Anesthesia Assistant Program · Ultrasound machine Difficult intubation equip[ment Syringe pumps IV...
Transcript of Anesthesia Assistant Program · Ultrasound machine Difficult intubation equip[ment Syringe pumps IV...
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Algonquin College Anesthesia Assistant Program
Clinical Rotation Handbook
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Algonquin College Anesthesia Assistant Program
Clinical Rotation Handbook
Table of Contents page #
Introduction 3
Section 1: Guidelines for Mentors 5
Section 2: Goals and Objectives 7
Section 3: Discussion topics for Anesthesiologist Mentors 14
Section 4: Discussion topics for Anesthesia Assistant Mentors 21
Section 5: Case plans 22
Section 6: Technical Skills Log 27
Section 7: Evaluation 38
Section 8: Daily evaluation card 51
Section 9: Summary of instructions for students 53
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Introduction
Welcome to your clinical rotation, the culmination of the Anesthesia Assistant Program!
The next few weeks are will be intense and challenging, but rewarding and enjoyable too.
During this time you are expected to practice and refine your technical skills, review and
consolidate the knowledge you have gained during the didactic part of the program and
begin to integrate it all in the care of patients in the perioperative setting.
Each student has a clinical mentor, a staff anaesthesiologist at your hospital who will
review your progress and will be the major resource person for you during your
placement. You should be booked frequently with this person, but not exclusively – to
allow for scheduling problems and to increase your exposure to alternate points of view
and methods of problem solving.
Your clinical mentors will have the Guidelines for Clinical Mentors document, detailing
your role. Please read it carefully and note that in every role, you will be acting under the
direct supervision of the attending anesthesiologist. During your clinical placement you
will are expected to be supervised by a staff anaesthesiologist and should not be left
alone with any anesthetized patients.
Section One is the “Guidelines for mentors” document that details the expectations for
your mentors and preceptors.
Section Two is a list of the goals and objectives that your will be expected to learn about
and achieve during your rotation.
Section Three covers discussion topics to be covered by your anesthesiologist
supervisors and mentors during your clinical rotation. Please sign these areas off as they
are covered. Read around them to review and expand on the material already taught in the
courses. It will be beneficial to record notes from discussions in the OR and to make
notes of specific questions you wish to discuss after reading up on the topic.
Section Four covers discussion topics to be covered by your Anesthesia Assistant
supervisors and mentors during your clinical rotation. Please sign these areas off as they
are covered.
Section Five covers a variety of cases and intra-operative problems. With the help of
your mentor you are required to develop an anesthetic plan for the patients presented. For
each of the complications, develop a differential diagnosis and treatment plan. It will be
beneficial to record any examples that you encounter in your practice.
Section Six allows you to keep a record of the basic technical procedures you perform or
assist with. A record of these competencies is expected and will be submitted for
completion.
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Section Seven is a final evaluation that will be completed by your mentor to document
your progress during your rotation.
Section Eight is a sample of the daily evaluation card that will be used to track your
progress.
As you are well aware, this is a new programme for Algonquin College. The role of
Anesthesia Assistant is in evolution, and you are the ambassadors for your emerging
profession. We welcome any feedback you have about this course to improve for the
future.
Good luck!
Patti Murphy MD, FRCPC
Education Director
University of Ottawa, Department of Anesthesia
Box 249C
1053 Carling Avenue
Ottawa, Ontario
K1Y 4E9
(613) 761-4169
fax (613) 761-5209
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Section 1: Guidelines for Mentors
To the mentors:
Thank you for agreeing to act as a clinical mentor to students in this program. As you are
aware, this is a new program, and the role of the Anesthesia Assistant (AA) is constantly
evolving, even as the course is progressing. CAS guidelines as to the scope of practice
for AAs are in evolution, so it is vital at this stage to clearly articulate our expectations
for the learners, both in terms of what we expect them to be doing by the end of their
training, and also what we expect of their supervising anesthesiologists.
Please not that during the duration of their clinical placement, students are not to be
left unsupervised in the care of patients.
The Anesthesia Assistant Program at Algonquin aims to educate graduate AAs to
function in the following roles (i.e. AFTER their clinical placement is completed):
1. Conscious sedation cases
The AA is expected to be able to assess the patient preoperatively in association with the
staff anesthesiologist, to administer sedation in accordance with the hospital protocols
and to monitor the patient throughout the procedure and until such time as the patient is
admitted to a recovery area and care is formally handed over to recovery room personnel.
The attending anesthesiologist must be immediately available throughout. Acceptable
staffing ratios for fully trained AAs would be one anesthesiologist to up to five AAs
depending on the complexity of the procedures being performed and assuming that the
geographical location of the cases allowed an immediate response from the
anesthesiologist.
2. Cases performed under regional block
The AA is expected to be able to assist the staff anesthesiologist with the placement of
the regional block and should be familiar with both the technical aspects of the procedure
and also the possible side effects and complications. The attending anesthesiologist must
be immediately available throughout.
3. Cases performed under general anesthesia
The AA is expected to have the technical skills and knowledge to assist the staff
anesthesiologist with the induction, maintenance and emergence phases of general
anesthesia. In the case of a stable patient during maintenance of anesthesia (ventilated or
spontaneously breathing), the AA would be able to monitor the patient for periods of up
to 30 minutes. The attending anesthesiologist would not have to be present in the OR but
would be immediately available.
In such cases where the patient is under general anesthesia, it is expected that the staff
anesthesiologist would supervise only one AA. It would be permissible for the attending
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anesthesiologist to use that 30 minute time period, to place a regional block in the next
patient on the list but only if they were able to respond immediately and in person to any
concerns regarding the patient under general anesthesia. The role of the AA in this
situation would be to expedite the OR list and NOT to allow the staff anesthesiologist to
attempt to cover more than one OR. Intervals covered by the AA should be uneventful
and will NOT include induction, emergence or any period of predictable instability e.g.
clamping or unclamping of major blood vessels during vascular procedures or periods of
significant blood loss.
