Goals and Objectives of Anesthesia Rotation
Director: Dr. Melissa Vu
The Anesthesia rotation is fifteen days in duration and is intended to provide the fellow with necessary cognitive and technical skills to manage the airway of patients in need of assisted ventilation. In addition, fellows are expected to gain familiarity with issues arising from use of induction agents, paralytics, and airway devices.
Medical Knowledge
Fellows are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and the application of their knowledge to patient care and the education of others.
Peri-operative Medicine
During the course of the rotation, fellows have the opportunity to acquaint themselves with the ASA operative risk grading system and also learn methods to reduce peri-operative cardiopulmonary complications.
At the end of the rotation, fellows will:
• Understand the common methodologies of endotracheal intubation
• Understand various difficult airway scenarios and the approach to difficult airway intubation
• Understand the common complications of endotracheal tubes and airway appliances
Pharmacology of Induction Agents/Paralytics
Over the course of the rotation the fellow will demonstrate knowledge of (induction) dose, rapidity of onset, predicted duration of effect, complications, and contraindications of the following agents:
• Sedatives/Analgesics- Propofol, midazolam, fentanyl(+/- other synthetic narcotics), etomidate, pentothal(sodium thiopental)
• Paralytics- Succinycholine, rocuronium, cis-atracurium, vecuronium
The fellow will demonstrate
I. Knowledge of the issues and approaches to intubation of high-risk patients with the following conditions:
• Ischemic Heart Disease
• Elevated Intracranial Pressure
• Pregnancy
• Unstable Cervical Spines
• Morbid Obesity
II. Pre-operative airway assessment, understanding of practice guidelines for management of the difficult airway and ability to formulate a plan for the known difficult airway
III. Methods to improve laryngoscopic view, including:
• Improved Jackson/sniffing position
• BURP technique
• Left molar approach
• Head-elevated laryngoscopy
• Proper positioning of the morbidly obese
IV. Familiarity with alternative airway devices (LMA, different blades, including glidescope); During the
course of the rotation, fellows may have significant blocks of time outside of the surgical suites in which
self-directed learning can occur. The following areas often impact the practice of Critical Care and
therefore require familiarity with the subject.
Conscious Sedation
• Describe the difference between levels of sedation(minimal, moderate, deep)
• List the requirements for credentialing in and performance of conscious sedation
Patient Care
Fellows are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease and at the end of life. During the rotation, the fellow will demonstrate the following airway assessment and management skills:
• Apply various scoring systems (Mallapati scoring system, lip bit test, thyromental distance, mouth opening, etc) in airway assessment
• Maintain an open airway and provide adequate bag-mask ventilation to sedated patients
• Demonstrate proper manipulation and intubation of the airway
• Provide standard grading of laryngeal view during laryngoscopy
• Demonstrate familiarity with Difficult Airway algorithm
• Perform alternative to conventional endotracheal intubation ( LMA placement, Bougie assisted placement)
• Provide levels of induction & paralytic agents appropriate to the clinical situation
• Maintain hemodynamic stability and adequate gas exchange around the time of induction/intubation
Practice based Learning
Fellows are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.
Fellows at all levels of training are expected to
1) identify areas for improvement and implement strategies to enhance knowledge, skills, attitudes and processes of care
2) analyze and evaluate practice experiences and implement strategies to continually improve the quality of patient practice
3) develop and maintain a willingness to learn from errors and use errors to improve the system or processes of care and
4) use information technology or other available methodologies to access and manage information, support patient care decisions and enhance both patient and physician education. Requirements for this competency include;
• Maintain a list of patients attended to experiencing an untoward event (morbidity and mortality) during the rotation
• Review relevant literature surrounding occurrences and presenting findings to fellows and faculty at MICU M&M conference
• Review key articles in the literature related to patient safety (see section on conferences) and present synopsis at MICU M&M conference
• Demonstrate ability to access critical event and adverse drug reporting forms and participating in surveillance
• Translate techniques & management skills learned in this rotation into other settings (familiarity with, use & maintenance of difficult airway, regular availability of routine induction
agents/paralytics)
Professionalism
Fellows are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding, sensitivity and a responsible attitude toward their patients, their profession, and society.
• Demonstrate respect, compassion, integrity, and altruism in relationships with patients, families, and colleagues
• Demonstrate sensitivity and responsiveness to the gender, age, culture, religion, sexual preference, socioeconomic status, beliefs, behaviors and disabilities of patients and professional colleagues
• Adhere to principles of confidentiality, scientific/academic integrity, and informed consent
• Recognize and identify deficiencies in peer performance
• Admit to and seek help in remedying errors
• Interact with nursing staff and other professionals as two-way educational opportunities when current approach does not appear to be effective
Interpersonal and Communication Skills
Fellows are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams.
