PGY 1-2 Group Study Guide

UNIVERSITY OF MANITOBA

DEPARTMENT OF ANESTHESIA

PGY 1-2 GROUP STUDY SERIES

Session Goals and Objectives

 

 

BASIC PHYSIOLOGY SERIES

 

This is a series of group sessions in which the residents will have the opportunity to work through the basic physiology relevant to anesthesia.  The intent is for them to increase their understanding of this subject material through discussion.  These topics will be explored in greater depth in their independent reading in senior years, during discussion with staff, and in staff-led didactic sessions in PGY1-2 and PGY2-5.

 

The sessions are as follows.  Each will be organized around a set of questions that the residents should ensure that they are able to answer completely, thoroughly explaining the underlying physiology.  It will be necessary for the residents to read beforehand to prepare for these sessions.  The volume of material is substantial.  It is not intended that the residents address this material completely in the session alone.  The purpose of the session is to amplify and clarify what they have already learned in their reading. The following resources are suggested.  The list is not intended to be exclusive, and residents should add whatever resources they find helpful.

            Stoelting                      Pharmacology and Physiology

            Nunn                           Applied Respiratory Physiology

            Miller/Barash              Relevant chapters

            West                            Respiratory Physiology- Essentials

            West                            Respiratory Pathophysiology- Essentials

            Dakin                          Making sense of Lung Function Tests

            Cottrell                        Neuroanesthesia

 

The table below lists the topics of the sessions.  The lists of questions that the residents are expected to address are to be found on the following pages.

 

GRP1

CVS physiology

GRP2

RS physiology

GRP3

CNS physiology

GRP4

Autonomic nervous system

GRP5

Fluids and renal physiology

GRP6

ECG  and arrhythmias

GRP7

Acid-Base and blood gases

GRP8

Temperature and Neuromuscular

GRP 1 : CVS Physiology

Systemic Circulation

  1. What is the role of endothelium in the systemic circulation, and how does it perform that role?

 

  1. What are the factors that may increase or decrease the pulse amplitude?

 

  1. Draw a central venous waveform, labeling the waves and descents.
    1. What is the explanation for each?
    2. What is the interpretation of

                                               i.     Cannon a waves

                                             ii.     Large a waves

                                            iii.     Large v waves

                                            iv.     Absent y descent

  1. The CVP reads 20mmHg and the transducer is 10cm below the level of the bed in a 70 kg average sized male.  Is the filling pressure high, normal or low?

 

  1. What is Poiseuille’s law and how does it relate to flow in blood vessels?

 

  1. What is Ohm’s law and how does it relate to flow in blood vessels?

 

  1. What is the mean circulatory pressure and what is it’s normal value?

 

  1. What factors determine blood flow to an individual tissue bed?

 

  1. Describe the control mechanisms for systemic blood pressure, in the immediate, short and long terms.

 

Heart

 

  1. Describe the action potential in cardiac muscle, purkinje and pacemaker cells.
    1. What is occurring at each stage of the action potential?
    2. What is the stimulus for initiation and termination of each ion current?
    3. What is Vmax?
    4. What is the refractory period, and when does it occur?
    5. What is the cause of automaticity, and what alters it?

 

  1. Describe the blood supply to
    1. The myocardium
    2. The av and sa nodes

 

  1. Describe the distribution of myocardial blood flow through the cardiac cycle
    1. How does tachycardia affect the O2 supply-demand ratio?
    2. Why is the subendocardium most susceptible to ischemia?

