NATIONAL CURRICULUM FOR CANADIAN ANESTHESIOLOGY RESIDENCY Second Edition November 2015 Edited by Dr. Mark Levine MD, FRCPC, Dr. Patti Murphy BScN, MD, FRCPC, Jennifer Stewart, MHS and David Pierce Contributors: ASSOCIATION OF CANADIAN UNIVERSITY DEPARTMENTS OF ANESTHESIA* *For a complete list of contributors, please see Appendix A NATIONAL CURRICULUM GUIDE FOR ANESTHESIOLOGY National Curriculum Guide For Anesthesiology The Royal College of Physicians and Surgeons of Canada 774 Echo Drive Ottawa, Ontario K1S 5N8 Canada Telephone: 1-800-668-3740 or 613-730-8177 Fax: 613-730-3707 Web site: http://royalcollege.ca E-mail: [email protected] © 2015 The Royal College of Physicians and Surgeons of Canada. All rights reserved. This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright © 2015 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Specialty Education, attn: Associate Director, Specialties. Written permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact: [email protected]. For questions regarding the use of this document, please contact: [email protected]. Page 2 NATIONAL CURRICULUM GUIDE FOR ANESTHESIOLOGY TABLE OF CONTENTS 1 Airway Evaluation and Management - See also Ear, Nose and Throat (Section 7) ......... 5 2 Ambulatory Anesthesiology ................................................................................. 15 3 Autonomic Nervous System ................................................................................. 20 4 Cardiovascular Anesthesia ................................................................................... 23 5 Complications of Anesthesia ................................................................................ 35 6 Critical Care ...................................................................................................... 38 7 Ear, Nose and Throat Surgery .............................................................................. 48 8 Endocrinology .................................................................................................... 56 9 Ethics ............................................................................................................... 58 10 Geriatrics .......................................................................................................... 60 11 Hematology ....................................................................................................... 64 12 Hepatobiliary ..................................................................................................... 70 13 Immunology and Rheumatology ........................................................................... 73 14 Infectious Diseases ............................................................................................ 76 15 Monitoring and Equipment ................................................................................... 79 16 Neurology/ Neurosurgical Anesthesiology .............................................................. 87 17 Neuromuscular Junction ...................................................................................... 91 18 Obstetrical Anesthesia ........................................................................................ 94 19 Ophthalmology ................................................................................................ 103 20 Orthopedic Surgery .......................................................................................... 106 21 Pain Management ............................................................................................. 111 22 Pediatric Anesthesia ......................................................................................... 123 23 Pharmacology .................................................................................................. 131 24 Plastic Surgery................................................................................................. 136 25 Post-Anesthetic Care Unit (PACU) ....................................................................... 139 26 Preoperative Consultation ................................................................................. 142 © 2015 The Royal College of Physicians and Surgeons of Canada. 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Page 3 NATIONAL CURRICULUM GUIDE FOR ANESTHESIOLOGY 27 Regional Anesthesia ......................................................................................... 152 28 Remote Locations ............................................................................................. 160 29 Renal / Urologic ............................................................................................... 163 30 Respiratory Physiology and Thoracic Anesthesia ................................................... 166 31 Statistics ......................................................................................................... 