anesthetics during cardiac anesthesia. # List 2 advantages and 2 disadvantages of using benzodiazepines for cardiac anesthesia # List 2 advantages and 2 disadvantages of hypothermia during cardiopulmonary bypass. # a. What is significance of acute hypokalemia after cardiopulmonary bypass? b. What level of hypokalemia requires treatment after bypass? c. List 3 ECG signs of hyperkalemia d. List 3 methods to treat acute hyperkalemia (drugs and dose, in order of onset time from fastest to slowest). # List conditions that decrease Sv02. # List conditions that may predispose to pulmonary artery rupture in a patient with a PAC. # List conditions that may predispose to massive air embolism during and after bypass. # a. List conditions that may mimic severe bronchospasm after bypass. b. List methods to treat confirmed severe bronchospasm after bypass. Defining Clinical Competence in Anesthesiology Essential Attributes The physician must possess those abilities, traits and skills that are essential to the safe practice of anesthesiology, critical care and pain management. The physician who lacks one or more of the following attributes is not competent to practice anesthesiology safely. 1. Is honest and ethical 2. Is reliable, conscientious and responsible 3. Learns from experience 4. Reacts to stressful situations in an appropriate manner 5. Has no current documented abuse of alcohol or illegal use of drugs 6. Has ability to acquire and process information in an independent and timely manner and adequate physical, sensory and motor faculties to function independently as an anesthesiologist Acquired Character Skills The physician should demonstrate the following acquired character skills that are important to the practice of anesthesiology and which develop and evolve during the anesthesiology continuum. 1. Communicates effectively with patients, their families and members of the health care team 2. Has a commitment to continuing education 3. Is adaptable and flexible 4. Is careful and thorough 5. Is complete and accurate in record keeping 6. Has breadth of thinking 7. Is appropriately self-confident Knowledge Committees on Clinical Competence judge residents' knowledge in arriving at their evaluations. The written and oral examinations of the ABA also measure the adequacy of knowledge. The scope of this knowledge is currently defined in the Content Outline of the In-Training Examination. Judgment The physician must possess the ability to elicit the essential information from patients and physicians and to integrate it with a fund of knowledge and cinical skills that permits diagnosis and understanding of conditions and prescriptions for appropriate and safe anesthetic management. 1. Demonstrates use of a sound background in general medicine in the management of problems relevant to the specialty of anesthesiology 2. Recognizes the adequacy of preoperative preparation of patients for anesthesia and surgery and recommends appropriate steps when preparation is inadequate 3. Selects anesthetic and adjuvant drugs and techniques for rational and safe anesthetic management 4. Recognizes and responds appropriately to significant changes in anesthetic course 5. Prescribes and advises appropriate postanesthetic care 6. Provides appropriate consultative support for patients who are critically ill 7. Evaluates, diagnoses, and selects appropriate therapy for acute and chronic pain disorders Clinical Skills The physician must demonstrate the facility to organize and expedite safe anesthetic procedures. The following contains examples that aid the evaluation of psychomotor performance. 1. General Preparation a. Adequacy and speed of preparation b. Indicated vascular cannulations including venous, arterial, central venous and pulmonary arterial catheter insertions c. Appropriate application and use of current technology for efficient and safe anesthesia care and life support of patients. Examples include direct and indirect blood pressure measurements, ventilation and respiratory gas monitoring, assessment of neuromuscular function, eletrocardiographic, electroencephalographic, and evoked-potential monitoring, and evaluation of laboratory results (chemistry, radiographs, etc.) d. Instrument and anesthesia machine testing and calibration e. Operating room safety procedures for oxygen delivery, electrical safety, and waste gas evacuation f. Proper patient positioning during anesthesia 2. General anesthesia a. Airway management: head position, ventilation by mask, appropriate use of oral and nasal airways b. Tracheal intubation: oral and nasal intubation by various techniques, appropriate and adequate tracheal and airway local anesthesia, fiberoptic techniques c. Maintenance of respiration and gas exchange including management of various types of mechanical ventilation d. Support of the circulation during the perioperative period, including management of all types of shock e. Support of renal function perioperatively f. Management of the patient with increased intracranial pressure g. Appropriate administration of fluids and maintenance of fluid, electrolyte and acid-base balance h. Judicious use of blood products 3. Regional anesthesia and pain (including postoperative) management a. Spinal and epidural anesthesia and analgesia b. IV regional anesthesia c. Nerve blocks for diagnostic, therapeutic and surgical procedures 4. Special procedures a. Management of cardiopulmonary resuscitation b. Anesthetic management of cardiopulmonary bypass c. One-lung ventilation d. Deliberate hypotension Overall Clinical Competence The competent physician must possess each of the Essential Attributes necessary to the safe practice of anesthesiology and demonstrate adequate Acquired Character Skills, Knowledge, Judgment and Clinical Skills for assuming independent responsibility for patient care. Core Competencies 1. Patient Care Physician must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: * communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families * gather essential and accurate information about their patients * make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment * develop and carry out patient management plans * counsel and educate patients and their families * use information technology to support patient care decisions and patient education * perform competently all medical and invasive procedures considered essential for the area of practice v * provide health care services aimed at preventing health problems or maintaining health * work with health care professionals, including those from other disciplines, to provide patient-focused care 2. Medical Knowledge Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to: * demonstrate an investigatory and analytic thinking approach to clinical situations * know and apply the basic and clinically supportive sciences which are appropriate to their discipline 3. Practiced-Based Learning and Improvement Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to: * analyze practice experience and perform practice-based improvement activities using a systematic methodology * locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems * obtain and use information about their own population of patients and the larger population from which their patients are drawn * apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness * use information technology to manage information, access on-line medical information; and support their own education * facilitate the learning of students and other health care professionals 4. Interpersonal and Communication Skills Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. Residents are expected to: * create and sustain a therapeutic and ethically sound relationship with patients * use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills * work effectively with others as a member or leader of a health care team or other professional group 5. Professionalism Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: * demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development * demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices * demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities 6. Systems-Based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: * understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice * know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources * practice cost-effective health care and resource allocation that does not compromise quality of care * advocate for quality patient care and assist patients in dealing with system complexities * know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance Cardiothoracic Anesthesia Neuro Anesthesia Obstetrical Anesthesia Pain Management Critical Care Pediatric Anesthesia Burn and Trauma Anesthesia Recovery Room Care Management Clinical anesthesia experience Total cases Intrathoracic with CPB Intrathoracic without CPB Major vascular Intracranial vascular Intracranial nonvascular Vaginal delivery C-section Ambulatory, same day Trauma Spinal anesthesia Epidural anesthesia Nerve block anesthesia Deliberate hypotension Insertion of A-line Insertion of PA catheter Insertion of CVP line Fiberoptic intubation TEE Double lumen ETT LMA EEG monitoring Evoked potential monitor Age < 45 weeks PCA 45 weeks PCA to 1 year Age 1 to 12 years Age > 65 years Acute pain management Chronic pain management Cancer pain management Total pain procedures Spinal procedure for pain Epidural for pain Nerve block for pain Daily Anesthesiology Resident Evaluations I. Room Preparation Unsatisfactory: Critical equipment not ready or missing (e.g., machine not checked, no larygoscope or suction, etc.) Average: All equipment present Outstanding: Room well-prepared and organized, nothing extraneous II. Preop Evaluation Unsatisfactory: Important information missing or overlooked (e.g., recent MI, previous history of anesthetic problems, difficult airway, etc.) Average: No important information lacking Outstanding: Complete problem-oriented preop done - well documented and well organized IV. Technical Skills Unsatisfactory: Unable to do straightforward procedures Average: Does routine procedures well, has difficulty with harder procedures Outstanding: Technically very adept V. Case Management Unsatisfactory: Fails to recognize or appropriately treat significant problems (BP, decreased SpO2, etc.) or fails to call for help when appropriate Average: Does well with routine problems, some difficulty with more complex issues Outstanding: Correctly and expeditiously recognizes and treats problems, major and minor VI. Knowledge Unsatisfactory: Major gaps in essential knowledge base, or inability to apply knowledge to the clinical situation Average Outstanding: Excellent knowledge base, appropriately applied VII. Essential Character Traits Unsatisfactory: Lacking one or more of: honesty, reliability, responsibility, ethics Average Outstanding: Extremely reliable, dependable, ethical and responsible Goals and Objectives for Cardiothoracic Anesthesia Goals and Objectives for Anesthesia for CA-1 and 2 Residents in Cardiothoracic Surgery I. Define the Rotation Anesthesia for cardiothoracic is a two month rotation. The first month occurs during the CA-1 year, and the second during the CA-2 year. II. Primary Area of Knowledge and Goals The overall goal of this rotation is to provide an introduction and a broad understanding for the sub-specialty of anesthesia for cardiothoracic surgery. The areas of knowledge to be covered will include: 1. an introduction to the preoperative assessment, intraoperative management and postoperative management of patients presenting for cardiac, aortic and/or thoracic surgery. 2. an introduction to one lung ventilation and fiberoptic bronchoscopy. 3. an introduction to invasive monitoring including arterial, central venous and pulmonary artery catheters III. Cognitive Objectives The resident will be able to: 1. describe the normal anatomy and physiology of the heart. 2. discuss pharmacology pertinent to the cardiovascular system. 3. describe coronary artery and valvular heart disease. 4. explain anesthesia implications of these diseases. 5. discuss and explain the rationale of induction and maintenance of anesthesia techniques for cardiothoracic surgery. 6. discuss the mechanism and anesthesia implications of cardiopulmonary bypass. 7. describe the pathophysiology and the anesthesia implications of anesthesia for aortic surgery. 8. describe the pathophysiology , and discuss the anesthesia implications of pulmonary surgery. 9. explain the sequential steps in cardiopulmonary resuscitation. 10. list the indications, and potential complications of : a. arterial catherization b. central venous catherization c. pulmonary artery catherization d. bronchoscopy e. double lumen tube placement f. epidural catheters 11. describe the expected postoperative recovery of the uncomplicated cardiac surgery patient. 12. list common problems and their treatments of this uncomplicated surgery patient. 13. describe the expected postoperative recovery of the uncomplicated thoracic surgery patient. 14. list common problems and their treatment of this uncomplicated surgery patient. 15. describe the management of ventilation of the uncomplicated cardiac/thoracic surgery patients. IV. Skill Objectives: The resident will be able to: 1. insert, manage, and interpret the results of arterial catherization, central venous catherization, and pulmonary artery catherization with minimal staff assistance. 2. perform fiberoptic bronchosopy with minimal staff assistance. 3. insert and manage double lumen endotracheal tubes with minimal staff assistance. 