Anesthsia Review 2009

7/29/2019 Anesthsia Review 2009

1/47

The UNOFFICIALUNOFFICIAL UCDAnesthesiology resident

Survival guide2009-2010

Contributors

Sara Cheng, MD, PhD-Editor

Rachel Boggus, MDMindy Cohen, MD

Matthew Coleman, MD

Georgia Guerra, RN

Jay Hacking, MD

Kellie Hancock, MD

Haley Hutting, MD

Gillian Johnson, MD

Matthew Koehler, MD

Allison Long, MD

Estee Piehl, MD

Prairie Robinson, MDJames Sederberg, MD

Cristina Wood, MD

1


2/47

TABLE OF CONTENTS

TABLE OF CONTENTS ..........................................................................................................................1

INTRODUCTION ..................................................................................................................................... 2

BASIC EXPECTATIONS .........................................................................................................................3

HOW TO SET UP A ROOM ....................................................................................................................4

WHAT TO DO AT A CODE .................................................................................................................... 5

GENERAL OR- UNIVERSITY HOSPITAL ............................................................................................. 6

IMPORTANT NUMBERS- UNIVERSITY HOSPITAL ............................................................................. 8

GENERAL OR- VA HOSPITAL .............................................................................................................. 9

GENERAL OR- DENVER HEALTH MEDICAL CENTER .................................................................... 12

IMPORTANT NUMBERS- DENVER HEALTH MEDICAL CENTER ................................................... 15

PRE-OP/PACU ROTATION- DENVER HEALTH MEDICAL CENTER ............................................... 16

OUTPATIENT ANESTHESIA (AOP) - UNIVERSITY HOSPITAL ........................................................22

IMPORTANT NUMBERS- AOP ............................................................................................................ 23

ACUTE PAIN SERVICE (APS) ............................................................................................................. 24

CARDIOTHORACIC SERVICE .............................................................................................................27

THE CHILDRENS HOSPITAL ............................................................................................................. 29

CHRONIC PAIN CLINIC ....................................................................................................................... 32

OBSTETRICS (LABOR AND DELIVERY) ........................................................................................... 34

TRANSPLANT ..................................................................................................................................... 36

SAMPLE NOTES .................................................................................................................................. 38

USEFUL WEBSITES .............................................................................................................................40

1


3/47

MAPS .....................................................................................................................................................41

NOTES ...................................................................................................................................................44

NOTES ...................................................................................................................................................45

NOTES ...................................................................................................................................................46

Introduction

For CA-1 residents:

Welcome to the University of Colorado anesthesia residency program! Were glad youre here. If

youre reading this, youve jumped through a dozen hoops, maybe moved across the country, replacedelectrolytes a bazillion times, and ADC VANDIML is your middle name. Congratulations- internship is over!

Youre doing what you really want to do, finally- passing gas.

That being said, youre probably a little nervous. It may have been a long time ago that you did anyanesthesia! And your daily routine is going to be far and away different from what youve been doing this past

year. Youre not alone- everyone says the first couple of weeks/months can be very anxiety-provoking. I

certainly didnt sleep very well those first couple of months. Rest assured- read when you can, and come towork every day ready to play ball- youll get through it just fine.

This little book is meant to help you through your first week at each new hospital. It is meant to be a

practical guide to those little daily details that will be second nature to you in a couple of months. It is NOT

meant to be a medical reference or a guide to anesthesiology. It was put together by CA-2 and CA-3 residents,for UCD residents only, and is not endorsed by the administration formally. Therefore we take no

responsibility for anything wrong or omitted by this guide- it will not substitute for reading, common sense, or

talking to your attending. It is simply meant to ease the pain just a little bit, and hey, Im all about easing thepain.

Never hesitate to ask for help when you need it. If youre in the OR, first call your attending. If he/she

is unavailable and youre in need of urgent help, call the charge attending or page overhead for any available

anesthesia attending. Also, dont hesitate to ask more senior residents for advice about how to set up or preparefor a casewere here for you. Finally, everyone goes through tough times during residency at some point-

when it happens to you, dont think youre alone! Talk to your friends, your spouse, a friend in the programwhom you trust it helps to get you through it.

For CA-2/3 residents:

This edition has new sections for the subspecialty rotations. Let them serve as an introduction andoverview for you, as well as a reference for all those pesky codes and phone numbers, etc.

Weve worked many hours on this guide and hope it is helpful. However, it is a work in progress!Please scribble things in this book that you think need to be in the next edition, and share them with next years

editor who by the way may be you. Im outta here

Good luck and have fun!

Sara Cheng, MD, PhD

Editor

2


4/47

Basic expectationsSARA CHENG, MD, PHD

Here are some pointers to get you up and running. I know, they may sound basic, but people have gotten in

trouble multiple times in the past for not doing these thingsrather than beating them with a you should have

known hammer, I think its just better to say these things up front:

Before starting at each hospital, try your very best to GET A TOUR of the place. At DH, Dr. Humphreygives a great orientation. At the VA, Dr. Friedman or one of the residents will show you around. At the

U, its best to find a resident to give you a tour. In July, youre not expected to have had much time toget an orientation before your first day in the OR. But later in the year, before your first day at a new

hospital, PLEASE be proactive and arrange with someone to get a tour. You can do it pre-call or post-

call, or after your scheduled cases with an on-call resident. Do NOT be the guy/gal who shows up at 3

PM on their first day for their first call and doesnt know where the OR is, doesnt know where to getdrugs, etc etc- it is painful for you and uncool for everybody involved. Believe me, its happened!

Each day, you should find the next days OR schedule (emailed to you at the U, on the little podium inthe PACS room at the end of the hall at the VA, at the OR bridge at DH). LOOK UP YOUR

PATIENTS on the computer and fill out what you can on an H & P form or on Centricity at the U,

including recent labs and imaging. At the VA and DH, past anesthetic records are readily available onthe computer too and are always useful. Then, even at this stage, try to FORMULATE A BASIC PLANin your head for each patient (see below). It may be as basic as I think this patient needs general

anesthesia with a tube and no invasive monitors but thats still a plan. Then, either find or CALL

YOUR ATTENDING about tomorrows cases. At the beginning of the year, you should always callyour attending to go over the plan for each- this is a basic expectation. It gives them a chance to go over

stuff before the busy morning and relieves their anxiety as much as yours. If they dont call you back or

dont talk very much, then at least you fulfilled your obligation. Later in the year, as you get to knowthem better and get more comfortable, there will be some attendings for some simple cases you wont

call, but for now- its safest to always call the first time youre working with an attending. If someone

establishes themselves as one who doesnt call back, then now you know.

Formulating a plan: take a stab at these basic questions when you present to your attending. What kindof anesthetic does this patient need to have this operation safely and comfortably? (general vs. neuraxial

vs. nerve block vs. local anesthesia). If a general, what kind of airway (ETT vs. LMA) and what kind of

induction (rapid sequence vs. standard). What drugs will you use? Do you need any additional IVaccess? Do you need any invasive monitors? Are there co-morbidities that will complicate your

management? You will not know the answers to many of these things initially, but have them in the

back of your mind and youll look like a thinker from the beginning.

Every morning, every case: PREPARE YOUR ROOM (see below). SEE THE PATIENT. Look at

vitals, do physical exam focusing on heart/lungs/airway. Obtain consent. Talk to your attending. Once

you and nursing are ready, start antibiotics/administer pre-med if appropriate and bring patient back toOR. Get your monitors on. Call your attending for induction.

POST-OP CHECKS: you are expected to go see your patients if they are still in the hospital within thefirst day or two after surgery. You should ask them about intraoperative recall, pain control, and any

questions/concerns about their anesthetic. Write just a couple of lines in the chart, documenting thisconversation. An example: Anesthesia f/u note: 64 yo POD#1 s/p ex-lap under GETA. Denies recall.

Denies complaints. Pain controlled. Questions answered. Signing off.

3


5/47

How to set up a roomSARACHENG, MD, PHD

You should always set up a room to be prepared to put a person to sleep under general anesthesia, even if you

are planning on using a different anesthetic technique. Patients get too uncomfortable, change their minds, goapneic you get the idea. The important thing about room setup is that you should use a system consistently.

An organized system is a safe one. This is how I do it but there are many ways

1. Turn on your machine. If your machine has an automatic start-up protocol, start it and follow thedirections. Otherwise, start the oxygen sensor calibration, as this takes some time.

2. While thats going, set up your drugs:

a. Emergency drugs to always have drawn up: Succinylcholine 5cc@20mg/ml, Ephedrine10cc@5mg/ml, Atropine [email protected]/ml, Glycopyrollate, [email protected]/ml, Phenylephrine,

several syringes, 10cc@100mcg/ml

b. Induction drugs- draw this up only if youre planning to do a general. Usually propofol 20

cc@10mg/ml, occasionally etomidate if CV unstable or thiopental for craniotomy, lidocaine3cc@20mg/ml if using propofol through a peripheral IV (propofol burns!)

c. Narcotics etc- fentanyl, midazolam, dilaudid- having at least 2 mg of midazolam and 250

fentanyl drawn up is a good start.d. Whatever else you and your attending have discussed.

