Goals and Objectives. Assessment Methods/Tools

Transcription

1 CA-2 CARDIOTHORACIC ANESTHESIA ROTATION Medical Center Fairview (UMMC) Rotation Site Director: Drs. Ioanna Apostolidou & Douglas Koehntop Rotation Duration: 6 weeks Introduction: The overall goal of the rotation is to provide an introduction and understanding of the perioperative management of patients undergoing a wide variety of complex cardiovascular procedures. During the rotation the resident will acquire knowledge and technical skills to practice cardiac anesthesia adults in a safe and compassionate manner. With the completion of the rotation the resident will be able to demonstrate proficiency in preoperative evaluation, intraoperative management and postoperative care including basic understanding of intraoperative transesophageal echocardiography. Due to the level residents are expected to perform at during the rotation, a senior resident will be paired up for the first two weeks of any CA-2 rotation. GOALS: o To train residents who are capable of providing high quality anesthesia care based on principles of teamwork and collaboration for cardiothoracic surgery patients o To train residents who use the bio-psychosocial model and life-long learning principles in providing high quality care to patients with cardiac and vascular pathology including preoperative assessment and preparation of patients for anesthesia, intraoperative, postoperative care and clinical management and teaching of physiologic changes related to cardiothoracic procedures. Approximate Training Level Assessment Methods/Tools OBJECTIVES (by ACGME Competency) Patient Care Clinical Skills and Reasoning: o Use of clinical skills of interviewing and physical examination to perform a thorough preoperative assessment of cardiac and major vascular patient (perception to mechanism) o Direct Observation o Simulation o Chart- review Page 1 of 8

2 o Formulates a safe anesthetic management and monitoring plan for a cardiac and major vascular patient (perception to mechanism) o Formulates a regional anesthetic plan when appropriate for the VA patient population (mechanism to complex overt response) o Formulates and discusses postoperative management plan for an cardiac and major vascular patients (perception to mechanism) o Able to interpret hemodynamic data and waveforms: systemic blood pressure, central venous pressure, pulmonary artery pressure, wedge pressure, cardiac output, mixed venous oxygen saturation, derived hemodynamic parameters (cardiac index, stroke volume, stroke volume index, systemic vascular resistance, pulmonary vascular resistance) and oxygen delivery parameters (arterial oxygen content, mixed venous oxygen content, arteriovenous oxygen content difference, pulmonary capillary oxygen content, pulmonary shunt fraction, oxygen delivery, oxygen consumption) (perception to mechanism) Technical/Device Related Skills o Prepares anesthesia work area for a complex case such as cardiac or major vascular surgery in an organized, systematic fashion (perception to complex overt response) o Sets and uses syringe pumps, intravenous pumps with drips appropriate for the patient in an organized, systematic fashion (perception to complex overt response) o Case logs o Demonstrates skill in use of rapid fluid infusing devices and blood warming devices. (perception to complex overt response) Patient Management o Performs placement of invasive monitors with minimal staff supervision: arterial, central line, pulmonary artery catheter (perception to complex overt response) o Provide safe anesthetic management for patients undergoing procedures such as coronary artery by-pass surgery, valvular surgery, heart and lung transplant, dysrhythmia, thoracic aortic and o Direct Observation o Simulation o Chart- review o Case logs Page 2 of 8

