TABLE OF CONTENTS
and Dosages used at EWSH ROTATION INTRODUCTION Although the performance of procedures (intubations, line placement, etc) is an integral daily function of the practicing anesthesiologist, they represent only a fraction of the practice of anesthesia. The participant is expected to achieve knowledge and skills relevant to the practice of anesthesia beyond simply performing procedures. The participant should develop an appreciation for the anatomy, physiology and pharmacology of anesthesiology as well as an understanding of how patient variability and disease processes affect our decisions. Each OR is a highly controlled physiology laboratory and offers an ideal teaching environment. We expect this knowledge of the physiologic effects of surgery and anesthetic drugs, coupled with the procedural skills obtained and refined during the rotation, to serve you well during a long and fulfilling medical career. Physician Anesthesia Services, P.C. (PAS) is a 24 member private corporation serving EWSH for 50 years. Generally, ten anesthesiologists run 22 operating rooms on a given day. Six anesthesiologists will be in an OR and four will generally supervise two or three nurse anesthetists. Anesthetists (CRNA’s) are BS-degree nurses (or physician assistants) who have critical care experience, study for a Master of Science degree in anesthesia and pass national board exams. If you have any questions about the rotation contact Drs. Tratechaud, Krogulecki or Everett. (surgery 364-4022) ROTATION OBJECTIVES 1. Procedural Skills: Develop techniques for insertion and learn the indications for and
the complications of: arterial lines, central venous lines, pulmonary arterial catheters, intravenous lines, airway management, lumbar punctures.
a. Types of anesthetics (general, spinal, epidural, IV, regional, nerve blocks, sedation) b. Pharmacology (narcotics, hypnotics, neuromuscular blocking agents, volatile
c. Physiology (autonomic NS, hemodynamics, disease process) d. Anatomy (larynx, vasculature, nervous system) e. Disease and Anesthesia (Coronary, Cerebrovascular, IDDM, Obesity,
1. Daily attendance: (0700 to 1630) unless previously excused for a mandatory
educational requirement or personal matter.
2. Invasive Procedures: Opportunities to perform invasive procedures will vary with
case load and availability of supervision. All rotators are expected to learn the indications for invasive monitoring, demonstrate an understanding of related safety issues, and interpret invasive monitors.
3. Direct a case: At the end of the rotation, the four week rotators will develop an
anesthetic plan and execute it with minimal input from the attending anesthesiologist (subject to availability of appropriate case and one on one anesthesiologist supervision).
4. Case Presentation: Subject to appropriate case availability, the rotator will be
presented with a patient profile and will prepare a case presentation for the anesthesia staff.
5. End of Rotation Test: All rotators are expected to demonstrate reasonable
understanding of anesthetic principles on an end of rotation test that will reflect: i) Assigned reading.
ii) Basic clinical principles commonly demonstrated in the OR
iii) A test (open book) to help you review and assimilate material presented during your anesthesia rotation. Please return the completed test to the office of the Assistant Dean in the Sparrow Professional Building or to your program advisor.
6. The text, Basics of Anesthesia, will be assigned and can be checked out at the
7. All videos to be viewed, reading assignments and tests can be procured from the
PAS website as seen on the Sparrow Intranet: paspc.org
8. Rotation objectives will very by the length of the rotation. 9. All evaluations must be signed by the anesthesiologist you spent the most time
with during your rotation and returned to your program coordinator.
WEEKLY SCHEDULE Week #1: We expect that you will spend this week:
• learning your way around the surgical suites, • observing the anesthesia for many types of surgery, • learning about the anesthesia equipment, • developing an appreciation for the role of the anesthesiologist and other
• doing basic anesthesia related reading, Vaporous anesthesics, IV anesthestics,
• practicing rudimentary skills such as starting IV’s, intubating, and mask
• learning indications and complications of invasive lines.
Those rotators with us for one week will take a multiple-choice examination based on the assigned reading and experiences on Friday.
