322 PG Curriculum MD Anaesthesia Index 1. Goals 2. Objectives 3. Syllabus 4. Teaching Program 5. Postings 6. Thesis 7. Assessment 8. Job Responsibilities 9. Suggested Books 10. Model Test Paper Curriculum MD (Anaesthesia) 323 Curriculum MD Anaesthesia The infrastructure and faculty of the department of Anaesthesia will be as per MCI regulation . 1. Goals The goal of MD course in Anaesthesia is to produce a knowledgeable and skillful anaesthesiologist who: (cid:1) Is competent to anaesthetize all categories of patients from ASA-I to V with medical problems for every type of elective and emergency surgery. (cid:1) Should be able to diagnose and treat acute and chronic pain conditions. (cid:1) Should be competent to manage critically ill patients in emergency and ICU requiring routine to advanced monitoring, mechanical ventilation and other interventions. (cid:1) Should be aware of the recent advances and developments in medical sciences as related to anaesthesia, analgesia and critical care. (cid:1) Should be oriented to principles of research methodology; and (cid:1) Is competent to teach acquired skills to medical and paramedical professionals. 2. Objectives Department of anaesthesia makes sure that the candidate develops in all fronts i.e. cognitive, affective and psychomotor domain as it is important for anaesthesiologist to work as member/ team leader in various clinical and critical situations in OR and outside OR. Candidate should be able to demonstrate following at the end of training. (cid:1) Demonstrate familiarity with diagnostic skills and laboratory procedures relevant to the diagnosis and evaluation of patients under Her / His care. (cid:1) Critically evaluate recent medical literature from journals, reference books: monographs update knowledge and adapt therapeutic procedures based on this appraisal. (cid:1) Manage administration of anaesthesia to patients of all grades of ASA risk grading and all types of surgical subspecialties both for elective and emergency procedures. (cid:1) Demonstrate aptitude and will to remain clear headed and act correctly when faced with critical incidence in the operating room and critical care units. (cid:1) Demonstrate the knowledge of ethics and medico legal aspects related to the practice of anaesthesiology and critical care. (cid:1) To work in a team and show leadership qualities in dealing with paramedics. 3. Syllabus 3.1 Theory (cid:1) Applied Anatomy and Physiology Curriculum MD (Anaesthesia) 324 (cid:2) Applied Anatomy (cid:3) Candidates should be able to demonstrate a good understanding of human anatomy relevant to the practice of anaesthesia. (cid:3) This will include the knowledge of anatomy as demonstrated by endoscopic and imaging techniques. (cid:2) Applied Physiology (cid:3) Candidates are expected to be able to apply the basic knowledge of human physiology necessary to clinical practice of anaesthesia and intensive care medicine. (cid:3) While all branches of physiology are of importance, it is recognized that clinical relevance dictates the topics selected for the examination. (cid:3) Haematalogical o Anaemia o Polycythaemia o Immunity and allergy o Inflammation o Blood groups o Alternative oxygen carrying solutions o Coagulation, haemostasis and disorders o Abnormal haemoglobins -sickle cell disease –thalassaemia (cid:3) Muscle Function o Malignant hyperthermia o Disturbances in neuromuscular transmission o Myopathies and Muscle contractures. (cid:3) Cardiovascular Physiology o Abnormal electrocardiogram and arrhythmias o Cardiomyopathy and abnormal ventricular function o Heart failure o Shock o Ischaemic heart disease o Valvular defects o Common congenital heart defects o Hypertension (cid:3) Kidney and Body Fluids o Serum electrolyte disturbances o Disturbances of fluid balance, oedema and dehydration o Management of acid-base abnormalities o Assessment of renal function o Renal failure and its management (cid:3) Liver o Liver function tests o Hepatic failure o Jaundice , causes and pathophysiology o Disorders of respiratory mechanics, gas exchange and transport (cid:3) Respiration o Disorders of the pulmonary circulation o Respiratory failure