 

  1. Describe the regulation of coronary blood flow.


  1. What is coronary steal?
    1. Draw an example of steal-prone anatomy.

 

  1. What are the mechanical determinants of cardiac output?

 

  1. What are the control mechanisms for cardiac output?
    1. What is the autonomic input to the heart?

 

  1. Describe the interpretation of pressure-volume loops, and how it would change in the face of:.
    1. Increased or decreased contractility
    2. Diastolic dysfunction
    3. Hypovolemia
    4. Sepsis

 

  1. What is the Frank-Starling phenomenon, and why does it happen?

 

  1. What is the precise definition, cardiac mechanical correlate of, and how do you clinically evaluate the following:
    1. Preload
    2. Afterload
    3. Contractility

 

  1. How does CVP relate to LV preload?

GRP 2: RS Physiology

 

Pulmonary Vasculature

  1. What determines PVR?
    1. Baseline Vasodilatory tone
    2. Autonomic input
    3. Endothelial

                                               i.     NO

                                             ii.     Prostacyclin

                                            iii.     Endothelin-1

    1. HPV
    2. Lung Volume
    3. Disease/embolic
    4. Chronically

 

  1. How does IPPV affect pulmonary blood flow?

 

  1. What are the Zones of the lung according to West and why do they matter?
    1. What factors will change these zones?

 

  1. Why is there very little interstitial fluid in the lung?

 

Mechanics of Breathing

  1. What is the sequence of events that results in normal inspiration and expiration?
  2. What is the distribution of ventilation throughout the lung? Why?
  3. What is the role of surfactant and how does it work?
    1. What is Laplace’s law, and how does surfactant counteract it?
  4. What is the FRC?
    1. What role does it play in gas exchange?
  5. What is closing capacity?
    1. How do the CC and the FRC interact?
  6. What is the MEFR and what is the advantage over FEV1?
    1. Why do they behave differently?

 

Control of Breathing

  1. How does CO2 regulate respiration?
    1. Where is the site?
    2. How does it work?
    3. What does it do?
    4. What is the time course?

 

  1. What are the inputs that determine minute ventilation and pattern at any given time?

 

Gas Exchange

  1. What are the physical/mechanical steps involved in transporting an atom of O2 from the lips to the alveolar capillary?

 

  1. What is a partial pressure? What is the inspired PO2 at sea level?
    1. At an atmospheric pressure of 760 mmHg, what would happen if you added 100mmHg of helium to:

                                               i.     A space with no compliance?

                                             ii.     An space with infinite compliance?

                                            iii.     An expandable space with limited compliance?

 

  1. What is a vapour pressure, and what determines the vapour pressure of a given gas?

 

  1. Qualitatively, how does the composition of alveolar gas differ from the inspiratory gas? Why?

 

  1. Write out and explain the alveolar gas equation  

 

  1. What is the O2 content of blood? 
    1. What is the oxy-hemoglobin dissociation curve?
    2. What affects the curve? 

 

  1. What is shunt?
    1. What are the sources of normal Rà L shunt?
    2. What are the causes of increased RàL shunt?
    3. How do you estimate the amount of Rà L shunt in the following example?

                                               i.     Using the shunt equation?

                                             ii.     Using the alveolar gas equation?

35 yo male pres with bilateral # femurs from being pinned between two cars  36 ago.   No other injuries, in OR for IM rod bilat under GA.  Intraoperatively SpO2 gradually declines to 92% on FiO2= 1.0 with  Paw = 35cm H2O, Vt= 700ml and RR= 15.  ABG shows

pO2=70

pCO2= 30

pH= 7.42

 

  1. What is the differential diagnosis of decreased SpO2?

 

  1. What is dead space?
    1. What are the components of dead space?
    2. How would you calculate the proportions of each compared to VT?
    3. What effect would an increase in dead space have on PaO2, PaCO2, PetCO2, minute ventilation?

                                               i.     Consider both controlled and spontaneous ventilation

 

GRP 3: CNS Physiology

  1. What is the CMRO2?
    1. What are the factors that determine CMRO2?
    2. What metabolic demands are met by the CMRO2, and what proportion of the total CMRO2 does each consume?
    3. What factors can be manipulated to decrease CMRO2 ?
    4. In the face of a progressive externally imposed reduction in cerebral oxygen delivery,

                                               i.     what will happen to the CMRO2 ?

                                             ii.     what will happen to the brain?

                                            iii.     at what point will ischemia ensue?

