Rotation Schedule Overview

• Interpret an EKG
• Manage and assess arterial and intravenous catheters, including indwelling central and pulmonary lines.
• Interpret basic chest radiographs related to pulmonary disease and complications, including the placement of central lines and endotracheal tube position.
• Manage acute airway emergencies.
• Formulate a postoperative care plan, upon admission, for both pediatric and adult patients.
• Understand common post-anesthesia care problems, such as…
  • Hypothermia
  • Hypoxia
  • Hypercarbia
  • Airway compromise
  • Post-obstructive pulmonary edema
  • Congestive heart failure
  • Pulmonary restrictive disease
  • Aspiration pneumonitis
  • Pulmonary embolism
  • Bradycardia
  • Tachycardia
  • Tachyarrhythmias
  • Hypotension
  • Hypertension
  • Bleeding dyscrasias
  • Transfusion reactions
  • Allergic drug reactions and drug interactions
  • Renal compromise and failure
  • Diabetes
  • Hepatic failure
  • Alcohol withdrawal
  • Ischemic neurovascular disease
  • Intracranial hypertension
  • Medication errors
  • Atypical pseudocholinesterase deficiency
• Discuss issues related to the selection and management of outpatients, including evolving concepts such as “accelerated discharge or fast tracking”. These discussions should include an understanding of the evolving concepts of discharge criteria.
• Discuss the causes and management of postoperative nausea and vomiting.
• Discuss the causes and management of postoperative pain. Residents should be able to measure, formulate, treat, and communicate a pain plan.
• Discuss the treatment of complications related to the treatment of pain.
• Understand the role of the anesthesiologist and the issues of communication and education of nurses.
• Understand the role of effective communication with family members, including issues of confidentiality.
• Understand the role of effective communication with the patient.
• Understand the role of effective communication with the surgeon(s).
• Understand the role of the postoperative visit and assessment.
• Understand the role of ergonomics and economics and their impact upon post-operative care unit.

Demonstrate an understanding of the objectives listed above and be able to clinically apply them.
Demonstrate the skill to diagnose, evaluate, and manage the preoperative patient with various medical conditions such as hypertension, diabetes, cardiac disease, dysrhythmias, & COPD.
Demonstrate the skills to evaluate multiple diagnostic modalities, such as chest x-ray, electrocardiogram, stress echocardiography, and pulmonary functions tests.
Demonstrate the skill to appropriately request a consultation, and effectively evaluate their assessment of the preoperative patient.
Demonstrate the understanding and skill to diagnose, evaluate, and manage multiple Pediatric medical conditions such as upper respiratory illness, asthma, and repaired heard disease.
Demonstrate the skill to appropriately clear a patient for surgery, and appropriately postpone surgery pending further medical evaluation.Satisfactory completion of this rotation will be based on whether the resident has accomplished these objectives. Also, a satisfactory score on the written exam at the end of the rotation is required for completion of this rotation.

• Learn how to appropriately evaluate and select patients for regional anesthesia
• Recognize the importance of proper informed consent for regional anesthesia
• Learn relevant anatomy
• Understand various approaches for performing the different blocks
• Learn the pharmacology and toxicity profiles of the local anesthetics.
• Recognize complications of regional anesthesia and manage those complications.

…and master:

• Spinal and epidural anesthesia, including thoracic epidural catheter placement
• Brachial plexus blockade, including interscalene, subclavian perivascular, inter-sternocleidomastoid supraclavicular, infraclavicular, and axillary approaches.
• Knowledge of anatomy of the brachial plexus in relation to surgical site for choice of blockade approach.
• Various techniques such as nerve stimulation, paresthesia, or transarterial.
• Lower extremity blockade. Femoral, Lateral Femoral Cutaneous, and Obturator nerve blockade will be taught as a three-in-one block.
• Various approaches; posterior, lateral, and posterior popliteal for sciatic nerve blockade.
• Ankle blocks
• I.V. Regional anesthesia, and other peripheral blocks, such as suprascapular blocks.