• Provide effective and professional consultation to other physicians and health care professionals and sustain therapeutic and ethically sound professional relationships with patients, their families, and colleagues.
• Communicate effectively in times of dynamically changing conditions
• Interact with consultants in a respectful, appropriate manner
• Transfer care of the patient in a manner that ensures patients safety, comfort and continuity of care
• Demonstrate respect for and recognition of particular skill sets possessed by other CC practitioners, such as CC nurses, RT, PT, OT, dieticians, pharmacists.
• Considers ethical issues and patient wishes in treatment decisions
Systems-Based Practice
Fellows are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care.
• Understand, access and utilize the resources, providers and systems necessary to provide optimal care
• Apply evidence-based, cost-conscious strategies to delivery of peri-operative care
• Demonstrate the Critical Care Practitioner’s role as patient/quality care advocate
• Establish multidisciplinary relationships needed to effect quality care
• Participate actively in PCCM or multidisciplinary M&M or case conferences
• Recognize how Critical Care services are documented, coded, billed, and reimbursed in different medical practices
• Interpret drug costs in context of outcomes
• Describe the proper procedure to correctly identify a patient to minimize patient errors.
Instructional Methods:
Introductory Lecture
Reading material provided throughout the rotation
Supervised bedside practical practice based learning
Weekly Critical Care Conference/Grand Rounds
Methods of Assessment
• Competency-based staff evaluations:
Minimum required competency:
10 Supervised Endotracheal intubations
5 Supervised LMA placements
• Conference attendance and participation
• Structured evaluations of airway management
Readings
Airway Adjuncts
1. Facemask, nasal, and oral airway devices, Greenberg RS, Anesthesiology Clin N Am 2002;20:833– 861
2. Using the laryngeal mask airway to manage the difficult airway, Bogetz MS, Anesthesiology Clin N Am 2002;20:863– 870
Complications of Intubation
3. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: A prospective, multiple-center study, Jaber S, Amraoui J, Lefrant J-V, et al, Crit Care Med 2006;34:2355–2361
4. Traumatic complications of intubation and other airway management procedures. Loh KS, Irish JC, Anesthesiol Clin North America. 2002 Dec;20(4):953-69.
Conscious Sedation
5. Procedural Sedation and Analgesia: A Review and New Concepts, Bahn EL, Holt KR, Emerg Med Clin N Am 2005;23:503–517
High Risk Patients
6. Emergent management of the airway: New pharmacology and the control of comorbidities in cardiac disease, ischemia, and valvular heart disease, Horak J, et al, Crit Care Clinics
2000;16(3):411-427
7. Airway Management in Adults after Cervical Spine Trauma, Crosby, ET, Anesthesiology 2006; 104:1293–318
8. Airway management of the Obstetric Patient, Lewin S, et al, Crit Care Clinics 2000; 16(3):505-513
9. Difficult airway in obstetric anesthesia: A review, Ezri T, et al, Obstet Gyn Survey 001;58(10):631-641
10. A practical clinical approach to management of the difficult airway, Eindhoven GB, et al, European J Anaesth 2001;18(Suppl 23):60-65
11. Awake intubation, Woodall N, Current Anaesthesia Crit Care 2001;12:218-24
Management of the Difficult Airway
12. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway, Anesthesiology 2003; 98:1269–77
13. Management of the difficult airway: alternative airway techniques and adjuncts, Butler KH, Clyne B, Emerg Med Clin N Am 2003;21:259–289
14. Head-elevated laryngoscopy position: Improving laryngeal exposure during laryngoscopy by increasing head elevation, Levitan R, et al, Ann Emerg Med. 2003;41:322-330.
15. Safe use of cricoid pressure, Vanner R, et al, Anaesthesia, 1999; 54:1–3
16. Left-molar approach improves the laryngeal view in patients with difficult laryngoscopy, Yamamoto L, et al, Anesthesiology 2000; 92(1):70-4
17. The efficacy of the “BURP” maneuver during a difficult laryngoscopy, Takahata O, et al, Anesth Analg. 1997;84(2):419-21
18. Manoeuvers used to clear the airway during fiberoptic intubation, Durga VK, Smith JE, Brit J Anaesthesia 2001;87(2):207-11 Pharmacology of Induction Agents/Paralytics
19. Choice of the hypnotic and the opioid for rapid-sequence induction, Lavazais S, European J Anaesth 2001;18(Suppl 23):66-70
20. Predictors of onset and offset of drug effect, Schnider W, et al, European J Anaesth 001;18(Suppl 23):26-31