3. Finish machine checkout:

a. Reattach your oxygen sensor.b. Check that monitor is on and displaying appropriately

c. Check that backup oxygen canister is full

d. Check that the vaporizers are full, that the vaporizer you want (i.e. sevoflurane or desflurane) ispresent (there are only 2 spots and occasionally youre want to use a gas thats not there- youll

have to ask the anesthesia tech to get it for you), and that the dials turn.

e. Check that all gas flow knobs by turning them all on, then turn air off, then turn oxygen off-

when you do, nitrous should go down to off too (safety mechanism).f. Check for circuit leak.

g. Check that gas sample line is connected and patent (blow on the end through your mask to see

CO2 appear on monitor)h. Check CO2 scavenging canister- all purple=need a new one.

4. Monitors: Put pulse ox and BP cuff at head of bed. Place EKG leads on bed- for 5 lead, green and white

on right. If using invasive monitors, make sure you have transducers in room and plugged in, wet down.5. Airway (SALTT)- suction on and at head of bed, airway (oral) in 2 sizes, laryngoscopes with 2 different

blades and light working, tube (endotracheal) in 7.0 and 8.0 sizes with balloon tested, syringe attached,

and stylet available), tongue depressor. Also, always good to know where the emergency LMAs are

located (in the room or in the anesthesia workroom, depending on your site).

Some favorite mnemonics:MSMAIDS (machine check, suction, monitors, airway, IV access, drugs, special/specific to case)MMM SALT (machine, meds, monitors, suction, airway, laryngoscope, tube)

All Electric Gadgets Need Proper Stimulation (emergency meds: Atropine/Ephedrine/Glycopyrrolate/

(neostigmine)/Phenylephrine/Succinylcholine

As always, go over all this with an attending or senior resident during the first week. It seems like a lot but

youll be able to get it all done in 15 minutes eventually.

4
mailto:[email protected]/mlmailto:[email protected]/mlmailto:[email protected]/mlmailto:[email protected]/ml


6/47

What to do at a codeSARA CHENG, MD, PHD

After you have been a CA-1 for approximately 30 days, you will start taking overnight call and will be handed a

small, scary, black plastic thing called the code pager. The first several times this thing goes off your heart will

start beating very fast and you may briefly contemplate running away. Instead, you will run and grab theairway box, having checked earlier that day that you knew where it was and that it was stocked appropriately,

and run your butt over to the patients room. Your job as the anesthesiologist is to manage the airway and

intubate if needed.

On the way there, call your attending and tell them where the patient is so that theyll meet you there.

Once there, eyeball the situation.

Is the patient lying there, out of it, but all vital signs on the monitor are stable and there are no people buzzing

around? You probably have time to talk to the nurse/team and figure out the history, as well as wait for yourattending. Remember the indications for intubation: oxygenation, ventilation, airway protection, operative

procedure.

On the other hand, is there a full-blown resuscitation going on with an RT or nurse bagging the patient? Youre

going to need to intubate. Remain calm and remember one thing: that after 30 days of being an anesthesia

resident you may know more about airway management than most of the people in the room. So, your place isat the head of the bed, not milling around talking to people or trying to assemble your stuff. Announce youre

with anesthesia. Push others out of the way if you need to. Try to assess the airway (morbidly obese/no neck/in

C-collar or halo/jaw wired shut=BAD) and bag the patient. If its difficult, two-hand mask and ask someoneelse to squeeze the bag. Ask others to assemble the minimum needed for intubation: suction on and within

reach, airway (oral), laryngoscope, endotracheal tube, free flowing IV, drugs (induction agent and paralytic).

Ask about full stomach (rapid sequence induction with cricoid pressure), if recent potassium was high or if

stroke/myopathy present (contraindications to sux), whether blood pressure has been stable (use etomidate overpropofol). If the patient is unconscious or almost unconscious then you may not need drugs- just do your DL

and if the cords are closed you can push some sux. By the time youve started some of this stuff your attending

will be there and you guys can get on with intubation together.

One very important pearl: ALWAYS take the time to position the patient optimally for intubation, just as you

would in the OR. Even if everyone looks very busy and they are in the middle of chest compressions, take the10 seconds to get everyone to move the bed away from the wall, adjust the height, and boost the patient up in

the bed towards you. It could be the difference between a first shot successful intubation and an initial failed

laryngoscopy that gets bloody and more difficult.

OK, one more very important pearl: Once youve successfully intubated, hold on to your tube for dear life until

it is safely taped. In the middle of a code, it can easily come out again (an event that caused personal asystole inthis author 3 years ago).

Some favorite mnemonics:

VISA (vent/ambu, IV functioning, suction on and within reach, airway tools)SALT (suction, airway (oral), laryngoscope, tube)

5


7/47

General OR- University HospitalCRISTINA WOOD, MD

Important people:

Program Coordinator: Jan Ratterree, office: 303-724-1758, fax: 303-724-1761, email:[email protected]

Administrative assistant: Suzanne Bullard, office: 303-724-1765, fax: 303-724-1761, email:[email protected]. Anesthesia IT: Ken Bullard, [email protected].

Before you start: You must have your ID badge (use it for parking and getting through doors), codes for Pyxis,Centricity, Clinical Workstation, Med Explore and Care Manager. When in doubt, call Jan or Suzanne, they are

lifesavers. Call a resident who is over at the University to give you a tour before starting.

Ask Jan about getting set up for Med Explore from home, and Ken about setting up VPN (virtual privatenetwork) from home. That way you can do your Centricity pre-ops from home.

Centricity: Learning Centricity, the Intraoperative charting system, is paramount before starting a case. If this

is your first month of CA-1 year, you will have an orientation scheduled for you at the University prior to

starting a case. Otherwise, please contact a superuser: either Cara English (720-333-0509), Mary Bidegaray(720-333-0631), Allison Rocco (720-333-0372) or Sarah Figueroa (303-946-4872) for your Centricity

orientation about 2 weeks before you are scheduled to come to UCH. If you have any difficulties scheduling

this training please contact Leslie Jameson, MD directly (303-333-0869).

Weekdays Daily Work Flow

Do H&Ps on patients coming into the hospital as best you can with info (including latest labs, EKG, CXR,TTE etc) from Clinical Workstation or Med Explore (for inpatients, vitals will be on Care Manager and you

must pre-op and consent these patients the night before).

Give yourself at least 30 minutes to set-up your OR before any morning conferences (Monday- GrandRounds 7:00, Wed- ITE lecture 6:30, Fri- Cardiac lecture 6:30). The techs are great and usually will set up

arterial lines and central lines for you, but you may need to do these yourself as well. You can always call

the techs to help (see numbers below).

Be sure that if you need infusions (i.e. TIVA- total intravenous anesthetic), you have all the pumps you needin the room.

If prone cases, be sure to check that you have a prone pillow. Ask the techs.

Get patients narcotic bag from Pyxis in the PACU (It is called narcotic bag on the list and includes 4mgVersed, 750mcg Fentanyl, 2mg Dilaudid and 400mg propofol). Other meds like Mannitol/Nimbex/Heparin

are in the Pyxis/refrigerator in the pod areas between the ORs and lasix/premade Sufentanil syringes are at

the pharmacy (window is located in the same hall as the main OR board). You can always call the pharmacyto make up a drip for you. Clark Lyda, the head pharmacist, is always an excellent resource for any and all

drug-related questions. All emergency drugs are in your cart in the OR.

Make sure you get Centricity loaded up in the OR before you head to pre-op.

Arrive in Pre-op around 7:00 (8:00 on Mondays).

Find your patient- paper OR schedule in pre-op on countertop shows bed number and nurse** Learn the preop and PACU nurses/names, they are a wonderful resource and really will help you ifyou make the effort!**.

1. Complete pre-op H&P in Centricity while talking with the patient. Nurses handwrite vitals in chart,

ask where.2. Sign Pre-op Order sheet (nurses need official order to give IV fluids, EKG, labs, scopalamine patch)

3. Consent the patient. (Check with attending about type of anesthesia first).

4. Start IV if not done already. Try to put in 18 gauge or larger.

5. Verify antibiotics and that they are on the bed, or on the way to the OR.6. Check with patients nurse and the OR nurse before wheeling out.

6
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


8/47

Get patient moved over and start pre-oxygenating first!

Put on monitors. I always put on pulse ox first, then BP and while it is cycling, I get on the EKG leads.

Call your attending to tell them you are in the OR. All communication at the U is via cell phones. Have all

the induction drugs ready to go, even plugged into the IV line. Do not push any drugs yet.

Your attending will come in for the induction, have fun!!

Remember that OR rooms 1-4 do not have great cell phone service. So have the attending number handy

and be ready to call from a land line if need be.

Call attending prior to extubation, no exceptions. After transporting to the PACU, help the PACU nurse apply patient monitors and give him/her your report.

Its helpful to take a look at the sheet they fill out so that you can have an idea of what they want to know.

Make sure all paperwork in anesthesia packet is signed. There are three parts: PACU orders, billing sheet(blue), confidential incident sheet (purple)

Write totals on narcotic bag; make sure they match Centricity totals. No needles! Drop off in metal box

next to Pyxis in PACU with patient sticker! Get meds for next case. (If you have quick cases, you may wantto pull out multiple narcotics first thing in the morning).