• Manage the ventilated patient.
  • Know the different types of ventilators.
  • Distinguish the different ventilator modes, understand why they are different, and know the typical indications for each mode.
  • Understand the use of positive airway pressure – its indications and adverse effects.
  • Recognize the signs and symptoms of impending respiratory failure and when to intervene.
  • Know the different methods to wean from mechanical ventilation; when to start weaning and how to assess weaning failure/success.
  • Know the concept of different modes of ventilation.
  • Understand the basis for the “lung protective strategy” and the management of patients with acute lung injury.
  • Interpret the chest X-ray.
  • Interpret arterial blood gas results and acid-base disturbances.
  • Understand the concept, indications, contraindications and techniques of non-invasive ventilation.
• Manage the hemodynamically unstable patient.
  • Recognize “shock states” and inadequate tissue perfusion.
  • Assess volume status clinically.
  • Differentiate between the various causes of poor tissue perfusion.
  • Understand the indications for invasive monitoring, how to initiate these techniques, and interpret their findings.
  • Understand use, benefits and adverse effects of the various vasoactive agents.
  • Recognize the goals of therapy.
• Manage the patient with renal failure.
  • How to diagnose impending renal failure.
  • How to formulate a differential diagnosis of the cause of renal failure.
  • How to manage incipient renal failure and try to prevent overt failure.
  • Know the various forms of hemodialysis – their indications, benefits, and adverse effects.
• Understand surgical nutrition.
  • Understand when to start nutritional support.
  • Understand the benefits and adverse effects of the different routes of nutritional support.
  • Understand the benefits of the enteral as opposed to the parenteral route for nutrition.
  • Recognize the different types of feeds.
  • Know how to calculate the nutritional needs of a patient.
  • Know how to manage adverse effects of nutrition.
• Understand surgical infection.
  • Know how to work up the febrile “infected” patient.
  • Know what are the most common sources of infection in a surgical patient.
  • Know how to interpret microbiological findings.
  • Understand antibiotics – their indications and adverse effects.
  • Recognize the signs of impending sepsis.
• Manage the septic patient and provide hemodynamic support.
• Understand the management of sedation and analgesia on the ICU.
  • Recognize the goals of analgesia/sedation.
  • Understand the various techniques to provide pain relief to the ICU patient.
  • Know the sedative agents in common use — their indication, benefits and adverse effects.
• Manage the patient receiving a solid organ transplant.
  • Know the different protocols for the management of the kidney, pancreas and liver transplant.
  • Recognize the complications of organ rejection/failure and how to manage these complications.
  • Know the various immunosuppressant medications.
• Recognize the diagnosis of infection in the transplanted patient.
• Understand the importance of the prophylaxis of deep venous thrombosis.
  • Be aware of the frequency of DVTs in the surgical population.
  • Understand the different approaches to DVT prophylaxis – their indication, benefits, and adverse effects.
• Recognize acute hematological disturbances.
  • Understand the subject of transfusion thresholds and how these may differ in different patients.
  • Know how to work up the patient with a coagulopathy.
  • Understand the management of the coagulopathic patient.
  • Understand the differences between the various blood factors.
• Insert invasive hemodynamic monitoring including central venous lines, arterial lines, and pulmonary artery catheters, hemodialysis catheters.
• Initiate mechanical ventilation.
• Insert of thoracotomy tubes.
• Know intubation techniques.