                                            iv.     At what point will infarction ensue?

  1. Define cerebral O2 delivery.
    1. What compensatory mechanisms exist to increase O2 delivery?
    2. What interventions can you impose to enhance cerebral O2 delivery?
  2. What is the normal cerebral blood flow (CBF)?
    1. What is the distribution of that flow within the brain?
    2. What is the cerebral perfusion pressure?

                                               i.     What hydraulic equation would you use to define the relationship of CBF to pressure?

                                             ii.     What factors increase or decrease cerebral blood flow?

    1. What is the main determinant of cerebral blood flow minute-to-minute?
    2. What factors affect cerebral vascular resistance?
    3. What is meant by the term flow-metabolic coupling and how does it work?
  1. What is the normal intracranial pressure?
    1. What are the components of the intracranial contents that take up space?
    2. What are the intracranial fluid compartments?
    3. How does ICP affect CBF?
    4. How does CBF affect ICP?
    5. What is the difference and relationship between CBF and cerebral blood volume (CBV)?
    6. If you inserted a small balloon into the intracranial epidural space and slowly inflated it,

                                               i.     what factors would mitigate the increase in ICP?

                                             ii.     what would the resultant ICP trace look like graphed over time?

    1. What interventions can you employ to reduce ICP?
  1. What is the normal spinal cord blood flow (SBF)?
    1. How is it distributed?
    2. What is the hydraulic equation you would use to define it?
    3. What determines spinal cord blood flow?
    4. Anatomically, what is the perfusion of the spinal cord?

                                               i.     Why is a high thoracic aortic clamp worse than an infrarenal one with respect to SBF?

    1. What is the normal intraspinal CSF pressure?

                                               i.     What factors will increase spinal CSF pressure?

GRP 4: Autonomic Nervous System

  1. What does the autonomic nervous system do?

 

  1. Describe the anatomy of the sympathetic and parasympathetic nervous systems.

 

  1. Describe the anatomic distribution, characteristics and function of the following within the autonomic nervous system
    1. Nicotinic receptors
    2. Muscarinic receptors
    3. Alpha receptors
    4. Beta receptors

 

  1. What are the endogenous compounds which stimulate the above receptors, and how are they delivered to the receptor?
    1. How is the effect terminated?

 

  1. Describe the process by which the catecholamines are formed.

 

  1. Describe amplification in signal transduction.
    1. What is a G protein?

 

  1. Why do NMBA’s not produce pronounced cardiovascular effects?

 

  1. What factors can alter the responses to
    1. Ephedrine
    2. Endogenous sympathetic responses (eg pain)
    3. Exogenous catecholamines
    4. Phenylephrine

 

  1. How can you assess autonomic dysfunction in a preop assessment?

 

GRP 5: Fluids and Renal Physiology

  1. How much fluid is there in:
    1. Your body
    2. The interstitial space
    3. The intracellular space
    4. The intravascular space
    5. With which anthropomorphic variables do these estimates vary? How?
  2. What is the significance of the distribution of the following through the spaces?
    1. Protein
    2. Sodium
    3. Potassium
  3. Explain osmosis
    1. What are the main osmoles in the body
  4. What is the difference between isotonic crystalloid and colloid for fluid replacement?
  5. How do we assess fluid status in the OR?
  6. How do you estimate fluid status in the preop assessment?
    1. Rules of thumb for total fluid deficit and blood loss
  7. Describe the function and events occurring in the:
    1. Afferent and efferent arterioles
    2. Glomerulus
    3. Proximal convoluted tubule
    4. Loop of Henle
    5. Distal Convoluted Tubule
    6. Collecting Ducts
  8. What factors determine renal blood flow?  GFR?
  9. What are the renal tubular mechanisms at each level for handling:
    1. Na
    2. K
    3. Water
    4. pH
  10. What are the regulatory influences on:
    1. Na
    2. K
    3. Water
    4. PH
  11. What are the causes of renal failure and how do you distinguish them?
  12. What is the therapeutic approach to renal failure?