172 32 Thermoregulation ............................................................................................. 175 33 Transplantation ................................................................................................ 178 34 Volatile Agents ................................................................................................. 183 Appendix A: List of Contributors ............................................................................... 190 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-subspecialized Anesthesiologist. Italicized items denote knowledge and skills that apply to specialty training of the subspecialty fellow. © 2015 The Royal College of Physicians and Surgeons of Canada. All rights reserved. Page 4 NATIONAL CURRICULUM GUIDE FOR ANESTHESIOLOGY MEDICAL EXPERT 1 Airway Evaluation and Management - See also Ear, Nose and Throat (Section 7) Upon completion of this training, the competent Anesthesiologist shall demonstrate advanced knowledge and proficiency in all the objectives related to airway evaluation and management listed below. A) Basic Science 1.1 Demonstrate knowledge of the structure and function of upper and lower airways, including but not limited to: 1.1.1 Nose, mouth, teeth, tongue 1.1.2 Nasopharynx, oropharynx, pharynx 1.1.3 Epiglottis, larynx, glottis, vocal cords, valleculae 1.1.4 Cartilages 1.1.5 Sensory and motor innervation 1.1.6 Conducting and respiratory airways: trachea, bronchi, bronchioles, alveoli 1.2 Demonstrate knowledge of the physiology and pathophysiology of ventilation and respiration, including but not limited to: 1.2.1 Control of breathing 1.2.2 Central nervous system 1.2.3 Diaphragm and accessory muscles B) Airway Obstruction 1.3 Demonstrate knowledge of the etiologies of airway obstruction 1.4 Demonstrate knowledge of the complications of airway obstruction, including but not limited to: 1.4.1 Hypercarbia/acidosis 1.4.2 Hypoxia 1.4.3 Aspiration C) Basic Airway Management 1.5 Demonstrate knowledge and expertise in basic airway management for the patient with an upper airway obstruction © 2015 The Royal College of Physicians and Surgeons of Canada. 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Page 5 NATIONAL CURRICULUM GUIDE FOR ANESTHESIOLOGY 1.6 Acute Airway Obstruction 1.6.1 Demonstrate proficiency in immediate recognition and management of the patient with an acutely obstructed airway, including but not limited to: 1.6.1.1 Basic Life Support (BLS) protocols: 1.6.1.1.1 Assessing patient responsiveness 1.6.1.1.2 Obtaining assistance 1.6.1.1.3 Patient positioning 1.6.1.1.4 Recovery position 1.6.1.1.5 Chin lift, head tilt, jaw thrust 1.6.1.1.6 Indications for and use of pharmacologic agents, including management of laryngospasm 1.6.1.1.7 Rescue breathing 1.6.1.1.8 Cardiopulmonary resuscitation 1.7 Bag-Valve-Mark Ventilation 1.7.1 Demonstrate knowledge and expertise in patient ventilation using bag- valve-mask devices, including but not limited to: 1.7.1.1 Selection of appropriately-sized masks 1.7.1.2 Assembly, use, and trouble-shooting of self-inflating ventilation devices 1.7.1.3 Two-person mask ventilation techniques 1.7.1.4 Role of positive end expiratory pressure (PEEP) valve 1.7.1.5 Role of reservoir bag 1.8 Basic Airway Adjuncts 1.8.1 Demonstrate understanding of the use of basic adjuncts to overcome acute airway obstruction including appropriate sizing and insertion techniques, including but not limited to: 1.8.1.1 Oropharyngeal airway 1.8.1.2 Nasopharyngeal airway D) Oxygen Delivery Systems 1.9 Demonstrate an understanding of systems designed for delivery of oxygen to the patient, including but not limited to: 1.9.1 Oxygen sources 1.9.2 Wall oxygen systems and specifications 1.9.3 High pressure oxygen supply © 2015 The Royal College of Physicians and Surgeons of Canada. 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Page 6 NATIONAL CURRICULUM GUIDE FOR ANESTHESIOLOGY 1.9.4 Diameter Index Safety System (DISS) 1.9.5 Quick-connect systems 1.9.6 Flowmeters 1.9.7 Cylinder sizes, pressures, capacities 1.9.8 Regulators and flowmeters 1.9.9 Nasal Cannulae 1.9.10 Flow rates and delivered oxygen 1.9.11 Capnography 1.9.12 Face masks 1.9.13 Types: Simple, Venturi, Non-rebreathing E) Universal Precautions - See Infectious Disease (Section 14) 1.10 Demonstrate knowledge and understanding of the role of universal precautions in patient care, including airway management using face shields, barrier masks, gloves F) Airway Evaluation 1.11 Demonstrate advanced knowledge and expertise in assessment of patient airways, particularly those features predisposing to difficulty in airway management 1.11.1 Elicit a satisfactory patient history, including but not limited to: 1.11.1.1 Review of old records 1.11.1.2 History of prior encounters with anesthetics 1.11.1.3 Dental/soft tissue damage 1.11.2 Perform a complete physical examination, including but not limited to: 1.11.2.1 Mallampati score 1.11.2.2 Thyromental distance 1.11.2.3 Upper lip bite test 1.11.2.4 Range of motion of neck 1.11.2.5 Neck circumference 1.11.2.6 Mandible, mouth opening 1.11.2.7 Other predictors of airway difficulty 1.11.2.7.1 Dentition 1.11.2.7.2 Tongue 1.11.2.7.3 Gender © 2015 The Royal College of Physicians and Surgeons of Canada. 