• Manage the ventilated patient.
  • Know the different types of ventilators.
  • Distinguish the different ventilator modes, understand why they are different, and know the typical indications for each mode.
  • Understand the use of positive airway pressure – its indications and adverse effects.
  • Recognize the signs and symptoms of impending respiratory failure and when to intervene.
  • Know the different methods to wean from mechanical ventilation; when to start weaning and how to assess weaning failure/success.
  • Know the concept of different modes of ventilation.
  • Understand the basis for the “lung protective strategy” and the management of patients with acute lung injury.
  • Interpret the chest X-ray.
  • Interpret arterial blood gas results and acid-base disturbances.
  • Understand the concept, indications, contraindications and techniques of non-invasive ventilation.
• Manage the hemodynamically unstable patient.
  • Recognize “shock states” and inadequate tissue perfusion.
  • Assess volume status clinically.
  • Differentiate between the various causes of poor tissue perfusion.
  • Understand the indications for invasive monitoring, how to initiate these techniques, and interpret their findings.
  • Understand use, benefits and adverse effects of the various vasoactive agents.
  • Recognize the goals of therapy.
• Manage the patient with renal failure.
  • How to diagnose impending renal failure.
  • How to formulate a differential diagnosis of the cause of renal failure.
  • How to manage incipient renal failure and try to prevent overt failure.
  • Know the various forms of hemodialysis – their indications, benefits, and adverse effects.
• Understand surgical nutrition.
  • Understand when to start nutritional support.
  • Understand the benefits and adverse effects of the different routes of nutritional support.
  • Understand the benefits of the enteral as opposed to the parenteral route for nutrition.
  • Recognize the different types of feeds.
  • Know how to calculate the nutritional needs of a patient.
  • Know how to manage adverse effects of nutrition.
• Understand surgical infection.
  • Know how to work up the febrile “infected” patient.
  • Know what are the most common sources of infection in a surgical patient.
  • Know how to interpret microbiological findings.
  • Understand antibiotics – their indications and adverse effects.
  • Recognize the signs of impending sepsis.
• Manage the septic patient and provide hemodynamic support.
• Understand the management of sedation and analgesia on the ICU.
  • Recognize the goals of analgesia/sedation.
  • Understand the various techniques to provide pain relief to the ICU patient.
  • Know the sedative agents in common use — their indication, benefits and adverse effects.
• Manage the patient receiving a solid organ transplant.
  • Know the different protocols for the management of the kidney, pancreas and liver transplant.
  • Recognize the complications of organ rejection/failure and how to manage these complications.
  • Know the various immunosuppressant medications.
• Recognize the diagnosis of infection in the transplanted patient.
• Understand the importance of the prophylaxis of deep venous thrombosis.
  • Be aware of the frequency of DVTs in the surgical population.
  • Understand the different approaches to DVT prophylaxis – their indication, benefits, and adverse effects.
• Recognize acute hematological disturbances.
  • Understand the subject of transfusion thresholds and how these may differ in different patients.
  • Know how to work up the patient with a coagulopathy.
  • Understand the management of the coagulopathic patient.
  • Understand the differences between the various blood factors.
• Insert invasive hemodynamic monitoring including central venous lines, arterial lines, and pulmonary artery catheters, hemodialysis catheters.
• Initiate mechanical ventilation.
• Insert of thoracotomy tubes.
• Know intubation techniques.

• Demonstrate competency in the pre-anesthetic assessment and formulation of the anesthetic plan.
• Perform a focused assessment of the patient with neurologic pathology
• Develop and justify the anesthesia plan for neurosurgical procedure
• Identify and confirm with the surgeons the neuromonitoring techniques that will be utilized for a particular patient and neurosurgical procedure
• Demonstrate basic understanding of intracranial pressure monitoring
• Anticipate the steps necessary to place a patient in the prone, lateral, park bench or sitting position.
• Assess and manage the airway in the following situations:
  • Intracranial hypertension
  • Head injury
  • Subarachnoid hemorrhage
  • Spinal cord pathology
  • Altered mental status due to stroke
  • Neuromuscular disorders
• Monitor for, diagnose and be prepared to treat intraoperative complications such as: venous air embolism, intracranial hypertension, cerebral edema, intracerebral hemorrhage complicating an endovascular procedure, or loss of neuromonitoring signals
• Outline and perform in practice, the anesthetic management for the following procedures:
  • Lumbar and cervical laminectomy
  • Superior fossa exploration for tumor resection
  • Transsphenoidal Craniotomy
  • Ventriculoperitoneal shunt placement or revision, and placement of stereotactic frames,
  • Posterior fossa exploration
  • Cerebral aneurysm clipping
  • Resection of arteriovenous malformation
  • Carotid endarterectomy, neuroradiologic procedures (including embolization)
  • Stereotactic biopsy
  • Cervical spine injury and spinal cord injury (acute and chronic)
  • Subdural and epidural hematoma
• Safely transition the patient from OR to PACU or NICU, and give proper hand-off report
• Follow-up on patients after the surgery and assess if anesthetic management was optimal, or if not, which aspects need improvement

