PROGRAM REQUIREMENTS FOR ADVANCED TRAINING IN Perioperative Neuroscience NEUROANESTHESIOLOGY

1 2 3 4 5 PROGRAM REQUIREMENTS FOR ADVANCED TRAINING IN Perioperative Neuroscience NEUROANESTHESIOLOGY 6 7 Mar 7, 2019 8 9 Table of Contents 10 11 I. INTRODUCTION 12 II. DEFINITION AND SCOPE OF EDUCATION 13 III. INSTITUTIONAL REQUIREMENTS 14 IV. PROGRAM PERSONNEL AND RESPONSIBILITIES 15 V. RESOURCES 16 VI. FELLOW APPOINTMENTS 17 VII. EDUCATIONAL PROGRAM 18 VIII. DESCRIPTION OF FELLOWSHIP ROTATIONS 19 1

20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 INTRODUCTION (back) Residency and fellowship programs are essential dimensions of the transformation of the medical student to independent practitioner as they begin the life-long continuum of medical education. This life-long educational process is physically, emotionally, and intellectually demanding, and requires longitudinally-concentrated effort. The specialty education of physicians to practice independently is largely experiential, and necessarily occurs within the context of the health care delivery system. Developing the skills, knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires the physician fellow to assume personal responsibility for the care of individual patients. For the fellow, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context, and meaning to those interactions. As fellows gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater independence based on capability to synthesize knowledge into a given patient context. This concept - graded and progressive responsibility - is one of the core tenets of graduate medical education. Supervision in the setting of graduate medical education assures patients safe and effective care. This supervision also assures the fellow expands their skills, knowledge, and attitudes as required to independently practice of neuroanesthesia and all related fields. They are prepared to become outstanding clinicians, educators and researchers, and instills in them the commitment to lifelong professional growth. Fellowship furthers this process by the development of in-depth knowledge in a specific area of anesthesiology beyond that acquired in specialty training. Fellows must also develop a level of subspecialty synthetic knowledge base to enable them to be leaders in their respective clinical and academic departments. ICPNT is concerned with all facets of perioperative neuroscience training. This document lays out minimum standards for fellowship training and program accreditation in neuroanesthesiology Description of Terms Accreditation: The status of a program indicating it has undergone an evaluation process resulting in recognition of meeting ICPNT- preset criteria for conducting a standardized training experience which facilitates attainment of ICPNT- defined competencies. 2

45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 Case Credit: In determining the experience of a fellow, credit for case participation, indicated in the summative evaluation transcript, is warranted when the fellow is significantly involved in the cognitive aspects of the anesthetic plan and conduct of anesthesia, and participates in the critical portion or portions of a procedure. Competency: An element of expertise indicating that a fellow has sufficient familiarity with a topic, concept, or procedure to be able to safely perform or deliver that specific competency in the course of being a neuroanesthesiologist. Core Faculty: Individuals identified by the program director who meet the qualification criteria identified by ICPNT in neuroanesthesiology, have a role in training and evaluating the candidates within a program. They may also be called core attending physicians or core consultants according to the vernacular of the local institution. Fellow: An individual who is a trainee in a fellowship program. In this capacity the fellow, who otherwise can conduct an anesthetic independently may be granted varying degrees of autonomy as judged appropriate by the program director. In situations of an enfolded (in-residency) fellowship, wherein the fellow will not have been fully trained in anesthesiology, it would be expected that supervision will be consistent with the fellow s level of experience. Fellowship: A post-graduate subspecialty training experience acquired during or after specialty training in anesthesiology. Fellowships are a minimum of one year in duration, but may be longer as determined by the requirements of the individual program, and qualifications and career goals of the trainee regarding the body of knowledge and the skills to be learned. Fully trained anesthesiologist: A physician who has successfully completed a post medical school training experience in anesthesiology consistent with the duration and demonstrated competencies as defined by the region or country where it is performed and who can practice anesthesiology independently. A minimum of two years of clinical anesthesiology training is expected for purposes of enrollment in an ICPNT accredited fellowship. 3

69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 Graduate training or education: Training provided after graduation from medical school. It can encompass residency or fellowship types of training. Program Director: The person in a sub-specialty leadership position among the core faculty responsible for ensuring subspecialty trainee candidates to successfully achieve curriculum-defined competencies in an ICPNT accredited program before graduating. Residency: A post medical school specialty training program. In anesthesiology, a residency duration will be as mandated by the region or country where it is performed. Subspecialty program: An academic setting within a clinical environment, comprising of teaching faculty, with appropriate staff support and facilities, which altogether delivers a curriculum to train subspecialists within a defined time period Synthetic Knowledge: Synthesizing (based on Bloom s taxonomy) involves building a structure or pattern from diverse elements of perioperative neurosciences which is accepted within the framework of the ICPNT; it also refers to the act of putting parts together to form a whole. Its characteristics include: production of a unique communication, production of a plan, or proposed set of operations, derivation of a set of abstract relations all related to combining and integrating a diverse combination of clinical and basic neurosciences knowledge relevant to neuroanesthesiology. Achieving synthetic knowledge is the goal of a fellowship which differentiates the neuroanesthesiology training experience from that acquired during residency. 89 4