Weeks #2: You will spend more time with individual anesthesiologists following cases through from beginning to end. Pediatric exposure will increase and cases will become more complex. Those rotators with us for two weeks will take a multiple-choice open book examination based on the assigned readings and experiences. The completed test will be returned to your program coordinator. Longer rotations, continued readings, locals and regional techniques. Weeks #3: Those participants with us for a month may be invited to come in early to insert invasive lines. The knowledge you acquire from direct observation, reading assignments and lectures will begin to coalesce as you begin to appreciate the ‘big” picture. Reading: O.B. and Peds. Week #4: You will become increasingly involved in managing cases. You will interview patients, develop an anesthetic plan, give the anesthetic (as appropriate cases and supervision is available), and follow through in PACU and post-op rounds. You will also take a multiple-choice open book examination covering the rotation to be returned to your program coordinator. Sub-speciality: Neuro and Cardiovascular.
ROTATION COORDINATORS (Surgery 364-4022) Welcome to the experience of anesthesiology in a large practice that involves essentially every type of anesthesia. Although all anesthesiologists participate in your education while on rotation, the following anesthesiologists are the most involved in education administration and related questions should be directed to them: Jason Tratechaud, DO Michael G. Krogulecki, DO John Everett M.D. GETTING STARTED This may be your first day and you may have just received this introductory handout and are wondering “now what?” This rotation can be a little challenging to get into the rhythm with, so this section will give you the basics to get through your first day.
a. You should report to the OR by 0700 on the first day
a. Go to the OR suite and find the Front Desk in the Neuman Wing. The
Front Desk is the primary nursing station and is where “The Board” is located.
b. At the Front Desk, introduce yourself (a very good habit for new people in
i. Where the locker room is so you can change into scrubs
ii. Show you what locker you can use during the rotation
c. After getting into scrubs (remember your ID badge)
ii. Find the anesthesiologist who is the “board runner” for the day,
he/she will make an assignment for you with an anesthesiologist to begin your anesthesia experience.
3. Shadowing – when introduced to one of the anesthesiologists:
a. Introduce yourself b. Sign in on the white board in the OR you will be in. c. Feel free to ask questions, but be sensitive to the needs of others. d. On your first day, don’t worry too much about doing procedures, etc. Just
relax, shadow one of the anesthesiologists, observe how things work in the
OR, and familiarize yourself with the role of the anesthesiologist and associated equipment and procedures.
4. Fill out Activity Chart (also on the website)
a. See example, print from the web site and bring with you the first day of
DAILY PROTOCOL 1. You should arrive daily at 0700 and will generally leave around 1630 hrs. 2. Contact the Board Runner or one of the Rotation Coordinators for your assignment after you get into surgical scrubs. 3. You do not take call (unless you want to). 4. You will only be excused for:
a. Medical Students: Wednesday noon lecture and your Friday meetings with your Director. b. Residents: Grand Rounds, your weekly clinic, and Thursday teaching afternoon conferences.
5. Document on your Activity Chart DAILY (in the Anesthesia Office):
1) Half day on Obstetric Anesthesia Service
SYLLABUS You will receive 1 book for the rotation. The primary text is “Basics of Anesthesia” by Stoelting and Miller. The test questions at the end of the rotation come directly from the reading. The required chapters of reading depend on the length of your rotation on anesthesia. Although there appears to be an abundance of reading for one and two week rotations, these participants will almost exclusively be residents who will already have some familiarity with some of the subjects. You will be expected to view the assigned videos found on the website as early as possible in the rotation.
For those interested in Anesthesia (optional reading) Anesthesia Systems Preoperative Medication Elderly Patients Chronic Pain Management (strongly recommended if spending time at the Pain Center)
PATIENT FLOW 1. Patients (Adults) coming for surgery, from home, go to OPS (Outpatient Surgery in
the West Wing Tower) where they change into patient attire, are prescreened by nursing, have IVs placed, etc. These patients will remain in the OPS until taken directly to the OR. When interviewing the patient, this will take place in the patient’s room in the OPSU prior to their coming to the OR.