Finish Centricity Record and print a copy. Place hard copy with patients chart.

Usually will get coffee (15min), lunch (30min), and tea (15min) break.

OR schedule with anesthesia assignments comes out around 2pm. It is emailed to us as a PDF and hard

copies are available at the OR desk. Look up patients for the next day and call attending the night before todiscuss plans. See all inpatients the night before and have the consent signed.

Weekday Hours

R1: This means overnight call: 3pm-7am. You will finish all of the late cases for the day and all of the

emergency overnight cases.

R2: Late shift: Start with the first cases of the day (so you need to be there about 6am to set up your room,etc) and you are in house until there are only a couple of rooms going. Usually until 6-8p.

R3: Very similar to R2, but you leave a little earlier. Usually 5-7p.

R4-Rinfinity: You usually finish and can leave after you have finished your cases, or about 3-5p.

Call Nights/Weekend Call

Weekday call nights usually arrive at 3pm but always check (look @ relief time on OR/Anes schedule).

Check OR board and/or with Anes Charge (85920) to see where youre needed. Keep your pager on duringthe day; they may need you to come in a little early if they are very busy. (Never happened to me though).

Weekend call is a 12 hour shift, changing over at 7am/7pm.

2 call rooms: 1) Leprino Office Building (near parking garage). 4th Floor, East side, door code is 3-1-2.Then go to the far North side of building to find our call room. 2) SICU anesthesia sleep room- must use if

you are carrying the code pager. Door code 0-1-5-8.

Code Pagers/Badge When on call you sometimes carry a code pager and badge that should let you in anylocked door (does NOT override elevator), if the anesthesia ICU resident is not in house.

Codes (See Section What to do at a code) Your responsibility is the A of the ABCs. Get to the head of

the bed, assess need for airway intervention. Its OK to push RTs, RNs, residents out of the way. Beforeintubation remember VISA V-ventilator or ambu-bag ready?, I- patent IV functioning?, S- suction ready? (is

often missing), A- airway tools available?

Airway Box Locations 1) main OR anesthesia workroom,2) in PACU, 3) in SICU supply room on top of

fridge (ask any SICU RN).

7


9/47

Important Numbers- University Hospital

Anes Charge Attg 85920

OR front desk 84351

RN charge 83512

Pre-op 86252PACU 86203

OR pharmacy 86132

Main pharmacy 81389Anes chief tech 85917

Anes techs 85912,-13,-14

OR Anes phone 864## (## = rm #)OR RN phone 863## (## = rm #)

Lab pager 266-5040

Lab land line 87086

Blood gas lab 85309Centricity Help 85915, 85919

Hospital Operator 720-848-0000

Blood Bank 84444

Door Codes

Locker Rooms & Faculty Lounge 04507Anes Workroom 2311

Call room Leprino 4th floor 312

SICU sleep room (must use when 0158carrying code pager)

Other:

BICU 8-7583SICU 8-7586 8-7400

Neuro ICU 8-5490

Engineering(room temp.) 8-8351

303-266-4500

Acute pain 266-6493Chronic pain 266-7291

Pain Clinic 8-1970

OB Anes. Att. 8-5973

OB Anes. Res. 8-5972OB Res page 266-5820

OB Anes. CRNA 8-5911OB 4th front desk 8-5233OB 5th front desk 8-4111

AOP Charge MD 8-1507AOP Pre-op 8-1350

AOP PACU 8-1360

8


10/47

General OR- VA HospitalHALEY HUTTING, MD; MATTHEW KOEHLER, MD

Important People:

Dr. Lyle Kirson head of VA anesthesia

Shirley Pfister, RN pre-op nurse and fund of knowledge about accessing pt records

Carrie Shurmantine Anesthesia Department controller, she handles all badge & ID questions. (303) 393-

2883. Email: [email protected]

John Hawk, PharmD handles Pyxis concerns (and is a fantastic resource for drugs)

Jake Friedman in charge of resident education, 303-609-3590.

Other attendings Dr. Dev Rai, Dr. Luke Osborn, Dr. Mohammed Javed, Dr. Peter Rowe, Dr. Allison Long

(all are super-friendly and excellent teachers)

Before you start: You must have your ID badge, scrub codes, parking hang tag, and computer codes. Carrie

handles most of these things. Get in touch with her at least a week early if you can. Also, in your first few days

you should get Pyxis access (from John) and iStat codes (from Anesthesia techs, for blood gas and ACT).

Phone Numbers

VA Hospital Main Phone number: (303) 399-8020All OR communication is done via overhead paging: just ask the circulating nurse to do this for you when you

need your attending or you are ready for induction/wakeup. They will also show you how to do it yourself if

you like.

Door Codes

Conference room 4-3-2-1

Anesthesia Workroom 4-3-2-1

Locker room code is the room number (listed on plaque next to door) many lockers are first-come,

first-served, so if its empty and it doesnt have a name on it, you can use it. There are also a few small

lockers in the anesthesia conference room for residents (next to the refrigerator) To access locked anesthesia carts: Turn dial to left, then press 1-2-3, then turn dial to the right.

Badges and Cards (all of these should be given to you during orientation)

General Badge is used for identification and for access to the OR by the locker rooms.

Scrub card badge will allow you to access scrubs from the scrub machine next to the locker rooms

Parking tag allows you to park in deck across from VA (9th & Clermont St), south of the VA building.

Weekdays Daily Work Flow

The pace at the VA Hospital is a little more leisurely than it is at the other hospitals, but they are reallytrying to get cases started on time and speed up turnovers as much as possible. H&Ps for all your cases should

be done the day before they are scheduled and discussed briefly with your attending (especially at the beginningof the year). The VA computer system is very thorough but is not accessible from home, so the work has to be

done before you leave. Also, if you have cases that have possible blocks for the next day, you should check theblock cart in pre-op before you leave and restock it (or ask an anesthesia tech to restock it).

Cases start at 07:45 (in the room) Tuesday through Thursday, 08:30 on Monday. You will start your

own IVs, so get there early enough to do this. Also, plan for time to do any blocks/epidurals if indicated. Youshould plan to be done interviewing the patient by 07:15 (08:15 on Monday). There are four groups that must

see a patient before sedation - pre-op holding nurses, surgeons (consent/marking), OR nurses, and anesthesia.

Do NOT start your block or give any sedation before verifying that everyone has seen the patient.

9


11/47

All patients go to the PACU EXCEPT patients being admitted to the ICU go directly to the ICU (even if

extubated). Also, after hours and weekends, patients will go to ICU for wake up only since there are noevening/weekend PACU nurses. Propacks are stored in the pre-op area. Please return them after transport and

plug them in to charge.

Since the VA is a smaller hospital with fewer ORs, everyone needs to help out in order for things to runsmoothly. If you have a cancelled or delayed case, try to get your own breaks/lunch and give breaks to others if

you have time - be proactive. On non-call days you usually go home around 16:00 - 17:00. On call days, you

stay until the last room is finished. One of the things that is different about the VA is that you relieve the

CRNAs at 15:00, but they may be hiring a late float CRNA to help with late afternoon cases.Printed schedules for the next day are located in the radiology room under the podium. Changes are

frequent, so make sure to check the white board in pre-op for the latest schedule. Make sure to check the board

for a blue triangle (pending labs, usually tox screen) or orange rectangle (anesthesia NP workup available).

Pharmacy

All non-controlled substances are stored in the anesthesia cart or the anesthesia workroom (cabinet orfridge).

Controlled substances are in the pharmacy in PACU (overhead page pharmacist if closed at lunchtime).

After hours (3pm) and on weekends, you will need to get controlled substances from the Pyxis in PACU.Check with John Hawk to get set up with access to this. Place all narcotics in a plastic bag along with a drug

count sticker (on top of Pyxis) and place it in the drop box in the pharmacy door at the end of your case.Equipments and meds for peripheral nerve blocks located in the block cart and the block room in pre-op.

Ropivicaine and clonidine is in the pharmacy.

Paperwork

3-4 photocopies of your anesthetic record should be made after each case: the original goes to thePACU nurse, one copy goes to the pharmacy with your returned controlled substances, one copy goes in

the folder in the lounge (for record-keeping), and one copy goes to the ICU nurse (if applicable).

Intra-op: you should complete an anesthetic record, an H&P, and a time-in/time-out/antibioticadministration sheet, QA sheet, and delay sheet.

Pre-op evaluations (Shirley Pfister or Terra Sharp): On complex pts, Shirley or Terra will do a pre-op

evaluation and write the H&P for you. A copy will either be pinned up on the cork board in the loungeor in the top left file cabinet in the lounge (filed by year of surgery and alphabetically). Check CPRS if

you cant find the copy.

Check VISTA for previous anesthesia records. Also, if the patient has had an operation within the last

calendar month, you can check the brown folder in the conference room for a copy of their anestheticrecord.

Post-op Orders are written in CPRS in the PACU. They should include an IV narcotic, a PO narcotic,

and an anti-emetic at the minimum.

Blood paperwork There is paperwork that accompanies each unit of transfused blood. Make sure to

check with your attending because they need to sign this.

Call & Weekends Call at the VA is HOME CALL (yea!). Keep your individual pager on. There is no VA-specific pager

Surgery resident will call you when a case needs to go at night or on the weekend. Get informationabout patient. Ask if surgery attending knows about the patient and when they will be ready to start.