90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 I. DEFINITION AND SCOPE OF EDUCATION (back) A. Definition of Neuroanesthesiology Neuroanesthesiology is the subspecialty of anesthesiology devoted to the comprehensive anesthetic and perioperative management of patients undergoing surgical and interventional neuroradiology procedures on the central and peripheral nervous systems. Neuroanesthesiologists can be involved in the overall care of neurosurgery and neuroradiology patients as well as patients with neurological disease who are undergoing any surgical procedure that places any component of the nervous system at risk; and are likely to be more involved in such patients as healthcare evolves. The most unique area of knowledge is in the area of providing support for patients undergoing neurosurgical and neuroradiology procedures. This entails developing a pharmacologic paradigm which provides hypnosis, analgesia, immobility, and physiologic stability with appropriate systemic and neurologic monitoring, while also providing a milieu which most optimally supports central nervous system physiology and neurochemistry during and after neurosurgery and interventional neuroradiology procedures. This also entails providing optimal management of medical and neurological comorbid conditions which may be important to an optimal outcome after the procedure. Another unique area of knowledge has to do with the neuropharmacology of anesthetic drugs used for neurosurgery and other surgical procedures. This area delves into mechanisms of anesthetic actions, potential neuroprotective and neurotoxic effects of anesthetics, interactions of anesthetic and non-anesthetic drugs with the pathophysiology of neurosurgical problems as affected by the procedural intervention and other intra-procedure physiologic aberrations. Neuroanesthesiology is not just focused on intraoperative issues. Indeed, reforms in health care worldwide are supporting increasing involvement of anesthesiologists in the perioperative continuum. Thus, neuroanesthesiologists are expected to be involved in activities which will include perioperative and neurocritical care assessment and management of neurosurgical and neuroradiological patients. 5

115 116 117 118 119 120 121 122 123 124 125 Neuroanesthesiology also involves an understanding of issues in perioperative neuromonitoring. Given that the anesthetic paradigm used for a given patient can significantly impact the data obtained from intraoperative neuromonitoring, this is an important and essential body of knowledge unique to neuroanesthesiology. As such there is overlap with the growing discipline of perioperative neuromonitoring. B. Duration and Scope of Training The minimum length of total neuroanesthesiology fellowship training is 12 months of which 10 months should be supervised clinical training. This minimum length of supervised clinical training should be covered in a maximum length of 24 months of clinical patient care, which may be discontinuous and interspersed with academic time to permit research or other nonclinical academic pursuits as a component of the overall fellowship experience. 126 6

127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 II. INSTITUTIONAL REQUIREMENTS (back) A. Sponsoring Programs 1. Sponsoring Institution A single sponsoring institution must assume ultimate responsibility for the program, and this responsibility extends to fellow assignments at all participating sites within the sponsoring institution. a. The sponsoring institution and the fellowship program must ensure that the program director has sufficient protected time and financial support for their educational and administrative responsibilities to the program. b. It is recommended that the sponsoring institution also sponsor an accredited (according to regional standards) residency program in anesthesiology. 2. Participating Sites There must be a program letter of agreement (PLA) or equivalent between the program and each participating clinical site providing a required experience. The PLA must be renewed at least every five years. The PLA should: a. Identify the faculty who will assume both educational and supervisory responsibilities for fellows. b. Specify their responsibilities for teaching, supervision, and formal evaluation of fellows, as specified later in this document. c. Specify the duration and content of the educational experience. d. State the policies and procedures that will govern fellow education during the assignment. e. Identify the institutional official who oversees the selected program director 145 7

146 147 148 149 150 151 B. Setting The setting for a neuroanesthesiology educational program must encompass a clinical program which includes the operating suite, post anesthesia care area, interventional radiology suite, surgical critical care/therapy unit or neurological critical care/therapy unit, and perioperative neuromonitoring. This education may take place in various settings that provide for the care of critically and neurologically ill adult and pediatric surgical patients, including those with traumatic injuries, cerebrovascular insults, neuro-oncologic/infectious disorders, status epilepticus, neuromuscular, and spine and spinal cord disorders 152 153 154 155 156 157 158 C. Procedure Sites and Intensive Care Unit Beds The institution must have operating suite and interventional radiology facilities sufficient to support performance of the numbers of procedures needed to fulfill the fellowship requirements. In addition, the institution must have a Neurologic/Neurosurgical Intensive Care Unit or dedicated beds in a general ICU devoted to neurological and neurosurgical conditions and patients. In institutions where all required sites to give experience to any of the mentioned educational and clinical cases are not available, the program should facilitate external rotations in an alternate academic program. These alternate facilities and their associated faculty should be listed in the application for accreditation for preapproval. 159 160 8