3 other major vascular surgery (perception to mechanism) o Monitor patient undergoing procedures with extracorporeal circulation (perception to mechanism) o Skillfully manages separation from cardiopulmonary bypass with minimal help (perception to mechanism) o Manages coagulation issues and blood component therapy (perception to complex overt response) o Diagnoses, monitors and treats perioperative myocardial ischemia, cardiac arrhythmia, left and right ventricular failure, acute pulmonary dysfunction (perception to mechanism) o Safely and efficiently transports and transfers care to a secondary provider (perception to complex overt response) Medical Knowledge o Discusses cardiac physiology cardiac cycle, pressure volume loops, systolic and diastolic function, preload, afterload, contractility (knowledge to application) o Discusses coronary anatomy and physiology describes coronary anatomy, determinants of coronary blood flow, pathogenesis of myocardial ischemia, determinants of myocardial oxygen supply/demand ratio, coronary steal, coronary reserve (knowledge to application) o Discusses preoperative cardiac evaluation history, medications, physical and airway examination, laboratory evaluation, CXR, EKG, stress testing, echocardiography, cardiac catheterization data (knowledge to application) o Discusses cardiovascular pharmacology, specific drug actions, indications, side effects, administration and dosage, drug interactions sympathomimetic drugs, beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors, peripheral vasodilators, antihypertensives, pulmonary vasodilators, antiarrhythmics, diuretics, thrombolytics, anticoagulants, heparin reversal agents, antifibrinolytics, miscellaneous agents such as o Introductory lecture series test o Anesthesia knowledge test o Annual in-training examination o Informal oral questioning o Simulation o Oral case presentations Page 3 of 8

4 magnesium, DDAVP, potassium (knowledge to application) o Describes anesthetic pharmacology during cardiac surgery inhalational anesthetics, intravenous anesthetics, effects of cardiopulmonary bypass on the pharmacokinetics of anesthetic drugs (knowledge to application) o Discusses anesthesia for myocardial revascularization with assessment of coronary artery disease, preoperative risk, associated disease assessment goals and choices of anesthetic management, premedication, hemodynamic monitoring, induction, maintenance, type of conduits and techniques, myocardial protection, complicatiosn, new techniques in coronary surgery, OPCAB, MIDCAB, robotic assisted cardiac surgery (knowledge to application) o Discuses anesthesia for valvular surgery aortic, mitral, tricuspid and pulmonic valve, normal anatomy, pathophysiology and indications for surgery, pressure volume loops, anesthetic considerations for each of valvular lesions, techniques of repair versus replacement and combined valve lesions, outcomes, TEE imaging, prosthetic valves (knowledge to application) o Discusses anesthesia for electrophyisologic procedures pacemaker terminology, indications for cardiac pacing, temporary pacing methods, preoperative management of a pacemaker patient, pacemaker malfunction, management of patient with cardioverterdefibrillator (AICD) (knowledge to application) o Discusses anesthesia for cardiac transplantation problems during weaning from cardiopulmonary bypass, management of right heart failure, physiology of denervated heart, anesthesia for surgical procedures after heart transplantation, outcomes (knowledge to application) o Discusses extracorporeal anesthesia membrane and bubble oxygenators, roller and centrifugal pumps, extracorporeal circuit setup, filters, hemoconcentration, safety measures, blood and artifical surface interactions, perfusion solutions, hemodilution, safety measures, blood and artificial surface interactions, perfusion Page 4 of 8

5 solutions, hemodilution, venous reservoir, blood gas control (phstat, alpha-stat), manipulation of flow, pressure, temperature, cannulation sites, cardioplegia, crystalloid versus blood, routes of cardioplegia (knowledge to application) - hemodynamic management during CPB, monitoring, pharmacology of drugs, metabolic and fluid management, blood pressure management, prevention of intraoperative awareness - management and brain protection during total hypothermic circulatory arrest - management of rare diseases affecting CPB such as heparin induced thrombocytopenia, antithrombin III deficiency, sickle cell disease or trait, cold hemagglutinin disease, cold urticaria, malignant hypothermia, hereditary angioedema, pregnancy -initiating and weaning from CBP sequence of events -myocardial protection during CPB -temperature management (knowledge to application) o Discusses management of coagulation during and after CPB, blood component therapy physiology, coagulation tests, heparin anticoagulation, monitoring, neutralization with protamine, heparin induced thrombocytopenia, differential diagnosis and management of CPB hemostatic disorders, blood component therapy, blood conservation techniques, indications for transfusion, (knowledge to application) o Discusses postoperative management of cardiac patients fast-track surgery, glycemic control, complications of cardiac surgery, reoperation for bleeding, pain management (knowledge to application) o Discusses anesthesia for thoracic aortic disease aortic dissection, classifications, thoracic aneurysm, coarctation of aorta, partial bypass techniques, CNS protection, spinal cord protection, deep hypothermic circulatory arrest (knowledge to application) o Discusses anesthesia for major vascular surgery pathophysiology Page 5 of 8