4. place and manage epidural catheters for patients having thoracic surgery. V. Conference and Literature Assignments The CA-1 or 2 rotating resident will attend the weekly conferences held by the Department of Anesthesiology. The annual curriculum is expected to fully cover the subject for cardiothoracic surgery, and include such specialty items such as journal club, and quality assurance issues. Reading and active participation is expected of these residents. Goals and Objectives for Anesthesia for CA-3 Residents in Cardiothoracic Surgery I. Definition Rotations for CA-3 residents in anesthesia for cardiothoracic surgery are provided for a duration of 1 to 6 months. II. Goals and Primary Area of Knowledge The overall goals to be attained will relate directly to the duration of training elected in this subspecialty by the CA-3 resident, but in general is intended to provide advanced training in anesthesia for cardiothoracic surgery. The area of knowledge includes a preoperative assessment, and the intraoperative and postoperative management of patients presented for cardiac, aortic, and/or thoracic surgery. Also included will be training in one lung ventilation, fiberoptic bronchoscopy, invasive monitoring, and introduction to transesophageal echocardiography. Some of these areas such as transesophageal echocardiography will be intended for those residents spending at least 6 months training in the subspecialty. III. Cognitive Objectives: The resident will be able to: 1. demonstrate mastery of all cognitive objectives expected of the CA-1 and 2 resident. 2. describe anesthesia implications of transesophageal echocardiographic monitoring. 3. describe the anatomy and pathophysiology of congenital heart abnormalities. IV. Skill Objectives: The resident will be able to: 1. demonstrate mastery of all skill objectives expected of a CA-1 and 2 resident with essentially no staff supervision. 2. Demonstrate the basic use and interpretation of transesophageal echocardiography. V. Conference and Literature Assignments The CA-3 rotating resident will attend the conferences held by the Department of Anesthesiology. The annual curriculum is expected to fully cover the subject for cardiothoracic surgery, and include such specialty items such as echocardiography, journal club and quality assurance issues. Reading and active participation is expected of these residents. There will be greater expectation of the CA-3 resident in reading, participation, and presentations at these sessions. Division of Neuroanesthesiology Clinical Training CA-1 and CA-2 Advanced Clinical Training CA-3 The Neuroanesthesia clinical rotation at MetroHealth Medical Center offers the resident experiences in a wide range of neurosurgical cases including: extra and intracranial (aneurysms and arteriovenous malformations) vascular surgery, benign and malignant intracranial tumors, craniobasal and craniofacial surgery, transsphenoidal pituitary surgery, posterior fossa craniotomies, head trauma, pediatric neurosurgery, stereotactic and brain biopsy procedures and spinal surgery involving Evoked Potential Monitoring. The objectives for the Clinical Training for CA-1 and CA-2 include: Didatic 1. Knowledge of cerebal, cerebrovascular and spinal cord physiology including blood flow dynamics, metabolism and causes/consequences of altered physiology. 2. Becoming familiar with the physiopathlology of intracranial pressure and cerebral edema, causes and treatment. 3. The effect of coexisting disease on cerebral pathophysiology. 4. Knowledge of cerebrovascular pharmacology of anesthetic agents and other drugs used on the neurosurgical patient; effects on physiology and metabolism. Clinical 1. Being familiar with various neurosurgical techniques and approaches of neurosurgery including sitting craniotomies, Evoked Potential Monitoring and electrostimulation implants. 2. Preoperative, intraoperative and postoperative care of the routine and emergency patients with neurological problems. 3. Patient evaluation, induction and maintenance of anesthesia, invasive and noninvasive monitoring. 4. Neuroanesthesia techniques such as induced hypothermia, reduction of increased intracranial pressure and the use of techniques that might attenuate sequelae of focal ischemia. 5. Satisfactory completion of neuroanesthesia clinical rotation exam. The objectives of the Advanced Clinical Training for the CA-3 include: 1. Review of the basic clinical objectives for CA-1 and CA-2. 2. Focusing on preoperative evaluation of the neurosurgical patient and clinical decision making. 3. Impact of coexisting disease on clinical decision making for the neurosurgical patient involving further preoperative testing, intraoperative monitors and postoperative pain management. 4. Evaluation of clinical involving choice of induction agent, neuromuscular blocking agents, maintenance anesthesia and postoperative planning. 5. Satisfactory completion of neuroanesthesia mock oral exam by staff attending anesthesiologist. Goals and Objectives for CA-1/2 and CA-3 Residents in Obstetrical Anesthesia 1. The rotation Anesthesia residents at the MetroHealth Medical center will be required to participate in a minimum of 2 one-month rotations in L&D learning Obstetrical Anesthesia. One rotation to be scheduled in the latter half of their CA-1 year, and one month in the CA-II year. In the CA-III year, one or more elective months may be selected. 2. Academic Objectives and Goals For the new resident, it is important to recognize that there is a core of knowledge that must be mastered to become a competent consultant in Obstetrical Anesthesia. The acquisition of this knowledge is vital for not only board certification, but for optimal patient care. The resident will be expected to gain an understanding of the basic principals of perinatal anesthetic delivery in both the normal parturient as well as those with complex medical requirements. They will develop the necessary skills in pre-anesthetic assessment and preparation, intra anesthetic management, and post- operative care including assessment of complications, care and prevention strategies. Additionally, residents in the CA III year will attain additional proficiency in all these areas allowing them to assist in junior resident training, act with more independence in both normal and high risk parturient care, and participate in optional research projects to advance knowledge in this field. 