Neuroanesthesia

1. Definition – The Neuroanesthesia rotation is four-week block for the CA-2 resident which will provide training and learning in the care of the patient undergoing neurosurgical and interventional neuroradiologic procedures.
2. Curriculum – This rotation takes place at University Hospital, in both the operating rooms and angiography suites.  The resident will be exposed to a wide variety of intracranial procedures, including tumor, neurovascular, and stereotactic surgery.  This experience includes procedures utilizing intraoperative MRI and interventional neuroradiology.  Exposure also includes simple and complex spine surgery, with and without neurophysiologic monitoring.  The departments of Neurosurgery, ENT, Ophthalmology, Plastics and OMFS collaborate on complex resections and reconstructions, which provides the resident with the opportunity to participate in complex multidisciplinary care.  Clinical teaching is supplemented with a manual provided prior to the rotation, with selected readings included. A one-month block in the yearly didactic schedule is dedicated to Neuroanesthesia.
3. Clinical Duties with Learning Pathways
   1. Evaluate the preoperative neurosurgical patient, integrating information specific to the neurosurgical patient such as neuroimaging studies, signs and symptoms of increased ICP, and neurologic deficits.  Present the anesthetic plan based on these findings to the anesthesia attending the day before surgery. 
   2. Set up the operating suite, gearing the set up to the neurosurgical case, which will include specialized monitoring and pharmacology. This will accomplished in a timely fashion, ideally having the first patient in the operating room by the scheduled time and striving for thirty minute turnover time for the remainder of the patients.  Tracking is done by the OR faculty. Recorded times in the computerized nursing records will be noted.
   3. Accomplish a smooth induction and emergence, which necessitates a thorough understanding of the various neurological issues so that each induction and emergence will be tailored to the patient, in accordance with NIPAC standards and to the satisfaction of the anesthesia attending and the neurosurgical team.
   4. Demonstrate the appropriate and judicious use of intraoperative fluids. 
   5. Be alert to sudden changes in hemodynamics, ICP, and neurosurgeon’s needs and be ready for rapid changes in management.  Any such incidents should be noted on the anesthesia record and discussed with the anesthesia faculty. 
   6. Understand and have facility with specialized monitoring techniques such as facial nerve and evoked potential monitoring, which necessitates a thorough understanding of the pharmacologic considerations with each type of monitoring, as evidenced by neurophysiologic parameters that are recorded by the neurophysiologists.  The resident will be able to explain to the faculty attending the changes associated with different anesthetics during facial nerve and evoked potential monitoring.  The attending will be able to ask the resident to explain the changes associated with significant findings when performing evoked potential and facial nerve monitoring.  The resident will log these cases and review them with the neuroanesthesia attending team leader.
   7. Be cognizant of the special considerations in airway management, e.g. Chiari Malformations, Cervical Spine pathology, etc.  The resident should be able to identify neurosurgical patients requiring special airway consideration.   Fiberoptic intubations should be used judiciously and in a timely fashion with minimal hemodynamic and ICP changes.  These cases should be recorded in the resident’s electronic log.
   8. Direct and assess patient positioning, with special emphasis on venous air embolism.  Included are monitoring, diagnostic, and treatment modalities and required experience with Doppler and TEE monitoring.  The resident will be able to explain to the faculty supervisor the measures utilized in positioning to minimize the risk of venous air embolism in all craniotomies with which she/he is involved, as well as explain the monitoring, diagnostic and treatment modalities used in these cases.  These cases will be listed in the resident’s electronic log.
   9. Use and apply ICP monitoring in the perioperative period.  The resident will recognize, troubleshoot and initially manage poor intraoperative brain conditions by using and monitoring ICP.  In all cranial cases, the resident must assess the intraoperative brain conditions upon opening the dura, treating when indicated under the supervision of the neuroanesthesia attending and in partnership with the neurosurgical team.
   10. Perform a complete neurologic exam in the postoperative period when indicated, which requires not only knowledge of said exam but also anesthetic management which allows for timely exam, as guided by patient status. 
   11. Perform complete preoperative and postoperative counseling sessions with all patients and/or their families, being cognizant of and sensitive to the special concerns of the neourosurgical patient.
   12. The resident is responsible for post-operative evaluations on each of his/her patients, a thorough exam performed including an emphasis on problems related to intraoperative positioning.  All morbidities will be reported in accordance with department and university Performance Improvement/Quality Assurance policies. Interesting cases will be presented at Tuesday Case Conference.  
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 will be provided, and the following references are suggested to help you meet your learning objectives:

   Anesthesia and Neurosurgery, 3rd Edition, edited by Cottrell JE and Smith DS. St. Louis, Mosby 1994.

   Basic Neurochemistry, 6th Edition, edited by Seigal GJ, Agranoff BW, Albers RW, Fisher SK, Uhler MD. Philadelphia, Lippincott-Raven 1999.  

   Clinical Neuroanesthesia, 2nd Edition, edited by Cucchiara RF, Black S, Michenfelder JD. New York, Churchill Livingstone Inc. 1998.

   Fundamental Neuroscience, edited by Zigmond MJ, Bloom FE, Landis SC, Roberts JL, Squire LR. San Diego, Academic Press 1999.

   Textbook of Neuroanesthesia, edited by Albin MS. New York, McGraw Hill 1996.

   Youman’s Neurologic Surgery, 5th Edition, edited by Winn HR. Philadelphia, Lippincott Raven.

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 Neuroanesthesia or designee.  When the resident has prepared and presented this information to the satisfaction of the DONA 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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