4. Other aspects of the AA role
The AA is also expected to assist the staff anesthesiologist in a variety of other situations
in terms of being able to perform tasks independently (eg insertion of IVs and arterial
lines), perform tasks under direct supervision (eg insertion of LMAs, intubation) or
assist the anesthesiologist (eg fibreoptic intubation, lung isolation, insertion of central
lines and pulmonary artery catheters, regional anesthesia procedures including spinals,
epidurals, peripheral nerve blocks and Biers blocks).
In addition to their technical skills regarding anesthetic equipment and monitoring
devices, AAs will function as an “extra pair of hands” for the staff anesthesiologist when
dealing with complex and/or unstable patients as detailed above and by performing other
tasks under the direction of the staff anesthesiologist such as checking blood and
preparing vasoactive medications.
Structure of the clinical placement
It is expected that each student will have one principal mentor who will supervise the
student on a regular and frequent basis. Students should be regularly, but not exclusively,
booked with their primary mentor.
Mentors should:
1. Discuss their progress at two weekly intervals throughout the placement and
be readily available to deal with any issues or problems.
2. Ensure that students are documenting the following items:
a. Cases performed
b. Technical skills log
c. Discussion topics covered
d. Case plans
There is a huge amount of material to be covered, and we want to ensure that
students make constant progress though the list in order to meet their objectives.
The College requires that competencies are documented in this way to enable
successful graduation from the course.
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Section 2: Goals and Objectives
PROFESSIONALISM
1. Function as a Professional
a. Adheres to the scope of practice
b. Works with anesthesia care team to provide quality care
2. Function within Medical, Legal and Ethical Guidelines
a. Adheres to medical ethics
b. Adheres to standards of practice
c. Maintains confidentiality
COMMUNICATION
1. Demonstrate Effective Oral Communication Skills
a. Communicates effectively with patient and family
b. Communicates effectively with other members of the health care team
c. Teaches caregivers patient care and equipment skills
2. Demonstrate Effective Written Communication Skills
a. Documents patient procedures appropriately
HEALTH AND SAFETY
1. Effectively Manages Environmental Factors Associated with Work a. Uses appropriate self-protection when exposed to potentially hazardous situations such as :
Infectious agents
Hazardous chemicals
Radiation exposure
LASER
b. Uses appropriate body mechanics for lifting, transferring and transporting patients
c. Takes measures to prevent OR pollution (N2O, volatiles)
2. Carries Out Procedures using WHIMIS standards
a. Follows appropriate procedures to safely manage hazardous materials
b. Instruct others with regard to W.H.M.I.S.
c. Labels all infectious material bags for purpose of disposal
d. Uses hand washing technique
e. Follows standard Universal Precautions
EQUIPMENT
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1. Clean and Disinfect Equipment
Uses appropriate cleaning and disinfecting procedures for the following equipment:
bronchoscopes
laryngoscopes
lighted stylette
LMA
Patient monitoring equipment
TEE
Ultrasound machine
Regional nerve stimulators
2. Maintains equipment
a. Performs preventative maintenance on the following equipment:
Ultrasound machine
Difficult intubation equip[ment
Syringe pumps
IV pumps
b. Calibrates equipment (Istat, Glucometer, Hemachron, Hemocue)
c. Maintains inventory
3.. Performs thorough Anesthetic machine checkout
4. Adheres to DOT and CSA regulations
ASSESSMENT
a. Takes a relevant patient history
b. Performs an appropriate physical examination of the patient
c. Interprets preop laboratory investigations correctly.
d. Correctly accesses lab information using hospital information technology
e. Discusses the patient with the attending anesthesiologist to develop an appropriate plan for
intraoperative management.
f. Educates patient regarding anesthesia procedures
ANESTHETIC MANAGEMENT (see subsections for more detailed objectives)
1. INDUCTION
Assists with the following types of induction:
a. IV
b. Modified/ Rapid-sequence
c. Inhalation
2. MAINTENANCE
Appropriate vigilance in monitoring patients
3. EMERGENCE
Takes steps to prepare patient for emergence from anesthesia:
Calls for staff presence
Adjusts level of anesthetic agent
Assesses/ reverses neuromuscular blockade
Optimizes analgesia
Adjusts ventilation to encourage spontaneous ventilation
Manages airway appropriately
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MONITORING
1. a. Correctly applies standard monitors:
5 lead ECG
NIPB
SPO2
Temperature probe
PNS
Expired CO2
Correctly applies the following non-invasive monitors:
BIS
b. Prepares equipment for the following invasive monitors:
Arterial line
CVP
PA catheter
TEE
Cardiac output
c. Prepares ultrasound machine for use during line insertion
d. Correctly inserts arterial line.
2. Performs arterial and venous puncture, Uses indwelling catheters to collect blood samples
Correctly sends samples to lab for CBC, coagulation tests, crossmatch
Interprets results from blood samples
Evaluate results relative to patient clinical status
Recommends appropriate corrective actions based on lab results.