3. Knowledge objectives At the conclusion of the resident’s two months of rotation in Obstetrical Anesthesia, the resident will: a. Have a thorough knowledge of the physiologic changes in pregnancy. b. Understand maternal uptake/distribution, placental transfer, and perinatal effects of volatile anesthetics, barbiturates, ketamine, narcotics, sedatives, tranquilizers, neuromuscular blocking agents, local anesthetics, antihypertensive agents, anticoagulants, Tocolytic, as well as glucose/hypoglycemic agents. c. Understand uterine blood flow it’s changes in pregnancy, how regional and general anesthetics effect it, and the effects of vasopressors/antihypertensive agents on it. d. Understand the physiology of labor, it’s stages, how anesthesia effects labor, and how agents used in labor and delivery (like tocolytic’s, ergot alkaloids, pitocin, prostaglandin’s, etc.) can effect maternal physiology and anesthetic management. e. Understand and be able to discuss the advantages, disadvantages, and risks of sedation, inhalation, epidural, spinal, and pudendial anesthesia for labor. f. Understand and be able to discuss the advantages, disadvantages, and risks of local, regional and general anesthesia for the patient undergoing cesarean section. g. Understand and manage induction, maintenance, and emergence from general anesthesia, the effects of volatile anesthetics on the uterus and fetus, the pros/cons of Nitrous Oxide, and the management of complications such as failed intubation, aspiration, hypotension, hypertension, etc. h. Understand and be able to discuss the advantages, disadvantages, and risks of anesthesia for the patient undergoing non-obstetric surgery during pregnancy. i. Understand how agents/ procedures in the induction/augmentation of labor can effect maternal anesthetic care such as amniotomy and the use of oxytocin. j. Understand the pharmacokinetics / pharmacodynamics of local anesthetics as well as complications/toxicity in the parturient and neonate. k. Understand the options for post-partum anesthesia care the advantages, disadvantages and risks. l. Understand and be able to describe the anatomic features and appropriate landmarks necessary to administer a regional anesthetic block including spinal dermatomes and pain pathways. m. Be able to identify and assess the relative and absolute contraindications to regional anesthesia related to coagulopathy, neurologic disease, hypovolemia, drug allergy, fever/sepsis, backache, scoliosis, etc. n. Understand, recognize, and manage patients with medical conditions in pregnancy such as: 1) pregnancy inducted hypertension 2) cardiac disease (congenital/ischemic/valvular/cardiomyopathy) 3) respiratory disease (restrictive/obstructive) 4) bleeding disorders in pregnancy ( placenta previa, abruption, accreta, etc.) 5) diabetes 6) morbid obesity 7) difficult airways 8) the causes of cardio- respiratory arrest 9) misc. disorders ( thyroid, NM disorders, MH, coagulopathies) 10) the patient with PDPH o. Describe/manage complications of regional anesthesia in pregnancy hemodynamic, backache, bladder dysfunction, neurologic sequela, infection, headache, etc. p. Understand and discuss obstetric and neonatal indications for cesarean section both elective and emergent and be able to discuss the risk/benefits of the various options for anesthetic management. q. Be able to discuss the obstetrical considerations/management of labor complications such as breech delivery, cord prolapse, transverse lie, multiple gestation, brow presentation, premature rupture of membranes, and premature delivery. r. Understand the management of maternal hemorrhage and the risks associated with such conditions as: previa, abruption, accreta, uterine rupture, uterine atony, retained placenta, uterine inversion, DIC. s. Understand the basic anatomy and physiology of the feto-placental unit, ante-partum fetal monitoring and assessment including non stress testing, oxytocin stress testing, biophysical profile, fetal lung maturity testing, fetal heart rate monitoring, and fetal pH monitoring. t. Understand, be able to discuss peripartum fetal asphyxia diagnosis/management of neonatal disorders such as meconium aspiration, diaphragmatic hernia, T-E fistula, sepsis, RDS of the newborn. 4. Skill Objectives a. To be able to safely and thoroughly prepare an operating room to be ready to administer an anesthetic for vaginal/cesarean delivery. b. To be proficient in the placement and management of regional anesthesia (both spinal and epidural anesthetics) in all clinical setting for labor, cesarean delivery, D&C, postpartum tubal ligation, cerclage, etc. The goal is to do a minimum of 50 regional anesthetics per month. c. To be able to select appropriate monitoring for the various clinical settings that occur in the parturient. d. To be able to safely administer general anesthesia to the parturient in both the non- emergent and emergent setting for both vaginal and cesarean delivery. e. To be able to pre-operatively evaluate and design a safe anesthetic plan for the anesthetic management of: 1) The healthy parturient for vaginal delivery with or w/o the use of forceps. 2) The healthy parturient presenting for elective cesarean section 3) The healthy parturient presenting for emergency cesarean section. 4) The parturient with Preeclampsia/Eclampsia for either vaginal/cesarean section 5) The parturient with antepartum/intrapartum/postpartum hemorrhage f. To be familiar with the diagnosis and management of the fetal/neonatal distress. g. Learn to interact/communicate effectively with all allied personnel in the obstetric care team, to lead in the pre-anesthetic evaluation, labor, intra-operative and post-operative care as well as maternal/fetal resuscitation. v h. Learn to function as a consultant to patients, families, colleagues in anesthesia, obstetrics and other specialties. 5. Literature Conference Obligations a. Attendance at Tuesday morning 7 AM grand rounds. b. Attendance at Wednesday afternoon 1 PM resident lecture. c. Attendance at Friday afternoon 1 PM resident lecture. d. The resident is to read all 16 chapters of the Obstetrical Anesthesia handbook that is supplied by the secretarial staff. They are to be able to answer the questions provided in each chapter of the manual. They are then to present each chapter to the attending staff to demonstrate their command of the information. The attending will then sign off on each chapter the resident presents. At the end of each rotation 8 chapters are to be completed and the resident is to give the signature sheet to the secretary at the end of the month. e. Shnider, S MD and Levinson, G. Anesthesia for Obstetrics f. Ostheimer, Gerald, MD Manual of Obstetric Anesthesia g. Gambling DR, Douglas J, Obstetric Anesthesia and Uncommon Disorders Anesthesia Resident Pain Management Rotation Goals and Objectives The Anesthesiology Department at MetroHealth Medical Center established the Pain Management Program in 1983. This program addresses the needs of our community in the treatment of Acute, Chronic and Cancer Pain. The program works hard to provide a significant educational experience to our Anesthesiology Residents during their rotation in Pain Management. We are proud that our Pain Management Program provides educational information and training opportunities to other interested residents or active physicians at MetroHealth Medical Center. Goals and objectives of CA-2 Resident Pain Rotation: Define rotation: 1. Two month rotation in pain management. The rotation will provide basic experience in acute, chronic and cancer pain. 2. The residents are fully committed to pain management during this rotation without any operating room coverage. 