161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 III. PROGRAM PERSONNEL AND RESPONSIBILITIES (back) A. Program Director 1. Qualifications of the program director: a. Requisite specialty expertise and documented educational and administrative experience. This optimally includes completion of anesthesiology training and three years of experience in clinical and academic neuroanesthesiology. 1. Such experience may take varied forms but should include involvement in the clinical practice of neuroanesthesiology and supporting academic (educational or research) work. 2. The program director s qualifications should reflect dedication to education and capability and knowledge in relevant educational methods 3. The program director should be willing and able to provide mentoring. b. Current certification in anesthesiology, as available, in the region of the fellowship c. Current medical licensure and appropriate institutional medical staff appointment as appropriate for the geographical locale of the fellowship program. Current appointment as a member of the anesthesiology faculty devoting a significant part of their clinical time (which can include academic and administrative effort) to neuroanesthesiology. d. Demonstrated ongoing academic achievements over the prior ten years in at least one of the following: 1. Publications 2. The development of educational curriculums 3. Significant involvement in neuroanesthesia educational efforts directed to residents 4. Invitations to deliver regional, national, or international educational lectures and seminars relevant to neuroanesthesiology, or; 9

182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 5. The conduct of research e. A member in good standing of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC). This is deemed important to foster communications between and among program directors and ICPNT, which is administratively in SNACC. Facility to communicate in English is an expected attribute of the program director. 2. Program Director Responsibilities The program director must administer and maintain an educational environment conducive to educating the fellows in each of the delineated competency areas. The program director shall: a. Prepare and submit all information required and requested by the ICPNT b. Be familiar with and oversee compliance with ICPNT policies and procedures, available on the ICPNT web page c. Obtain review and approval of the sponsoring institution s general medical office or Designated Institutional Official, or equivalent local institutional oversight official (which may be the chair or head of anesthesiology or local equivalent), before submitting to the ICPNT information or requests for the following: 1. Applications for ICPNT accreditation of new programs; 2. Major changes in program structure outlined in original application; 3. Fellowship program citations, and responses to all proposed adverse actions regarding the fellowship program; 4. Voluntary withdrawal as a ICPNT-accredited program; 5. Requests for appeal of an adverse action regarding the fellowship program. 198 10

199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 d. Coordinate supervision policy with the residency program director that specifies the lines of responsibility for the anesthesiology residents or other direct providers and the neuroanesthesiology fellows. e. Organize a formal and transparent selection process for neuroanesthesiology fellows and complete all necessary institutional and ICPNT requirements for documentation of selection and recruitment f. Based on ICPNT guidelines as an educational template, maintain a written outline of the educational goals of the program with respect to the knowledge, skills, and other attributes of fellows at each level of education, and for each major rotation or other program assignment. g. Provide for appropriate clinical supervision / guidance to the fellows h. Regularly organize teaching and academic activities for the fellows such as journal clubs, case conferences, morbidity and mortality meetings, continuous quality improvement activities, didactic conferences, webinars (or other internet based educational opportunities), and research conferences i. Implement a formal evaluation process documenting satisfactory accomplishment of educational goals and objectives; and provide periodic feedback and evaluation to the fellows j. Monitor and document work-hours of the fellows and ensure that the institutional work-hour policy is followed k. Provide mentorship and career guidance to the fellows l. Certify and document successful completion of fellowship by fellows. m. Maintain up to date records of all fellowship activities. Maintain a transcript of successful fellowship rotations and case numbers and forward to ICPNT at the conclusion of a successful fellowship. n. Report to ICPNT any unsuccessful completion, program withdrawal or termination of fellowship. Documentation of the 11

218 219 220 221 222 223 basis for each should be provided o. Upon successful completion of the fellowship provide to the graduating fellow an institutional certificate of completion of the fellowship. As allowed by institutional protocols the certificate should indicate that the completed fellowship was accredited by the International Council on Perioperative Neuroscience Training of the Society for Neuroscience in Anesthesiology and Critical Care. Upon notification of successful completion of the fellowship by the program director ICPNT will also issue a certificate indicating that the successfully completed fellowship was accredited by the ICPNT. 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 B. Core Faculty a. A neuroanesthesiology fellowship training program should have dedicated faculty for mentoring, training, providing feedback, and evaluating performance of the trainees. b. There must be at least two core faculty members (including the program director) with documented qualifications to instruct and supervise all fellows. c. The neuroanesthesiology training program core faculty should have the following qualifications: 1. The core physician faculty must possess current medical licensure as appropriate to the geographic region and possess appropriate institutional medical staff appointment. 2. The core physician faculty must have current certification in anesthesiology as regionally required or possess other acceptable qualifications or experience that allows the practice of anesthesiology. 3. The core physician faculty must have neuroanesthesiology, Neurocritical Care, or Neuromonitoring fellowship education or significant experience, secondary certification (or completed training) in Neurology or Neurosurgery, or at least 3 years of post-residency experience in respective subspecialties with a significant portion of their practice (or academic time) directed towards patients with neurological diseases. 12