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Page 7 NATIONAL CURRICULUM GUIDE FOR ANESTHESIOLOGY 1.11.2.7.4 Age 1.11.2.7.5 Body habitus/obesity 1.11.2.7.6 Facial hair 1.11.2.7.7 Medical conditions, tumours, trauma, pregnancy 1.11.2.8 Investigations 1.11.2.8.1 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, including but not limited to: 1.11.2.8.1.1 Pulmonary function testing (vitalometry) 1.11.2.8.1.2 Blood gas testing 1.11.2.8.1.3 Flow-volume loops G) Communicator Competencies 1.12 Demonstrate appropriate communication skills regarding the patient airway, evaluation and planning 1.12.1 Provide clear communication of pre-operative findings/concerns/plans to the patient 1.12.2 Provide accurate written documentation of pre-operative assessment and patient discussion for colleagues 1.12.3 Provide accurate written documentation of intra-operative airway findings 1.12.4 Identify the patient with a difficult airway and be able to: 1.12.4.1 Write a “Difficult Airway Letter” 1.12.4.2 Communicate this finding with the patient and family, and other physicians including the family physician 1.12.4.3 Recommend wearing a MedicAlert bracelet H) Airway Management Techniques 1.13 Demonstrate knowledge and expertise in airway management using endotracheal intubation 1.13.1 Describe the indications for intubation 1.13.1.1 Airway obstruction unrelieved by basic maneuvers 1.13.1.2 Oxygenation and Ventilation 1.13.1.3 Management of hypoxia, hypercarbia 1.13.1.4 Ventilatory support 1.13.1.5 Airway protection © 2015 The Royal College of Physicians and Surgeons of Canada. 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Page 8 NATIONAL CURRICULUM GUIDE FOR ANESTHESIOLOGY 1.13.1.6 Trauma/burns 1.13.1.7 Obtunded patient 1.13.1.8 Tracheobronchial toilet/suctioning 1.13.1.9 Anesthetics and surgery 1.13.1.10 Cases in which muscle relaxants are required 1.13.1.11 Surgery around head and neck 1.13.1.12 Airway procedures 1.13.1.13 Bronchoscopy, biopsies, therapeutic procedures 1.13.2 Route of intubation 1.13.2.1 Orotracheal intubation 1.13.2.2 Nasotracheal intubation 1.13.2.2.1 Surgical and anatomic indications 1.13.2.2.2 Considerations 1.13.2.2.3 Contraindications 1.13.2.2.4 Blind nasal intubation 1.13.2.3 Transtracheal intubation 1.13.2.3.1 In situ via tracheotomy stoma 1.13.2.3.2 Considerations of fresh tracheotomy versus mature stoma 1.13.2.4 Urgent non-elective endobronchial intubation 1.13.2.5 Technique/considerations using standard endotracheal tube 1.13.3 Intubation 1.13.3.1 Demonstrate knowledge and expertise in managing normal and difficult airways using direct laryngoscopy and intubation, with appropriate use of adjuncts where necessary: 1.13.3.1.1 Preparation 1.13.3.1.1.1 Equipment choice 1.13.3.1.1.2 Appropriate laryngoscope blade size 1.13.3.1.1.3 Appropriate endotracheal tube size 1.13.3.1.1.4 Equipment check 1.13.3.1.1.5 Monitors 1.13.3.1.1.6 Suction © 2015 The Royal College of Physicians and Surgeons of Canada. 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Page 9 NATIONAL CURRICULUM GUIDE FOR ANESTHESIOLOGY 1.13.3.1.1.7 Alternative airway devices, airways 1.13.3.1.2 Direct laryngoscopy 1.13.3.1.2.1 Curved blades 1.13.3.1.2.2 Straight blades 1.13.3.1.2.3 Levering blades 1.13.3.1.2.4 Other specialized blades 1.13.3.1.3 Indirect laryngoscopy techniques 1.13.3.1.3.1 Demonstrate knowledge and expertise in managing normal and difficult airways using alternatives to direct laryngoscopy, including but not limited to: 1.13.3.1.3.1.1 Fibreoptic laryngoscopes 1.13.3.1.3.1.2 Rigid fiberoptic laryngoscopes 1.13.3.1.3.1.3 Shikani, Bullard, etc. 1.13.3.1.3.1.4 Flexible fiberoptic laryngoscopes 1.13.3.1.3.1.5 Video laryngoscopes 1.13.3.1.3.1.6 Glidescope, McGrath laryngoscope, etc. 1.13.3.1.4 Adjuncts to facilitate endotracheal tube placement 1.13.3.1.4.1 Gum elastic bougie 1.13.3.1.4.2 Stylets 1.13.3.1.4.3 Malleable 1.13.3.1.4.4 Lighted (e.g. Trachlight, Tubestat) 1.13.3.1.4.5 Manoeuvres to facilitate visualization 1.13.3.1.4.6 Optimal patient positioning 1.13.3.1.4.7 BURP (backward upward rightward position) 1.13.3.1.4.8 OELM (optimal external laryngeal manipulation) 1.13.3.1.5 Confirmation of intubation 1.13.3.1.5.1 Visualization 1.13.3.1.5.2 Auscultation 1.13.3.1.5.3 Capnography 1.13.3.1.5.4 Radiography © 2015 The Royal College of Physicians and Surgeons of Canada. 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