The challenges of learning perioperative anesthesia care have grown considerably as the specialty, and medicine in general, have evolved. The beginning anesthesia trainee is faced with an ever-increasing quantity of knowledge, the need for adequate patient care experiences, and increased attention to patient safety as well as cost containment. Most training programs begin with close clinical supervision by an attending anesthesiologist. More experienced trainees may offer their perspectives and practical advice. Some programs use a mannequin-based patient simulator or other forms of simulation to facilitate the learning process. The practice of anesthesia involves the development of flexible patient care routines, factual and theoretical knowledge, manual and procedural skills, and the mental abilities to adapt to changing situations.
Competencies and Milestones
The anesthesia provider must be skilled in many areas. The Accreditation Council for Graduate Medical Education (ACGME) developed its Outcome Project, which includes a focus on six core competencies: patient care, medical knowledge, professionalism, interpersonal and communication skills, systems-based practice, and practice-based learning and improvement ( Table 2.1 ). More recently, the ACGME has advanced the core competencies approach by adopting the Dreyfus model of skill acquisition to create a framework of “milestones” in the development of anesthesia residents during 4 years of training. Table 2.2 shows an example of a milestone in the patient care competency. The milestones incorporate several aspects of residency training, including a description of expected behavior, the complexity of the patient and the surgical procedure, and the level of supervision needed by the resident.
| Procedure Event/Problem | Competency |
|---|---|
| Perform preoperative history and physical | Patient care, communication |
| Determine dose of neuromuscular blocking drug to facilitate tracheal intubation | Medical knowledge |
| Perform laryngoscopy and tracheal intubation | Patient care |
| Interact with surgeons and nurses in operating room | Professionalism, communication |
| Manage maintenance and emergence from anesthesia | Patient care |
| Patient with dental injury: refer to quality assurance committee | Systems-based practice |
| Patient with postoperative nausea: compare prophylaxis strategy with published literature | Practice-based learning and improvement |
| Level 1 | Level 2 | Level 3 | Level 4 | Level 5 |
|---|---|---|---|---|
| Formulates patient care plans that include consideration of underlying clinical conditions, past medical history, and patient, medical, or surgical risk factors Adapts to new settings for delivery of patient care | Formulates anesthetic plans for patients undergoing routine procedures that include consideration of underlying clinical conditions, past medical history, patient, anesthetic and surgical risk factors, and patient choice Conducts routine anesthetics, including management of commonly encountered physiologic alterations associated with anesthetic care, with indirect supervision | Formulates anesthetic plans for patients undergoing common subspecialty procedures that include consideration of medical, anesthetic, and surgical risk factors and that take into consideration a patient’s anesthetic preference Conducts subspecialty anesthetics with indirect supervision but may require direct supervision for more complex procedures and patients | Formulates and tailors anesthetic plans that include consideration of medical, anesthetic, and surgical risk factors and patient preference for patients with complex medical issues undergoing complex procedures with conditional independence Conducts complex anesthetics with conditional independence; may supervise others in the management of complex clinical problems | Independently formulates anesthetic plans that include consideration of medical, anesthetic, and surgical risk factors as well as patient preference for complex patients and procedures Conducts complex anesthetic management independently |
Level 1: Resident has completed one postgraduate year of education.
Level 2: Resident is without significant experience in subspecialties of anesthesiology.
Level 3: Resident has experience in subspecialties of anesthesiology.
Level 4: Resident substantially fulfills milestones expected of an anesthesiology residency; designated as graduation target.
Level 5: Resident has advanced beyond performance targets defined for residency and is demonstrating “aspirational” goals.
Structured Approach to Anesthesia Care
Anesthesia providers care for the surgical patient in the preoperative, intraoperative, and postoperative periods ( Box 2.1 ). Important patient care decisions reflect on assessing the preoperative evaluation, creating the anesthesia plan, preparing the operating room, and managing the intraoperative anesthetic, postoperative care, and outcome. An understanding of this framework will facilitate the learning process.
Preoperative Phase
Preoperative evaluation
Choice of anesthesia
Premedication
Intraoperative Phase
Physiologic monitoring and vascular access
General anesthesia (i.e., plan for induction, maintenance, and emergence)
Regional anesthesia (i.e., plan for type of block, needle, local anesthetic)
Postoperative Phase
Postoperative pain control method
Special monitoring or treatment based on surgery or anesthetic course
Disposition (e.g., home, postanesthesia care unit, ward, monitored ward, step-down unit, intensive care unit)
Follow-up (anesthesia complications, patient outcome)
Preoperative Evaluation
The goals of preoperative evaluation include assessing the risk of coexisting diseases, modifying risks, addressing patients’ concerns, and discussing options for anesthesia care (see Chapter 13, Chapter 14 ). The beginning trainee should learn the types of questions that are the most important to understanding the patient and the proposed surgery. Some specific questions and their potential importance follow.