GRP 6: ECG and Arrhythmias

 The group is to go through the following EKG’s together.  By the end of this session the resident should be able to:

  • Read an EKG using a systematic approach
  • Identify common EKG abnormalities

 

Once the group has finished reading the provided EKG’s the source textbook, EKG’s by example is available in the dept.  It includes that author’s interpretations of each of the EKGs for comparison.  Residents are encouraged to read the tracings themselves before consulting the book.  The ultimate goal is to reinforce the systematic approach, which is only possible through practice.  There is no test of the rigor with which this task was completed, other than your ultimate proficiency, which will become evident in clinical patient care.

 


GRP 7: Acid-Base and Blood Gases

  1. What is the normal pH of
    1. Arterial blood
    2. Venous blood
    3. Interstitial fluid
    4. Intracellular fluid
  2. What is a buffering system and how does it work?
  3. What buffering systems exist in the body?
  4. Describe the Henderson -Hasselbach equation and what it means.
  5. Beyond the buffering of changes in H+ concentration, how does the body regulate pH?
    1. What are the stimuli to activate the regulatory responses?
    2. What are the specific mechanisms?

GRP 8: Temperature and Neuromuscular

Temperature:

  1. What is the normal body temperature?
    1. How do you measure it?
  2. What are the sources of thermal energy in the body?
    1. How is thermal energy distributed within the body?
  3. What are the mechanisms by which thermal energy enters/leaves the body?
  4. How is body temperature regulated?
    1. What are the relevant afferent and efferent pathways?
  5. As ambient temperature drops,
    1. what are the natural protective mechanisms that are employed to combat hypothermia?
    2. at what point is each initiated?
    3. which of the mechanisms in 2 and 3 above does each impact?
    4. what physiologic effects and clinical manifestations would you expect as body temperature decreases?
  6. As ambient temperature increases,
    1. what are the natural protective mechanisms that are employed to combat hyperthermia?
    2. at what point is each initiated?
    3. which of the above mechanisms does each impact?
    4. what physiologic effects and clinical manifestations would you expect as body temperature increases?
  7. Why does infection cause a fever, and through which of the above mechanisms?

 

Neuromuscular:

  1. What are the efferent pathways involved in voluntary motor activity?
  2. Describe the structure of a motor neuron.
    1. What is the normal resting transmembrane potential?
    2. In the resting state, how is it maintained?
    3. What is the role of the cell membrane in this process?
  3. What is a nerve action potential?
    1. What are biochemical events that result in an action potential?
    2. How/why does an action potential travel along the axon?
    3. How is the transmembrane potential restored?
  4. Describe the structure of the neuromuscular junction (NMJ).
  5. What is the sequence of events that leads from the arrival of an action potential at the motor nerve ending to the release of acetylcholine (ACH) into the synaptic cleft?  
  6. What is the sequence of events that leads from the arrival of ACH in the synaptic cleft to the generation of an action potential within the neuromuscular endplate?
  7. How is the ACH removed from the synaptic cleft?
  8. With rapid intense stimuli at short intervals, as in a tetanic stimulus, what is the pattern of ACH release into the neuromuscular cleft?
    1. What effect does  this have on neuromuscular contraction in the unmedicated state?
    2. What is the role of the prejunctional ACH receptors on the motor nerve ending?
  9. Once the motor endplate has been depolarized by an action potential, what is the sequence of events by which that results in muscle contraction?
    1. What are actin and myosin, and how do they interect?
    2. What is the biochemical stimulus to that interaction, and where does it come from?
    3. What terminates the contraction?
  10. Contrast the defect in
    1. Eaton-Lambert
    2. Botulinum poisoning
    3. Myasthenia gravis

 

ANATOMY SERIES

 

The purpose of the Anatomy study curriculum is to give the resident the opportunity to review the anatomy of the neck, trunk, upper and lower extremities.  More specifically, this review is intended to reinforce the understanding of the various anesthetic procedures that will eventually become a part of the resident’s repertoire.  Each section of the outline contains a list of the procedures that the resident will be required to learn in the course of the training program, along with a reference for the actual technique.  The resident should review the actual techniques prior to the session.  The intent is not to learn the procedure itself.  Rather, the resident is intended to study the anatomy with reflection on these techniques in order to arrive at a deeper understanding of the geometry, obstacles and complications of each. 