Also verify that surgery resident is calling the nursing supervisor, who will call in OR nurses. The

process from first phone call to case start usually takes at least one hour.

Talk to your attending some want to be called immediately, some want to be called when the nurses

arrive. Any calls for ED anesthesia or difficult airways should be immediately discussed with the

attending (do not come in first). When in doubt, call your attending.

10


12/47

Try to clean up your anesthesia machine after night/weekend cases (pick up monitors, throw awaydrugs, etc)

Weekend call is also Home Call, but you are also in charge of the acute pain service, so you may have to

come in and round in the morning (see below).

In general, anesthesia is not responsible for intubations outside of the OR. There are some

circumstances when we do get involved. Any questions, call attending.

Also, there is always a separate anesthesia team on for cardiothoracic. If you get called for a CT case,

pass it on.

Acute Pain Service

The VA is the only hospital that has you follow the pain service before you have you APS rotation, somake sure you get all of your questions answered before you start a weekend call. Ask Dr. Osborne for the

instruction sheet on epidural management at the VA. You will round on the patient, write orders, and write an

APS note in CPRS on each weekend day. There is an epidural clipboard in the anesthesia conference room that

has one sheet of paper for every epidural patient (document level, infusion, and verify that a note is written eachday). Over the weekend, the call person rounds on all epidural patients. During the week, generally the

resident who placed the epidural rounds on the patient. However, it is ultimately the call persons responsibility

to make sure that a note is written in CPRS.

Acute Pain Service Keys:

1. Write order to hold sq Heparin on mornings you are pulling an epidural.

2. Write order to restart Heparin one hour after epidural is pulled.3. Discuss with primary team. All pain meds by primary team after epidural d/cd.

4. Make sure all epidural catheters come out with the catheter tip intact and document this.

Lectures:

Mon(07:00) Grand Rounds teleconferenced from Univ.

Tues (06:40) Lecture in 4th Fl. Conference Room

Tues (15:30) - if available - Lecture teleconferenced from University.

Wed (06:15) ITE lecture teleconferenced from Univ.

Thurs (06:40) Lecture in 4th Fl. Conference room

Fri (06:30) Lecture in 4th Fl. Conference room*Teleconferenced lectures are viewed in the 3rd floor Pathology conference room. If the door is locked, the key

can be found in the pathology office. If the pathology office door is locked, that key is located in the Histology

lab. See Dr. Osborne for detailed instruction sheet how to set up teleconference. The scavenger hunt for thekey can be time consuming, so lectures can also be viewed live on the intranet now (computers in the anesthesia

conference room).

*Make sure to check the schedule on the door of the anesthesia conference room. Residents are scheduled to

give one lecture each month.* Friday is usually QA or CCC (Clinical Case Conference) = oral board style

VA Computers

Get all codes for general access and CPRS access through IRMS (1st floor by Clermont entrance).

Make sure to set up a signature code in order to be able to sign orders and view images through VISTA

Talk to John Hawk if you are unable to write orders, you may need to sign some narcotic paperworkthrough pharmacy office

Old Anesthesia Records and EKGs are viewed by going under the Tools tab in VISTA and accessing

VISTA IMAGING from the drop-down menu.

11


13/47

General OR- Denver Health Medical CenterALLISON LONG, MD; RACHEL L BOGGUS, MD

Important people:

Residency administrator: Dr. Jack Humphrey

Medical Education Coordinator: Laura Rendon, Phone: 303/436-6029; Email: [email protected] Secretary: DeVindra Randall; Phone: 303/436-8375; Fax: 303/436-6548;

Email: [email protected]

Speak to DeVindra Randall at least 1-2 weeks prior to your arrival to arrange the following:

-parking

-ID badge-locker assignment and code to the lock

-scrub machine code

-who to call for computer access codes

-Pyxis access code*Contact Dr. Humphrey prior to your arrival to arrange a tour before your actual start day

Phone numbers- At DH they generally use an overhead paging system to reach attendings, anesthesia techs,etc. After picking up the phone, you press page and then say your message (Dr. Sawyer please call room

one or Anesthesia tech, please bring the glidescope to room 1)then hang up the phone. If you pick up the

phone, press page, then hear a busy signal then someone else is paging overhead at that time and just try againin a few seconds.

Door codes-

Resident call room- 1924

Anesthesia work room- locked after 11p.m., key is the same one that opens the call room; it is in the lock box

outside of the call room (after 11p.m. you should keep the key with you)

Locker rooms- are not locked

Weekdays

Most patients go to the pre-op clinic and the H&P will be completed for you. Find them in the file folder in thebull-pen. If its not there, they either did not go to the pre-op clinic and you can do it in the a.m. or it is still

being completed and may show up by morning. If you are scheduled to take care of an INPATIENT, you

should see them and complete the green H&P form before you go home the night before. Generally, attendingsdo not expect you to call them the night before to discuss cases. The OR schedule for the next day is available

in the early afternoon and is in the bull-pen.

Arrive 30 min prior to conferences to set your room up. Get all medications (including narcotics) out of thePyxis in your OR room. Make sure to label/date/time all your meds because they fill the Pyxis in the mornings

and they find meds in there that are not labeled they will throw them away. Mondays- Grand rounds areteleconferenced to DH at 7 a.m. Lectures other days of the week are from 6:45-7:15 a.m. in the lunch room- seebulletin board in that room for exact days as some days there are no lectures.

After conference (or before if you have time) see your pt in pre-op. Marker board has pts name and chairlocation. Complete H&P/Consent/IV access (usually nurses do the IVs unless they are difficult in which case

they will give it a try or two then call you). After all consents have been signed pt can have premedication and

can be pushed back to the OR in their chair. Dont transport patients past the main OR board, go around (itviolates HIPPA). Overhead page your attending when you are in the room if you have not already seen them.

12


14/47

Unused narcotics have to be wasted with another resident, CRNA, or attending by having them witness youdiscard medications at a Pyxis machine. Ask someone how to do it. You can save all leftovers throughout the

day until you have some time to do this, just stick a patient sticker on each syringe.

Call Nights/Weekends

Weekday call (C1) - be ready to go at 3 p.m. Check board or contact charge to see where to go.

Weekend call is 12 hr shifts 7a.m. to 7 p.m., 7 p.m. to 7 a.m.

*When you arrive for call, check that the trauma rooms (OR 1 and 5) have been set-up. See following page ontrauma room set-up. It is important to have them set-up, as there is usually no time when a trauma patient is on

their way up to the OR.

Float- arrive at 11a.m., start day by giving lunch breaks, you will be the last to leave on this dayLate- arrive at usual morning time and you will be the 2nd to last resident to leave

O- You are not on call, arrive at usual morning time and you will likely be relieved around 3 pm. This is pretty

consistently true at DHMC, which is lovely.

Code pager- you will carry this when you are on call. The float CRNA will give it to you and you can hand it

off post-call to the new float CRNA

Codes- same responsibility as other hospitals- primarily airway (see Section What to do at a code)

Airway box location- It is just inside the anesthesia workroom to the left of the door when you walk in. TheGlidescope and fiberoptic card are also stored in this room. You may occasionally get paged to bring these

things to a patients bedside.

13


15/47

Guidelines for Trauma Room Set-up at Denver Health

Anesthesia Machine, Circuit, and Work Area

Standard anesthesia machine set-up and checked out, including suction

Two functional laryngoscope handles and selection of blades

Three prepared endotracheal tubes (7.0, 8.0, and 9.0) with stylets and 12 cc syringe in place

Oral airways (80 mm and 90 mm) and tongue depressor

16f NG tube

Esophageal temperature probe

Monitors

ECG cables deployed with electrodes attached, paper in ECG recorder

Non-invasive BP cuff deployed at head of bed under mattress

Pulse ox deployed on circuit tree

Art line set-up on transducer with wet down pressure bag, pressure cable connected to machine. Second

pressure module and cable available should CVP be needed

Fluids, Warmers, IVs Two Level I warmers assembled with (1) D-50, and (1) D-100 style tubing, stop cock, extension, and

1000 cc bag of LR, notwet down until needed

One 250 cc bag NS with 400 mg dopamine, and one 250 cc bag NS with epinephrine (4 amps) taped to

their sides and IMED tubing placed in plastic bag hanging on Level I

One two chamber IVAC pump

Drugs Available with labeled syringes but not drawn up

Etomidate

Vecuronium

Emergency drugs prepared and stored in top drawer of Pyxis Atropine 400 mcg/ml

Succinylcholine 20 mg/ml

Ephedrine 5 mg/ml

Neosynephrine 100 mcg/ml

Epinephrine 2 syringes: syringe 1 10mcg/ml, syringe 2 100 mcg/ml

Invasive Lines

Arterial catheter start kit bundled and available

Triple lumen catheter and Cordis introducer on top of anesthesia machine

IV start kit bundled and available

14


16/47

Important Numbers- Denver Health Medical Center

Attending In Charge (AIC) 123-118

OB CRNA 123-104

Anesthesia Call Resident 123-102

Calling from outside: 303-436-xxxx

Bridge 68061

Blood bank 66929

SICU 68333

OR nursing phone 680xx

OR anesthesia phone 630xx

Attending Physicians Pager

Herren, Michelle 303/201-4160

Bui, Camelia 303/206-7654Chandler, Mark 303/208-1730

Duke, James 303/540-3983

Humphrey, Jack 303/851-4182Juels, Alma 303/208-7049

Kumar, Sunil 303/208-0485

Lockrem, John 303/207-1950Meyer, Eric 303/266-2413

Michel, Theresa 303/208-0272

Miller, Howard 303/540-3982Packer, Mac 303/891-3465

Sawyer, Mike 303/206-9785

Valdivieso, Ron 303/208-1220

Practice Manager Phone Ext.