3. Performs arterial line insertion (see monitoring section)
4. Correctly uses I-Stat
Correctly uses glucometer
Correctly uses Hemachron
Correctly uses Hemocue
AIRWAY MANAGEMENT
1. Bag/ mask ventilation
Applies head tilt, chin lift , jaw thrust
Inserts oral airway
Inserts nasopharyngeal airway
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2. Intubation
Prepares the following equipment:
Regular ETT
Oral/ nasal RAE ETT
Armoured ETT
LASER ETT
DLT
LMA/ Proseal
Combitube
Fast-track
Direct laryngoscope
Bougie
Fiberoptic scope/ DAVI cart
Glidescope
Lighted stylette
Bullard scope
Tube exchanger
Retrograde intubation kit
Cricothyrotomy kit
Describes correct use of the following accessory equipment
Glidescope
McCoy blade
Lighted stylette
Fiberoptic scope
Fast-track
Magill forceps
Stylets
Tube exchangers
DLT
LMA/ Proseal
Combitube
Direct laryngoscope
Bougie
Bullard scope
Retrograde intubation kit
Cricothyrotomy kit
Troop pillow/ bath blankets for positioning
Assesses tube placement/seal
Performs oral intubation via direct laryngoscopy
Performs nasal intubation via direct laryngoscopy
Secures tube
Recognizes complications and takes action PRN
4. Perform extubation
Correctly assesses patient readiness for extubation Correctly performs adult extubation
Correctly assesses and manages patient post-extubation. Recognizes complications and takes
corrective action
5. Tracheostomy Tube exchange
Assists with exchange of existing tracheostomy tube
VENTILATION MANAGEMENT
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Assesses the ventilation requirements relative to current patient status. Selects appropriate
ventilatory parameters
Evaluates initial patient response to mechanical ventilation, and adjusts parameters accordingly
Records appropriate ventilation data
MEDICATION
a. Correctly draws up routinely used induction, maintenance and emergence drugs
b. Correctly draws up routinely used emergency drugs
c. Actively practices preventative strategies to avoid medication errors
d. Demonstrates correct calculations when diluting medications
e. Demonstrates correct use of IV syringe pump
f. Demonstrated correct use and programming of IV infusion pumps
g. Correctly and safely administers medications used for conscious sedation
h. Correctly administers the following medications for maintenance of general anesthesia:
Opioids
Inhalation agents
Nitrous oxide
Neuromuscular blockers
Propofol infusion
POSITIONING
1. Assists with positioning in the following intraoperative positions:
Supine, arms abducted
Supine arms tucked
Supine, left uterine displacement
Prone, horseshoe
Prone, Mayfield tongs
Prone, Jackson table, (including Flip)
Lateral decubitus
Beach chair
Lithotomy
2. Safely able to move OR table with draped patient.
3. Assists with draping, following principles of sterility
FLUID MANAGEMENT
1. Prepares the following lines for administration of IV fluids:
Standard IV line (vented, non-vented)
PCA extension
Blood administration set
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Hotline warmer
Level 1 warmer
2. Performs peripheral intravenous cannula insertion
3. Assists with central line insertion
4. Correctly sets up and runs the Cell saver
5. Correctly checks blood products
6. Correctly administers the following fluids:
Crystalloid
Colloid
Blood products
Mannitol
g. Monitors patient volume and electrolyte status
SUCTION
a. AIRWAY
Correctly suctions the airway using the following equipment:
Yankauer suction
Flexible suction
Bronchoscope
Assists with obtaining samples via bronchoscope
b Thoracic Suction. Correctly assembles/tests equipment
Assesses function of chest tubes
Monitors drainage
C. Gastric Suction
Correctly inserts Naso Gastric tube
Assesses correct placement.
Recognizes incorrect placement
Uses appropriate suction for NG drainage.
THERMOREGULATION
Demonstrates proper use of the following equipment:
Air warming blanket (Bair Hugger)
Fluid warming/ cooling mattress
(See monitoring, fluids sections)
Selects patients appropriately for warming/ cooling measures
REGIONAL ANESTHESIA
Correctly prepares local anesthetic for regional anesthesia after discussion with the attending
anesthesiologist
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Prepares equipment for regional anesthesia:
Spinal
Epidural
CSE
Peripheral nerve block
Peripheral nerve catheter
IV block
Correctly manages peripheral nerve stimulator for peripheral nerve blocks
Uses safe injection technique for local anesthetic administration for nerve blockade.
COMPLICATIONS
1. Calls for help appropriately
2. Able to recognize, list a differential diagnosis for, and initiate management for the following
complications:
a. Hypertension
b. Hypotension
c. Hemorrhage
d. Tachycardia
e. Bradycardia
f. Patient movement
g. Leak/ disconnect
h. High airway pressure
i. Hypoxia
k. Hypercarbia
l. Hypoventilation/ apnea
PATIENT TRANSPORT
a. Selects appropriate equipment, monitors and drugs for an intra-hospital patient transport
b. Assemble equipment and ensure equipment function
pre-transport checkout
monitor and troubleshoot during transport
c. Monitors patient response during transport
d. Trouble-shoots during transport
ADMINISTRATION
a. Plans work schedules.
b. Applies cost containment procedures.
c. Develops policies and procedures.
d. Provides workload data. Conducts workload measurement
g. Participate in research as needed.
2. Develops, Implements quality assurance programs.
b. Evaluates processes, practices or equipment. Interprets findings. Makes recommendations
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Section 2: Discussion Topics for Anesthesiologist Mentors
Read up on these topics yourself and then come to the OR prepared to discuss them with
your mentors. Be proactive in looking for the necessary information at your hospital.
I. Preoperative Issues
Topic Discussed
1. Preoperative history.
What are the components of a preop history that should be
gathered from every patient?
2. Preop physical examination.
How do you assess an airway for ability to intubate?
What are the indicators for potential difficult intubation/
ventilation?
Discuss normal heart sounds and the changes you might
expect to hear in common disease states.
Discuss breaths sounds and the changes you might expect to
hear in common disease states.
3. Review preoperative testing
What investigations are indicated prior to coming to the OR?
4. Review the concept of the anesthesia care plan.
Discuss how patient and surgical considerations contribute to the
anesthetic plan
Develop your own standardized approach to ensure that you take
all these issues into consideration every time.