239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 C. Ancillary Faculty 4. The core faculty physician must have a current appointment as a member of the academic anesthesiology faculty 5. The core physician faculty should be academically productive in a fashion relevant to neuroanesthesiology with at least one of the following: publications, educational experience, documented educational activities, or the conduct of research. 6. The core physician faculty should be appointed by the program director. 7. It is recommended that the core faculty be members in good standing of a professional neuroscience-oriented organization or interest group a. The ancillary faculty must devote sufficient time to the educational program to meet the supervisory and teaching responsibilities required by the neuroanesthesiology program director and demonstrate a strong interest in the education of neuroanesthesiology fellows. b. Ancillary faculty will be responsible to teach, supervise, and provide formal feedback and evaluations of fellows c. Ancillary faculty must participate in the program s didactic educational program d. This faculty must participate in the formal and transparent selection process for neuroanesthesiology fellows as desired by the program director e. Ancillary faculty must be familiar with and must contribute to the review and /or revision of the educational goals of the program as desired by the program director f. Ancillary faculty must be willing to supervise/organize/educate any fellow including develop a rotation for the fellowship for which they are appropriately experienced and as requested by the program director 259 13

260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 D. Adjunct Faculty a. In addition to the core faculty who are mainly neuroanesthesiologists, faculty from other subspecialty training programs (such as neurological intensive care, pediatric anesthesiology, neurosurgery, neurology, pain management, interventional neuroradiology neuroscience research or other expertise relevant to neuroanesthesia practice) will also be involved in training and evaluation of fellows as determined by the program director. The professional qualifications of these external adjunct faculty need to be approved by the program director and included in the fellowship program accreditation application. These faculties may include: 1. Physician faculty who do not fulfill qualifications for core neuroansthesiology faculty but who possess significant experience in Perioperative Neurosciences (neuroanesthesiology, pediatric neuroanesthesiology, intraoperative neuromonitoring, Neurocritical care, neurosurgery, neurology, neuroradiology or neuroscience research, etc.). They may also serve as fellowship core faculty and supervise one or more fellowship rotations on the request of the program director. 2. Noncore neuroscientist faculty- faculty who are not clinicians and do not fulfill qualifications for core faculty but with significant experience in clinical or basic neuroscience may also serve as fellowship faculty and supervise one or more fellowship rotations on the request of the program director. 3. Non-physician program personnel qualified technicians (e.g. perioperative neuromonitoring technicians, transcranial Doppler sonographers, and research staff), advanced practice medical professionals may contribute to the training of the neuroanesthesiology fellows. b. Qualifications of the non-physician faculty are as follows: 1. Non-physician faculty must be appropriately qualified in their fields. 2. Non-physician faculty must possess appropriate institutional appointments and licensure as required by the institution and regional laws and regulations. 14

283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 E. Administrative Personnel A well-functioning program requires administrative support in the form of sufficient appropriately equipped and supplied personnel to enable performance of support functions such as scheduling, organizing educational events, and reporting activities and educational statistics to ICPNT. IV. Resources (back) A. The institution and the program must jointly ensure the availability of all necessary professional, technical, and clerical personnel for the effective administration of the program B. There must be operating suites designed and equipped for the management of complex neurosurgical patients C. There must be a Neurocritical care service with specialized nursing for Neurocritical care which may be a component of a general intensive care (or therapy) unit D. There must be dedicated Neuroradiological services capable of performing CT scanning, MRI, Neuroangiography, and interventional neuroradiology procedures E. Intraoperative Neuromonitoring services are a desired but not required attribute. When not locally available there should be wherewithal to gain exposure to such services elsewhere at the discretion of the program director 15

306 307 308 309 310 311 312 F. There must be prompt access to consultation with other disciplines, including cardiology, critical care medicine, emergency medicine, neurology, pulmonology, laboratory medicine and surgical fields. There must be allied health staff and other support personnel necessary for the comprehensive care of patients with acute neurological illness G. Medical Information Access. Fellows, faculty, and staff must have ready access to specialty-specific and other appropriate reference material in print or electronic format. Internet-based medical literature databases with search capabilities and institutional access to research publications should be available 313 16