Cottrell, Judy 68377, I.C. 77

Support Staff Phone Ext.

Camp, LeeAnn 68378, I.C. 79

Randall, DeVindra 68375, I.C. 83

Pre-operative Clinic Phone Ext.

Goldsmith, Kathy NP 65995

Pre-Op Center 65990

CRNAs Pager

Adams, Heather 303/208-0840

Bosso, Jennifer 303/208-0636

Bradley, John 303/206-4959

Ebeling, Steven 303/206-2197Faughnan, Gretchen 303/206-7646

Feldaverd, Brad 303/206-4972

Ford, Christie 303/206-7657Harenberg, Jennifer 303/461-8269

Mejia, Tina 303/206-4043

Moffitt, Aimee 303/206-4437Morgan, David 303/208-6121

Phillips, Susan 303/266-7324

Quist, Barbara 303/855-0795

Singer, Fred 303/760-6971Strittmater, Elton 303/208-8857

Taber, Alexis 303/461-1754

Temple, Michael 303/206-1725Tubac, Gregory 303/461-0698

Warnecke, Doug 303/826-5718

Wehrman, Amy 303/207-8897Winckler, Chris 303/201-2257

OR Nurse Manager Pager

Andis, Ann 303/826-2570

Phone Ext. 66492, I.C. 27

OR Clerical Super. Phone Ext.

Higgins, Stephanie 66573

Anesthesia Technicians

Dallas, Rueben 123-339

Montoya, Sophia 123-325Mantano, Liz 123-146

Snelling, Ron 123-105

von Holdt, Kevin 123-905

15


17/47

Pre-Op/PACU rotation- Denver Health Medical CenterRachel L. Boggus, MD

This is a rotation spanning 1 month 2 weeks of it will be spent in the pre-op clinic and 2 weeks will be spent

in the PACU. Dr. Chandler mans the pre-op weeks and Dr. Sawyer mans the PACU weeks. They will decide

how to split up the month for you usually it is 2 weeks of PACU first then 2 weeks of pre-op clinic but this isnot set in stone. Speak to Drs. Chandler and Sawyer to confirm the order you will be doing these in.

PACU

GOALS

This is a fairly straightforward rotation: your goal is to hang out in the PACU for the majority of the day taking

care of any issues that may arise. These include: airways problems, regional nerve blocks, any orders that thenurses may need that are not already written on the PACU order sheet, cardiovascular problem (high BPs,

arrhythmias, etc), calling consults if needed (neuro for altered mental status, cards for arrhythmias or ST

changes, etc.).

DAILY SCHEDULE

When you are on the PACU rotation you are expected to attend morning conferences. This includes grand

rounds on Monday and any 6:45am lectures that are on the schedule (which Dr. Duke emails you; it can also befound posted in the anesthesia lounge). If there are no lectures that morning arrive around 7-730 UNLESS you

are planning to do a pre-op nerve block for a patient who is the first case of the day; then you are going to need

to arrive earlier to get the block done and still allow time for the OR resident or CRNA to get the patient back tothe room on time. It is helpful if you look at the schedule the day before to see if any of the first cases may need

pre-op nerve blocks if so, plan on arriving a little earlier that day so you can get the block cart set up, etc.

When you arrive at the PACU at 7/730ish introduce yourself to the PACU nurses so they know you will be

around to help that day. If they dont know you are there then sometimes they call the attending directly and

you miss out on valuable learning. They are very good about coming to you for any issues that may arise. They

also are very good at letting you know if a patient may need a block.

There is a small computer nook in the back of the PACU this is your home base. Start out there and

read/study/drink coffee/do whatever. When you see a patient arrive to the PACU get up and help the patient getsettled in attach monitors, change the O2 from the tank to the wall O2, etc. The PACU nurses appreciate your

help. Then stay there and listen to the report. After report ask the OR anesthesia provider if they anticipate any

issues. Check on the patient every 10-15 minutes or so to be sure they are doing ok. Repeat this process forevery patient that comes to the PACU. If there are major issues with a patient or if you are going to have to call

a consult for something always make sure to run it by the attending for that case.

The days on PACU usually end around 3-4pm (sometimes you may stick around later if you are waiting for apatient to come out who you are planning on blocking). You dont have to ask anyone for permission to

leave, just leave when you feel it is appropriate.

DOING BLOCKS ON THE PACU ROTATION

Check out the schedule the day before to see if any of the first cases may need blocks. If so, run it by whomever

the attending will be and see if they want to do the block pre-op or post-op. If they want to do it pre-op you willneed to arrive earlier that day to get the block done as mentioned above. If they want to do it post op then you

can arrive at your normal time. For all other patients who may need blocks and ARE NOT the first case of the

day you can wait until that day to see what the attending wants to do.

16


18/47

When you arrive in the morning get an OR schedule and highlight all possible cases that may

need blocks.

Talk to the attendings for these cases and see if they want to do blocks. If they do not, stop here.

If they do, ask whether they want to do the block pre-op or post-op. Also see if they want to use

ultrasound. Write that down on your highlighted OR schedule.

Once you have determined a patient is a candidate for a block and confirmed the attending will

do a block, check in the APC/pre-op area and talk to these patients AND CONSENT THEM for

blocks. Try to catch the patients as soon as they get there so you not hold up the OR team when

they are trying to do everything in their 20 minute turnover window. Consent them in the APCregardless of whether they are getting a pre-op or post-op block.

4a. If the attending wants to do the block pre-op get it set up as soon as the patient gets there.

Find out when the patient is supposed to arrive. You can also let Scott, the APC charge nurse,know that you will be blocking that patient and he can call the PACU to let you know when they

arrive. When the patient gets there let the pre-op nurse do their paperwork and get the IV in then

make sure the anesthesia and surgical HP/consents are done (if they arent then you cannot givethe patient any sedation). Then take the patient over to the PACU and ask the nurses where you

can do your block. You cant do blocks in the pre-op area because there is not enough room and

there is not adequate monitoring equipment. Hook the patient up to the EKG, BP, pulse ox. Theblock cart and ultrasound are always in the PACU near the nurses office. If the ultrasound is

gone someone may be using it for a central line or something. Just page the anesthesia techoverhead and have them bring it to you. Get your block equipment all set up, then page your

attending and do the block. Keep the patient on the monitors in the PACU and keep an eye onthem until the OR team is ready to take them back.

4b. If you are going to do the block post-op STILL CONSENT THEM FOR IT

PREOPERATIVELY (see #3). Then have the block cart all set up for when they come out.When they come out of the OR help get them settled in and listen to report. Then get all set up

for your block and then call the attending and do it up.

There is paperwork that needs to be filled out for blocks. It is located on the side of the blockcart. Fill out this paper, have your attending sign it, and attach it to the OR packet that the OR

team fills out and turns in. MAKE SURE YOU FILL OUT A BILLING SHEET FOR THE

BLOCK (this is the same white sheet you fill out when in the OR). You can either fill out abrand new one or just add what you did to the one the OR team has already filled out. Make sure

to check ultrasound if you used ultrasound.

Dr. Ciarillo asks that you take a sticker and get a contact number for each patient you block. Call

them 2 days after you block them to see how the block worked and see you they are doing.

Pre-Op

GOALSYou will be working in the pre-op clinic. Your goal is to evaluate patients preoperatively and determine if they

need any further work up/labs/testing. You will also be ordering any meds or lab tests you think will be

beneficial the morning of surgery. Also, you will be filling out the anesthesia H&Ps and consents. Write down

any issues you may anticipate very clearly on the H&P so the OR team will be aware. Also, answer anyquestions the patient may have regarding anesthesia.

DAILY SCHEDULEA few days before the start of your pre-op rotation call up Kathy Goldsmith, the NP (stands for both nurse

practitioner and nicest person alive) that runs the pre-op clinic. You can reach her at 65990 or 65995. Go down

to the pre-op clinic and she will give you a little tour/orientation. To get to the pre-op clinic enter through themain entrance you normally do. However, where you normally turn left and go by the main street caf to get to

the OR, instead walk straight in and go straight (towards the urgent care center). When you reach the entrance

to the urgent care center just look to the left you will see a sign that says anesthesia clinic and there you have it.

17


19/47

You usually arrive about 8am you are not expected to attend the morning lectures while on the pre-op clinicrotation. There is a workroom in the back of the clinic that is your home base. Kathy will print you out a list

of patients who are coming in that day. Look over the list and if there are any really sick patients , patients

getting big surgeries, or patients with big-time medical problems let Kathy know and she will let you see themore complicated patients.

