PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
TABLE OF CONTENTS SCORE: CLINICAL ORIENTATION ...... 4 I. SCHEDULE ...... 5 A. QGenda ...... 5 B. Weekly Schedule ...... 5 C. OR Daily Schedule ...... 5 D. Anesthesia Daily Call Team ...... 6 II. ELECTRONIC MEDICAL RECORD ...... 6 A. BIDMC Portal: ...... 6 B. Anesthesia Intranet ...... 6 C. Perioperative Information Management System (PIMS) ...... 7 D. Talis: ...... 7 E. Online Medical Record (OMR): ...... 7 III. CLINICIAN CONTACT INFORMATION ...... 8 IV. OVERVIEW OF ANESTHESIA LOCATIONS ...... 8 A. West Main ORs ...... 8 B. Feldberg ORs ...... 8 C. Shapiro ORs ...... 8 D. GI Locations ...... 8 E. West Remote Locations: ...... 8 F. East Remote Locations ...... 9 G. Labor and Delivery: ...... 9 H. Intensive Care Units (ICUs ...... 10 I. Offsite Locations ...... 10 V. DEPARTMENT MDs & CRNAs ...... 10 VI. EAST AND WEST OPERATING ROOM WORKFLOW ...... 12 A. Clinician Support and Resources ...... 12 B. Preoperative Anesthesia Testing (PAT): ...... 13 C. Preoperative ...... 13 D. Intraop ...... 18 E. Postop ...... 18 PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
F. Regional Anesthesia ...... 20 G. ICU Patients ...... 21 H. Nurse Practitioners (NPs): ...... 21 I. Anesthesia Technician Support ...... 23 J. Equipment ...... 24 VII. West Anesthesia Supplies ...... 25 VIII. REMOTE LOCATIONS ...... 30 A. Electroconvulsive therapy (ECT) ...... 30 B. West CT Scan ...... 30 C. West IR ...... 31 D. Interventional Neuroradiology (INR) ...... 31 E. MRI ...... 31 F. East IR ...... 31 G. Electrophysiology (EP)...... 32 H. Cath Lab Holding- Thursday CV/TEE assignment ...... 32 I. GI ...... 32 IX. CALL ...... 33 A. Weekday Late Call ...... 33 B. Weekend Call (not overnight) ...... 33 C. Pager Call ...... 33 D. Overnight Call ...... 34 X. OVERNIGHT CALL RESPONSIBILITIES ...... 34 A. Cases ...... 34 B. PACU Coverage ...... 34 C. Late Call Relief ...... 35 D. Code Blue Coverage ...... 35 E. Other Responsibilities...... 35 SCORE: Administrative Information ...... 36 I. Executive Leadership ...... 36 II. Division Directors ...... 37 III. Administrative Departments ...... 38 Billing and Coding (Anesthesia Financial Services) ...... 38 Communications ...... 39
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Finance ...... 40 Medical Education ...... 40 Professional Affairs ...... 43 Quality, Safety, Innovation and Informatics ...... 45 Scheduling ...... 47 General Info ...... 48 Phone Card Numbers (Room Phone Cards) ...... 52 Supporting Documents (Clinical) ...... 53 Anesthesia Administrator On Call ...... 53 OR Crisis Manual ...... 54 Post Anesthesia Transport Monitoring ...... 55 INR Case Setup ...... 56 Call Relief Guide ...... 57 West Late Call Relief ...... 58 East Late Call Relief ...... 59 PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
SCORE: CLINICAL ORIENTATION ROADMAP FOR CLINICAL ORIENTATION OF NEW STAFF
Overall, there is no fixed duration of Orientation Time Frame. We do collectively envision at a minimum each person will require a minimum of three weeks or 15 working days to be oriented to the various clinical sites/ assignments.