3. The residents are responsible along with their CA-3 colleagues, to operate and provide 24 hour pain coverage under the supervision of the Pain Management Specialist. Cognitive Objectives: To enable our Residents to reach the following goals: 1. Understand the anatomy, physiology and patho-physiology of pain, e.g., nociceptors, pathways, mechanisms and spinal or central modulations. 2. Understand the pharmacology and pharmacodynamics of oral, I.V., cutaneous and spinal opiates. 3. Understand the importance of post-operative and post-trauma pain management. 4. Understand the multiple acute pain management modalities, e.g., I.V. PCA, peripheral nerve blocks, neuro-axial blocks, the role of NSAID’s and neurolytic drugs, TENS units, and psychotherapies. 5. Understand the complex pathways and mechanisms in chronic pain patients. 6. Understand the nature of neuropathic pain and the mechanisms, e.g., CRPS type I & II, post-herpetic neuralgia, diabetic neuropathy, and trigeminal neuralgia. 7. Understand the complex mechanisms involved in back and neck pain. 8. Understand the role of nerve blocks and the neuro-axial implants in the treatment of chronic pain e.g., dorsal column stimulators and intra-thecal drug delivery systems 9. Understand the principles of diagnostic testing. 10. Understand the human aspect of pain and suffering and the possibility of failure to relieve the pain of some chronic pain sufferers. Skill Objectives: 1. Order and manage PCA pumps and provide the necessary documentation. 2. Perform peripheral or neuro-axial nerve blocks in accordance with their level of training. 3. Recognize and treat the side effects of these treatments. 4. Conduct a full history taking and physical examination including neuro-muscular exam. 5. Assist and perform some chronic pain management therapies. 6. Conduct Acute and Chronic Pain Management service rounds and respond to in-house consults. 7. Assist in all intrathecal pump refills and drug refill orders. Conference and Literature Assignments: 1. Attendance at Anesthesiology Grand Rounds. 2. Attendance at Wednesday lectures series. 3. Attendance at the Journal Clubs. 4. Prepare and read about the procedures prior to performing them. Discuss cases with the attending. 5. Read the entire pain management handout prior to the rotation. Make use of the pain reference textbooks and journals during the rotation. Goals and Objectives for CA-3 Resident Pain Rotation: Define Rotation: 1. A two to six month rotation in pain management. The rotation will enhance their knowledge and skills in acute and chronic pain management. 2. The CA-3 resident has the same commitments and the responsibilities of the CA-2 resident, in addition the responsibility to be a leader and a teacher for CA-2 resident. Cognitive Objectives: To enable our residents to attain the following goals: 1. Demonstrate mastery of all cognitive objectives expected of CA-2 resident. 2. Discuss in depth the acute pain management modalities and their complications. 3. List the indication and contraindications for each acute pain management modality. 4. Describe the effect of centrally acting drugs. 5. Understand the difference between tolerance and addiction to narcotics. 6. Demonstrate mastery in evaluating pain patients and formulating a plan of treatment. 7. Describe the benefit of additional testing and consults. 8. Discuss the measurement and assessment of pain and function. 9. Discuss the role of nerve blocks in pain management. 10. Discuss the indications and contraindications of advanced implantable therapies. 11. Discuss the indications and contraindications for radio-frequency therapy. 12. Discuss the importance of a multidisciplinary approach to pain management, and the contributions of other specialties to the success of the treatment. Skill objectives: 1. Demonstrate mastery of all skill objectives of CA-2 residents. 2. Perform thoracic epidurals and neuro-axial blocks. 3. Perform peripheral continuous nerve blocks. 4. Perform a full history and physical examination. 5. Perform a wide range of chronic pain blocks. 6. Assist in the insertion of implantable therapies. 7. Refill and manage the pumps. Conference and Literature Assignments: 1. Attendance at Anesthesiology Grand Rounds. 2. Attendance at Wednesday lectures series. 3. Attendance at the Journal Clubs. 4. Current Review of Pain, by P. Raj 5. The Pain Clinic Manual, by S. Abraham 6. Cancer Pain, by R. Patt 7. The Clinical Journal of Pain. 8. The Journal of Regional Anesthesia. Case Western Reserve University, MetroHealth Medical Center Department of Anesthesiology CA-3 Resident Advanced Rotation Curriculum Define Rotation: 1. Two to six months rotation in pain management. The rotation will enhance their knowledge and skills in acute and chronic pain management. 2. CA-3 resident has the commitment and the responsibility of a CA-2 resident, in addition to the responsibility to be a leader and a teacher for CA-2 resident. Cognitive Objectives: To enable our residents reach their goals in: 1. Demonstrate mastery of all cognitive objectives expected of CA-2resident. 2. Discuss in depth the acute pain management modalities and their complications. 3. List the indication and contra-indications to each acute pain management modalities. 4. Describe the effect of centrally acting drugs. 5. Understand the difference between tolerance and addiction to narcotics. 6. Demonstrate mastery in evaluating pain patients and formulating a plan of treatment. 7. Describe the benefit of additional testing and consults. 8. Discuss the measurement of and assessment of pain and function. 9. Discuss the role of nerve blocks in pain management. 10. Discuss the indications and contraindications of advanced implantable therapies. 11. Discuss the indications and contraindications for Radio-frequency therapy. 12. Discuss the importance of a multidisciplinary approach to pain management, and the contributions of other specialties to the success of the treatment. Skill objectives: 1. Demonstrate mastery of all skill objectives of the CA-2 resident. 2. Perform thoracic epidurals and neuro-axial blocks. 3. Perform peripheral continuous nerve blocks. 4. Perform a full history and physical examination. 5. Perform a wide range of chronic pain blocks. 6. Assist in the insertion of implantable therapies. 7. Refill and manage pumps. Conference and Literature Assignments: 1. Attendance of Anesthesiology Grand Rounds. 2. Attendance of Wednesday lectures series. 3. Attendance of the Journal Clubs. 