department of anesthesia and Perioperative medicine

MSIII Anesthesia Selective Outline

I     Preanesthetic Evaluation
      A     The student shall acquire an appreciation of the Anesthesiologist's considerations in preoperative evaluation of the patient.  This is demonstrated by:
               1     Conduction several preanesthetic assessments, including
                      a     Taking and recording a pertinent history
                              i     Must turn in 2 Case Planning reports
                      b     Performing an appropriate physical examination, including assessment of:
                              i     airway – Miller Ch. 12
                              ii    cardiovascular system – Bates Ch. 8
                              iii    respiratory system – Bates Ch. 9
                              iv   other systems as indicated
                      c     Reviewing pertinent laboratory data
                      d     Assigning appropriate ASA physical status – Miller Ch. 9
               2     Discussing how the following factors may influence the patient's course during the perioperative period: 
                     (Sample case discussions in OR)
                      a     Age
                      b     Nature of surgery, including minor versus major, peripheral versus central, and elective versus emergent
                      c     Cardiovascular disorders, including but not limited to:
                                  coronary insufficiency
                                  hypertension
                                  myocardial failure
                                  dysrhythmias
                      d     Respiratory disorders
                                  known or suspected difficult intubation
                                  upper and/or lower respiratory infection
                                  asthma
                                  chronic obstructive pulmonary disease
                                  lab work-up
                      e     Central nervous system disorders
                                  increased intracranial pressure
                                  convulsive disorders
                                  cerebrovascular insufficiency
                                  quadriplegia or paraplegia
                      f     Gastrointestinal disorders
                                  pulmonary aspiration risks
                                  hiatal hernia/gastro-esophageal reflux/full stomach
                                  functional or mechanical bowel obstructions
                                  hepatitis, hepatic insufficiency, portal hypertension
                      g     Renal insufficiency and electrolyte abnormalities
                      h     Hematologic disorders
                                  anemias
                                  coagulopathies
                                  hemoglobinopathies
                      i     Personal or family history of unusual response to anesthesia
                                  malignant hyperthermia susceptibility
                                  abnormal succinylcholine metabolism
                      j     Lifestyle factors
                                  obesity
                                  substance abuse - tobacco, alcohol, chemicals
                      k     Pregnancy
                                  concomitant surgery
                                  pre-eclampsia and eclampsia
               3     Discussing medication histories and the influence of chronic and current medications on the perianesthtic period, including:
                      a     Which drugs should be discontinued and why
                             Do monoamine oxidase inhibitors pose a potential danger?
                             The rebound phenomena resulting from abrupt discontinuation of some classes of drugs, notably beta blockers, and clonidine
                      b     Approaches to perioperative management of patients taking insulin or anticoagulants
                      c     Do they affect MAC?

II    Preoperative Medication (Fill out Drug Chart)
      A       The student shall demonstrate knowledge of the objectives of effective preanesthesia medication by naming and discussing drugs used for:  
               1     Relief of anxiety
               2     Sedation
               3     Amnesia
               4     Analgesia
               5     Drying secretions
               6     Reducing gastric acidity and volume
      B       The student shall demonstrate knowledge of the basic pharmacology and pharmacokinetics of the following premedication agents, including dosage schedules and relative and absolute contraindications:
               1     Narcotics
                      a     Morphine
                      b     Meperidine
                      c     Others
               2     Sedatives
                      a     Benzodiazepines: Midazolam
                      b     Antihistamines: Benadryl
                      c     Barbiturates: Thiopental
                      d     alpha-2 agonists: Dexmedetomidine
               3     Anticholinergics
                      a     Atropine
               4     Drugs used to reduce the incidence or consequences of pulmonary aspiration
                      a     H2 antagonists
                      b     Antacids
      C       NPO guidelines: 
               1      Fasting periods (assuming no risk for increased gastric emptying time)
                      a     Adults
                             2 hours clear liquids
                             6 hours for solids
                      b     Pediatrics
                             2 hours clear liquids
                             4 hours breast milk
                             6 hours formula, non human milk, solids
                             8 hours or more for full meal
               2     Definition of clear liquids
                             Water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee

III   The Operating Room
      A      The student will demonstrate knowledge of procedures and observe induction of
Anesthesia:
               1     Identify several agents used on induction of general anesthesia and give their advantages and disadvantages: (fill out drug chart)
                      a     Intravenous agents
                      b     Inhalation agents
                      c     Neuromuscular blocking agents
               2     Discuss emergency intubations, indications, techniques, and complications; concentrate on aspiration prophylaxis
               3     Observe and practice airway management during several uncomplicated intravenous inductions
      B       The student will demonstrate proper airway and ventilatory management by:
               (see articles on airway management and chapter in Miller)
               1     Describing the indications, risks and benefits of airway management by mask versus intubation versus laryngeal mask airway (LMA)
               2     Describing and identifying basic oropharyngeal and laryngotracheal anatomy
               3     Identifying and overcoming upper airway obstruction with mask ventilation, using
                      a     Various masks
                      b     Jaw thrust
                      c     Nasopharyngeal airway
                      d     Oropharyngeal airway
               4     Naming several techniques of intubation and practicing direct laryngoscopy
               5     Understanding principles of airway complications and difficult airway management.
      C       In order to demonstrate understanding of the principles and practice of routine intraoperative monitoring, the student will: (Questions for OR discussions)
               1     Explain and demonstrate ECG lead placement and selection to optimize detection of dysrhythmias and ischemia
               2     Indications and risks for invasive methods for monitoring blood pressure
               3     Demonstrate results of arterial blood gas analysis in terms of: (acid-base article)
                      a     Oxyhemoglobin dissociation curve
                      b     Acid-base status
      D       Student will prescribe and conduct appropriate intraoperative electrolyte and fluid therapy with the guidance of his instructor by:
               1     Explaining the rationales for establishing both central and peripheral venous access
               2     Identifying the common sites for venous access and the contraindications and indications for each
               3     Demonstrating skill at establishing venous access by:
                      a     Using sterile technique and universal precautions
                      b     Successfully inserting several peripheral catheters of various calibers
                      c     Protecting the venipuncture site and immobilizing the catheter
               4     Prescribing maintenance fluid and blood transfusion:
                      a     Predicting how the following preoperative conditions will alter requirements for perioperative maintenance therapy:
                            1     NPO (adults and children)
                            2     Bowel prep
                            3     NG suction
                            4     Fever
                      b     Discussing intraoperative considerations which after maintenance fluid and electrolyte therapy including:                     
                            1     Blood loss
                            2     "Third space" loss
                            3     Temperature
                      c     Correctly interpreting data from the following monitors of volume status:
                            1     Examination of the patient
                            2     Pulse and blood pressure
                            3     Urine output
                            4     CVP
                            5     PCWP
                      d     Discussing indications, risks and benefits of crystalloid, colloid and blood product replacement therapies:
                            1     Regarding the functions of:
                                   blood volume
                                   oxygen carrying capacity
                                   coagulation
                            2     Regarding complications of each type of therapy
      E       The student shall identify several position-related injuries that patients may sustain while unconscious
      F       The student will discuss methods of recognizing and treating various perioperative problems, including: (see Questions/Scenarios)
               1     Dysrhythmias
               2     Ventricular dysfunction
               3     Hypertension
               4     Myocardial ischemia
               5     Low oxygen saturation
               6     Hypercarbia
               7     Endobronchial intubation
               8     Esophageal intubation

IV   Neuraxial/Regional Anesthesia
      A       The student will demonstrate knowledge of local anesthetic pharmacology appropriate to the practice of general medicine by:
               1     Classifying commonly used agents according to amide or ester linkage
               2     Listing commonly used local anesthetics for: (Miller Ch. 7)
                      a     Topical use
                      b     Local infiltration
                      c     Peripheral nerve blocks
               3     Listing acceptable doses of at least two agents used for topical and local infiltration anesthesia
               4     Describing and identifying signs of impending local anesthetic and/or vasopressor toxicity vs. "allergic reaction"
               5     Describing therapeutic steps necessary to prevent or treat local anesthetic toxicity in the event of an accidental intravascular injection
               6     Discussing allergic reactions to local anesthetics
               7     Contrasting allergic reactions to systemic and/or toxic reactions in local anesthetics
               8     Have a basic understanding of neuraxial/regional techniques and rationale for use (Miller Ch 13-14)

V    Post operative pain management
      A       The student will demonstrate knowledge of the different types of pain management, including:
               1     PCA
               2     Epidural catheters
               3     Prn vs round-the clock dosing
               4     PO medications
                      a    Narcotics
                      b    Acetaminophen w/wo codeine
                      c    Ketorolac
                      d    N-SAIDS
      B       The student will demonstrate knowledge of assessing post-op pain
               1     Pain scales
               2     Visual analog scales

VI   Post Operative nausea and vomiting (PONV)
       
A       The student will demonstrate knowledge of current PONV management.

VII  The student should successfully complete basic CPR and ACLS training during medical school.