Orientation to Assignments
For BIDMC Faculty Assignments, minimum requisite assignments: West Main OR 3 days East Main OR 3 days EP x1, GI 3 x1, GI4 x 1, IR (East + West Friday), IP WPC, CT/INR (combined) Shadowing floor manager for a few hours (these can be minimums and then add a general mix)
Orientation to Coverage Models
All orientation faculty will be ideally:
- Exposed to types of coverage models—solo, residents, CRNAs (should see a mix of all three)
- Work 2 days in their first week with their two assigned mentors as best the schedule allows
- Daily assignments will be location based with appropriate pairing of faculty at schedulers’ discretion
- Ideally no solo assignments without overseeing faculty unless and until officially finished with clinical orientation
Orientation to Call
- Shadowing late call—similar to overnight call X1 West; X1 East. Orientee will shadow 4-6/7pm (key to be there for board handoff and relief of one round of late staff)
- One weekend day call prior to taking weekends on West to understand workflow. This will also be a chance to learn about East. Late calls and weekend day will be reimbursed
Conclusion of Clinical Orientation
- A survey before will be completed by orientee before coming off orientation, confirming exposure and comfort with various locations and types of cases
- The VCs of Clinical Affairs / Professional Affairs together will be in charge of moving faculty from orientation to independent practice PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
I. SCHEDULE
A. QGENDA . QGenda is our scheduling software and will be covered separately during orientation. QGenda lists clinical assignments and days off (including meeting days and vacation). . Can also be used to request days off or swap calls
B. WEEKLY SCHEDULE . Joanne Grzybinski sends out an email once the weekly schedule is finalized on QGenda. o Your weekly schedule can be viewed on your QGenda account o Please check the Weekly closely and notify Joanne of any errors o There must be an assignment listed for every date
C. OR DAILY SCHEDULE . The daily schedule is made based off the weekly schedule—for example, an attending whose assignment is listed as “Thoracic” on QGenda weekly will likely be assigned to thoracic cases. . Daily schedule is finalized every day by 4pm. Please check the daily schedule once it comes out and contact the Floor Manager with any questions/concerns. . The daily schedule can be viewed by going to PIMS (see below)->selecting the date.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
D. ANESTHESIA DAILY CALL TEAM . A list of the day, late and overnight teams is sent out by email every day for the following day and is also listed on the Anesthesia Intranet. . This is a handy reference to know who the floor manager, regional attending, late call team and administrator on call are.
II. ELECTRONIC MEDICAL RECORD
A. BIDMC PORTAL: • The Portal (portal.bidmc.org) is the home screen on all hospital internet browsers. On the home page, under Applications->Manage My Apps the following applications listed under Clinical should be added to your home screen:
Anesthesia Intranet Online Medical Records Perioperative Information Management System Provider Order Entry Talis Anesthesia
• Other applications that may be helpful: Emergency Department Dashboard, Interventional Radiology Information System (Dashboard for IR cases), Metavision Adult (ICU inpatient EMR) and UpToDate. • Hospital policies, procedures and guidelines are listed to the top right of the portal home screen under the section entitled PPGD.