4. Current Review of Pain, by P. Raj 5. The Pain Clinic Manual, by S. Abraham 6. Cancer Pain, by R. Patt 7. The Clinical Journal of Pain 8. The Journal of Regional Anesthesia Anesthesiology Resident Education/Training Goals and Objectives The overall general objectives of resident education and training in Pediatric Anesthesiology are to develop consultant-level knowledge in all areas of the subspecialty and to develop the knowledge and skill, based especially on hands-on clinical experience, to provide state-of-the-art pediatric anesthesia care in most situations likely to be encountered in future practice. Residents may also be encouraged, though not required, to participate in clinical research projects under the direction of the attending staff. Our two to three month Pediatric Anesthesia Rotation is focused on facilitating the achievement of these and the following more specific goals and objectives. Pediatric Anesthesia Description The rotation is designed as two separate months during the CA1 and/or CA2 years, plus an elective third month during the CA3 year. Pediatric anesthsia information for preview and concurrent study is available online. Suggested reading list follows. During the three months residents are directly supervised by faculty members of the MHMC Department of Anesthesia in the provision of anesthesia and post-anesthetic care for newborns, infants, children and adolescents to age 18 undergoing therapeutic, diagnostic and surgical procedures. This care is inclusive of general anesthesia, regional anesthesia, intravenous sedation as well as appropriate regimes for analgesia in this population. A core curriculum of topics in Pediatric Anesthesia is presented throughout the year as part of the regular Tuesday morning, Wednesday afternoon and Thursday afternoon lecture series. This didactic material emphasizes the anatomy, physiology and pharmacology as it pertains to the practice of pediatric anesthesiology. A syllabus of regularly updated study material is available online. Each resident is expected to begin study of the relevant material prior to the first month of the rotation. Goals Specifically, residents will be able to demonstrate: * Essential Character Attributes o Be punctual o Be honest and ethical o Learn from experience o React appropriately in stressful situations * Good judgment (including recognition of personal limitations) * Understanding and application of: 1. Special pediatric considerations in temperature regulation 2. Malignant hyperthermia 3. Resuscitation of the newborn 4. Pediatric apparatus, including breathing circuits, humidifying methods, thermal control 5. Appropriate thorough preoperative evaluation and development of positive rapport with the pediatric patient and family. 6. Appropriate preparation of the operating room and equipment for the pediatric patient. 7. Premedication: drugs, dosage, routes, vehicles 8. Agents and technics o Anesthetic: actions different from adults o Neuromuscular blockers (sensitivity, congenital diseases) o Selection of and demonstrate skillful application of technics of pediatric anesthetic induction: intravenous (IV) inhalational rectal intramuscular (IM) o Skillful management of the pediatric airway by hand and mask o Achievement of IV access in the pediatric patient o Performance of efficient atraumatic endotracheal intubation of the pediatric patient o Appropriate selection and performance of basic pediatric regional anesthetic technics including + Caudal epidural block + Spinal + Ilioinguinal-hypogastric nerve block + Penile block + Peripheral nerve blocks 9. Fluid therapy and blood replacement, physiologic anemia 10. Problems in intubation (full stomach, diaphragmatic hernia, T-E fistula, Pierre-Robin, awake intubation) 11. Proficiency in the anesthetic management of routine pediatric cases (tympanotomy tubes, adenoidectomy and tonsillectomy, herniorrhaphy,...) explaining the selection of airway, fluid type and rate, agents and adjuvants 12. Anesthetic implications of common and critical pediatric conditions o Asthma o Upper respiratory infection (URI) o Tonsillar and adenoidal hypertrophy/tonsillitis o Serous otitis media (SOM) o Croup o Epiglottitis o Obstructive sleep apnea (OSA) 13. Neonatal physiology o Respiratory + Development, anatomy, surfactant + Pulmonary oxygen toxicity + Pulmonary function + Lung volumes vs. adult + Airway differences, infant vs. adult o Cardiovascular + Transition, fetal to adult + Persistent fetal circulation o Metabolism, fluid distribution and renal function o Thermal regulation (neutral temperature, brown fat) o Fetal hemoglobin o Clinical problems of prematurity + Respiratory distress syndrome (RDS) + Bronchopulmonary dysplasia (BPD) + Apnea of prematurity + Retinopathy of prematurity (ROP): anesthetic implications + Necrotizing enterocolitis (NEC) 14. Congenital heart disease o Cyanotic defects, primary pulmonary hypertension o Acyanotic defects o Altered uptake/distribution of IV and inhalation anesthetics o Other anesthetic considerations o Anesthetic considerations of specific lesions + Patient ductus arteriosus (PDA) + Atrial septal defect (ASD) + Ventricular septal defect (VSD) + Tetralogy of Fallot (TOF) + Transposition of the great arteries (TGA) + Persistent pulmonary hypertension of the newborn ("PFC") 15. Emergencies in the newborn o Diaphragmatic hernia o T-E fistula o Neonatal lobar emphysema o Pyloric stenosis o Necrotizing enterocolitis o Omphalocele/gastroschisis o RDS: etiology, management, ventilation technics o Myelomeningocele 16. Management of the anesthetic recovery of pediatric patients 17. Postoperative analgesia CA3 Residents completing the third month of Pediatric Anesthesia will additionally be able to 1. Supervise junior residents and medical students in performing pediatric anesthesia care 2. Appropriately manage anesthesia for complex and/or difficult cases (diaphragmatic hernia, T-E fistula, omphalocele/gastroschisis, Pierre-Robin syndrome, epiglottitis, ...) 3. Lead discussions with junior residents on principles of pediatric anesthesia 4. Assume role of consultant anesthesiologist Pediatric Anesthesia Educational Objectives The following serves as a guide to the education and evaluation of residents rotating in Pediatric Anesthesia. 1. MEDICAL KNOWLEDGE: * Cognitive ability: residents will learn the principles of anesthesia for pediatric patients including the anatomy and physiology of neonates and children; the pathophysiological process involved in pediatric surgical conditions; the pharmacology of anesthetic agents as it effects neonates, infants and children; the principles of temperature regulation for neonates, infants and children; the principles of equipment and monitoring devises used in pediatric anesthesia; * Psychomotor ability: residents will develop a working knowledge and understanding of the indications and contraindications, risks and benefits of the various procedures they learn; residents will develop technical skill with procedures such as intravenous, intraarterial and central venous catheter insertion in infants and children, neuroaxial and other regional procedures in infants and children. * Affective ability: residents will begin to develop behavior patterns related to working with pediatric patients and their parents in the preparation and administration of anesthesia, including the need for careful assessment, the ability to respond to rapidly changing patient conditions and the team approach to pediatric anesthesia.. 