Hepatobiliary

1. Definition – Anesthesia for Hepatobiliary Surgery is a one-month rotation for the CA-3 resident which will provide training and learning in the perioperative care of the patient with acute and chronic liver disease.
2. Curriculum – This rotation takes place exclusively at University Hospital.  The goal is to provide an experience that will enhance the CA-3 resident’s understanding of end-stage liver disease and its operative treatment.  Residents will be assigned to a variety of cases including liver transplantation and hepatobilary reconstruction.  The experience will be supplemented by assignment of non-operative invasive procedures such as TIPS and ERCP.  The resident is expected to participate in the care of patients for liver transplantation as part of a team which includes core Anesthesiologists and CRNA’s, as well as surgeons, perfusionists, Nurse Practitioners, and coordinators.  On-call responsibilities will include specialty call (Liver Transplant and Cardiac) via beeper from home.
3. Clinical Duties with Learning Pathways
   1. Perform thorough preoperative evaluations, with emphasis on ESLD as well as other coexisting disease states.  Recognize pertinent physical findings which will be present depending on the severity of the disease.  Appreciate the significance of the NPO status of patients with liver disease, especially for the transplant patient.  Be familiar with various chronic medications which patients may be taking preoperatively.  The anesthetic plan is then formulated and discussed with the supervising attending. 
   2. Obtain an informed consent for the anesthetic management of the patient for hepatobiliary surgery.  The description should be comprehensive, and well-communicated to the patient, and documented on the preoperative record.
   3. Assemble and organize equipment, medications, and supplies necessary to perform anesthesia for liver transplantation and other extensive hepatobiliary procedures.  Maintain an organized work area at all times.
   4. Ensure that the patient has been Typed & Crossed for surgery and that appropriate blood products have been requested.  Recognize that many liver patients have had blood products, therefore follow up with the Blood Bank prior to induction is necessary so that unanticipated cross matching difficulties (e.g. rare antibodies) will be identified and addressed.
   5. Place and monitor all large bore and invasive lines, being cognizant of coagulopathies common to patients with liver disease.  Determine severe coagulopathy in advance and treat appropriately prior to line placement.
   6. Have a thorough understanding of the surgical stages of OLT.  Be vigilant in monitoring the progess of the surgery and anticipate surgeon’s needs.
   7. Maintain contact with the liver transplant team, both surgeons and coordinators, such that the patient can be ready for surgery (induction and invasive lines accomplished) when the liver arrives.
   8. Participate in the immediate post-operative care of the patient, with particular attention on hemodynamic status and ventilatory management.
4. References – Residents are expected to complete required readings from major textbooks (e.g. Miller, Barash) during the three year program.  In addition, selected journal articles and other references will be provided throughout the rotation to help you meet your learning objectives.
5. Objectives - attached
6. Evaluation – All learning objectives will be evaluated as stated in section V.  Each resident will receive at the beginning of the rotation a topic card for discussion by the Director of Ambulatory Anesthesia or his designee.  When the resident has prepared and presented this information to the satisfaction of the DOAA or the supervising attending, the card must be signed by the attending.  It is the resident’s responsibility to fulfill these responsibilities as well as to turn in the card to the Resident Education Committee (in the person of Ms. Venino).

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