 

The following table lists the sessions in this part of the Group study series.  The specific session details are found in the pages following the table.

 

GRP9

 Anatomy of the neck and Airway

GRP10

Anatomy of the neck and related procedures

GRP11

Anatomy of the Upper Extremity

GRP12

Spine and Trunk

GRP13

Lower Extremity

 

GRP 9: Anatomy of the Neck and Airway

While reviewing the anatomy of the neck, in addition to specific procedural anatomy, the resident is intended to gain an appreciation of the anatomic structures at risk and resultant anesthetic implications of neck trauma.

Neck trauma

References:  1,2,3

The resident will need to understand:

§  The borders, contents and relations of the triangles of the neck

§  The borders, contents and relations of the three neck zones as defined with respect to neck trauma

§  The contents and relationships of the carotid sheath

§  The locations, course and relationships of the jugular vein, the carotid and vertebral arteries, cervical plexus, pleura, esophagus, spine, and airway

§  The structure of the cervical spine, structural basis of c-spine stability

 

Airway

References:1, 4

The resident will need to understand:

§  The borders, contents and functions of the oropharynx, nasopharynx, and glottis

§  The mechanism and anatomy of phonation

§  The mechanism and anatomy of swallowing

§  The mechanism and anatomy of glottic closure

§  The innervation of the upper airway with specific emphasis on the techniques of airway anesthesia

 

 

GRP10: Anatomy of the Neck and related Procedures

 

Internal jugular vein catheterization

            Anterior, posterior and midline approaches

References: 1, 5 or 6

The resident will need to understand:

§  The location, orientation and path of the internal jugular vein, with respect to surface and deep landmarks

§  The contents and relationships of the carotid sheath

§  Relationships of the jugular vein to the carotid artery, cervical plexus, pleura, esophagus, spine, and airway

Subclavian Vein Catheterization

References: 1, 5 or 6

The resident will need to understand:

§  The location, orientation and path of the subclavian vein, with respect to surface and deep landmarks

§  The contents and relationships of the brachial sheath

§  Anatomic parts and branches of the subclavian artery

§  Relationships of the subclavian vein to the subclavian artery, brachial plexus, pleura, first rib, clavicle, airway

 

Interscalene brachial plexus block

References: 1, 7, 8

The resident will need to understand:

§  Brachial plexus

o   Localization of deep and superficial plexus

o   Branches

o   Dermatomes, sclerotomes and myotomes

o   Bony, fascial, vascular and other relations

 

§  Fascial planes of the neck

o   Spread of LA

o   Fascial compartments

o   Arrangement of muscular layers

o   Carotid sheath, major nerves

 

Deep and superficial cervical plexus blocks

References: 1, 7, 8

The resident will need to understand:

§  Cervical plexus

    • Localization of deep and superficial plexus
    • Branches
    • Dermatomes, sclerotomes and myotomes
    • Bony, fascial, vascular and other relations

§  Fascial planes of the neck

    • Spread of LA
    • Fascial compartments
    • Arrangement of muscular layers

§  Carotid sheath, major nerves

 

 

GRP 11: Anatomy of the Upper Extremity

Supraclavicular & Infraclavicular Brachial Plexus Blocks

References: 1, 7, 8

The resident will need to understand:

§  The organization and location of roots, trunks, divisions, cords and branches of the brachial plexus

§  The location, orientation and path of the brachial plexus in the neck and axilla, with respect to surface and deep landmarks

§  The contents and relationships of the brachial sheath

§  Anatomic parts and branches of the subclavian and axillary artery

§  Relationships of the brachial plexus to the subclavian vein, subclavian artery, , pleura, first rib, clavicle