B. ANESTHESIA INTRANET • Can be navigated using the tabs
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
• Points for call are entered under Schedules-> Points • Clinical Affairs tab: Click on Clinical to access our department policies and guidelines and to view Care Pathways • Professional Affairs tab: Includes orientation and other information
C. PERIOPERATIVE INFORMATION MANAGEMENT SYSTEM (PIMS) • Can also be accessed off the BIDMC Portal • “OR Schedule Display Options” allows you to view the entire OR schedule. This can be customized for date, surgeon and anesthesiologist • The “OR Case Dashboard” options are live dashboards and follow color coding to show the status of a case. There are separate links to West OR Case Dashboard and East OR Case Dashboard. • Information obtained from the preoperative phone call can be accessed by clicking on a particular case in the OR Case Dashboard and then clicking on Preoperative Assessment • Similarly day of surgery nursing assessment can be found by clicking on a particular case in the OR Case Dashboard and then on Holding Assessment • OMR, POE and eMAR can be accessed using the OR Dashboard
D. Talis: • Talis is our perioperative information management system and will be covered separately during orientation. • Talis Support on weekdays 7am-5pm can be reached via pager at 3AIMS (32467) • Talis Support after hours and weekends can be reached at 844-522-2846
E. ONLINE MEDICAL RECORD (OMR): • OMR is the clinical EMR and includes results of laboratory testing, radiology studies, cardiology studies and prior anesthesia records • OMR can be accessed via the BIDMC Portal (using the patient MRN) or the OR Dashboard • Lab results are listed under Results • All other relevant information is largely listed under Reports. The Cardiovascular tab includes EKG, echo and other cardiac testing. • Prior anesthesia records can be found under the Anesthesia tab (for Talis records) and under the other reports tab for historical records
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
III. CLINICIAN CONTACT INFORMATION
• Intranet: Full phone and pager list can be accessed under Department Info -> Lists/Forms-> Forms • QGenda: Clicking on a name accesses pager and/or cellphone information • Paging System: Can be accessed from the home page by clicking on “Pager (In and Out of Network)” or on the Portal through Pager in the top right corner. • OR front desks and badge cards have phone numbers listed for the ORs, ICUs and other anesthesia locations
IV. OVERVIEW OF ANESTHESIA LOCATIONS
A. WEST MAIN ORS Located on the 5th floor of the Rosenberg/West Clinical Center Building. ORs are numbered 1-19. West ORs house the majority of our inpatient surgical services including cardiac, vascular, thoracic, transplant, ENT, neuro, ortho trauma and acute care surgery.
B. FELDBERG ORS Located on the 3rd floor of the Feldberg Building on East campus. ORs are numbered 1-11. Case mix in Feldberg ORs includes outpatient and same day admission for total joint replacements, gynecologic surgery, ENT, plastics amongst others.
C. SHAPIRO ORS Located on the 3rd floor of the Shapiro Building of East campus. ORs are numbered 1-9. The Feldberg and Shapiro perioperative space (including preop holding and PACU) are in continuity connected by a bridge. Cases in Shapiro ORs include largely outpatient gynecologic, general surgery, plastics, orthopedic and urology cases.
D. GI LOCATIONS • West Procedural Center (WPC): West Campus, Lobby/1st floor of the Farr Building. Across from the Security Office • GI3: East Campus. 3rd floor of the Stoneman building. Across the hall from the Feldberg ORs. Take a right from the elevators. • GI4: East Campus. 4th floor of the Stoneman Building. Cross the elevator lobby near the Anesthesia Sandbox, take a right and the endoscopy suites are at the end of the hall.
E. WEST REMOTE LOCATIONS: On the schedule the offsite locations are sometimes noted as “Remote West 1-3”. This is a virtual location. Please ask the floor manager where the physical location is. The Rosenberg and Farr
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
buildings are connected by a bridge on floors 3-7. The Farr locations can be reached by crossing the bridge.
• ECT: Walk through PACU into the Farr Building. Once on Farr 2 take a right at the nurses station, the Deaconess building is at the end of the hallway. Follow the signs to ECT. • WPC: Lobby of the Farr building • Electrophysiology(EP)/Cath Lab: Farr 4. Follow the hallway from the OR locker rooms towards the Rosenberg-Farr bridge. Set of double doors at the end of the bridge gives access to the cath lab holding area, cath lab procedure rooms and electrophysiology rooms. • IR/Angio: Rosenberg 3 • Interventional neuroradiology/INR: Rosenberg 3 • CT Scan: Rosenberg 3 • MRI: Rosenberg basement
F. EAST REMOTE LOCATIONS a. GI3: Stoneman 3 across the elevator lobby from the Feldberg ORs b. GI4: Stoneman 4 across the elevator lobby from the Anesthesia Sandbox c. IR: Located on the same floor as the East campus ORs ie 3rd floor. Walk past the patient transport elevators and take a left. Double doors are marked in red.
