ASSOCIATION OF CANADIAN UNIVERSITY DEPARTMENTS OF ANESTHESIA National Curriculum for Canadian Anesthesia Residency First Edition April 2010 Edited by Dr. Mark Levine MD, FRCPC, Dr. Patti Murphy BScN, MD, FRCPC Original Contributors: Drs. Fred Baxter, Rob Brown, Johanne Carrier, Francois Girard, Carolyn Goyer, Melanie Jaeger, Ramona Kearney, Mark Levine, Jean-Pierre Morin, Patti Murphy, Jeremy Pridham, Mateen Raazi, Bruce Ramsey, Sal Spadafora, Joanne Todesco, Narendra Vakharia, Clinton Wong, and Linda Wynne. This is not an official document of the Royal College of Physicians and Surgeons of Canada. This is a draft of a document being developed by ACUDA Education. Please refer to the RCPSC Objectives of Training for current guidelines regarding anesthesia training in Canada. Table of Contents 1 Airway Evaluation and Management ........................................................................................................................................... 4 2 Ambulatory Anesthesia ............................................................................................................................................................... 11 3 Autonomic Nervous System ....................................................................................................................................................... 14 4 Cardiovascular Anesthesia .......................................................................................................................................................... 16 5 Complications of Anesthesia....................................................................................................................................................... 22 6 Critical Care ................................................................................................................................................................................. 25 7 Ear, Nose and Throat Surgery ..................................................................................................................................................... 32 8 Endocrinology.............................................................................................................................................................................. 36 9 Ethics ............................................................................................................................................................................................ 38 10 Geriatrics ...................................................................................................................................................................................... 39 11 Hematology .................................................................................................................................................................................. 42 12 Hepatobiliary ............................................................................................................................................................................... 46 13 Immunology and Rheumatology ................................................................................................................................................. 48 14 Infectious Diseases ...................................................................................................................................................................... 50 15 Monitoring and Equipment ......................................................................................................................................................... 52 16 Neurology/ Neurosurgical Anesthesiology................................................................................................................................. 56 17 Neuromuscular Junction .............................................................................................................................................................. 59 18 Obstetrical Anesthesia ................................................................................................................................................................. 61 19 Ophthalmology ............................................................................................................................................................................ 67 20 Orthopedic Surgery ..................................................................................................................................................................... 69 21 Pain Management ........................................................................................................................................................................ 72 22 Pediatric Anesthesia .................................................................................................................................................................... 79 23 Pharmacology .............................................................................................................................................................................. 83 24 Plastic Surgery ............................................................................................................................................................................. 87 25 Post-Anesthetic Care Unit (PACU) ............................................................................................................................................ 