2. Peds patients are taken to the Neuman PACU 3. Same Day Surgery (SDS) patients will be admitted to the OPSU in the West Wing
and transported to the West Wing Holding Area prior to Surgery or to West PACU if blocks or invasive lines need to be done.
4. Patients (inpatients) come either to Patient Holding (located close to the Front Desk)
or to the PACU (Post Anesthesia Care Unit) if they require a preoperative procedure to ready them for their operation (there is more monitoring equipment and space in the PACU for these procedures)
A. Screened by nursing for a completed surgical consent, etc B. Seen by anesthesia to review the patient’s history/labs/studies, perform a
directed physical exam, take a directed medical history from the patient, and explain the plan of anesthesia to the patient and/or responsible adult
C. Possibly seen by the surgeon (may or may not see the patient prior to their
A. The patient has been by evaluated by all interested parties in patient
B. The OR is setup and ready for the patient C. The surgeon is available for the surgical procedure
7. After the surgical procedure, the patient is
A. Usually taken to the PACU for recovery, either Neuman or PACU West,
before going to their room in the hospital
B. Occasionally taken to an intensive care unit directly. C. If the patient will be sent home, he/she will be taken to one of the PACUs and
then returned to the OPSU, in the east end of the basemant.
D. Some Pts who have a MAC anesthetic will go directly to OPSU east.
THE BOARD 1. The Board is a large magnetic wall panel broken into 24 boxes 2. Each box represents one operating room and contains a column of magnetic stickers that summarize the scheduled operations in that OR for the day 3. At the top of each OR box is either a yellow or gold sticker which represents the anesthesia provider for that OR
A. The yellow stickers represent Anesthesiologists who are personally performing the anesthesia for that OR B. The gold stickers represent Certified Nurse Anesthetists (CRNAs) that are performing the anesthesia for that room, and are Medically Directed by an Anesthesiologist usually on a 3 to 1 basis
4. The right side of the board contains several yellow stickers with 2 to 4 OR numbers written next to them. These represent the anesthesiologists who are medically directing multiple rooms and are assigned initials. 5. ORs
A. The ORs are numbered 1 to 12, 14-23 (Room 6, 11, 13 are not used) B. Within each OR box are a column of operation magnetic stickers each of which represents a scheduled operation and lists
C. Generally, operation magnetic stickers are either blue or pink
iv. Blue stickers represent patients who are brought to the Patient Holding
area just before being brought to the OR
v. Pink stickers represent patients who are brought to the PACU in the
Neuman, West wing or PACU, because they require a special procedure (invasive lines, epidural, peripheral nerve block, etc) before going to the OR
vi. Many blocks are done in WW OPS spots 1-19.
6. The Board is very fluid and room assignments and times for operations can change according to the flow of the day
A. The Board is the only schedule that reflects these changes throughout the day
8. The other board that is available at the front desk in the Neuman wing and also in the
West Wing is a Stat Com which gives the information: where the patient is ie. In Patient room in the OPS, in the OR, in the PACU (either in the Neuman Wing for admitted patients or in the West Wing Tower). This board is kept up to date by the HUCs at the main OR desk. The STAT Com is also in the West Wing Tower as well.
ANESTHESIA DO’S AND DON’TS DO be vigilant (vigilance is the buzzword of the anesthesia profession). DO put your name on the board as soon as you enter an OR. DO introduce yourself in the holding area to every patient with whom you will work. DO use the side door to the OR (not the hallway door). DO be courteous to the nurses and scrub techs. DO always have an alternate plan of action. DON’T leave any gaps in the anesthesia chart. Fill in every blank. DON’T ever administer a paralyzing agent without first assessing the airway. DON’T ever use an unlabeled syringe. DON’T use needles (we have a needleless system). DON’T recap needles. DON’T become so transfixed on the charting or equipment that you forget to observe the pt.