• Function effectively as part of a team with obstetricians, nursing staff, neonatologists and pediatricians to provide optimal medical, obstetric, and anesthetic care for patients and their fetuses/neonates.
• Know the ASA guidelines pertaining to obstetric anesthesia.
• Set up equipment expeditiously for elective and emergent cesarean section.
• Perform spinal, epidural and combined spinal-epidurals without difficulty.
• Execute simple vascular cannulations such as IV’s and arterial lines without difficulty and perform central venous and pulmonary artery catheter insertions with guidance.
• Manage anesthesia for routine obstetric cases fairly independently including placement of regional blocks for labor and elective cesarean section.
• Recognize and treat regional anesthetic complications.
• Manage anesthesia for complicated obstetric patients with guidance.
• Describe the maternal physiological changes of pregnancy as well as MAC and local anesthetic adjustments and their implications for the management of CPR in the parturient.
• Describe fetal and placental physiology as well as fetal and neonatal effects of maternally administered anesthetic drugs, fetal adaptations to hypoxia and fetal heart rate patterns during labor.
• Describe neonatal physiological adaptations to extra-uterine life and newborn resuscitation protocols.
• Describe the physiology of labor, including the stages, effects of uterine contractions on placental exchange and fetal oxygenation and the indications for and effects of labor analgesia.
• Discuss the obstetric indications for and management of urgent abdominal deliveries.
• Discuss the general principles of local anesthetic pharmacology including the treatment of systemic local anesthetic toxicity and total spinal as well as fetal and uterine effects of local anesthetics.
• Discuss the general principles of neuroaxial opioid pharmacology, including fetal and uterine effects, interactions with local anesthetics and treatment of opioid side effects.
• Describe the pain pathways involved in labor and delivery.
• Discuss the options available for maternal analgesia during labor and delivery.
• Discuss the different types of regional anesthesia and analgesia available to the parturient as well as the contraindications to and diagnosis and management of complications of regional anesthesia.
• Discuss the indications for general endotracheal anesthesia in obstetrics including ventilatory requirements, medication choices for induction and maintenance and fetal effects.
• Discuss obstetrical complications and their management including postpartum hemorrhage and maternal embolic events.
• Discuss medical diseases during pregnancy and their peri-operative management with a view towards:
  • Disease impact on pregnancy
  • How pregnancy impacts on the disease
  • Obstetric implications and management of the disease
  • Assessment of the severity of the disease and need for transfer to high risk facility
  • Anesthetic management of the patient for vaginal or cesarean delivery. In particular, the resident should be able to discuss the obstetric and anesthetic management of major systemic disease in the parturient.
• Discuss the anesthetic management of non-obstetric surgery during pregnancy including the issues of teratogenicity, preterm labor, requirements for fetal monitoring and tocolysis and choice of anesthetic technique.
• Discuss the major ethical issues involved in obstetric anesthesia practice including issues such as autonomy and maternal-fetal conflicts of interest.

• Manage mask, LMA, and intubation of children with class I and II airways
• Preoperatively assess and formulate an anesthetic plan for children of ASA 1 and 2 status.
• Show proficiency in obtaining pediatric intravenous access, including the use of central lines in older children.
• Recognize age-related equipment, especially the use of warming devices, endotracheal tubes, cuffed and uncuffed, blood pressure cuffs, oximetry and end-tidal CO2 monitoring.
• Recognize the use of drugs commonly encountered in day-to-day pediatric practice.
• Understand age-related differences in the measurement and management of acute pain.
• Know and provide basic local anesthetic techniques, especially penile, ilioinguinal and femoral nerve block and caudal anesthesia/analgesia.
• Manage common complications related to the induction, maintenance, and emergence of anesthesia in children.
• Assess and manage ASA 1 and 2 children in the recovery room, including the assessment and management of pain
• Understand of a variety of pediatric disease states including, but not limited to:
  • Prematurity
  • Apnea of prematurity
  • Bronchopulmonary dysplasia
  • Neonatal surgical emergencies including T-E fistula
  • Omphalocele
  • Gastroschisis
  • Pyloric stenosis
  • Diaphragmatic hernia and meconium ileus
  • Wilms tumor
  • Neuroblastoma
  • Lymph/hemangiomas
  • Stridor
  • Croup
  • Epiglottitis
  • Obstructive sleep apnea
  • Pediatric trauma, including open and closed head injuries
  • Anterior and posterior fossa tumors
  • Craniosynostosis
  • Leukemias
  • Anterior mediastinal masses
  • Malignant hyperthermia
  • Cerebral palsy
  • Myelomeningocele
  • Latex allergy
  • Tethered cord
    Scoliosis
  • Neurofibromatosis
  • Muscular dystrophies
  • Pierre Robin syndrome and hemifacial microsomias
  • Diabetes
  • Sickle cell trait and disease
  • Thermal injuries