When the patients arrive they will get their vitals taken and usually an EKG then the nurse will put them in a

room. There is a yellow room and a blue room. The color of the file folder the nurse gives you with their files init will either be yellow or blue and this is how you know what room they are in. Anyhow, the nurse will put

them in the room then give you their file with all their paperwork in it. The paperwork included in this file

contains basically everything from their computer file printed out for you, the surgical H&P and consent, andthe day of surgery order form (the day of surgery order form is yellow and will become important later). There

are usually a lot of papers in this file.

Go through all the papers before you see the patient and start filling out their green H&P form from the papers.

As you are going through the papers make 3 piles:

1. Can be thrown away/not important papers (50 pages of EKG from a stress test, duplicate sheets, etc.)2. Important papers that should be stapled to the anesthesia H&P (notes from the PCP, most recent med

list, copies of echo results)3. Surgerys papers (their consent form and H&P will also be in the packet) and the yellow day of

surgery order sheet.

These 3 piles are all going to go to different places so it is important to separate them. Once you have gone

through the entire packet and have all sheets separated into piles, discard all the useless sheets into the papershredder. Leave the other 2 piles and you will deal with them after you see the patient.

Then go see the patient. Go through the H&P form with them and fill it out as completely as possible. Bringyour stethoscope and do a mini-physical exam. Then go through the anesthesia consent form with them and

have them sign it. Answer any questions they may have. Also consent them for blocks if they may be

candidates. Then they can leave UNLESS you think they need labs. If they need labs you must fill out a labsheet and give it to the nurse and she will draw the labs for you. You should also make a note on your H&P that

you drew labs that day so the OR team will know to look in the computer for labs. If you order labs they get

those drawn and then they can leave right afterwards.

You then go back to the workroom and finish any last things on the H&P. RIP OFF THE WHITE CARBON

COPY OF THE H&P (the H&P is a green packet that has a white carbon copy attached to it so when you fill it

out there is the green part you wrote on and also the white carbon copy on the back) AND STAPLE IT TO THEPILE OF IMPORTANT PAPERS YOU GATHERED FROM THEIR FILE. So, you have the carbon copy of

the H&P and the important papers pile stapled together you then take this up to the front of the office and put

it in the slot designated to go up to the anesthesia bull pen. The nurse will take these upstairs and file them later

on.

You are then left with the green anesthesia H&P, the blue anesthesia consent form you just did, the surgical

H&P/consent, and the yellow day of surgery order form. If you want to order any meds or labs for the morningof surgery (albuterol neb, pepcid, bicitra, urine pregnancy test) there is place on the yellow form for this. Look

under anesthesia and write your orders there and sign them. Once you are completely done with the yellow

day or surgery order form and your H&P, paper clip them to the surgery forms and your consent form (so youwill have your green H&P, your blue consent, surgerys H&P and consent, and the yellow day of surgery order

form) and PUT THESE BACK IN THE BLUE OR YELLOW FILE FOLDER YOU WERE GIVEN AND PUT

18


20/47

THE FILE INTO THE FILE CABINET UNDER THE DATE OF THEIR SURGERY. The file cabinet is right

next to your workroom.

Then you fill out a billing sheet and drop it off in the basket in the front of the office. Kathy will show you how

to fill out the billing sheet it is very simple, you just circle stuff.

Repeat this process for all patients until all patients have been seen. Patients are usually scheduled up to 4pm so

you can get out of there around 430/5ish. If you have any questions about how to do anything just ask Kathy.

She knows all.

If you see any very complicated patients that you think may need to be cancelled or may need further testing

review them with Dr. Chandler THE DAY YOU SEE THEM. If Dr. Chandler is not there then just grab anyattending. Make a plan for that patient and order any consults or further tests they may need.

19


21/47

SICU Rotation- University HospitalJAY HACKING, MD; JAMES SEDERBERG, MD

Door Codes

Call Room 0158Store Room 642

Storage Room (Site Rite ultrasound for line placement) 2007

Schedule

There are two residents on at a time, and there are basically four days: 1. Call- come in and round, stay all day

and overnight. That day the call persons job is to get the other resident home as quickly after rounds aspossible. That means doing all of the scut work, etc... 2. Post call- After rounding your fellow resident should

get you out of there ASAP. 3. Short day- This is the day the other resident is on call, and you should leave

quickly after rounds. 4. Long day- This is the other residents post call day so you get them out ASAP, and stay

until admissions come out of the OR. Usually 5 PM or so but is variable. Arrange things with the CT residentso you get them out at a reasonable time and vice versa. Then back to call and start the rotation all over again.

Its basically like being an intern again.

Pre-Rounds

I usually get there about 6 AM depending on how many patients there are. Since we are cross-covering CT

(more on that later) you round with the CT team each morning, so you might want a little time before rounds tostart gathering your info. First, talk to the resident on call and see if anything happened to your patients

overnight (they bled, they coded, etc), and see if there were any overnight admissions that need to be seen.

There are templates for daily notes so grab a stack of those, and start at the computer and using Care Managerwrite down Is/Os, vitals, labs, new radiology, etc Then go around and see your patients, perform a quick and

focused exam. Next I would always write my assessment and plan and write any orders that are urgent

(transfuse, replace lytes, etc), and finish filling in the days note for that patient. If time permits then write

orders for the next days labs, films, etc. as well to save time later. Make sure everyone is seen by the timerounds start.

RoundsSICU rounds usually start at 8 AM (9 AM on Mondays) in the room on the west side with the PACS computer

to look at Chest films, CT rounds start at 6:30 AM at the CT patients room who has the lowest room number.

Rounds are variable and attending dependent, and you go from room to room and read off of your note to theattending. What is helpful is to have the resident not presenting to grab the chart and write any orders that

might come up then, and make sure there are orders for the next AM. Once rounds finish, get the post-call/short

resident out and the remaining resident does any work that still needs to be done.

Rest of the day

Then I would usually go check the OR board and see what might be coming to you out of the OR and if time

permits start a brief accept note on them to make it easier later on (get on Centricity to get the scoop). There are

always surprises, some cases that say ICU dont come and some that you dont expect to do come, but at leastyou have some idea.

Accepting a patient

When you get a patient the primary team should write all the admit orders. You see the patient, do a focused

physical exam, get pertinent info from Centricity or the resident doing the case (brief medical history, airway,

I/Os, drugs given, drips, IV access, invasive monitors, etc), and write a brief accept note. Then follow up onlabs and replace/fix things that might come up. Some teams are VERY hands on (transplant, sometimes white

20


22/47

surgery), and some dont care what you do (ENT, ortho). See if patient needs any lines (central or arterial), you

often need to swap out a Cordis for a triple lumen catheter to give the nurses more ports.

CT Cross Cover

We cover the CT ICU patients when on call, which is a relatively new development in our program, and istherefore both good and bad. It is important to round with them on call day (so you know what to expect) and

post call so you can tell them what happened if necessary. The fellows are great and readily accessible (most of

the time) and feel free to call them with any questions, and ALWAYS call if you are going to give blood, make

changes to pressors, or if there is any change in pt status. They want to know whats going on. When you

Pearls

1. Never transfuse a transplant patient without talking to their team first.2. Call your attending with any major issues, or with any questions, they would rather you call than not

and they only do 1 week at a time, so its not as bad for them.

3. Talk to the nurses about what they might need IF you might get the chance to lay down, it will saveyou some calls.

4. There is always an in-house intensivist to call if you need help with a line or if there are any

questions.5. Call CT fellow with any questions, but gather information about hemodynamics and ins/outs first,

get specific numbers from nurse (i.e. chest tube 2 put out 100 in the last hour etc).6. When extubating, get ABG on CPAP, weaning parameters, and then text page the attending with

your plan and give them a way to call back if they have questions. Then wait a few minutes andextubate.

7. Ask for help if you need it, from nurses, CT residents, other anesthesia residents or attendings, etc

21


23/47

Outpatient Anesthesia (AOP) - University HospitalMATTHEW COLEMAN, MD

Important people:

AOP charge: John Armstrong, MD

Pharmacy: Mary Cousins, Carol Mckinney, Liz LykeAnesthesia Techs: Johnny Lawerence, Andrea Flores

Before you start: Know the lay of the land; Preop and PACU, ORs, GI, Pharmacy, Anesthesia workroom,Locker rooms, storage room where block equipment is stored, and lounge. Your Pyxis codes will work the

same as the AIP. ORs include AOP 8, 9, 11-17, GI (except 13).

Schedule and Call

Schedule: Tuesday Friday 630 to 3-5 pm (rarely there past 5 pm). Mondays youll be scheduled at the

AIP, usually covering R2 or R3.

Call: Expect to be on call 1 Saturday night during the month, 2 if they are strapped for people, or if there

are 5 weekends in the month.

Cases: Most of the time youll be doing Ortho cases that require blocks, with a few days in the month doingENT, gyn, dental, etc. You will not likely do any GI or eyeballs.

The current agreement is that the residents in the AOP start and finish their rooms (almost all of the time).

You are not expected to take over CRNA rooms if you finish early, and they will not take over your room

unless it is well past 5 pm.

If you are out before noon, you should help give some lunches and make sure there are no potential add-ons.

Call the charge before taking off.