ACTIVITY CHART (example)
ACTIVITY CHART MONTH: January ROTATOR: Day Attendence Airway mgmt tasks Invasive Procedures
Intubation Arterial Central Epidural Nerve
NOTES:_ January 4th afternoon: observed cardioversions and endoscopies with Dr. Kochan_______ __ Access your copy from the website ___________________________________________________________________________________
EXPLANATION FOR ABOVE SAMPLE: (actual numbers on the chart are completely theoretical and do not represent expectations)
• Mr. Mouse’s first day was January 2nd, and he has documented his attendance for his first
• On his first day (January 2nd), he observed one arterial line, one central line, and two
• On January 3rd Mr. Mouse placed his first LMA • On January 4th Mr. Mouse was able to accomplish his first intubation, and successfully
mask ventilate 3 patients. Additionally, Mr. Mouse made a special request to see some offsite procedures with Dr. Kochan which he documented under “NOTES”
• On January 10th, he took the IV class and placed his first IV • On January 12th, he placed his first arterial line Give completed sheets to the program director/mentor at end of rotation
CHECKLISTS Holding Area in the Neuman Wing or OPSU in the West Wing Tower patient room
1. Review medical history including: Indication for operation, co-existing diseases,
ALLERGIES, medications and surgical concerns.
2. Check Lab Values: Potassium, hemoglobin, B-HCG, ECG, Coagulation studies,
3. Interview the patient: ALLERGIES, Problems in the past with anesthesia? NPO
Status? Recent upper respiratory infection? Does the patient have GERD? How well controlled is the patient’s GERD.
4. Examine heart, lung, and airway (dentition, Mallampatti class, thyromental
5. Discuss the anesthetic plan with the patient. 6. Advise patient of risks of anesthesia. 7. Check status of IV lines.
Operating Room: Observe only until told otherwise
A. 2% Lidocaine: 50 mg (2.5 ml) B. Propofol 200 mg (20 ml) C. Fentanyl 100 mic (2 ml) D. Neuromuscular Blocker
E. Ephedrine: 50 mg (diluted in 5 ml saline) F. Atropine 0.4 mg (1.0 ml)
2. Check the anesthesia machine, breathing circuit, laryngoscope, and LMA,
3. Check the suction. 4. Check the IV. 5. Apply monitors (BP cuff, pulse oximeter, EKG leads) and document baseline
6. Apply pre-cordial stethoscope. 7. Circulating nurse ready and surgeon nearby. 8. Begin the anesthesia induction (only in presence of anesthesiologist)
2. Push induction agent (propofol, Etomidate, thiopental, etc)
3. Assess the airway (can you mask ventilate the patient?) 4. Ventilate the patient 5. Push the NMB agent (only after confirm can mask ventilate the patient, exception is during RSI [Rapid Sequence Induction]) 6. Administer volatile agent as indicated (ensure patient remains asleep while relaxed)
7. Tape the eyes 8. Monitor vitals frequently
11. Check breath sounds, chest movement, C02, lung compliance.
14. Insert the esophageal stethoscope (if using one)
17. Observe the incision and its physiologic effects
18. Perform appropriate charting (only after ensure patient stable and
During the Case:
1. Accurate charting of five-minute vitals 2. Monitor blood loss and urine output closely 3. Know what the surgeon is doing at all times
1. Check neuromuscular blockade (must have at least 1-2 twitches before
attempting reversal of neuromuscular blockade)
2. Administer reversal agents (usually neostigmine and glycopyrrolate) 3. Establish spontaneous ventilation 4. Remove esophageal stethoscope 5. Place bite block 6. Suction oropharynx 7. Remove eye tape 8. Extubate usually awake/occasionally asleep 9. Extubate at the end of inhalation (with full lungs) 10. Gently suction oropharynx 11. Check vital signs 12. Remove monitors and go to PACU