 

Axillary Brachial Plexus Block

References: 1, 7, 8

The resident will need to understand:

§  The organization and location of roots, trunks, divisions, cords and branches of the brachial plexus

§  Functional assessment of the brachial plexus, including dermatomes, sclerotomes, and myotomes

§  The location, orientation and path of the brachial plexus in the axilla, with respect to surface and deep landmarks

§  The contents and anatomic boundaries of the axilla

§  The contents and relationships of the axillary sheath

§  Anatomic parts and branches of the subclavian and axillary artery

§  Relationships of the brachial plexus to the axillary vein, axillary artery,  head of humerus, pectoralis, biceps, coracobrachialis

§  Location of the musculocutaneous nerve in the axilla

 

 

 

Peripheral Nerve Blocks

Median, ulnar, radial, and MCN at the elbow and wrist

References: 1, 7, 8

The resident will need to understand:

§  The organization and location of roots, trunks, divisions, cords and branches of the brachial plexus

§  The location, orientation and path of the at the elbow, forearm and wrist

§  Sensory and motor innervations of the median, ulnar, radial and musculocutaneous nerves

 

Axillary Arterial line Insertion

References: 1, 5 or 6

The resident will need to understand:

§  The location, orientation and path of the axillary artery in the axilla, with respect to surface and deep landmarks

§  The contents and anatomic boundaries of the axilla

§  The contents and relationships of the axillary sheath

§  Anatomic parts and branches of the subclavian and axillary artery

§  Relationships of the axillary artery to the axillary vein, brachial plexus, head of humerus, pectoralis, biceps, coracobrachialis

 

 

GRP 12: Spine and trunk

Epidural and spinal

The resident will need to understand:

§  Organization and structure of the spinal cord and roots, including dermatomes, sclerotomes, and myotomes

§  Structure and relationships of individual vertebrae with specific attention to , differences between C T and L spines with respect to shape and orientation of laminae, spinous processes, facet joints

§  Boundaries and contents of the spinal canal, epidural space, dural sac

 

 

Paravertebral block

References: 1, 7, 8

The resident will need to understand:

§  Organization and structure of the spinal roots, including dermatomes, sclerotomes, and myotomes

§  Structure and relationships of individual vertebrae with specific attention to , differences between C T and L spines with respect to shape and orientation of laminae, spinous processes, facet joints

§  Boundaries and contents of the thoracic paravertebral space and relationship to the rib, pleura, vertebral body

 

           

GRP 13: Lower Extremity

Psoas Compartment Lumbar plexus Block

References: 1, 7, 8

The resident will need to understand:

§  The organization and location of lumbar roots and branches of the lumbar plexus

§  Sensory and motor innervation of the branches of the lumbar plexus

§  The location, orientation and path of the lumbar plexus from the transverse foraminae to the inguinal ligament, with respect to surface and deep landmarks

§  The boundaries, contents and relationships of the psoas sheath, and lumbar paravertebral space

§  Fascial planes of the pelvis

§  Relationships of the lumbar plexus to the femoral vein, femoral artery

 

Femoral Nerve Block

References: 1, 7, 8

The resident will need to understand:

§  The organization and location of lumbar roots and branches of the lumbar plexus

§  Sensory and motor innervation of the branches of the lumbar plexus

§  The location, orientation and path of the lumbar plexus from the transverse foraminae to the femoral canal, with respect to surface and deep landmarks

§  The boundaries, contents and relationships of the psoas sheath, femoral canal, inguinal triangle and fascial planes of the pelvis

§  Relationships of the lumbar plexus to the femoral vein, femoral artery, peritoneum, inguinal ligament

 

Femoral Artery and Vein catheterization           

References: 1, 5 or 6

The resident will need to understand:

§  The structure, location and course and branches of the iliac and femoral arteries

§  The boundaries, contents and relationships of the psoas sheath, femoral canal, inguinal triangle and fascial planes of the pelvis