OR Logistics

Arrive in Pre-op around 7:00, unless you will block the first patient, shoot for 6:45.

If you would like a locker at the AOP, there are usually a few empty ones you could claim for the day.

There is also a scrub machine available at the AOP. Most patients are pretty healthy and the preops can usually be done in the morning if youre quick. Give

yourself more time if youre doing urology, gyn, GI, dental, ENT as these patients sometimes have moreextensive histories. Also plan ahead with your ortho cases, as most of them get blocks.

Pharmacy: Get patients narcotics bag from the pharmacy. You can pick up your entire day of narcotic

bags at once. Just sign your name next to each patient on the preprinted pyxis form, and take the bags. Also

pick up anticipated drugs for the day, e.g. propofol, ketorolac, local for blocks, and phenylephrine sticks (inthe pharmacy refrigerator). Pharmacy hours are 6:30 am 5:00 pm

Anesthesia Techs and Workroom: The workroom is located on the southwest side of the AOP near OR 16.

Call Russ Ingram prior to starting to make sure you have a code to the workroom. Anesthesia techs arrivelater than at the AIP and are usually not available to help get ready for your first cases. So, be ready to get

in the workroom, get LMAs, pumps, etc. Also, be prepared to turn over your OR room from the day beforeif the techs left prior to cases finishing.

The block cart and ultrasound (US) are located in a storage closet located at the entrance of the preop area.

Ask the charge nurse to let you in if you get there early.

Blocks: the block cart contains sterile block trays and US covers in the bottom drawer. The block traycontains the drape, syringes, three-way stopcock, tubing, epi, sterile guaze, and iodine. In preparation for a

block, pull out a tray, US cover, the drugs (usually 0.5% Bupiv or 1.5% Mepiv or a combo of both), and the

needle.

22


24/47

Be sure and print a copy of the US images, as this is needed to bill for the US. Fill out a centricityprocedure form, print it, staple a copy of the US image and put it with the chart.

Important Numbers- AOP

Anes Charge Attg 84439

RN charge 81508Pre-op 86252

PACU 86203AOP pharmacy 81391

Anes techs 84459

OR RN phone Anes phone8 83208 82201

9 83209 81375

11 82511 8134212 81412 81412

14 81414 81419

15 81415 8142316 81416 81421

17 81417 81159

Lab pager 266-5040

Lab land line 87086

Blood gas lab 85309

Centricity Help 85912Hospital Operator 720-848-0000

Blood Bank 84444

Door Codes

Anes Workroom get your code from Russ Ingram

23


25/47

Acute Pain Service (APS)Prairie Robinson, MD; Estee Piehl, MD; Kellie Hancock, MD

Important people:

Director, Acute Pain Service: Dr. Matt Fiegel

Administrative Assistant: Suzanne Bullard, office: 303-724-1765APS advanced practice nurses: Robert Montgomery and Lynn Hornick

Acute pain is a different month since you are not in the OR. You will be placing pre-operative regional nerveblocks and epidurals for post-operative pain management. You will also be managing patients with epidurals

and nerve block catheters on the floor. It can be hectic at times, and being very organizedis key as you will be

managing orders and checking out drugs for many different patients over the course of the day. There is a lot ofpaperwork!

Reading/ Preparation

The main focus of this rotation is the placement and management of thoracic epidurals and lower extremityblocks. Upper extremity blocks are rare on APS, but you will do them. Cater your initial reading to local

anesthetics, lower extremity blocks, and neuraxial anesthesia. As always, try to invest some time in getting an

orientation tour from the previous resident. It is helpful to familiarize yourself with the block cart, basic set-upfor a nerve block, and paperwork prior to starting.

Resources

At the beginning of the rotation, you will get a notebook from Suzanne. It has your reading schedule for the

month, several informative articles, and some examples of how to fill out the paperwork. There are also guides

on epidural and spinal dosing of narcotics and local anesthetics that you will use daily. The textbook providedwhile you are on APS is excellent. A useful adjunctive website is www.nysora.com. It includes detailed

directions, pictures, and videos on how to do the different blocks. Dr. Fiegel is another important resource,

especially when it comes to ultrasound-guided blocks. He gives a great interactive, practical lecture that

involves looking at your own anatomy with ultrasound. (That way youll know if youre one of those freakswithout a right-sided IJ.) Make sure you make time to go through this with him before you start the 3rd week of

APS.

Daily Workflow

For the first several days, Rob and Lynn (the advanced practice nurses on the service) will be around a lot to

show you how to fill out the documentation, help with set-up, and talk about acute pain management. You willfind that Rob and Lynn are extremely helpful and knowledgeable. If you have questions and your attending is

not available, they will usually have the answer. They have loads of experience in pain management, so dont

forget to use them as a resource.

As in everything, your days are often attending dependent. You are expected to look at the OR schedule when it

comes out (usually around noon each day) with the pain attending or a pain nurse. Mark "block" next to eachpatient that is a likely candidate for a block or epidural. Note the number of first case blocks. If there aremultiple procedures, the regional nerve blocks are your priority. (The order of priority is lower extremity block,

upper extremity block, thoracic epidural, and finally lumbar epidural.) If you are unable to do all of the

blocks/epidurals, you should touch base with the anesthesia resident who will be doing the case to make surethey are planning on doing the block/epidural. If you are working with Dr. Fiegel, you will be able to do

multiple first case blocks, because he helps with the consent and set-up.

AM Set-up

24
http://www.nysora.com/http://www.nysora.com/


26/47

It is helpful, especially on busy days, to have syringes ready to use. Prepare the day before by having a bag of

premade 20cc syringes, because you will go through them quickly. A total knee uses 4-20cc syringes, andbilateral knees use 8-20cc syringes, so you can go through your bag quickly. It is also helpful to have premade

syringes ready to draw up fentanyl and versed. When you arrive (usually around 6:30am), you can draw up your

local anesthetic for your first few cases. See anesthesia attending preference below for the local anesthetic ofchoice. To make a 1:400,000 epi concentration (which you will use for most blocks), add 0.07ml (yes, less than

0.1cc) epi with the TB syringe to a 30ml vial.

Pre-procedure workupIn the morning, see your patient and do a targeted H&P. You are NOT expected to do the full pre-op H&P in

Centricity, but you need enough information to do a safe regional anesthetic. Major things to assess:

1) Surgical sitewhere is the incision?2) Cardiopulmonary status.

3) Allergies.

4) Is the patient on any medications that affect coagulation or does the patient have any existing diseasesthat might affect coagulation status (i.e. liver disease)? Is there any reason to order coags?

5) Any history of pre-existing neuropathy?

6) Any previous history of regional anesthesia?7) Is there unusual anatomy that might make regional anesthetic difficult or unsafe (i.e. it may difficult

to place an epidural in a patient with multiple back surgeries)?

Obtain consent for your regional technique plus the surgical anesthetic. Ask your attending for the appropriatefacts to convey to the patient regarding risks. Things that should always be coveredrisk of bleeding, infection,

nerve injury, new or worse pain, reaction to local anesthetic.

Procedure

Grab a sheet of stickers for each patient you block and set them aside. You will need them for the paperwork

and orders. The patient needs to have monitors on prior to starting the procedure. The pre-op nurse needs to bepresent and a time-out done that includes procedure site, allergies, and planned block. Do not give sedation

unless ALL consents, including surgical consent, are done. After the block, make sure and get a print-off of the

vitals. The nurses can show you how to print them. You will need to attach the recorded vitals to the procedurenote. Dont forget to tell the pre-op nurse what sedation and local were given. It will take a few days to learn

which pharmacy orders and post-op orders are needed for which type of block.

AttendingsDr. FiegelHe is currently in charge of APS, goes out of his way to help you, and does a lot of teaching. He

will help you keep up with the paperwork and procedure notes and will help you get set up and get consent. He

usually prefers 30cc 0.5% bupivicaine or 0.5% ropivacaine for the femoral and lumbar plexus. He prefers 30 cc0.25% bupivacaine or 0.25% ropivacaine for the sciatic block. Dr. Fiegel is very liberal with sedation and often

uses up to 5 cc of fentanyl, so you will probably want to check out 2 of versed and 5 of fentanyl when working

with him. He will want you to work on doing the blocks with nerve stimulation and will move on to ultrasound

once you are comfortable with stimulation techniques (usually week 3).

Dr. RamirezHe likes 0.5% ropivicaine or 0.375% bupivicaine for lumbar plexus blocks, popliteal and femoral

blocks with 1:400,000 epinephrine, mepivicaine 1.5% for the sciatic blocks. Get set up, draw your landmarksand then call him in. He will occasionally have you add clonidine 50mcg-100mcg to the ropivicaine (especially

for amputations).

Dr. Hendrickse, Dr. Schiffer, Dr. Shindell, Dr. Shiffrin These attending are flexible. They usually dont have

strong opinions on the local anesthetic used.

25


27/47

Tips on Meds

Its important to remember that you will be checking out a lot of narcotics for multiple patients in rapid

sequence or at the same time. You have to turn in empty bags with the patients name even if you give all ofyour drugs, so make sure you put a patient sticker on a pharmacy bag when you take out a controlled substance

from Pyxis. It can be a couple hours between when you give the med and when you do the procedure note, so

its easy to forget what you gave to which patient on a busy day. Pick a system that will help you keep track.