314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 V. Fellow Appointments (back) A. Eligibility Criteria. Each fellow must a. Be eligible for a medical license (full and independent, training, or institutional) as required by law and applicable to the institution(s) participating in the fellowship program. b. Have successfully completed an accredited (as customarily defined in the relevant region) Anesthesiology residency, or c. For an enfolded (during residency) fellowship, be a resident in good standing in an accredited residency program (as customarily defined in the relevant region) and having completed at least two years of clinical anesthesiology residency; and an expectation of completion of residency training after completion of the fellowship 1. The program must document that each fellow has met the eligibility criteria. 2. The program must adhere to Code of Ethics and Professional Conduct of the World Health Organization relating to non-discrimination in selection of fellows (http://www.who.int/about/ethics/code_of_ethics_full_version.pdf ) B. Number of Fellows The program s educational resources must be adequate to support the number of fellows appointed to the program. The number of fellows cannot exceed the number of core faculty. The presence of other learners or staff members must not interfere with the appointed fellows education. A fellowship program without enrolled fellows can be accredited. 17

336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 VI. Educational Program (back) A. Competencies: The program must integrate the following competencies into the curriculum: a. Patient Care and Procedural Skills. Fellows must be able to provide safe, effective, evidence-based patient care that is compassionate and appropriate. Under the direction of faculty member s fellows must demonstrate: 1. The ability to provide clinical consultation for neurosurgical and neuroradiology patients, including assessment of the appropriateness of a patient s preparation for surgery / interventional neuroradiology 2. The ability to provide clinical consultation for non-neurosurgical patients with neurological diseases, regarding assessment of the appropriateness of a patient s preparation and clinical management and monitoring for nonneurological surgery or interventional radiology. 3. Competence in patient management and peri-operative care of neurological patients for neurosurgery or interventional neuroradiology. 4. Capability to independently execute all procedures relating to the area of neuroanesthesiology performed in the region of practice. Recommended procedures include: i. Intra arterial cannulation ii. Central venous cannulation iii. Processed EEG iv. Precordial Doppler v. Scalp blocks vi. Advanced airway management for unstable or immobile c-spine includes fiberoptic, video laryngoscopic intubations and LMA techniques as well as administration of appropriate sedation or 18

360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 anesthesia. 5. Competence in the comprehensive anesthetic management of patients undergoing neurosurgical or neuroradiology procedures (as specifically delineated in the fellowship modules). This must include: i. Pre-operative assessment, optimization and risk stratification. Obtaining the appropriate diagnostic testing and consultation and communication with the multi-disciplinary team. ii. Airway management iii. Hemodynamic management iv. Anesthetic drug administration v. Safe positioning vi. Appropriate interpretation of EEG and evoked potential data acquired during anesthesia. vii. Provision of anesthetic support which accommodates needs for valid interpretation of intraoperative evoked potential or EEG monitoring viii. Interpretation of relevant neuroimaging, neuromonitoring, and laboratory results ix. Perioperative Neuroprotection and Neuro-resuscitation x. Post anesthesia recovery and neurocritical care management xi. Management of a ventricular and spinal drain. xii. Detection and management of venous air embolism, hemorrhage, and other complications xiii. Monitoring and management of patients with brain edema, intracranial hypertension, cerebral ischemia, and epilepsy xiv. Provision of anesthetic support which accommodates needs for awake craniotomy xv. Perioperative pain management 6. Capability to understand and use common Neuro ICU diagnostic and monitoring modalities including i. Long term EEG ii. Intracranial pressure via various types of monitors 19

384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 iii. Transcranial Doppler iv. Magnetic resonance imaging v. Computed tomography vi. Evoked potentials vii. Electromyogram viii. Cerebral angiography ix. Transthoracic echocardiography 7. Capability to understand the potential roles of less common Neuro ICU diagnostic and monitoring modalities including: i. Brain oxygen partial pressure ii. Cerebral blood flow by various techniques iii. Jugular bulb oxygen saturation iv. Cerebral microdialysis v. Intracranial EEG b. Medical Knowledge Fellows must demonstrate knowledge of established and evolving relevant neuroscience, biomedical, clinical, epidemiological, anesthesiology, and social- behavioral sciences, as well as the synthesis and application of this knowledge to patient care. Fellows must demonstrate competence in their knowledge of the following areas, with specific emphasis on the anesthetic implications of the altered central and peripheral nervous system: 1. Neuroanatomy of the brain, spine, and major peripheral nerves 2. Neuro- and systemic pharmacology of anesthetic drugs 3. Intracranial and spinal blood supply, and accompanying changes in pathophysiologic conditions. 4. Principles of cerebral blood flow regulation including effects of intramural pressure, biochemical milieu, and cerebral metabolic rate. 20