2. PATIENT CARE: * Cognitive ability: residents will learn the basic principles of caring for pediatric patients undergoing surgery for general, urological, orthopedic, ENT, cardiac, neurosurgical, ambulatory and other surgical procedures; residents will also understand the principles of sedation and monitoring for pediatric patients having procedures outside the operating room such as radiological procedures; the recognition, treatment and prevention of postoperative pain in children and infants. * Psychomotor ability: residents will have the opportunity to anesthetize at least 100 patients aged between 2 to 12 years and at least 15 under 2 years, including neonates and premature babies; residents will learn how to perform invasive procedures with appropriate concern for patient safety such as epidural, caudal and spinal anesthesia; sedation and monitoring techniques; * Affective ability: residents will develop a behavioral approach that pays attention to all aspects of caring for pediatric patients and their parents in the perioperative period; residents will pay particular attention to patient safety; residents will be expected to work at the appropriate level of supervision for their training and for the condition of their patients; residents should demonstrate independent thinking but also show appropriate judgment and decision making including knowing when to ask for help from their supervising attendings. 3. INTERPERSONAL & COMMUNICATION SKILLS: * Cognitive ability: residents will learn techniques for effective communication with pediatric patients and their parents concerning pre-operative assessment, explaining the process of anesthesia and discussing risks of general and regional anesthesia. * Psychomotor ability: residents will be able to demonstrate skills for making a thorough preoperative assessment of each patient, they will also develop effective communication skills for explaining the process of anesthesia and discussing risks of general anesthesia to patients and their parents; residents will develop effective listening skills and show effective communication with patients, their parents and families and other members of the pediatric care team. * Affective ability: residents will demonstrate behaviors that show commitment to effective communication with patients, their families and other members of the pediatric surgical team; residents should be able to communicate pertinent data about the patient to their attending in a precise and efficient manner. 4. PROFESSIONALISM: * Cognitive ability: residents will learn the basic definitions of professional conduct as it applies to the practice of anesthesia for pediatric surgery and basic ethical principles. * Psychomotor ability: residents will act in a way that shows commitment to professional practice in their interactions with patients, their parents and families, colleagues and other members of the pediatric health care team; residents will be expected to contribute to the smooth running of the pediatric operating rooms; residents will be expected to complete all pre, intraoperative and post operative documentation in accordance with departmental requirements. * Affective ability: residents will demonstrate commitment to professional practice in their interactions with patients, their families, colleagues and other members of the pediatric health care team. 5. PRACTICE-BASED LEARNING: * Cognitive ability: residents will learn the practice of reflection on their performance and how to learn from expereince; they will understand the principles of life-longer learning and evidence – based medicine as it relates to pediatric anesthesia. * Psychomotor ability: residents will demonstrate reflective practice and develop skills to enhance learning from various sources including the use of web-based learning; residents will participate in feedback with their tutors to help improve their practice of pediatric anesthesia. * Affective ability: residents will demonstrate commitment to continually trying to improve their performance and take an active role in furthering their knowledge by attending organized educational activities especially the pediatric didactic lecture schedule and by preparing a 20 minute presentation for the end of the rotation. 6. SYSTEMS BASED PRACTICE: * Cognitive ability: residents will understand the team approach to how pediatric patients present, are investigated and assessed and optimized for their surgical procedures and how their management impacts on this team approach; residents will understand how the pediatricians, surgeons, nurses and intensive care departments interact with the pediatric surgical patients. * Psychomotor ability: residents will take part in practices and initiatives such as quality improvement programs that interact with other areas of the health care system; residents will be expected to function as a team member and work with nurses, surgeons and operating room staff to improve the care they offer their patients and their own understanding of the broader aspects of the health care system. * Affective ability: residents will develop behaviors that show an appreciation for the impact of their practices on the whole system caring for pediatric patients undergoing surgery. Syllabus for CA-1/CA-2 Anesthesia Rotation in the Surgical Intensive Care Unit Airway Management * Indications for an endotracheal tube * The compromised airway * Intrathoracic vs extrathoracic airway obstruction * Evaluation for airway protection and edema * Management of post-extubation stridor * Intubation techniques in unstable patients * Medicating the hemodynamically unstable patient * Intubating the patient with closed head or cervical spine injury * Cuff leaks - evaluation and management * Timing of tracheostomy Respiratory Management Respiratory physiology * Ventilation perfusion relationships * Causes of hypoxemia * Postoperative changes in respiratory function * PaO2/FIO2 relationships * Oxygen delivery and consumption Mechanical ventilation * Modes of mechanical ventilation - volume vs pressure * PEEP - indications, systemic effects, contraindications * Non-invasive mechanical ventilation Weaning from mechanical ventilation * Determining patients who are candidates for ventilator weaning * Use of weaning parameters * Controversies in weaning modes - AC/SIMV, T-piece trials Respiratory issues in trauma * Pulmonary contusion - physiology, management * Flail chest * Fat embolism ARDS * Diagnostic criteria * Management - fluid balance, ventilator strategies, steroids * Oxygen toxicity * Barotrauma Fluid Balance in the Surgical Patient Perioperative fluid management * Intraoperative fluid balance * Sources of intraoperative fluid loss * Postoperative fluid balance – patterns of third spacing and mobilization * Crystalloid vs colloids Transfusion therapy * Optimal hematocrit * Indications for blood products * Albumin controversies Electrolyte and Acid-base disorders * Acid base balance, compensatory mechanisms * Renal failure- diagnostic