What are the risks of anesthesia?
5. Airway management
How will the potential difficult airway cause you to modify your
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anesthetic plan at every stage of the perioperative period?
Review the ASA algorithm for management of the difficult
airway.
6. Premedication.
Which drugs are commonly used?
Which of their usual medications do patients take on the day
of surgery?
Which of their usual medications do patients need to
discontinue?
How do you manage chronic pain meds preop?
How do you manage chronic anticoagulation?
How do you manage diabetic meds?
7. Fasting guidelines.
Discuss which patients should always be
considered as “full stomach” regardless of NPO
status.
Review current guidelines
8. What is your approach to the preoperative patient with
symptoms of URTI?
9. Review patient safety protocols in the pre and intra operative
periods.
What is the procedure for confirming patient
identity and confirming procedure preoperatively?
How do you ensure that the correct side for the
procedure has been identified and clearly
communicated to the whole team?
Preop pause
Discuss specific patient considerations:
o Patients unable to give consent
o Jehovah’s Witness patients
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II. Intraoperative issues
Topic Discussed
1. Review infection control measures in the OR.
Principles of maintaining sterility during procedures
review separation of “dirty” and “clean” areas in the anesthesia
workspace,
review use of Universal Precautions
discuss accidental needle stick injuries
reinforce the importance/timing of prophylactic antibiotics
2. Discuss strategies for clear and effective communication in the
OR, crisis management
3. Review standards for monitoring under anesthesia.
What are the standard monitors?
Use of other commonly used monitors
Describe the indications for and the complications of arterial
line insertion.
Review the techniques, indications for and the complications
for central line insertion.
Describe the indications for and the complications of
pulmonary artery catheter insertion.
Review record keeping in the OR.
Difficult intubation letter
Standards for recording vital signs under anesthesia
4. Review induction of anesthesia
Rapid sequence induction vs. the usual IV induction of
anesthesia.
When is an inhalational induction used?
Review factors which would require and alteration in the
doses of drugs used for induction.
5. Airway management
ASA Difficult Airway Algorithm
Alternate methods of intubation
Indications and contraindications for the use of the
Laryngeal Mask Airway
Complications of intubation
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Location and contents of the Difficult Intubation Cart at
your hospital.
Discuss patient positioning in the OR.
Complications of various
common positions used in the OR
Physiologic consequences of different patient positions
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8. Discuss the creation of a perioperative analgesic plan.
Pain history preop
Effects of pain
Use of and complications of narcotic use in the surgical patient
Titration narcotics intraoperatively
Adjunctive medication
Regional analgesia
Review any pre-printed order sheets used for PCA and PCEA
administration.
Management of the chronic narcotic user
9. Review the importance of temperature control in the OR.
Risks and benefits of hypothermia
Temperature monitoring
Mechanisms of hypothermia
Management of perioperative heat loss
10. Perioperative fluid management.
Calculate perioperative fluid requirements
Risk factors for fluid deficits
Choices for fluid replacement.
Monitoring adequacy of fluid therapy
Consequences of over and under filling
Potential consequences and treatment of electrolyte
imbalances: potassium, sodium, calcium, pH.
11. Review the use of neuromuscular blocking agents.
Indications for neuromuscular blockade (NMB)?
Review the commonly used NMBs including doses.
Use of nerve stimulator
Adequacy of recovery from relaxants
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Reversal agents
Causes of prolonged NMB
Specific contra-indications and phase two blockade with
succinylcholine
12. Maintenance
Different anesthetic volatiles
Risks and benefits of using nitrous oxide?
TIVA
Awareness
Use of BIS monitoring
13. Blood products.
Calculate allowable blood loss
Estimating blood loss in the OR
Blood conservation strategies
Risks of a single unit transfusion
Risks of massive transfusion
Blood checking procedures
Transfusion triggers
Coagulation and relevant tests used at your hospital.
Review types of blood products available and indications for
each.
Transfusion reaction under anesthesia
ISTAT, Hemocue, Hemachron, ACT
Cell saver
14. Post-operative nausea and vomiting (PONV).
Risk factors
Anti-emetics.
Prevention
15. Emergence from anesthesia.
Readiness for extubation?
Complications and management of premature extubation
Indications for post-operative intubation and/or ventilation?
16. Discuss the information necessary when taking over the care of the
anesthetized patient from another colleague.
Develop a checklist to cover all the necessary issues and to
confirm contact information for your colleague
In which situations is it NOT appropriate to accept hand over
of care?
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17. Malignant Hyperthermia
OR preparation
What is Dantrolene? What is the dose and how is it prepared?
What are the challenges of administering dantrolene?
Differential diagnosis of an MH crisis.
Treatment protocol for an MH crisis.
18. How would you set up for a case of known latex sensitivity?
Risk factors
Items in the OR which contain latex.
Which parts of the anesthesia machine contain latex?
OR preparation
19. What are the indications for lung isolation?
Methods to achieve one lung ventilation (OLV)?
Describe the technique for insertion of double lumen tubes and
bronchial blockers.
Mechanical ventilation strategies during one-lung ventilation.
Risk factors and management of hypoxia on OLV
20. Discuss the management of procedures requiring cardiopulmonary
bypass.
Preparation to go on CPB
Preparations before weaning from CPB
Complications after prolonged periods on CPB
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III. Postoperative issues
Topic Discussed
1. Handover of your patient to the PACU/ ICU nurses.
Review the patient history, intraop events
Postoperative management plan/ orders
When is it inappropriate to hand over care to the PACU
nurse?