§  Relationships of the lumbar plexus to the femoral vein, femoral artery, peritoneum, inguinal ligament     

 

Sciatic Nerve Block

Modified Labat and popliteal approaches

References: 1, 7, 8

The resident will need to understand:

§  The organization and location of lumbosacral roots, sciatic nerve and its branches

§  Sensory and motor innervation of the branches of the lumbosacral plexus and sciatic nerve

§  The location, orientation and path of the sciatic from the sacrum to the popliteal fossa, including bony muscular and fascial relationships

§  The boundaries, contents and relationships of the popliteal fossa

 

Ankle Block

References: 1, 7, 8

The resident will need to understand:

§  The orientation, location and course of terminal branches of the sciatic nerve

§  Sensory and motor innervation of the branches of the sciatic nerve

§  The location, orientation and course of the tibial and peroneal nerves, including bony muscular and fascial relationships

 

AnatomyReferences:

  1. “ Grant’s Atlas of Human Anatomy”
  2. Newton, Kim , “Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed.”, Chap 41, Neck. 
  3. Maisel, R.  Hom, D.  “Blunt and penetrating Trauma to the Neck” in Cummings Otolaryngology:  Head and Neck Surgery, 4th ed.  Chap 111,
  4. Woodson, G.  “  Laryngeal and Pharyngeal Function”  in Cummings Otolaryngology:  Head and Neck Surgery, 4th ed.  Chap 85a
  5. Miller’s Anesthesia, 6th ed.  Miller R. ed.  Churchill Livingston
  6. Clinical Anesthesia, Barash, P. ed.   Lippincott, Williams and Wilkins
  7. “Atlas of Regional Anesthesia”  David L. Brown, WB Saunders, 1999
  8. “Regional Anesthesia and Analgesia”  David L. Brown,  W.B. Saunders 1996

CLINICAL MANAGEMENT SERIES

The intent of this component of the group study series is to allow residents to develop the basic organizational building blocks to independent practice.  The ability to independently manage emergency situations hinges upon having an organized approach.  There is no universally correct approach.  It is crucial that each resident develop an approach that not only addresses all the necessary elements, but also is easily implemented in times of stress.

 

The following table lists the sessions in this part of the Group study series.  The specific session details are found in the pages following the table.

 

GRP14

Preop assessment

GRP15

Planning and Anesthetic

GRP16

Machine Check

GRP17

CVS emergencies

GRP18

RS emergencies 1

GRP19

RS emergencies 2

GRP10

PACU Decision Making

 

 

GRP 14:  Preop assessment

In this session the residents will work through and generate a concise, complete and organized approach to preoperative assessment.  This should be applicable to assessment in clinic, consult or emergency encounters, be easily articulated and applied.  This approach should contain all of the elements necessary to completely evaluate ASA1-3 patients for routine procedures.  It should have a structure that easily accommodates the extension to specific medical problems or surgical procedures as that knowledge develops.  A comprehensive knowledge of the preop considerations of the entire spectrum of diseases and procedures is beyond the scope of this session.  It is not necessary for all residents to end up with the same approach.  The ultimate goal is for each resident to have a clear plan that s/he can apply in the actual assessment of patients.  This structured approach should also allow the resident to convey that assessment clearly and concisely to staff or other team members. 

            Specific elements of the session

·      The main focus is to generate the overall structured approach

·      Airway assessment

·      Functional assessment

·      What labs are needed and when?

o   Preop indications for CBC, lytes, ABGs, CXR, coags,

Suggested Resources

·      Discussion with senior residents and staff in the OR

·      Miller/Barash  preop assessment chapters

·      WRHA/ College of Phys and Surgeons re preop testing

·      Guidelines to practice of Anesthesia  (CAS)

 

GRP 15: Planning an Anesthetic

In this session, the residents will work through and generate a concise, complete and organized approach to the planning of an anesthetic.  As in the first session, the goal is not to have a comprehensive plan for all possible diseases and procedures.  The goal is to have a structured approach that will allow for logical and complete planning of all of the required elements of an anesthetic for ASA 1-3 patients for routine procedures.  The structure of the approach should easily accommodate extension to more complex scenarios as experience grows.  The ultimate goal is for each resident to have a clear plan that s/he can apply in the actual management of patients.  This structured approach should also allow the resident to convey clearly and concisely to staff or other team members what the plan of the anesthetic is to be. 