and ventilatory support o Effects of high and low atmospheric pressure (cid:3) Nervous System o Consciousness and coma o Phases of sleep Curriculum MD (Anaesthesia) 325 o Depth of anaesthesia o Consequences of spinal cord injury o Monitoring of spinal cord function under general anaesthesia o Mechanisms of pain; somatic, visceral, neuropathic o Control of cerebral circulation, intracranial and intraocular pressures o Disorders of the autonomic nervous system (cid:3) Gastrointestinal Tract o Nausea and vomiting o Oesophageal reflux o Obstruction o Swallowing disorders (cid:3) Metabolism and Body Temperature o Hormonal and metabolic response to surgery and other trauma o Hyperthermia and hypothermia o Starvation/obesity (cid:3) Endocrinology Endocrine diseases of significance in anaesthesia (Thyroid, parathyroid, pancreas, adrenal etc.) (cid:3) Obstetrics and Paediatrics o Principles of neonatal physiology o Effects of prematurity o Development in infancy and childhood o Physiology of normal and abnormal pregnancy (cid:1) Applied Clinical Pharmacology (cid:3) For drugs used in anaesthesia and intensive care medicine, candidates will also be expected to be aware of new drugs which are undergoing evaluation and whose human application has been reported in the mainstream anaesthetic journals. (cid:3) There will be emphasis on the practical application of pharmacological and pharmacokinetic knowledge, and upon an appreciation of the hazards and limitation of individual techniques. (cid:2) General therapeutics: (cid:3) Pharmacological management of: Heart failure, coronary insufficiency and arrhythmias (cid:3) Hypertension, including hypertension in pregnancy (cid:3) Acute and chronic respiratory diseases (cid:3) Hepatic and renal failure (cid:3) Gastrointestinal disorders including modification of gastric contents (cid:3) Musculo-skeletal problems such as rheumatoid and osteoarthritis (cid:3) Myasthenia and muscle diseases (cid:3) Pituitary, adrenal and thyroid dysfunction (cid:3) Antipsychotic drugs (cid:3) Epilepsy and anticonvulsants (cid:3) Bacterial, fungal and viral infections (cid:3) Malignant disease (cid:3) Adverse reactions: Types of reactions (cid:2) Application of pharmacological principles for the management of : (cid:3) General anaesthesia: - o Premedication: anxiolytics, sedatives and antisialogogues. o Pro-kinetic and anti- emetic drugs. o H and proton pump antagonists 2 Curriculum MD (Anaesthesia) 326 o Inhalational anaesthesia o Intravenous Anaesthesia, TIVA o Control of alveolar tension during induction and recovery o Control of anaesthetic depth and prevention of awareness o Control of autonomic response to laryngoscopy o Methods for achieving specified plasma concentrations. o Bolus, infusion, and profiled administration o Management of neuromuscular blockade and reversal (cid:3) Regional anaesthesia: - o Choice of agent and technique. o Additives o Systemic effects. Avoidance of toxicity (cid:3) Control of acute pain (including intraoperative analgesia and postoperative pain management) and chronic pain: - o Opioid and non-opioid drugs o Opioid infusions o Patient-controlled analgesia o Regional techniques o Inhalational techniques o Other drugs used to manage chronic pain - antidepressants, anticonvulsants, antiarrythmics, etc. o Management of severe pain and associated symptoms in terminal care o Non-pharmacological methods (e.g. T.E.N.S., acupuncture) (cid:2) Application of pharmacological principles for the management of: (cid:3) Neurosurgery and management of head injuries:- o Management of cerebral ischaemia o Effect of drugs on cerebral blood flow o Control of intracranial pressure o Control of convulsions (cid:3) Cardiovascular Surgery :- o Inotropes and vasopressors o Vasodilators o Anticoagulant and thrombolytic therapies. o Management of coagulopathies o Pharmacalogical control of blood sugar o Pharmacological problems in cardiopulmonary bypass. o Cardioplegia (cid:2) Other Therapeutic Drug groups (cid:3) Management of malignant hyperthermia (cid:3) Pharmacological considerations in cardiopulmonary resuscitation, major trauma and exsanguinations (cid:3) Pharmacological control of