89 26 Preoperative Consultation ........................................................................................................................................................... 91 27 Regional Anesthesia .................................................................................................................................................................... 96 28 Remote Locations ...................................................................................................................................................................... 100 2 This is not an official document of the Royal College of Physicians and Surgeons of Canada. This is a draft of a document being developed by ACUDA Education. Please refer to the RCPSC Objectives of Training for current guidelines regarding anesthesia training in Canada. 29 Renal / Urologic......................................................................................................................................................................... 102 30 Respiratory Physiology and Thoracic Anesthesia .................................................................................................................... 104 31 Statistics ..................................................................................................................................................................................... 107 32 Thermoregulation ...................................................................................................................................................................... 109 33 Transplantation .......................................................................................................................................................................... 111 34 Volatile Agents .......................................................................................................................................................................... 114 Note: As a convention in this document, plain text denotes skills and knowledge that apply to the specialty training at the graduate level of a non-sub specialized Anesthesiology Resident. Italicized items denote knowledge and skills that apply to specialty training of the Subspecialty Fellow. 3 This is not an official document of the Royal College of Physicians and Surgeons of Canada. This is a draft of a document being developed by ACUDA Education. Please refer to the RCPSC Objectives of Training for current guidelines regarding anesthesia training in Canada. 1 Airway Evaluation and Management See Ear, Nose and Throat 7 The competent Anesthesiologist shall demonstrate advanced knowledge and proficiency in all the objectives related to airway evaluation and management listed below. 1.1 Basic Science a) Structure and function of upper and lower airways: i. Nose, mouth, teeth, tongue ii. Nasopharynx, oropharynx, pharynx iii. Epiglottis, larynx, glottis, vocal cords, valleculae iv. Cartilages v. Sensory and motor innervation vi. Conducting and respiratory airways: trachea, bronchi, bronchioles, alveoli b) Physiology and pathophysiology of ventilation and respiration i. Control of breathing ii. Central nervous system iii. Diaphragm and accessory muscles 1.2 Airway Obstruction a) Etiologies of airway obstruction b) Complications i. Hypercarbia/acidosis ii. Hypoxia iii. Aspiration 1.3 Basic Airway Management The competent Anesthesiologist must demonstrate knowledge and expertise in basic airway management for the patient with upper airway obstruction. a) Acute Airway Obstruction The competent Anesthesiologist must demonstrate proficiency in immediate recognition and management of the patient with an acutely obstructed airway i. Basic Life Support (BLS) protocols: ii. Assessing patient responsiveness iii. Obtaining assistance iv. Patient positioning v. Recovery position vi. Chin lift, head tilt, jaw thrust vii. Indications for and use of pharmacologic agents e.g. in management of laryngospasm viii. Rescue breathing ix. Cardiopulmonary resuscitation b) Bag-Valve-Mark Ventilation 4 This is not an official document of the Royal College of Physicians and Surgeons of Canada. This is a draft of a document being developed by ACUDA Education. Please refer to the RCPSC Objectives of Training for current guidelines regarding anesthesia training in Canada. The competent Anesthesiologist must demonstrate knowledge and expertise in patient ventilation using bag-valve-mask devices, including: i. Selection of appropriately-sized masks ii. Assembly, use, and trouble-shooting of self-inflating ventilation devices iii. Two-person mask ventilation techniques iv. Role of PEEP valve v. Role of reservoir bag c) Basic Airway Adjuncts The competent Anesthesiologist must demonstrate understanding of the use of basic adjuncts to overcome acute airway obstruction including appropriate sizing and insertion techniques: i. Oropharyngeal airway ii. Nasopharyngeal airway 1.4 Oxygen Delivery Systems The competent Anesthesiologist must demonstrate an understanding of systems designed for delivery of oxygen to the patient, including: i. Oxygen sources ii. Wall oxygen systems and specifications iii. High pressure oxygen supply iv. Diameter Index Safety System (DISS) v. Quick-connect systems vi. Flowmeters vii. Cylinder sizes, pressures, capacities viii. Regulators and flowmeters ix. Nasal Cannulae x. Flow rates and delivered oxygen xi. Capnography xii. Face masks xiii. Types: Simple, Venturi, Non-rebreathing xiv. Flow rates and