Patients who are still intubated/ have a laryngeal mask in situ
2. PACU admission and discharge
- Criteria for discharge
- Surgical procedures requiring prolonged PACU stay
- Patient conditions requiring prolonged PACU stay e.g. OSA
- Indications for direct admission to ICU
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Section 3: Discussion Topics for Anesthesia Assistant Mentors
Topic Discussed
WHIMIS standards Uses appropriate cleaning and disinfecting procedures for the following
equipment:
bronchoscopes
laryngoscopes
lighted stylette
LMA
Patient monitoring equipment
TEE
Ultrasound machine
Regional nerve stimulators
Preventative maintenance on the following equipment:
Ultrasound machine
Difficult intubation equip[ment
Syringe pumps
IV pumps
Maintains inventory DOT and CSA regulations
Calibrates ISTAT, Hemachron, Gucometer, Hemocue Administrative Responsibilities.
work schedules
cost containment
workload data, workload measurement
quality assurance programs
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Section 4: Case Plans
a. List of cases
b. Sample of anesthetic plan
c. Blank anesthetic plan
Please complete the following anesthetic plan for each of the following
cases, and discuss one case per week with your mentor or other supervising
anesthesiologist.
Read up on each patient condition. Expect to be quizzed about the anesthetic
implications of each disease process and surgical procedure.
For each intra-operative complication, create a list of possible causes, and
outline your initial management steps.
a. List of cases
Week # Patient
condition
Surgical procedure Intraoperative
complication
1 Coronary
artery
disease
Open Hemicolectomy ST segment
depression on the
ECG monitor
2 Asthma
Laparoscopic
cholecystectomy
High airway pressure
3 Morbid
obesity
UPPP
(uvulopalatophagoplasty)
Low saturation
4 Alcoholic
cirrhosis
Hysterectomy
bradycardia
5 GERD
Craniotomy for brain
tumour (meningioma)
resection
hypertension
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6 Chronic
renal
failure
Above knee amputation tachycardia
7 Diabetes
(Type 1
and Type
2)
Laminectomy Low airway pressure
8 Placenta
previa
Cesarean section Hypotension
b. Sample of anesthetic plan
Case:
Preop
Assessment Patient Considerations:
List the history, physical exam and lab
work that is appropriate for this patient
with their underlying pathology. What
are the presenting symptoms and physical
signs you would look for? What lab
abnormalities do you expect to find?
Surgical Considerations
What are the anticipated implications of the
planned surgery?
Orders Premed/ medication What premedication should be ordered for
this patient?
Other
Discussion
topics with
patient
What should be dicussed with this patient
preoperatively?
Intra-op
Monitors What monitors are indicated?
IV access/
expected
How much blood loss is anticipated for this
type of surgery? How big should the IV(s)
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blood loss be, and where should they be placed?
Plan for pain
management
How painful is this procedure? Is a regional
block/ catheter, IV PCA appropriate?
Special
equipment
Do you need anything unusual, such as
ultrasound, BIS monitor, airway cart?
Position
What position will be used?
Duration of
surgery
How long will the surgery be? What impact
does this have on your pplan?
Type of
anesthetic
General? Regional? Local?
Airway plan ETT? LMA? Mask?
Ventilation
plan
Spontaneous ventilation or PPV? Best mode
of ventilation?
Induction What drugs and doses will you use?
Maintenance What drugs and doses will you use? What
problems do you anticipate?
Emergence What is your plan for emerging the patient?
Anticipated
complications
List problems for which the patient is at risk.
Assigned intraop complication for this case (from list in section a)
Differential
diagnosis
List all the possible causes/ contributing
factors
Management Describe your immediate assessment and
management
Postop
Pain
management
What is your plan? Is it the same as your
preop pain plan? What doses will you give of
what medication?
Disposition
of patient
Where does the patient go postop? Any
special orders that should be written?
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c. Blank anesthetic plan
Case:
Preop
Assessment Patient Considerations:
Surgical Considerations
Orders Premed/ medication
Other
Discussion
topics with
patient
Intra-op
Monitors
IV access/
expected
blood loss
Plan for pain
management
Special
equipment
Position
Duration of
surgery
Type of
anesthetic
Airway plan
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Ventilation
plan
Induction
Maintenance
Emergence
Anticipated
complications
Assigned intraop complication for this case (from list in section a)
Differential
diagnosis
Management
Postop
Pain
management
Disposition
of patient
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Section 5: Technical Skills Log
OR setup
Minimum 20
Please consider the following in your assessment:
Ability to check the Anesthesia machine
Preparation of airway equipment
Preparation of appropriate drugs
Preparation of appropriate IV lines
Recognition of need for additional equipment
Date Comments Score Signature
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IV insertion
Minimum 20
Date Comments Score Signature
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Arterial line insertion
Minimum 5
Please include in your assessment:
Sterile technique
Insertion technique
Setting up equipment
Toubleshooting
Drawing blood samples
Date Comments Signature
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Intubation (by direct laryngoscopy)
Minimum 10
Please include in your assessment:
Accurate preop assessment of the airway
Bag-mask ventilation, Oral/ nasal airway insertion
Laryngoscopy technique
Placement of ETT
Confirmation of position, Securing tube
Date Comments Signature
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Intubation (by alternate methods)
Please include in your assessment:
Accurate preop assessment of the airway