severe infections (cid:3) Pharmacological treatment of severe asthma (cid:3) Effects of renal or hepatic impairment on drug disposition (cid:2) The Statistical Basis of Clinical Trial Management (cid:3) Candidates will be expected to understand the statistical fundamentals upon which most clinical research is based. (cid:3) They may be asked to suggest suitable approaches to test problems, or to comment on experimental results. Curriculum MD (Anaesthesia) 327 (cid:3) They will not be asked to perform detailed calculations or individual statistical tests. (cid:3) Data collection and analysis: simple aspects of study design defining outcome measures and the uncertainty of measuring them (cid:3) Application to clinical practice: distinguishing statistical from clinical significance understanding the limits of clinical trials the basics of systematic review and its pitfalls (cid:3) Study design. Defining a clinical research question understanding bias controls, placebos, randomization, blinding exclusion criteria statistical issues, especially sample size ethical issues. (cid:2) Knowledge of Basic Computer Application including MS office (cid:1) Principles of Anaesthesia (cid:2) General Anaesthesia (cid:3) Anaesthetic equipment (cid:3) Preoperative assessment and investigations (cid:3) Perioperative management of anaesthesia (cid:3) Anaesthesia for patients with coexisting disease including diabetes and cardiovascular disorders (cid:3) Regional anaesthesia (cid:3) Audit and quality control (cid:3) Ethics, relevant legislation and the duty of care, consent, and information given to patients before anaesthesia (cid:3) Anaesthesia for particular disciplines – general surgery and subspecialities, obstetric, ENT, dental/ maxillofacial, orthopaedic, trauma, ophthalmic, paediatric, day care, anaesthesia and sedation for remote procedures such as radiology, endoscopy (cid:2) Regional Anaesthesia (cid:3) Basic sciences applied to regional anaesthesia: anatomy, physiology and pharmacology. (cid:3) Principles and practice of spinal and epidural anaesthesia, intravenous regional anaesthesia and nerve blocks. (cid:3) Recognition and management of adverse effects (cid:3) In addition, candidates will be assessed on their understanding of principles in the following areas: (cid:1) Anaesthesia for specialties (cid:2) Obstetrics (cid:3) Physiological changes of pregnancy (cid:3) Anaesthesia in early pregnancy (cid:3) Antenatal assessment of the pregnant woman (cid:3) Medical diseases complicating pregnancy (cid:3) Pain relief in labour (cid:3) Anaesthesia for operative obstetrics (cid:3) Emergencies in obstetrics (cid:3) Neonatal resuscitation (cid:2) ENT (cid:3) Preoperative assessment, particularly prediction of a difficult intubation. (cid:3) Management of patients of all ages to include patients with: -stridor - intubation difficulties -sleep apnoea -concomitant diseases (cid:3) Local techniques and surface analgesia. Curriculum MD (Anaesthesia) 328 (cid:3) Acute ENT emergencies (e.g. bleeding tonsils, croup, epigiottitis, foreign bodies) (cid:3) Laryngoscopy and bronchoscopy (cid:3) Knowledge of special tubes, gags and equipment for microlaryngoscopy, bronchoscopy, laser surgery (e.g. Venturi devices, ventilating bronchoscope and fibre-optic bronchoscopy). (cid:3) Middle ear surgery including hypotensive techniques. (cid:3) Neck surgery (cid:3) Emergency airway management including tracheostomy. (cid:3) Postoperative management. (cid:2) Dental/ Maxillofacial. (cid:3) Preoperative assessment (cid:3) Day case/inpatient requirements (cid:3) Resuscitation facilities (cid:3) Dental chair anaesthesia (cid:3) Sedative, anaesthetic and analgesic techniques for dental extractions. (cid:3) Assessment and management of the difficult airway including fibreoptic intubation (cid:3) Anaesthesia for maxillofacial surgery including the perioperative management of the fractured jaw and other major facial injuries. (cid:3) Postoperative management (cid:2) Orthopaedics (cid:3) Preoperative assessment with particular reference to the problems of children, the elderly and the patient with rheumatoid arthritis. (cid:3) Emergency anaesthesia for