delivered oxygen 1.5 Universal Precautions The competent Anesthesiologist must be able to demonstrate knowledge and understanding of the role of universal precautions in patient care, including airway management using face shields, barrier masks, gloves See Infectious Disease 14 1.6 Airway Evaluation The competent Anesthesiologist must demonstrate advanced knowledge and expertise in assessment of patient airways, particularly those features predisposing to difficulty in airway management. a) Elicit a satisfactory patient history, including: i. Review of old records ii. History of prior encounters with anesthesia iii. Dental/soft tissue damage b) Physical Examination i. Mallampati score ii. Thyromental distance 5 This is not an official document of the Royal College of Physicians and Surgeons of Canada. This is a draft of a document being developed by ACUDA Education. Please refer to the RCPSC Objectives of Training for current guidelines regarding anesthesia training in Canada. iii. Upper lip bite test iv. Range of motion of neck v. Neck circumference vi. Mandible, mouth opening vii. Other predictors of airway difficulty  Dentition  Tongue  Gender  Age  Body habitus/obesity  Facial hair  Medical conditions, tumours, trauma, pregnancy c) Investigations The competent Anesthesiologist must demonstrate appropriate use and understanding of diagnostic testing and imaging where results may impact the planning of a patient’s pre-operative and post-operative airway and ventilatory management: i. Pulmonary function testing (vitalometry) ii. Blood gas testing iii. Flow-volume loops 1.7 Communication The competent Anesthesiologist must demonstrate appropriate communication skills regarding the patient airway evaluation and planning a) Clear communication of pre-operative findings/concerns/plans to the patient b) Accurate written documentation of pre-operative assessment and patient discussion for colleagues c) Accurate written documentation of intra-operative airway findings d) After identification of the patient with a difficult airway the anesthesiologist must: i. Write a “Difficult Airway Letter” ii. Communicate this finding with the patient and family, other physicians including family physician iii. Recommend wearing of a Medicalert Bracelet. 1.8 Endotracheal Intubation The competent Anesthesiologist must demonstrate knowledge and expertise in airway management using endotracheal intubation a) Indications for Intubation i. Airway obstruction unrelieved by basic manoeuvres ii. Oxygenation and Ventilation iii. Etiologies of hypoxia, hypercarbia iv. Definition of respiratory failure v. Objective criteria for intubation vi. Ventilatory Support vii. Mechanical ventilation strategies viii. Role of CPAP and PEEP ix. Airway protection x. Trauma/burns xi. Obtunded patient xii. Tracheobronchial toilet/suctioning xiii. Anesthesia and Surgery xiv. Muscle relaxant cases xv. Surgery around head and neck xvi. Airway procedures 6 This is not an official document of the Royal College of Physicians and Surgeons of Canada. This is a draft of a document being developed by ACUDA Education. Please refer to the RCPSC Objectives of Training for current guidelines regarding anesthesia training in Canada. xvii. Bronchoscopy, biopsies, therapeutic procedures b) Route of Intubation i. Orotracheal intubation ii. Nasotracheal intubation  Surgical and anatomic indications  Considerations  Contraindications  Blind nasal intubation iii. Transtracheal intubation  In situ via tracheotomy stoma  Considerations of fresh tracheotomy versus mature stoma iv. Urgent non-elective endobronchial intubation v. Indications for one-lung ventilation  Pulmonary hemorrhage  Foreign body vi. Technique/considerations using standard endotracheal tube c) Intubation The competent Anesthesiologist must demonstrate knowledge and expertise in managing normal and difficult airways using direct laryngoscopy and intubation, with appropriate use of adjuncts where necessary: i. Preparation  Equipment choice  Appropriate laryngoscope blade size  Appropriate endotracheal tube size  Equipment check  Monitors  Suction  Alternative airway devices, airways ii. Direct laryngoscopy  Curved blades  Straight blades  Levering blades  Other specialized blades iii. Indirect Laryngoscopy Techniques The competent Anesthesiologist must demonstrate knowledge and expertise in managing normal and difficult airways using alternative to direct laryngoscopy:  Fibreoptic laryngoscopes  Rigid fiberoptic laryngoscopes  Shikani, Bullard, etc.  Flexible fiberoptic laryngoscopes  Video laryngoscopes  Glidescope, McGrath laryngoscope, etc. iv. Adjuncts to facilitate endotracheal tube placement  Gum elastic bougie  Stylets  Malleable  Lighted (eg. Trachlight, Tubestat)  Manoeuvres to facilitate visualization  Optimal patient positioning 7 This is not an official document of the Royal College of Physicians and Surgeons of Canada. This is a draft of a document being developed by ACUDA Education. Please refer to the RCPSC Objectives of Training for current guidelines regarding anesthesia training in Canada.  