• Show significant improvement in knowledge, in-depth understanding of physiology and pathophysiology, more advanced technical skills, and clinical experience in the care of patients undergoing complicated neurosurgical procedures
• Demonstrate competency in the pre-anesthetic evaluation and formulation of the anesthetic plan that requires minimal input from attending neuroanesthesia and function as a team leader developing comprehensive management plans in communication with the anesthesia faculty and surgical and nursing teams.
• Have the opportunity to provide supervision for junior residents, when appropriate, and participate in quality improvement and OR efficiency projects.
• Perform a thorough and concise preoperative evaluation of complex or critically ill patients, to include a focused neurologic exam and to identify and prioritize medical and anesthetic concerns
• Demonstrate good judgment in patient care applying neuroanesthesia principles to complex patient conditions and procedures
• Show an appreciation for recent literature in the subspecialty giving evidence-based decisions for patient care and participate in academic activity relating to neuroanesthesia resulting in a peer-reviewed publication
• Formulate an appropriate management plan for patients with acute elevations of intracranial pressure, intracranial hemorrhage, head trauma, and other complex neurosurgical conditions
• Demonstrate leadership and teamwork to safely position the patient in the prone, lateral, park bench or sitting positions
• Exhibit the ability to give a basic interpretation of x-rays, angiograms, CT, MRI and MRA scans
• Demonstrate the competency in complex airway management
• Demonstrate the ability to use and interpret complex monitoring such as EEG and evoked potential optimize hemodynamic and ventilatory parameters and provide optimal operating conditions
• Show application of neuroanesthesiology principles in the perioperative management of patients with complex neurological conditions and procedures such as:
  • Acute elevations of intracranial pressure due to intracranial hemorrhage and head trauma
  • The patient with acute ischemic or hemorrhagic stroke
  • Intracranial vascular surgery, including: cerebral aneurysms and AVMs, ECIC bypass, Encephaloduroarteriosynangiosis (EDAS) for Moyamoya disease
  • Neuroradiological procedures for aneurysms, AVMs and stroke.
  • Procedures for intractable epilepsy for seizure focus resection, vagal nerve stimulator
  • Awake craniotomy for tumor or epileptic focus resection
  • Secreting and non-secreting pituitary tumors
  • Complex spinal surgery (major spine reconstruction, spinal tumor resection), including: an understanding of neurophysiologic monitoring; the potential use of an intraoperative “wake-up” test; and developing a multi-modal perioperative analgesic plan for an opioid-dependent spine patient
  • Surgery for myelomeningocele and Arnold-Chiari malformation
  • The anesthetic for patients with movement disorders, including Parkinson’s disease, essential tremor and other indications for deep brain stimulation
  • The anesthetic of various surgical approaches for the treatment of trigeminal neuralgia or other microvascular compression syndromes, including microvascular decompression, balloon rhizotomy, and radiofrequency ablation
  • The acoustic neuroma resection
• Identify options for improving patient care, patient safety, efficiency and quality with other members of the healthcare team
• Participate in all transitions of care giving standardized reports and ensuring safe transfer of patient care
• Improve patient care; postoperative visits should be performed with documentation of anesthesiology outcomes

• Demonstrate mastery of all cognitive objectives expected of a CA-1/2 resident
• Evaluate the anesthetic implications of complex medical problems for the sickest patients.
• Perform a risk/benefit assessment of a variety of anesthetic techniques.
• Discuss the anesthetic implications of various obstetric techniques in labor and delivery.
• Teach and assist junior residents in obstetric anesthesia.
• Teach, explain and perform all relevant regional techniques.
• Demonstrate a level of technical skill requiring little or no staff assistance.
• Act as a consultant anesthesiologist for obstetric patients.
• Formulate an optimal anesthetic plan with appropriate alternatives for both routine and complex obstetric cases.
• Formulate anesthetic plans and describe techniques for all types of clinical cases, including for those with which he/she has no direct experience.
• Assess techniques and protocols used at other institutions.
• Demonstrate the ability to clearly communicate his/her knowledge to colleagues. CA-3 residents will be assigned to the more difficult cases involving patients with serious medical problems. They will be expected to teach and supervise junior residents, essentially acting in the role of junior staff anesthesiologist.