You can write on the OR schedule what meds were checked out and given for each patient. Alternatively, youcan record it on each individual bag as you go.

Another word about meds: You will often have multiple blocks in rapid sequence, especially on Mon, Tues andFri. On those days, you will need to draw up several doses of local for blocks prior to the start of the day. You

need to get all these vials out of the Pyxis without overcharging someone at the beginning of the day. The

easiest way to do this is to charge one vial of local (i.e. ropivicaine) to the first patient, but when the door openstake out 4-5 vials and draw these up into syringes. Then, charge the vials to each individual patient as you go

along during the day when you take out narcotics. That way you charge everyone for the appropriate drugs but

can still be ready to go before the first patient.

ChartingAll blocks need to be charted in Centricity. The process is simple and self-explanatory, but its important to

enter your name, your attendings name, and the appropriate sedative drugs on the procedure note. Pharmacywill track you down if the narcotics arent accurate. Staple the vitals to the printed note, and Rob or Lynn can

show you where to leave them.

26


28/47

Cardiothoracic ServicePRAIRIE ROBINSON, MD; SARA S. CHENG, MD, PHD

The cardiothoracic month is pretty tiring but you sure learn a lot!

Things to do before you get started (highly recommended to reduce start-up pain):1. Get handouts and the book "Cardiac Anesthesia" from Suzanne Bullard

2. Get a 15 minute lowdown from Russ Ingram (head anesthesia tech) on the Baxter pumps and Swan box

3. Get a tour on the heart room set-up from a resident who's done CT

Things to read before you get started:

1. Cardiopulmonary physiology and anesthesia chapters in Morgan and Mikhail2. Website written by Dr. Seres: http://www.uchsc.edu/anes/residency/cardiacfellowshipsyllabus.php.

There are a couple of things that need updating (ie. aprotinin is no longer used), but otherwise it's very good and

exactly the way he wants things.

3. Cardiac Anesthesia (Hensley/Martin/Gravlee: NOTE THE LAST AUTHOR). The one part I think isreally useful beforehand is the 1 page section in the Chapter "Anesthetic Management during CPB" entitled

"The CPB Sequence," so you know what the heck they are doing over there.

Things to read as you lose that "deer in the headlights" look (these make for great onbypass reading):

1. More of the Hensley book

2. More on TEE (Shanewise et al. Anesth Analg 1999 is the definitive paper on the topic)

Heart Room set-up checklist

(I kept this exact list on a little card in my pocket and never got caught missing something big even if it wasemergent and everyone was going crazy)

Equipment: ETT (#8,9), Baxter pumps x 2, Level 1 primed with NS, pacing box (batteries working?), oximetric

swan box, TEE machine/probe, BIS, triple transducer, aline supplies- be prepared to start the aline in pre-op,

2nd IV supplies, cordis, swan, sonosite, ABG syringes (heparinized), ACT syringes (not heparinized)Drips: Normal saline 500 cc bag (this will be your carrier,and you will add the Amicar to this bag after heparin

administration), nitroglycerin (200 mcg/ml in 250 cc bottle, start at 0.1 mcg/kg/min), epinephrine (4 mg into a

250 cc bag equals 16 mcg/ml, start at 0.01 mcg/kg/min), insulin drip (if diabetic), vasopressin (attendingdependent)

Drugs: FastTrack box and Heart Resuscitation box from Pyxis, fentanyl 3 x 20 cc, midazolam 2 x 10cc,

phenylephrine 5 x 10 cc, ephedrine 10 cc, epinephrine 2 x 10 cc (16 mcg/ml pulled from drip bag, can alsodouble dilute the glass vial in drawer to a 100mcg/ml and 10mcg/ml concentration), nitroglycerin 0.2mcg/cc in

10 ml x2 (20 mcg/ml diluted from drip bag), atropine, glycopyrrolate, vecuronium, sux, etomidate, esmolol 10

cc, HEPARIN 30 cc kept drawn up at all times!, protamine (do not draw up until nearing the end of bypass),

Amicar 5G x2, calcium 1 gram, lidocaine 20 cc, magnesium 2 gm.Other stuff to check: is there blood in the fridge? (need it at start of case esp with redo- they might rip the heart

open during sternotomy- it has happened!)

Following is an outline of the flow of the cardiac cases that go on bypass and things to think about during each

period. The first couple of times you do this, the attending will be with you and show you where/how to hook up

some of this stuff.Pre-bypass: Patient should have one large bore IV to go to sleep with, cardiac induction (midazolam, fentanyl,

etomidate, paralytic) place another large bore IV (14 or 16g), A line placement if not done in preop, right sided

IJ cordis, float swan if indicated, place BIS, OG to remove gastric contents, bite guard for TEE, place the baracross the IV poles, label all of your IV lines both at the bag and on the table. I like to put down blue towels

27
http://www.uchsc.edu/anes/residency/cardiacfellowshipsyllabus.phphttp://www.uchsc.edu/anes/residency/cardiacfellowshipsyllabus.php


29/47

under the patients shoulders and tape IV lines down with labels so I always know where they come from and

the gauge. Hook your drips to the VIP port of the cordis. Tape down the cordis once the patient is completelypositioned so that it is not being pulled on, these have been pulled out during the case or during transport. The

attending or CT fellow will place the TEE. Set foley up so that you can easily monitor urine output. Titrate your

anesthesia to a BP within 20% of initial pressures. Send baseline ACT/ABG. Also send baseline labs if patientdoes not have recent labs on file. The surgeon will give you the pacing wires- hook them up to the pacer box,

the coronary sinus line will attach to the CVP port, flush this line. For sternotomy: give fentanyl pre sawing 10-

20 cc (check with attending), hold ventilation!! At aortic cannulation, goal of MAP around 60, SBP 90-100.

Prior to going on bypass, dose heparin 300-400u/kg, perfusionist will tell you the dose. 3 minutes later drawACT, give to perfusionist. Usual goal is >400 (CT attending dependent). So you may have to give more, set the

timer again and recheck an ACT. Give 5g of Amicar after the heparin, prior to bypass initiation. Put the other

5g of amicar in your NS carrier and run at 1g/hr. Empty the foley prior to bypass and note the amount. Chartcross clamp and bypass times or ask nurse if you miss it. You may need to redose your paralytic, narcotics,

midazolam right at or right after bypass initiation.

Bypass: Stop ventilating when pump flows adequate, turn off inhalational and O2, redose paralytic, narcotics,midazolam if you havent already. Labs are drawn by perfusionist, follow the hct, glucose, lytes and treat as

needed. They will transfuse blood. Start/stop drips as needed, goal MAP >40. Turn your machine to CPB mode.

Follow UOP, tell perfusionist if less than 100cc/hr. TEE on standby, no warm fluids running.Ending Bypass: Patient will be rewarmed, turn all monitors/alarms on, redose paralytic, versed if needed, when

surgeon requests- give lidocaine 100mg and magnesium 2g, note when cross clamp is removed, depending onthe rhythm may have to pace, may need more lido or Mg or drips started. Give Ca 1g when requested by

surgeon-usually about 20min after cross clamp is off and the heart is beating well. Re-expand lungs, watch thelungs come up, make sure there is no tension on the LIMA graft, turn on vent, and send PT/PTT/CBC/Lytes to

lab. Continue to follow ABG. Protamine dose will be given to you by the perfusionist, when asked- give test

dose, then give slowly through peripheral IV, tell surgeon when half of the dose is in. After protamine is givendraw ACT 3min later. Note off bypass time. Empty urine when off bypass and tell perfusionist total on bypass

UOP. Post-bypass: Follow coags/bleeding status and transfuse products as indicated. Repeat TEE exam.

Remove TEE, clean up your lines, disconnect PIVs for transport, remove BIS, empty foley, place dressing oncordis, patient remains intubated, to SICU. Take drugs with you- phenylephrine, epi, ephedrine, atropine,

paralytic, narcotics, esmolol.

One more thing:Teamwork is key on this service. There are 3 residents on service who are kind of a self-contained group, plus a

senior float resident who participates in the CT call pool. On any given day they might be spread over 3 sites:

UCH, VA, and St. Joe's- so helping each other out by calling around when you're done with your cases, doingthe pre-ops for the next day at your site so that your friend doesn't have to come over from across town just to

do it, relieving the higher numbered call people, keeping clearly labeled stashes of drugs in the fridge for each

other- all this stuff helps a lot and can keep you from being totally miserable.

28


30/47

The Childrens HospitalGILLIANJOHNSON, MBBCHIR; CRISTINA WOOD, MD

Important people:

Program Coordinator: Morris Dressler MD 74820

Administrative assistant: Cindy Garone 76224 or Lindsay Johnson 76226

On Day One:

You will be scheduled for orientation.This will include 1. a morning of Epic (computer medical record) training

2. badge collection3. parking information and access

On the first day you may park in the visitor lot out the front of the hospital. Onsubsequent days you will be ticketed if you do not park in the assigned lot. Your badgewill be your method of access to the parking lot, hospital and all departments and doorsin the OR (includes anes work room)

When you complete orientation please go to the OR and call the ch

Anesthsia Review 2009

Documents

Transcript of Anesthsia Review 2009