Bag-mask ventilation, Oral/ nasal airway insertion
Intubation technique
Confirmation of position
Securing tube
Date Technique used/ Comments Signature
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LMA insertion
Minimum 10
Please include in your assessment:
Accurate preop assessment of airway
Rationale for use of LMA
Preparation of equipment
Correct insertion technique
Confirmation of LMA placement
Securing of LMA
Date Comments Signature
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Assisting with Fibreoptic Intubation
Minimum 3
Please include in your assessment:
Preparation of equipment
Assisting with airway topicalization
Assisting with intubation
Confirmation of position
Securing tube
Date Comments Signature
Assisting with OLV (One Lung Ventilation)
Minimum 2
Please include in your assessment :
Knowledge of indications for lung isolation
Methods available, their advantages and limitations
Ability to assist with procedure
Knowledge of management of desaturation during OLV
Date Comments Signature
34
Assisting with Central Venous Line/ PAC Insertion
Minimum 3 for CVP, 1 for PAC
Please include in your assessment:
Sterile technique
Knowledge of potential complications
Knowledge of relevant landmarks
Setting up equipment (including Ultrasound)
Recognition of CVP/ PAC/ PCWP waveform
Ability to perform CO measurements
Knowledge of immediate treatment of PA rupture
Date Comments Signature
Assisting with peripheral nerve block/ catheter
Minimum 5
Please include in your assessment:
Sterile technique
Knowledge of relevant landmarks
Setting up drugs, monitors and equipment
Safe injection technique
Date Comments Signature
35
Cases performed under conscious sedation
Minimum 15
Please consider the following in your assessment:
Ability to perform initial preoperative assessment
Ability to recognize patients in at additional risk/AA supervision unsuitable
Demonstration of vigilant monitoring of the patient
Ability to administer and titrate appropriate sedative and analgesic agents
Administration of fluids and vasoactive agents
Prompt recognition of problems
Correctly initiates corrective measures
Date Type of case/ Comments Signature
36
Cases performed under regional anesthesia
Minimum 10
Please consider the following in your assessment:
Ability to perform initial preoperative assessment
Ability to recognize patients in at additional risk/AA supervision unsuitable
Demonstration of vigilant monitoring of the patient
Ability to administer and titrate appropriate sedative and analgesic agents
Administration of fluids and vasoactive agents
Prompt recognition of problems
Correctly initiates corrective measures
Date Type of case/ Comments Signature
37
Cases under General anesthesia (Maintenance)
Minimum 20
Please consider the following in your assessment:
Ability to perform initial preoperative assessment
Ability to recognize patients in at additional risk/AA supervision unsuitable
Demonstration of vigilant monitoring of the patient
Ability to administer and titrate appropriate sedative and analgesic agents
Administration of fluids and vasoactive agents
Prompt recognition of problems
Correctly initiates corrective measures
Date Type of case/ Comments Signature
38
Section Six: Evaluation
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
PROFESSIONALISM
1. Function as a Professional
a. Adheres to the scope of
practice
O M
D
S I
b. Works with anesthesia care
team to provide quality care
O M
D
S I
2. Function within Medical,
Legal and Ethical
Guidelines
O M
D
a. Adheres to medical ethics O M
D
S I
b. Adheres to standards of
practice
O M
D
S I
c. Maintains confidentiality O M
D
S I
COMMUNICATION
1. Demonstrate Effective
Oral Communication
Skills
O M
D
a. Communicates effectively
with patient and family
O M
D
S I
b. Communicates effectively
with other members of the
health care team
O M
D
S I
c. Teaches caregivers patient
care and equipment skills
O M
D C
S I
2. Demonstrate Effective
Written Communication
Skills
a. Documents patient
procedures appropriately
O M
D
S I
HEALTH AND SAFETY
1. Effectively Manages
Environmental Factors
Associated with Work
a. Uses appropriate self-
protection when exposed to
potentially hazardous
situations such as :
Infectious agents
O M
D
S I
39
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
Hazardous chemicals
Radiation exposure
LASER
b. Uses appropriate body
mechanics for lifting,
transferring and transporting
patients
O M
D
S I
c. Takes measures to prevent
OR pollution (N2O,
volatiles)
O M
D
S I
2. Carries Out Procedures
using WHIMIS standards
O M
D
S I
Follows appropriate
procedures to safely manage
hazardous materials
O M
D
S I
Instruct others with regard to
W.H.M.I.S.
O M
D
S I
INFECTION CONTROL
Labels all infectious material
bags for purpose of disposal
O M
D
S I
Uses hand washing technique O M
D
S I
Follows standard Universal
Precautions
O M
D
S I
EQUIPMENT
1. Clean and Disinfect
Equipment
Uses appropriate cleaning and
disinfecting procedures for the
following equipment:
bronchoscopes
laryngoscopes
lighted stylette
LMA
Patient monitoring
equipment
TEE
Ultrasound machine
Regional nerve
stimulators
O M
D
S I
2. Maintains equipment O M
D
S I
d. Performs preventative
maintenance on the
following equipment:
Ultrasound machine
Difficult intubation
O M
D
S I
40
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
equip[ment
Syringe pumps
IV pumps
e. Calibrates equipment
(Istat, Glucometer,
Hemachron, Hemocue)
O M
D
S I
f. Maintains inventory O M
D C
S I
d.. Performs thorough
Anesthetic machine checkout
O M
D
S I
e. Adheres to DOT and CSA
regulations
O M
D
S I
PATIENT ASSESSMENT
1. Assessment O M
D
S I
a. Takes a relevant patient
history
O M
D
S I
b. Performs an appropriate
physical examination of the
patient
O M
D
S I
c. Interprets preop laboratory
investigations correctly.
Correctly accesses lab
information using hospital
information technology
O M
D
S I
d. Discusses the patient with
the attending anesthesiologist
to develop an appropriate
plan for intraoperative
management.