6 for major vascular disease, preoperative evaluation, risk assessment and risk reduction, anesthesia for carotid endarterectomy (general versus regional anesthesia, intraoperative blood pressure management, monitoring of cerebral perfusion, postoperative complications), abdominal aortic reconstruction, endovascular abdominal aortic aneurysm repair (knowledge to application) o Discusses anesthesia for cardiac tumors, pericardial disease, pulmonary embolism, cardiac trauma (knowledge to application) Practice Based Learning and Improvement o Identify own learning deficits, develop a learning plan and carry it out (receiving to valuing) o Respond appropriately to constructive feedback (receiving to o Immediate formative feedback from attending valuing) o Demonstrate ability to effectively search for literature (perception to o Direct observation o Journal club complex overt response) presentations and o Read, analyze and interpret the scientific literature case presentations o Analyze own practice and determine ways in which you can improve your comprehensive anesthetic plan (analysis, valuing) Interpersonal and Communication Skills o Use of effective listening, questioning, and explanatory skills in gathering information from patients and in providing information to patients, families, the public, and other health care providers (receiving to valuing) o Effectively and efficiently communicates pertinent patient information to a secondary care provider (resident to obstetric or PACU nurse) (receiving to valuing) o Skill in working as a member of a patient care team including other physicians, nurses, perfusionist, other health care professionals, social workers, and volunteers (receiving to valuing) o Maintain comprehensive, timely, and legible medical records o Direct observation with patient o Direct observation in simulation o 360 global rating o Learner classroom presentation Page 6 of 8

7 (receiving to valuing) Professionalism o Awareness and management of his/her own values and attitudes, which might interfere with appropriate patient care specific to management of cardiac and vascular patient (receiving to valuing) o Responsiveness to and management of issues that relate to sociocultural aspects of family life, and social adjustment related to ethnicity, religion, culture, gender or sexual preference (receiving to valuing) o Consistent compassion, honesty, integrity and respect for others in all professional activities (receiving to valuing) System Based Practice o direct observation o 360 o Work in inter-professional teams to increase patient safety and quality of care (perception to complex overt response) o Coordinate patient care in the settings of cardiac surgery (perception o direct observation o 360 o M&M conference to complex overt response) o Discuss system-based problems as they pertain to patient care at M&M conferences (knowledge to analysis) presentation with system analysis Page 7 of 8

8 Scholarly/Research Activities Reading Requirements The resident should read the following chapters while taking the rotation: Text: Chapters: 1. CARDIAC ANESTHESIA by Kaplan 4th edition (there is a copy in the library) 2. PRACTICAL APPROACH TO CARDIAC ANESTHESIA by Hensley 3 rd edition 3. CARDIAC ANESTHESIA by Estefanous, Barash and Reves 2 nd edition Suggested Readings 1. Manual of Cardiac Anesthesia by Thomas and Kramer 2 nd edition 2. Pediatric Cardiac Anesthesia by Lake 4th edition 3. Textbook of Cardiothoracic Anesthesiology by Thys 1 st edition 4. Anesthesia for Congenital Heart Disease by Andropoulos, Stayer and Russel 1 st edition 5. Cardiopulmonary bypass: Principles and Practice by Gravlee 2 nd edition 6. Atlas of cardiovascular monitoring by Jonathan B. Mark Assessments The resident will receive a summative written evaluation form at the end of the rotation from the Site Director, as well as verbal feedback informally throughout the rotation. The case-logs of the resident will also be evaluated periodically by the clinical competency committee for the number and type of procedures and anesthetic techniques entered to ensure they are obtaining adequate experience. Notes Page 8 of 8