fractures (cid:3) Routine anaesthesia for joint replacement surgery, arthroscopy, fractured bones, dislocations and tendon repair (cid:3) Procedures under tourniquet. (cid:3) Anaesthesia for spinal surgery. (cid:3) Regional blocks. (cid:3) Perioperative analgesia (cid:3) Prevention, diagnosis and management of fat emboli, deep vein thrombosis and pulmonary emboli (cid:2) Trauma (cid:3) Management of head injury, spinal injury and multiple trauma with major blood loss (cid:3) Major incident management, triage and anaesthesia in situations outside the hospital transfer of the traumatized patient. (cid:3) Management of the burned patient (cid:3) Management of major vascular accidents (cid:3) Postoperative management (cid:3) Perioperative analgesia. (cid:2) Ophthalmic (cid:3) Preoperative assessment with particular reference to patients with underlying disease Strabismus, cataract and detached retina surgery (cid:3) Penetrating eye injury (cid:3) Control of intraocular pressure (cid:3) Anatomy relevant to local anaesthetic blocks (cid:3) Peribulbar and retrobulbar techniques of local anaesthesia (cid:3) Postoperative care (cid:2) Paediatric Curriculum MD (Anaesthesia) 329 (cid:3) Preoperative assessment and psychological preparation for surgery (cid:3) Anaesthetic management of children for major elective and emergency surgery. (cid:3) The anaesthetic implications of major congenital anomalies including congenital heart disease (cid:3) Management of recovery. (cid:3) Management of postoperative pain in children (cid:3) Management of acute airway obstruction including croup and epigiottitis (cid:2) Anaesthesia for Day Care Surgery (cid:3) Selection criteria and preoperative evaluation (cid:3) Instructions to patients (cid:3) Regional and general anaesthesia (cid:3) Appropriate drugs (cid:3) Postoperative analgesia (cid:3) Recovery assessment and discharge criteria (cid:2) Anaesthesia in Remote Areas (cid:3) Diagnostic lmaging - Anaesthesia and Sedation (cid:3) Preanaesthetic preparation (cid:3) Techniques appropriate for adults and children for CT scanning MR imaging and angiography (cid:3) Post-investigation care (cid:2) Cardiac Anaesthesia (cid:3) Preoperative assessment and management of patients with cardiac disease. (cid:3) Anaesthesia for cardiovascular imaging. (cid:3) Pacemakers (cid:3) Non-invasive and invasive vascular and non-vascular monitoring appropriate to the cardiovascular system (cid:3) Anaesthesia for cardiac surgery. (cid:3) Principles of cardiopulmonary bypass and cardiac surgery (cid:3) Postoperative management (cid:2) Thoracic Anaesthesia (cid:3) Preoperative lung function tests (cid:3) Local and general anaesthesia for bronchoscopy to include techniques of ventilation. (cid:3) Familiarity with fibreoptic bronchoscopic techniques for airway management and diagnostic procedures (cid:3) Techniques of one-lung anaesthesia to include single and double lumen endobronchial tubes (cid:3) Principles of thoracic anaesthesia to include management of pneumothorax (cid:3) Principles of underwater seals on chest drains (cid:3) Tracheostomy and other techniques of emergency airway management (cid:2) Neurosurgical Anaesthesia (cid:3) Preoperative assessment and management of patients with neurological disease (cid:3) Anaesthesia for imaging relevant to the CNS (cid:3) Principles of anaesthesia for craniotomy, to include vascular disease, cerebral tumours and posterior fossa lesions (cid:3) Perioperative management of interventional neuroradiological procedures Curriculum MD (Anaesthesia) 330 (cid:3) Anaesthesia for spinal column surgery (cid:3) Principles of immediate postoperative management. (cid:3) Neurological monitoring. (cid:2) Neonatal and other specialized areas (cid:3) Preoperative assessment (cid:3) Recognition of common congenital anomalies requiring surgical correction at birth and their anaesthetic implications (including oesophageal atresia, diaphragmatic hernia, exomphalos, intestinal obstruction) (cid:3) Principles of anaesthetic management in the neonate undergoing major surgery (cid:3) Congenital pyloric stenosis (cid:3) Postoperative pain management (cid:3) Transport of the critically