G. LABOR AND DELIVERY: Located on Reisman 10. Can take the main East campus elevators to the 10th floor from the lobby or ORs or sandbox. Keycard access required. L&D has three ORs: A, B and C.
While it is unusual, you may be called to help on labor and delivery in case of an emergency. The algorithm used by the OB Anesthesiologists is:
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H. INTENSIVE CARE UNITS (ICUS
a. Finard ICU: Only ICU on East campus. Located on the 4th floor down the hallway from the locker rooms and the Sandbox. Take a left at the patient transport elevators and Finard ICU is at the end of the hallway. b. MICU A and B: Rosenberg CC7 c. CVICU A and B; CCU: Rosenberg CC6 d. NeuroICU: Farr 6 e. Trauma SICU (TSICU): Rosenberg 5, down the hall from the ORs
I. OFFSITE LOCATIONS Include the Arnold Warfield Pain Center, other pain clinics, Longwood Plastics and 1 Brookline Place. Orientation for these locations is covered separately for those working at these sites.
V. DEPARTMENT MDS & CRNAS
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
VI. EAST AND WEST OPERATING ROOM WORKFLOW
A. CLINICIAN SUPPORT AND RESOURCES • Immediate help/Patient Safety Concern: Ask the circulating nurse to call an “Anesthesia STAT” in the operating rooms. This is an overhead announcement and brings all available anesthesia staff and technicians to your location. In all out-of-OR locations (including GI): ask the nurse to call a Code Blue. This activates the Code Team which includes the Floor Manager and Anesthesia Critical Care Attendings carrying code pagers. • Floor Manager: There is a floor manager/ “floor runner” assigned to each campus on all weekdays. The floor manager is an excellent resource if you have questions about a location, case specifics, need a second opinion or additional resources, for example help with a known difficult airway. The floor manager should be informed of any delays in first-start cases or other patient care issues. • Administrator-On-Call (AOC): The Anesthesia Daily Call Team lists the Anesthesia AOC. The AOC is a member of the senior leadership team who is available 24/7 for
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
consultation. The AOC can be contacted with any questions regarding policies or serious intraop adverse events (like patient death). More info here. • Cognitive aide/Emergency Manual: Physical copy located in all anesthesia locations. ORs also have a QR code on the wall that can be used to access a digital copy. Complete copy of the Emergency Manual available here.
B. PREOPERATIVE ANESTHESIA TESTING (PAT): • All patients are contacted prior to anesthesia, with the exception of patients who are at a long-term facility or undergoing specific procedures. Information from the preoperative phone call is included in the OR Dashboard as noted above. • Some patients undergo an in-person visit at the PAT Clinic located on East campus. Information entered there by residents, NPs or attendings is available as a Talis PAT evaluation. • The PAT Clinic also orders relevant bloodwork and other tests including a type and screen as indicated and communicates with the surgeon if there are any questions or concerns. • Anesthesia Alerts identified during the preoperative phone call or in PAT Clinic will be emailed to the anesthesia team assigned to the case when the daily OR schedule is finalized. These include patient-specific risks such as a history of MH, known difficult airway etc.
C. PREOPERATIVE • OR first-case start times are: Mondays, Thursdays, Fridays at 7:30am Tuesdays at 8am (following Faculty Hour meetings) Wednesdays at 9:30am (following Departmental Grand Rounds and M&M) • Ideal workflow to ensure an on-time first-case start is shown below
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
• Preop/holding area nurses denote that a patient is ready to go to the OR both through the use of a colored card on the chart (see pictures below) and by signing the preop checklist. Both these steps must be completed before a patient can be taken into the operating room.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
• Given the large number of add-ons, the West Campus schedule is also written out on the whiteboard. Please check your assignments in the morning to make sure there are no changes to the room or cases. • PreAnesthesia Evaluation (PAE) in Talis can be completed by residents/fellows, CRNAs or attendings but must be finalized by an attending for all non-emergency cases prior to the patient entering the OR • Appropriate preop prep, including PAE, IV and consent is the responsibility of the anesthesia team including residents/fellows, CRNAs and attendings. The attendings are expected to help with workflow for subsequent cases through the day. For attendings working solo on East campus, the NPs help out with preop evals and IVs as able. For attendings working solo on West campus, they should expect to complete their own PAEs and IVs. The West Floor Manager will help with workflow as able. • Preoperative medications or tests can be ordered via the PIMS OR Dashboard the night before. Any last minute changes must be verbally communicated to the preop nurse.