O M
D
S I
Educates patient regarding
anesthesia procedures
O M
D
S I
MANAGEMENT OF ANESTHESIA
INDUCTION
Assists with the following
types of induction:
IV
O M
D
S I
Modified/ Rapid-sequence
O M
D
S I
Inhalation
O M
D C
S I
41
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
MAINTENANCE
Appropriate vigilance in
monitoring patients
O M
D
S I
EMERGENCE
Takes steps to prepare patient
for emergence from
anesthesia:
Calls for staff presence
Adjusts level of anesthetic
agent
Assesses/ reverses
neuromuscular blockade
Optimizes analgesia
Adjusts ventilation to
encourage spontaneous
ventilation
Manages airway appropriately
O M
D
S I
MONITORING
a. Correctly applies
standard monitors:
5 lead ECG
NIPB
SPO2
Temperature probe
PNS
Expired CO2
b. Correctly applies the
following non-invasive
monitors:
BIS
O M
D
S I
S I
S I
S I
b. Prepares equipment
for the following
invasive monitors:
Arterial line
CVP
PA catheter
TEE
Cardiac output
O M
D
S I
c. Prepares ultrasound
machine for use
during line insertion
O M
D
S I
d. Correctly inserts
arterial line.
O M
D
S I
42
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
Performs arterial and venous
puncture, Uses indwelling
catheters to collect blood
samples
Correctly sends samples to
lab for CBC, coagulation
tests, crossmatch
Interprets results from blood
samples
Evaluate results relative to
patient clinical status
Recommends appropriate
corrective actions based on
lab results.
Performs arterial line
insertion (see monitoring
section)
Correctly uses I-Stat
Correctly uses glucometer
Correctly uses Hemachron
Correctly uses Hemocue
O M
D
S I
1.
Bag/ mask ventilation
Applies head tilt, chin lift ,
jaw thrust
O M
D
S I
Inserts oral airway O M
D
Inserts nasopharyngeal airway O M
D
S I
2. Intubation
Prepares equipment the
following equipment:
Regular ETT
Oral/ nasal RAE ETT
Armoured ETT
LASER ETT
DLT
LMA/ Proseal
Combitube
Fast-track
Direct laryngoscope
Bougie
Fiberoptic scope/ DAVI cart
Glidescope
Lighted stylette
Bullard scope
Tube exchanger
O M
D
S I
43
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
Retrograde intubation kit
Cricothyrotomy kit
Demonstrates correct use of
the following accessory
equipment
Glydescope
McCoy blade
Fiberoptic scope
Fast-track
Magill forceps
Stylets
DLT
LMA/ Proseal
Combitube
Direct laryngoscope
Bougie
Glidescope
Lighted stylette
Bullard scope
Tube exchanger
Retrograde intubation
kit
Cricothyrotomy kit
Troop pillow/ bath
blankets for
positioning
O M
D
S I
Assesses tube placement/seal
Performs oral intubation via
direct laryngoscopy
Performs nasal intubation via
direct laryngoscopy
Secures tube O M
D
S I
Recognizes complications and
takes action PRN
O M
D
S I
4. Perform extubation
Correctly assesses patient
readiness for extubation
Correctly performs adult
extubation
O M
D
S I
Correctly assesses and
manages patient post-
extubation. Recognizes
complications and takes
corrective action
O M
D
S I
5. Tracheostomy Tube O M S I
44
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
exchange Assists with exchange of
existing tracheostomy tube
D C
VENTILATION MANAGEMENT
Assesses the ventilation
requirements relative to
current patient status. Selects
appropriate ventilatory
parameters
O M
D
S I
Evaluates initial patient
response to mechanical
ventilation, and adjusts
parameters accordingly
O M
D
S I
Records appropriate
ventilation data
O M
D
S I
MEDICATIONS
a. Correctly draws up
routinely used induction,
maintenance and emergence
drugs
O M
D
S I
b. Correctly draws up
routinely used emergency
drugs
O M
D
S I
c. Actively practices
preventative strategies to
avoid medication errors
O M
D
S I
d. Demonstrates correct
calculations when diluting
medications
O M
D
S I
e. Demonstrates correct use of
IV syringe pump
O M
D
S I
f. Demonstrated correct use
and programming of IV
infusion pumps
O M
D
S I
g. Correctly and safely
administers medications
used for conscious sedation
O M
D
O M D
45
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
h. Correctly administers the
following medications for
maintenance of general
anesthesia:
Opioids
Inhalation agents
Nitrous oxide
Neuromuscular
blockers
Propofol infusion
O M
D
S I
POSITIONING
2. Assists with
positioning in the
following
intraoperative
positions:
Supine, arms
abducted
Supine arms tucked
Supine, left uterine
displacement
Prone, horseshoe
Prone, Mayfield
tongs
Prone, Jackson table,
(including Flip)
Lateral decubitus
Beach chair
Lithotomy
O M
D
S I
2. Safely able to move OR
table with draped patient.
O M
D
S I
4. Assists with draping,
following principles
of sterility
O M
D
S I
FLUID MANAGEMENT
a. Prepares the
following lines
foradministration of
IV fluids:
Standard IV line (vented,
non-vented)
PCA extension
Blood administration set
Hotline warmer
Level 1 warmer
b. Performs peripheral
O M
D
S I
46
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
intravenous cannula
insertion
c. Assists with central
line insertion
d. Correctly sets up and
runs the Cell saver
e. Correctly checks
blood products
f. Correctly administers
the following fluids:
Crystalloid
Colloid
Blood products
Mannitol
g. Monitors patient
volume and electrolyte
status
SUCTION
a. AIRWAY
Correctly suctions the
airway using the
following equipment:
Yankauer suction
Flexible suction
Bronchoscope
Assists with obtaining samples
via bronchoscope
O M
D
S I
Thoracic Suction. Correctly
assembles/tests equipment
O M
D
S I
Assesses function of chest
tubes
O M
D
S I
Monitors drainage O M
D
S I
b Gastric Suction
Correctly inserts Naso Gastric
tube
Assesses correct placement.
Recognizes incorrect
placement
Uses appropriate suction for
NG drainage.