407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 5. Neuroprotection and neurotoxicity and relevant pharmacology. 6. Pharmacology of antiepileptic drugs. 7. Pharmacology of fluids, sodium regulation, diuretics, and osmotherapeutic agents 8. Indications, contraindications, and potential complications of the following procedures: i. Arterial catheterization, ii. Central venous catheterization, iii. Pulmonary artery catheterization, iv. Noninvasive and invasive cardiac output monitoring, v. Cerebrospinal fluid drainage catheters, ventricular and spinal vi. Precordial Doppler sonography, vii. Jugular venous oximetry, viii. Intracranial pressure monitoring, and ix. Neurophysiological monitoring 9. Interactions between neuropathology and anesthetic pharmacology. 10. Hemodynamic goals in relation to the intracranial or spinal pathology. 11. Interactions between vasoactive drugs and neuropathology 12. Grading scales for coma, subarachnoid hemorrhage, intraparenchymal hemorrhage, cranial computed tomographic imaging, arteriovenous malformation and neurologic outcome. 13. Risk and benefits of patient positioning for different neurosurgical procedures 14. Intracranial pressure and treatment options for intracranial hypertension. 15. Diagnosis and management of hyper- and hyponatremia and abnormalities of plasma osmolarity 16. Initiation, maintenance, and reversal of anticoagulation strategies in neurosurgery and interventional neuroradiology. 17. Classification and pathophysiology of epilepsy, seizures, and status epilepticus. 21

431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 18. Pathophysiology, perioperative management, and postoperative care of patients with pituitary tumors. 19. Definition, diagnosis, and management of the unstable and immobile cervical spine. 20. Classification of intracranial tumors, their presentation, and their management. 21. Diagnosis and management of venous air embolism. 22. Benefits and risks of craniotomy in the sitting position 23. Legal and ethical issues related to severe neurologic illness including surrogate permission, brain death, organ donation, definition and implementation of goals of care 24. Principles of research in neurologically impaired patients 25. Organization and management of a neuroanesthesiology service, including health care delivery models, funding, building a service, and regional regulatory agencies with jurisdiction; 26. Transport and monitoring of critically-ill neurological patients 27. The history, breadth and scope of neuroanesthesiology; 28. The basic science and clinical knowledge pertaining to routine and complicated neurosurgical anesthesia care; 29. Related disciplines, particularly involving neurosurgery, neurology, trauma surgery, and pediatric neurosurgery/neurology 30. Processes involved in designing and implementing clinical trials; 31. The impact of different anesthetic and analgesic techniques on health care resources, including room allocation, staffing, and patient throughput; 32. Sound business practices and the direct and indirect costs of different neuroanesthetic analgesic and anesthetic techniques c. Professionalism. Fellows are expected to have already assimilated during residency training and continue to manifest skills and habits related to professionalism. The program should ensure a culture of professionalism that supports patient safety, personal responsibility, and culture competency. This includes practice-based learning and improvement, quality 22

455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 B. Didactic Component improvement, respect for peers within and outside the specialty, sharing expertise as a consultant and educator, interpersonal and communication skills, professionalism, and systems-based practice a. The didactic curriculum should be provided through journal clubs, lectures, case conferences, morbidity and mortality meetings, research conferences, facilitated self-learning, and workshops, and should supplement clinical experience all of which should include participation and/or leadership of fellow b. Faculty members should lead the majority of the sessions. Conferences may be supplemented by attendance at external meetings, webinars, or other methods of internet-based education c. The didactic curriculum should include all topics previously listed as expected medical knowledge competencies C. Clinical Components. This area addresses the curriculum elements that will be addressed in a clinical or practice setting. The curriculum must have a goal to develop synthetic knowledge in perioperative neuroscience with capability of graduating fellows to be able to incorporate principles and knowledge in neuropathophysiology, neuropharmacology, and general medicine to provide high level care to patients undergoing neurosurgical and neurointerventional procedures. The clinical curriculum shall be structured to include: a. Clinical (>6 four-week modules) May include pediatric neuroanesthesiology with duration and number of modules as defined by the program director but without interfering with the global educational goals of a neuroanesthesiology fellowship. b. Critical Care of the Neurologic Patient (>1 four-week module) c. Anesthesia for Neuroradiology/ NeuroEndovascular Care (>1 four-week module or equivalent experience embedded in the Clinical neuroanesthesiology rotations) d. Intraoperative monitoring (>1 four-week module or significant experience concurrently during neuroanesthesiology modules) 23

480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 e. Neuroscience Scholarship (>1 four-week module or significant experience concurrently during neuroanesthesiology modules) f. Elective Rotation (>1 four-week module) D. Scholarly Activities. This area addresses the curriculum elements that will be related through scholarly activities and included: a. Each fellow should conduct, or be substantially involved in, a scholarly project which leads to presentations, preferably by the fellow, at a national or regional meeting, and/or publication. At a minimum each fellow should deliver oral presentations related to their or others research in a local context b. Fellows must have a faculty mentor overseeing the project and any presentations or publications E. Educational Program Resources and Facilities a. The institution and the program must jointly ensure the availability ty of adequate resources for fellow education, as defined in the specialty program requirements. b. Clinical facilities available to support the educational mission must include: i. A designated area or areas for neurosurgical procedures ii. A designated area or areas for interventional neuroradiology procedures iii. Intraoperative Neuro monitoring and advanced life-support equipment representative of current levels of technology; iv. A Neurocritical care service with specialized nursing for Neurocritical care which may be a component of a general intensive care (or therapy) unit. v. A clinical laboratory that provides prompt and readily available diagnostic and laboratory measurements pertinent to the care of critically ill neurological patients 24