criteria, management, indications for dialysis, renal replacement techniques Hemodynamic monitoring Pulmonary artery catheters * Use of hemodynamic monitoring data, limitations of data, waveform recognition * Complications of catheters Hemodynamic mangement * Management of hypertension * Management of tachyarrhythmias * Inotropic agents * Vasopressor agents * Recognition and management of shock states Infectious diseases * Sources of infection in the ICU patient * Management of fever in the ICU * Sinusitis * Preventive measures * Antibiotic management, empiric coverage, rotation of antibiotics * Management of central lines in the ICU patient Nutritional support * Enteral vs parenteral nutrition * Uses of indirect calorimetry Neurosurgical concepts Closed head injury, intracranial pressure * Basic concepts of cerebral hemodynamics * Management of elevated intracranial pressure * Concepts of cerebral perfusion pressure Cerebral aneurysms * Complications of aneurysmal rupture * Management of cerebral vasospasm * Timing of aneurysmal clipping Cervical spine injuries * Respiratory pathophysiology * Hemodynamic management * Steroids in spinal cord injury * Timing of spine stabilization Radiology in the ICU * Limitations of plain films * Proper placement of tubes, central lines * Recognition of pulmonary collapse * Use of CT scans in the ICU patient Recommended reading: * Anesthesiology Resident’s Guide to Learning in the Intensive Care Unit * The ICU Book 1. All of the strategies for definitive airway management are acceptable in patients with Angioedema EXCEPT: 1. Awake fiberoptic intubation 2. Awake Direct Laryngoscopy 3. Rapid Sequence Intubation 4. Cricothyrotomy 5. Tracheotomy See the answer Answer: C. Rapid Sequence Intubation 2. Which of the following statements concerning the head-injured patient is TRUE? 1. Improved neurological outcome is associated with the avoidance of direct laryngoscopy for intubation in this population. 2. The unconscious head-injured patient (GCS<8) has a three-fold chance of cervical spine injury. v 3. Avoidance of cervical spine movement during airway management is mvore important than avoiding transient hypoxia and hypotension. 4. The safest way of proceeding with intubation is proven to be the flexible fiberoptic bronchoscope. 5. The use of muscle relaxants for intubation of these patients is contraindicated because they will interfere with subsequent neurological evaluation. Answer: B. The unconscious head-injured patient (GCS<8) has a three-fold chance of cervical spine injury. Question 1 1. All of the strategies for definitive airway management are acceptable in patients with Angioedema EXCEPT: 1. Awake fiberoptic intubation 2. Awake Direct Laryngoscopy 3. Rapid Sequence Intubation 4. Cricothyrotomy 5. Tracheotomy Answer: C. Rapid Sequence Intubation Question 2 2. Which of the following statements concerning the head-injured patient is TRUE? 1. Improved neurological outcome is associated with the avoidance of direct laryngoscopy for intubation in this population. v 2. The unconscious head-injured patient (GCS<8) has a three-fold chance of cervical spine injury. 3. Avoidance of cervical spine movement during airway management is more important than avoiding transient hypoxia and hypotension. 4. The safest way of proceeding with intubation is proven to be the flexible fiberoptic bronchoscope. 5. The use of muscle relaxants for intubation of these patients is contraindicated because they will interfere with subsequent neurological evaluation. Answer: B. The unconscious head-injured patient (GCS<8) has a three-fold chance of cervical spine injury. Bonus Question Which behavior results in the most airway management negligence law suits? Answer: "Failure to evaluate the airway for difficulty before embarking on airway management." 1. When do I talk to an Anesthesiologist? The anesthesia interview is conducted prior to your surgery by an anesthesiologist. 2. What are the risks of anesthesia? The risk of complications is present any time you undergo anesthesia and surgery. Fortunately, serious or debilitating complications are extremely rare in healthy patients. However, the extremes of age, the seriously ill, and those undergoing major or emergency operations share an increased risk profile. Some major risks routinely discussed include death, myocardial infarction, stroke, allergic reactions, arrhythmias, aspiration, asphyxiation, awareness, bronchospasm, nerve damage, vocal cord damage, dental damage and corneal abrasions. Minor postoperative side effects include grogginess, muscle aches, nausea/vomiting, sore throat, hoarseness, or bruised lip. Generally, these are self-limited problems that resolve early in the postoperative period. Please alert us if you had any of these problems in the past, so that we can plan a better anesthetic experience for you. v 3. What are the side effects of anesthesia? Although we are constantly improving our techniques, certain side effects from anesthesia and surgery are common, such as sore throat, dizziness, grogginess, muscle pain and nausea/vomiting. These problems generally respond to treatment or resolve with time. Please let us know if you had these problems or any other problems in the past, as that can help us plan a better anesthetic experience. v Pain relief after you leave the recovery area is under the control of your surgeon. It is a good idea to obtain and fill your prescription before your surgery or as soon as possible after your surgery. Nausea and vomiting are not uncommon with narcotic-based pain medicines, so be sure to ask your surgeon about this possible problem before going home. 4. What is a spinal? A spinal anesthetic is a form of regional anesthesia, most often utilized for operations on the legs, lower abdomen, perineum, or back, and occasionally for upper abdominal operations. A delicate needle is inserted between the bones of the lower spine (below the level of the spinal cord) into a sac containing cerebrospinal fluid (CSF) and exiting nerve roots. A local anesthetic is then injected, “numbing” these nerves and providing surgical anesthesia. 5. What is an epidural? An epidural anesthetic is another form of regional anesthesia used for many of the same operations as a spinal. Unlike a spinal in which a onetime dose of local anesthetic is administered, providing a fixed time period of “numbing,” a small epidural catheter is left in place just outside the fluid sac. This catheter can be reinjected during a surgical procedure or childbirth to prolong the anesthetic effect. Epidurals are frequently placed prior to major abdominal and thoracic procedures. After your surgery, these epidural catheters can be infused with a narcotic and/or local anesthetic to provide pain relief. This service is managed by the Anesthesia Department and typically runs for several days after your surgery. * Before your surgery * During your surgery * After your surgery Before your surgery Preanesthesia Testing (PAT) process |