O M
D
S I
THERMOREGULATION
Demonstrates proper use of
the following equipment:
Air warming blanket (Bair
Hugger)
O M
D
S I
47
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
Fluid warming/ cooling
mattress
(See monitoring, fluids
sections)
Selects patients appropriately
for warming/ cooling
measures
O M
D
S I
REGIONAL ANESTHESIA
Correctly prepares local
anesthetic for regional
anesthesia after discussion
with the attending
anesthesiologist
O M
D
S I
Prepares equipment for
regional anesthesia:
Spinal
Epidural
CSE
Peripheral nerve
block
Peripheral nerve
catheter
IV block
O M
D
S I
Correctly manages peripheral
nerve stimulator for peripheral
nerve blocks
O M
D
S I
Uses safe injection technique
for local anesthetic
administration for nerve
blockade.
O M
D
S I
COMPLICATIONS
1. Calls for help appropriately
O M
D
S I
2. Able to recognize, list a
differential diagnosis for, and
initiate management for the
following complications:
O M
D
S I
a. Hypertension
O M
D
S I
b. Hypotension
O M
D
S I
48
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
c. Hemorrhage
O M
D
S I
d. Tachycardia
O M
D
S I
e. Bradycardia
O M
D
S I
f. Patient movement
O M
D
S I
g. Leak/ disconnect
O M
D
S I
h. High airway pressure
O M
D
S I
i. Hypoxia
O M
D
S I
k. Hypercarbia
O M
D
S I
l. Hypoventilation/ apnea
O M
D
S I
3. Perform Advanced Cardiac
Life Support Resuscitation
Protocols
O M
D C
S I
PATIENT TRANSPORT
a. Selects appropriate
equipment, monitors and
drugs for an intra-hospital
patient transport
O M
D
S I
b. Assemble equipment and
ensure equipment function
pre-transport checkout
monitor and troubleshoot
during transport
O M
D
S I
O M
D
S I
c. Monitors patient response
during transport
O M
D
S I
d. Trouble-shoots during
transport
O M
D
S I
ADMINISTRATION
a. Plans work schedules. O M
D
S I
b. Applies cost containment
procedures.
O M
D
S I
c. Develops policies and
procedures.
O M
D
S I
d. Provides workload data.
Conducts workload
O M
D
S I
49
COMPETENCY DATE Method of
assessment
EVALUATION COMMENT/ Signature
measurement
g. Participate in research as
needed.
O M
D
S I
2. Develops, Implements
quality assurance
programs.
O M
D
S I
b. Evaluates processes,
practices or equipment.
Interprets findings. Makes
recommendations
O M
D
S I
50
Completion of Clinical Component of Anesthesia Assistant Program
This letter confirms that ____________________________________________________
completed the clinical component of the above course in the Ottawa Hospital
______________________ Campus, University of Ottawa Department of Anesthesia
between the dates of ________________ to _________________.
I have reviewed the student’s performance with the other members of my department and
confirm that they have achieved the competencies as listed in the accompanying
document from their main mentor, Dr._____________________.
Course Supervisor: ______________________________________________
Signature: _____________________________ Date: ________________
51
ALGONQUIN COLLEGE ANESTHESIA ASSISTANT DAILY EVALUATION
Please return this card to (Mentor’s name) _____________________________________
Student’s name: __________
Staff name: _____
Date: _________
SKILL SCORE
Prepares equipment 1 2 3 4 5
Patient assessment 1 2 3 4 5
Patient monitoring 1 2 3 4 5
Induction of anesthesia 1 2 3 4 5
Airway and ventilation management 1 2 3 4 5
Patient positioning 1 2 3 4 5
Fluid administration
Medication administration 1 2 3 4 5
Emergence 1 2 3 4 5
Transport to recovery or ICU 1 2 3 4 5
Use of personal protective equipment 1 2 3 4 5
Oral and written communication 1 2 3 4 5
Rating Scale 1 Significantly below expectations. Fails to perform skill adequately or does not
attempt to perform skill. Poor knowledge.
2 Does not meet expectations. Makes one or more critical mistakes. Gaps in
knowledge
3 Meets expectations. Without critical mistakes, may make minor mistakes. Minor
gaps in knowledge.
4 Exceeds expectations. Performs confidently without prompting, corrects minor
mistakes safely. No significant gaps in knowledge.
5 Outstanding. Anticipates issues, proactive. Knowledge level above average.
52
Type of cases on this date:
_________________________________________________________________
Technical Skills Witnessed:
_
Topics Discussed:
Comments (include strengths & weaknesses):
___________
53
Summary of Student Responsibilities
1. We will do our best to coordinate your schedule to give you a variety of
exposures to different types of cases, including general, regional, local/sedation,
thoracics, cardiac, neuro, vascular. You can assist us by identifying areas that you
have yet to cover as your rotation progresses so that we have the opportunity to
meet all your objectives.
2. During this rotation, you are considered a student, and are not to be left
unsupervised for patient care. This may be at odds with your usual role in the OR,
but those are the terms of your role as a student. Please remind your mentor of
this, and if there are any issues in this regard, please refer your staff to me.
3. Please hand a daily evaluation card to your supervising staff every day. Since they
will not be working with you all the time, your mentors will use this to track how
you are progressing.
4. Please ensure that you keep the following records:
a. Cases performed
b. Technical skills log
c. Discussion topics covered
5. Please complete one of the Case plans per week and review it with a staff
anesthesiologist.
Documentation of #3, #4, #5 above is required for successful completion of the program.
Please let me know if you are experiencing any difficulty with any aspect of this
program. I will do my utmost to assist you.
Patti Murphy MD, FRCPC
Education Director
University of Ottawa, Department of Anesthesia
Box 249C
1053 Carling Avenue
Ottawa, Ontario
K1Y 4E9
(613) 761-4169
fax (613) 761-5209