What is the indication for the proposed surgery? Is it elective or an emergency? The indication for surgery may have particular anesthetic implications. For example, a patient requiring esophageal fundoplication will likely have severe gastroesophageal reflux disease, which may require modification of the anesthesia plan (e.g., preoperative nonparticulate antacid, intraoperative rapid-sequence induction of anesthesia).
A given procedure may also have implications for anesthetic choice. Anesthesia for hand surgery, for example, can be accomplished with local anesthesia, peripheral nerve blockade, general anesthesia, or sometimes a combination of techniques. The urgency of a given procedure (e.g., acute appendicitis) may preclude lengthy delay of the surgery for additional testing, without increasing the risk of complications (e.g., appendiceal rupture, peritonitis).
What are the inherent risks of this surgery? Surgical procedures have different inherent risks. For example, a patient undergoing coronary artery bypass graft has a significant risk of problems such as death, stroke, or myocardial infarction. A patient undergoing cataract extraction has an infrequent risk of major organ damage.
Does the patient have coexisting medical problems? Does the surgery or anesthesia care plan need to be modified because of them? To anticipate the effects of a given medical problem, the anesthesia provider must understand the physiologic effects of the surgery and anesthetic and the potential interaction with the medical problem. For example, a patient with poorly controlled systemic hypertension is more likely to have an exaggerated hypertensive response to direct laryngoscopy to facilitate tracheal intubation. The anesthesia provider may change the anesthetic plan to increase the induction dose of intravenously administered anesthetic (e.g., propofol) and administer a short-acting β-adrenergic blocker (e.g., esmolol) before instrumentation of the airway. Depending on the medical problem, the anesthesia plan may require modification during any phase of the procedure.
Has the patient had anesthesia before? Were there complications such as difficult airway management? Does the patient have risk factors for difficult airway management? Anesthesia records from previous surgery can yield much useful information. The most important fact is the ease of airway management techniques such as direct laryngoscopy. If physical examination reveals some risk factors for difficult tracheal intubation, but the patient had a clearly documented uncomplicated direct laryngoscopy for recent surgery, the anesthesia provider may choose to proceed with routine laryngoscopy. Other useful historical information includes intraoperative hemodynamic and respiratory instability and occurrence of postoperative nausea.
Creating the Anesthesia Plan
After the preoperative evaluation, the anesthesia plan can be completed. The plan should list drug choices and doses in detail, as well as anticipated problems ( Boxes 2.2 and 2.3 ). Many variations on a given plan may be acceptable, but the trainee and the supervising anesthesia provider should agree in advance on the details.
Case
A 47-year-old woman with biliary colic and well-controlled asthma requires anesthesia for laparoscopic cholecystectomy.
Preoperative Phase
Premedication:
Midazolam, 1-2 mg intravenous (IV), to reduce anxiety
Albuterol, two puffs, to prevent bronchospasm
Intraoperative Phase
Vascular Access and Monitoring
Vascular access: one peripheral IV catheter
Monitors: pulse oximetry, capnography, electrocardiogram, noninvasive blood pressure with standard adult cuff size, temperature
Induction
Propofol, 2 mg/kg IV (may precede with lidocaine, 1 mg/kg IV)
Neuromuscular blocking drug to facilitate tracheal intubation (succinylcholine, 1-2 mg/kg IV) or nondepolarizing neuromuscular blocking drugs (rocuronium, 0.6 mg/kg)
Airway management
Face mask: adult medium size
Direct laryngoscopy: Macintosh 3 blade, 7.0-mm internal diameter (ID) endotracheal tube
Maintenance
Inhaled anesthetic: sevoflurane or desflurane
Opioid: fentanyl, anticipate 2-4 μg/kg IV total during procedure
Neuromuscular blocking drug titrated to train-of-four monitor (peripheral nerve stimulator) at the ulnar nerve a
a Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.
Emergence
Antagonize effects of nondepolarizing neuromuscular blocking drug: neostigmine, 70 μg/kg, and glycopyrrolate, 14 μg/kg IV, titrated to train-of-four monitor
Antiemetic: dexamethasone, 4 mg IV, at start of procedure; ondansetron, 4 mg IV, at end of procedure
Tracheal extubation: when patient is awake, breathing, and following commands
Possible intraoperative problem and approach:
Bronchospasm: increase inspired oxygen and inhaled anesthetic concentrations, decrease surgical stimulation if possible, administer albuterol through endotracheal tube (5-10 puffs), adjust ventilator to maximize expiratory flow
Postoperative Phase
Postoperative pain control: patient-controlled analgesia—hydromorphone, 0.2 mg IV; 6-min lockout interval, do not use basal rate
Disposition: postanesthesia care unit, then hospital ward
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