            Specific elements of the session

·      Generate a structured and easily used approach

o   Consider all of the relevant steps in designing and executing an anesthetic

·      Recognize the key decision points in each step

o   Be able to discuss the rationale for each key decision

Suggested Resources

·      Intraoperative discussion with staff and senior residents

·      Gaba

·      Morgan

 

GRP 16: Machine Check

In this session, the residents will solidify their approach to the machine check.  This is an opportunity to discuss and compare approaches and review the existing policies and recommendations.  Most importantly, it is an opportunity to understand the rationale behind each step in the machine check, in particular what problems might be found, and how to solve them (on your own!)

 

            Specific elements of the session

·      Review established policies for machine check

·      Identify likely problems at each step

·      Discover remedial plan for each potential problem

Suggested resources

·      Departmental anesthesia policies

·      CAS Guidelines

·      Dorsch and Dorsch

 

GRP 17:Cardiovascular Emergencies

In this session, the residents will collaborate to generate complete concise and organized management plans for each of the major cardiovascular emergencies that can present in the OR.  The goal is to have a plan that will allow the resident to effectively diagnose manage the majority of emergencies with no staff intervention other than to confirm the plan.

 

            Specific elements of the session:

            Generate an organized, easily articulated and applied approach to

·      Hypotension

·      Hypertension

·      Tachycardia

·      Myocardial ischemia

·      Bradycardia

 

Suggested resources           

·      GABA- Crisis managementr in Anesthesiology

·      Bready- Decision making in Anesthesiology

·      Intraop and talk rounds discussions with staff and senior residents

 

GRP 18: Respiratory Emergencies 1

In this session, the residents will collaborate to generate complete concise and organized management plans for each of the major respiratory emergencies that can present in the OR.  The goal is to have a plan that will allow the resident to effectively diagnose and manage the majority of emergencies with no staff intervention other than to confirm the plan.

 

            Specific elements of the session

            Generate an organized, easily articulated and applied approach to

·      Decreased SpO2

·      Increased CO2

·      Decreased CO2

·      Increased Paw

·      Decreased Paw

 

Suggested resources           

·      GABA- Crisis management in Anesthesiology

·      Bready- Decision making in Anesthesiology

·      Intraop and talk rounds discussions with staff and senior residents

 

GRP 19: Respiratory Emergencies 2

In this session, the residents will collaborate to generate complete concise and organized management plans for the airway emergencies that can present in the OR.  The goal is to have a plan that will allow the resident to effectively diagnose and manage the majority of emergencies with no staff intervention other than to provide support for technical difficulty.

 

            Specific elements of the session

            Generate an organized, easily articulated and applied approach to

·      Difficult airway

·      Failed airway

·      Obstructed airway

Suggested resources           

·      GABA- Crisis management in Anesthesiology

·      Bready- Decision making in Anesthesiology

·      ASA difficult airway algorithm

·      Intraop and talk rounds discussions with staff and senior residents

 

GRP 20: PACU Decision making

In this session, the residents will collaborate to generate complete concise and organized approaches to common issues encountered in the Post Anesthesia Care Unit (PACU).  The goal is to be able to present to attending staff a well-worked out plan for the resolution of the following issues.

 

            Specific elements of the session

Generate an organized, easily articulated and applied approach to the following questions.

·      When is it appropriate to discharge a patient from recovery room?

·      Where should the patient go?

·      When is it appropriate to extubate?

 

Generate an organized, easily articulated and applied approach to the following common problems in PACU.

·      Pain

·      Decreased LOC

·      Respiratory Distress