BURP (backward upward rightward position)  OELM (optimal external laryngeal manipulation) v. Confirmation of intubation  Visualization  Auscultation  Capnography  Radiography d) Management of Extubation The Anesthesiologist must demonstrate an understanding of the methods of and considerations for airway management at the extubation phase, including: i. Airway toilet, suctioning ii. Awake extubation criteria iii. Deep extubation technique iv. Post-extubation stridor v. Extubation of the patient with a difficult airway e) Supraglottic Devices The competent Anesthesiologist must demonstrate knowledge and proficiency in airway management using supraglottic devices. i. Indications and contraindications of different supraglottic devices ii. Elective use as alternative to endotracheal intubation iii. Laryngeal mask airway (LMA) iv. LMA – ProSeal v. LMA – Classic vi. Emerging alternatives vii. Conduit for endotracheal intubation viii. Use of specific types of LMA as a conduit for endotracheal intubation ix. Emergent use in difficult airway algorithms x. CVCI (Cannot Ventilate, Cannot Intubate) situation f) Complications of Airway Management The competent Anesthesiologist must demonstrate an understanding of and an ability to recognize and treat the complications of airway management, including: i. Errors of endotracheal tube placement ii. Endobronchial intubation iii. Overinsertion iv. Patient repositioning, neck flexion v. Esophageal intubation vi. Airway trauma vii. Dental trauma viii. Soft tissue trauma ix. Post-extubation stridor x. Nasal trauma for nasal intubation xi. Aspiration xii. Prevention xiii. Fasting guidelines xiv. Anti-reflux pre-treatment strategies 8 This is not an official document of the Royal College of Physicians and Surgeons of Canada. This is a draft of a document being developed by ACUDA Education. Please refer to the RCPSC Objectives of Training for current guidelines regarding anesthesia training in Canada. xv. Role of cricoid pressure xvi. Management xvii. Current guidelines, role of bronchoscopy, lavage, antibiotics, other 1.9 The Difficult Airway The competent Anesthesiologist must demonstrate advanced knowledge and skills for the recognition and management of predicted and unexpected difficult airways. He/she must demonstrate knowledge of a range of safe options for securing difficult airways. He/she also must demonstrate appropriate communication, management and technical skills in doing so. a) General Considerations The competent Anesthesiologist must demonstrate a sound working knowledge of the difficult airway algorithms and current accepted airway guidelines. He/she must understand and be able to utilize the considerations and recommendations for difficult airway management, including: i. Predicted versus unpredicted difficult airway ii. Awake versus asleep strategy iii. Failed intubation strategy iv. Cannot ventilate, cannot intubate strategy v. Calling for assistance vi. Special considerations in the pediatric and obstetric populations b) Further classification of difficult airways into descriptive categories: i. Difficult mask ventilation ii. Difficult laryngoscopy iii. Difficult intubation iv. Difficult ventilation c) Predicted Difficult Airway The competent Anesthesiologist must demonstrate knowledge and proficiency in formulating an approach to the recognized difficult airway. He/she must understand and be able to weigh alternative strategies. Management Plan: i. Intubation versus alternatives ii. Supraglottic devices iii. Regional anesthesia iv. Awake versus asleep intubation v. Fibreoptic versus videolaryngoscopic techniques vi. Other devices vii. Lighted stylet viii. Other approaches  Retrograde wire or catheter-assisted intubation  Patient preparation for awake intubation  Psychological, communication of plan/concerns  Pharmacological  Anti-sialogogue  Anxiolytic  Strategies for uncooperative patients  Airway topicalization techniques  Local anesthetic pharmacology  Nerve block techniques  Aerosolized, spray, contact, injection 9 This is not an official document of the Royal College of Physicians and Surgeons of Canada. This is a draft of a document being developed by ACUDA Education. Please refer to the RCPSC Objectives of Training for current guidelines regarding anesthesia training in Canada. d) Unpredicted Difficult Airway The competent Anesthesiologist must demonstrate an ability to deal with unexpected difficult airways. He/she must understand and be able to apply the guidelines provided in difficult airway algorithms, including the role of supraglottic devices, surgical airways, and patient wake-up options. The Anesthesiologist should understand the principles of anesthesia crisis resource management and the various types of human error when faced with an unanticipated difficult airway. e) The Surgical Airway The competent Anesthesiologist must be able to demonstrate a working knowledge of surgical options for emergency airway management. He/she must demonstrate knowledge of the use of at least one cricothyrotomy kit or approach: i. Mini-tracheostomy ii. Cricothyrotomy iii. Jet ventilation iv. Contraindications to surgical airway techniques f) Extubation of the Difficult Airway Patient The competent Anesthesiologist must demonstrate an understanding of the implications for airway management at the extubation of the difficult airway patient. He/she should be able to demonstrate consideration of the following additional concerns: i. The patient with a wired jaw ii. The patient with airway edema iii. Extubation over an introducer iv. Assessment for readiness for extubation 1.10 Airway Education Resources The competent Anesthesiologist must demonstrate familiarity with current and emerging airway management options through awareness of and scholarly participation in: i. Internet airway resources and discussion groups ii. Continuing medical education options iii. Dedicated airway textbooks iv. Patient airway simulators 10