ill neonate (cid:2) Other specialised areas (cid:3) Transplantation, Principles and complications of immunosuppression (cid:3) Specific anaesthetic problems associated with renal transplantation (cid:3) Anaesthetic management of patients with transplanted organs (cid:3) Anaesthesia for: Electro-convulsive therapy (ECT) (cid:3) Radiotherapy (cid:3) Minimal access surgery (cid:3) Plastic surgery Burns (cid:1) Intensive Care Medicine (cid:2) Intensive Care Unit, transport of the critically ill, nutrition and trauma (cid:3) Candidates should have a good understanding of the diagnosis and management of the critically ill patient and should be skilled in resuscitation to an advanced standard. (cid:3) An understanding of the particular problems associated with the critically ill child (excluding neonates) will be expected. (cid:3) All candidates should be familiar with the monitoring and life support equipment used in the treatment of critically ill patients. (cid:3) Candidates must be able to demonstrate their knowledge of practical invasive procedures, with an understanding of the principles and hazards involved. Interpretation of data from such procedures. (cid:3) An awareness of the importance of communication skills and interpersonal relationships will be expected. (cid:2) Candidate should be familiar with following: (cid:3) Infection, sepsis, and endotoxaemia (cid:3) Multiple Organ Dysfunction Syndome (cid:3) Nosocomial infections (cid:3) Assessment and management of oxygen delivery (cid:3) Antibiotics and immunotherapy (cid:3) Reperfusion injury and antioxidants (cid:3) Shock (cid:3) DVT and Pulmonary embolism (cid:3) Investigation and management of cardiac failure (cid:3) Investigation and management of arrhythmias (cid:3) Airway management and care (cid:3) Ventilators modes and care of patient on ventilation (cid:3) Management of acute and chronic respiratory failure Curriculum MD (Anaesthesia) 331 (cid:3) Cerebrovascular Accidents (cid:3) Acute polyneuropathy (cid:3) Traumatic and non-traumatic coma (cid:3) Status epilepticus (cid:3) Brain stem death (cid:3) Renal, Electrolyte and Metabolic Disorders to include Diagnosis, prevention and management of acute renal failure (cid:3) Fluid, electrolyte and acid-base disorders (cid:3) Body temperature (cid:3) Haematological disorders (cid:3) Coagulopathies (cid:3) lmmunocompromised patients (cid:3) Gastrointestinal Disorders (cid:3) Acute liver failure - diagnosis and management (cid:3) Acute pancreatitis (cid:3) Gut ischaemia, gastrointestinal ulceration and bleeding (cid:2) Nutrition Requirements for enteral and parenteral nutrition (cid:2) Analgesia, Anxiolysis and Sedation (cid:2) Trauma (cid:3) Management of multiple injuries (cid:3) Near-drowning (cid:3) Burns and smoke inhalation (cid:3) Management of Acute Poisoning (cid:3) Organ Donation (cid:3) Scoring Systems (cid:3) Audit Ethics (cid:1) Pain Management (cid:2) A detailed knowledge of the control of acute pain in the context of postoperative and post-traumatic conditions will be expected, as will an understanding of the principles of chronic pain management in the pain clinic setting. (cid:2) Anatomy, physiology, pharmacology and basic psychology relevant to pain management (cid:2) Assessment and measurement of acute pain - including special problems with children, the elderly, and patients who are unconscious or in intensive care (cid:2) Assessment of patients with chronic pain and pain in patients with cancer (cid:2) Use of medication for pain management; conventional analgesics and adjuvant analgesics; side effects; problems of drug dependency and addiction (cid:2) The role of and indications for neural blockade: peripheral nerve, plexus, epidural and subarachnoid blocks, techniques of sympathetic blockade,neurolytic agents and procedures, implanted catheters and pumps for drug delivery (cid:2) Stimulation produced analgesia including transcutaneous techniques and acupuncture (cid:2) Other treatment modalities; physical therapy, surgery, psychological approaches, rehabilitation approaches, pain management programmes (cid:2) Pain relief and palliation in terminal illness Curriculum MD (Anaesthesia)