503 504 vi. Neuroradiology imaging capability including magnetic resonance imaging, cranial computed tomography, and neuroangiography. 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 c. The patient population must include both high- and low-risk neurological and neurosurgical patients in sufficient volume and variety to provide a broad clinical and educational experience for each fellow. d. There must be an active critical care service that is regularly involved in multidisciplinary care including neurocritical care. A satisfactory clinical care environment may include neurocritical care in a general critical care service but if a focused neurocritical care service or focused neurocritical care experience in the context of a general critical care rotation is not available the program should allow fellows to participate in an external rotation focused on neurocritical care. e. An active intraoperative Neuromonitoring service that is regularly involved in perioperative multidisciplinary care is recommended but not required. This service must be overseen by a neuroanesthesiologist, neurologist, or neurosurgeon with appropriate qualifications, certification, and experience. Appropriately trained PhD-level neurophysiologists may also oversee this program. An external rotation with duration specified by the program director can be arranged if this service is not available in the applicant hospital. f. There must be facilities and space for the education of fellows, including meeting space, conference space, space for academic activities, and access to computers and medical records. g. Medical Information Access. Fellows, faculty, and staff must have ready access to specialty-specific and other appropriate reference material in print or electronic format. Internet-based medical literature databases with search capabilities and institutional access to research publications should be available. 521 25

522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 VII. Description of Fellowship Rotations (back) The one-year fellowship consists of 4-week modules (which can be divided into two week blocks if needed) which include: A. Description of Rotations a. Adult Clinical Surgical Neuroanesthesiology (>6 four-week modules) 1. Curriculum Each fellow, who successfully completes the fellowship, should be cognitively and technically competent, at an advanced synthetic level, in the preanesthetic evaluation and perioperative management of patients undergoing neurosurgical and interventional neuroradioogy procedures. These include intracranial, spine, and peripheral nerve surgeries, as well as interventional neuroradiologic procedures, which are described separately. The rotation for Adult Neurosurgical Patients consists of six mandatory modules. During this rotation, fellows develop expertise in the care of neurosurgical patients, including supervision or direct patient care of supra and infratentorial craniotomy, and complex spine. surgery, including spinal instrumentation procedures and encompassing a mixture of spine cases including cervical, thoracic, and lumbar spine, as well as variety of pathologies (such as spinal tumors, trauma, scoliosis, degenerative diseases, oncologic). Craniotomies should include experience with awake/sedated craniotomy, craniotomy for seizure focus localization and resection, and craniotomy for intracranial vascular lesions including intracranial aneurysm and arteriovenous malformation. In addition, fellows should be involved in the management of intracranial cerebrospinal fluid shunt procedures. It is anticipated that many craniotomies will be for the resection of mass lesions such as tumors but it is desirable that the fellows gain experience in anesthetic management of traumatic brain injury, endoscopic neurosurgery, and sitting position craniotomy. The 4- week interventional neuroradiology rotation (described below) may be included as one of the six mandatory adult neuroanesthesia rotations, conducted as part of the neuroanesthesia experience or as a distinct rotation. The over-arching goal is acquisition of an advanced degree of expertise in the management of such procedures. The acquisition of such expertise will vary according to complexity, supervision, and responsibility borne by the fellow. The recommended minimum experience needed to acquire expertise is: 26

549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 50 Neurosurgical procedures (supratentorial, infratentorial, spinal cord) that include o 5 awake craniotomies, (including deep brain stimulator placement) o 5 craniotomies for seizure focus localization or excision, o 10 craniotomies for intracranial vascular lesions, including intracranial aneurysms and arteriovenous malformations. o 30 spine surgeries, 20 of which should include instrumentation. o 5 intracranial spinal fluid shunt procedures. 30 interventional neuroradiology cases including stroke recovery procedures. Further interventional neuroradiology cases are listed subsequently. Some procedures (e.g. spine, carotid surgery) may be performed by non-neurosurgeons and can be included in the clinical experience. Case numbers can be documented by a system which is determined internally in accordance with ICPNT definition of case credit, and a summary of fellow case experience will be reported to ICPNT in the transcript reported in association with the summative evaluation. 2. Competencies & patient care At the conclusion of the six (or more) modules of this rotation fellows will be competent to administer anesthesia for a. Craniotomy for subarachnoid hemorrhage and intracranial vascular pathology b. Supratentorial and infratentorial tumor resection, including sedated/awake craniotomy. c. Pituitary adenoma surgery and management of the associated endocrine abnormalities (including Acromegaly) d. Spinal surgery including spinal cord injury, unstable cervical spine, immobilized cervical spine, spinal tumor resection and spinal instrumentation e. Traumatic brain injury with brain compression. f. Occlusive cerebrovascular disease including carotid endarterectomy g. Epilepsy surgery 27