Arrival in the PACU:
a. Patient’s name b. Surgical procedure c. Type of anesthesia d. Significant medical history e. Problems during case f. Narcotics, anti-emetics, analgesics given g. Which analgesics are ordered for PACU
3. Monitor and document the PACU vital signs 4. Complete the anesthesia chart (anesthesia end time, anything else to complete
5. Write the PACU orders (if not done preoperatively)
MOST COMMON ANESTHETIC DRUGS AND DOSAGES USED AT EWSH Neuromuscular Blocking Agents (induction doses, not maintenance doses): Rocuronium (Zemuron) 0.6 mg/kg Pancuronium (Pavulon) 0.1 mg/kg
Succinylcholine (Anectine) 1-2 mg/kg Cisatracurium ( Nimbex) .1 mg/kg Narcotics: Fentanyl (Sublimaze) 1-2 mcg/kg [unit dose] Morphine Sulfate .05- 0.1 mg/kg [unit dose] Hydromorphone (Dilaudid) 0.5 - 2.0 mg adults Narcotic Antagonist: Naloxone (Narcan): adult 0.04-0.4 mg (usually administered 0.04 mg at a time until desired effect), kids 1 - 10 mcg/kg. Not benign, can be dangerous. Non-narcotic Analgesics: Ketorolac (Toradol) 15-30 mg IV NSAID (15 mg for elderly or chronic renal disease). Acetaminophen (Tylenol) 20-30mg/kg (max. 2 G). PO preop for kids Antiemetics: Metoclopramide (Reglan) 10-20 mg - dopamine antagonist Droperidol (lnapsine) 0.01 mg/kg – butyrophenone (requires postop ECG monitoring) Ondansetron (Zofran) 0.05 mg/kg - serotonin antagonist Decadron 0.2 mg/kg Local Anesthetics: Xylocaine (Lidocaine) - amide, local administration toxic level 4.0 mg/kg without epinephrine, 7.0 mg/kg with epinephrine
Bupivicaine (Marcaine) - amide, local administration toxic level 2.5 mg/kg without epinephrine, 3.0 mg/kg with epinephrine
Tetracaine (Pontocaine) – ester Ropivacaine 0.2 – 0.5 % less toxic than Marcaine Anticholinergics: Atropine 0.01 mg/kg Glycopyrrolate (Robinul) 0.01 mg/kg - minimal vagolytic effects Anticholinesterases: Neostigmine (Prostigmin) 0.057 mg/kg (5 mg maximum dose) Edrophonium (Tensilon) 0.5-1.0 mg/kg- fast onset but expensive (40 mg maximum dose) Hemodynamic Modulators: Epinephrine (Adrenaline) - 1.0 - 5.0 mics/min, mixed agonist Dopamine - 2 -20 mics/kg/min, mixed agonist Dobutamine (Dobutrex) 2 - 20 mics/kg/min, mixed agonist Norepinephrine (Levophed) - 2-20 mics/min, alpha agonist Nitroprusside (Nipride) - 0.5 - 8.0 mics/kg/min, vasodilator Labetalol (Trandate, Normodyne) - up to 1 mg/kg, mixed antagonist Phenylephrine (Neosynephrine) 25-200 mics/min, pure alpha agonist• Esmolol (Brevibloc) - 50-200 mics/kg/min, short acting beta antagonist at usual dosing Ephedrine 5-10 mg, indirect synthetic sympathomimetic Induction Agents: Propofol (Diprivan) 2 mg/kg bolus, 25-160 mics/kg/mm - benzyl alkaloid induction agent Etomidate (Amidate) 0.3 mg/kg imidazole induction agent - minimal cardiac effects Ketamine (Ketalar) 1-2 mg/kg - phencyclidine derivative - Sissociative Brevital 1% 1-2 mg/kg for ECT at SLH Anxiolytics: Midazolam (Versed) 1 -2 mg PO for Kids 0.5 mg/kg max 20mg for Kids Lorazepam (Ativan) 1-4 mg (rarely used in OR) Diazepam (Valium) 2-10 mg (rarely used in OR) Benzodiazepine Antagonists: Flumazenil (Romazicon) – 0.1mg-0.5 mg. Not benign, can be dangerous.
Ototoxicity Ahmad M Alamadi FRCS (Glasg), John A Rutka FRCS(C) Ototoxicity can be defined as the tendency of certain substances, either systemic or topical, to cause functional impairment and cellular damage to the tissues of the inner ear and especially to the end organs of the cochlear and vestibular divisions of the eighth cranial nerve 1 . Major systemic ototoxic substances include;
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