575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594 595 596 h. Ischemic stroke requiring endovascular therapy. i. Subdural and intra-parenchymal hemorrhage j. Neuromuscular and movement disorders k. Acute and chronic quadriplegia and paraplegia l. Microvascular decompression and skull base surgery m. Deep brain stimulation n. Endoscopic and minimally invasive neurosurgery o. Diagnostic and interventional neuroradiology including but not limited to coiling of aneurysms, embolization of intracranial arteriovenous malformations and tumors, endovascular management of acute ischemic stroke, endovascular treatment of cerebral vasospasm and Carotid Stent. p. Procedures performed in the sitting position. This is an unusual procedure but cognitive competency should be the goal if no cases appear, or use of high fidelity simulation may be employed if available. q. Decompressive craniectomy for trauma or stroke r. Surgical management of acute and chronic hydrocephalus (e.g. extra-ventricular drain insertion, ventriculo-peritoneal shunt insertion, ventriculoscopy) s. Non-neurosurgical procedures in patients with neurological/neurosurgical disease (as a consultant). t. Chiari malformations u. Implications of Intraoperative Neurophysiologic Monitoring and Anesthetic Management At the conclusion of the six clinical rotations the fellow must be able to: a. Perform a basic neurologic examination. b. Recognize the need for and provide advanced airway management in patients with intracranial hypertension, unstable intracranial vascular problems, and unstable or immobilized cervical spine 28

597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 c. Establish hemodynamic parameters according to the patient baseline, pathology, and surgical procedure, and adjust hemodynamic parameters in a dynamic fashion, including fluid therapy and pharmacologic support of the circulation to optimize cerebral and spinal cord perfusion, depending on the clinical course. d. Understand and apply principles of neuroprotection and neuroresuscitation using physiologic and pharmacologic means. e. Manage intracranial hypertension and cerebral edema using physiologic, pharmacologic, and positioning techniques. f. Manage cerebral and spinal perfusion pressure appropriately with respect to underlying neuropathology. g. Be aware of anesthetic considerations in cases involving neurophysiologic monitoring and choose anesthetic techniques that facilitate monitoring. h. Manage spinal and ventriculoscopy drains, as well as intracranial pressure (ICP) monitors. i. Prevent and manage complications related to patient positioning. j. Manage awake craniotomy and deep brain stimulator placement cases during which an alert patient is needed for monitoring during the procedure. k. Perform a scalp block. l. Monitoring, prevention, and management of venous air embolism including use of precordial Doppler ultrasound and central venous cannulation. m. Manage blood pressure and transfusion requirements in complex spine and intracranial neurosurgery cases. n. Plan and execute rapid emergence after neurologic interventions. o. Care for patients undergoing diagnostic neuroradiologic procedures with anxiety, claustrophobia, or other psychological/psychiatric conditions 3. Medical Knowledge At the conclusion of the six rotations the fellow must demonstrate advanced synthetic knowledge of: a. Neuroanatomy of the normal brain, spine, and major peripheral nerves. 29

621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 b. Intracranial and spinal blood supply, and accompanying changes in pathophysiologic conditions. c. Principles of cerebral blood flow regulation such as autoregulation, chemoregulation, and cerebral metabolic rate. d. Neuroprotection and relevant pharmacology. e. Basic pharmacology of common antiepileptic drugs. f. Indications, contraindications, and potential complications of the following procedures: arterial catheterization, central venous catheterization, pulmonary artery catheterization, noninvasive cardiac output monitoring, cerebrospinal fluid drainage catheters, precordial Doppler sonography, jugular venous oximetry, intracranial pressure monitoring, and neurophysiological monitoring. g. Interactions between neuropathology and anesthetic pharmacology. h. Hemodynamic goals in relation to the intracranial or spinal pathology. i. Grading scales for coma, subarachnoid hemorrhage, and arteriovenous malformation. j. Risk and Benefits of patient positioning for neurosurgical procedures. k. Intracranial pressure and treatment options for intracranial hypertension. l. Initiation, maintenance, and reversal of anticoagulation strategies in cerebrovascular surgery and interventional neuroradiology. m. Classification and pathophysiology of epilepsy. n. Pathophysiology, perioperative management and post-operative care of patients with pituitary tumors. o. Pathophysiology of traumatic brain injury and spinal cord injury p. Pathophysiology of ischemic stroke, intraparenchymal hemorrhage, subarachnoid hemorrhage, subdural hemorrhage, and epidural hemorrhage q. Definition, diagnosis, and management of the unstable cervical spine and spinal cord injury. r. Classification of intracranial tumors, their presentation, and their management. s. Diagnosis and management of venous air embolism. t. Anesthetic management of endoscopic intracranial procedures. 30