• Regional workflow is detailed separately below.
D. INTRAOP • The patient is transported to the OR by members of the anesthesia and surgery teams. • A sign-in is done by the circulating RN on arrival to the OR and includes verification of name, DOB, MRN, allergies and procedure. Anesthesia should not be induced until the procedure is verified by the surgical team. • A final time out occurs prior to surgical incision. All team members should be fully focused and participate in the time out. • Attendings should give their residents/fellows and CRNAs a morning break (15 minutes), lunch break (30 minutes) and afternoon break (15 minutes). The floor manager is responsible for providing appropriate breaks for staff working solo.
E. POSTOP • At case completion, the circulating nurse calls the PACU to obtain a slot. Patients are transported to their PACU slot by members of the anesthesia and surgical teams. • Postop orders can be placed by residents/fellows, CRNAs and attendings using POE. All patients should have PACU orders placed.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
• West Campus main ORs: All patients are recovered in the West PACU. The West PACU is covered by the PACU resident and the Float Intensivist. All concerns should be discussed with this team. • East Campus ORs: All patients staying overnight are recovered in the Feldberg PACU and all outpatients (being discharged home) are recovered in the Shapiro PACU independent of which OR their procedure took place in. Outpatients who received MAC and meet Phase II criteria are directly transported to Phase II of the Shapiro PACU. Both Feldberg and Shapiro PACU are covered by the East floor manager with assistance from the NPs and the regional teams. • Remote location recovery: detailed below • Any change in patient condition that necessitates unexpected postop ICU admission should be discussed with the surgeon. If the surgeon or the anesthesiologist determines that a patient needs postoperative ICU care, the circulating nurse contacts the admissions facilitator for a postop ICU bed. ICU patients frequently board in the West PACU, the Float Intensivist can be contacted with any questions. • Appropriate monitoring should be included for transport, details here. • PACU handoff is given by both the surgical and anesthesia teams. Anesthesia handoff includes the printed Talis summary but also includes a verbal handoff highlighting type of anesthetic, airway management, controlled meds given, PONV/PDNV meds and fluid totals. Patient should be stable at the time of handoff.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
F. REGIONAL ANESTHESIA • Neuraxial as a primary anesthetic: All spinals (and CSE if deemed necessary) for primary anesthetic for the operation (for example: spinals done for TJA) are performed by the primary anesthesia team assigned to the case ("team in the room"). The spinal is performed in the Operating Room. Currently, there is no separate spinal time out. • Peripheral Nerve Blocks: All cases where surgeon requests a block as a primary anesthetic should say "BLOCK" on the schedule. This block will be performed by the regional team on either campus. For cases booked as GEN/BL, the surgeon is requesting pre-operative nerve block for post-op pain. For cases booked as NERVE, the surgeon is requesting a peripheral nerve catheter. In this case the patient may also need general anesthesia and has to be admitted to the hospital as there is no outpatient catheter program at BIDMC. The regional team will perform these procedures in pre-op holding prior to patient proceeding to the OR. As the primary anesthesia team, you are responsible for placing a PIV and completing the pre-op assessment. The regional team will frequently assist with the consent. The regional team for each campus is listed on the Daily Call Schedule on the Intranet and sent by our scheduling administrators. • Epidurals for postoperative analgesia: Epidurals for all first start cases (7:30 cases M/Th/F, 8:30 cases Tu, 9:30 cases Weds) are to be performed in the pre-op holding by the primary anesthesia team assigned to the case. This includes consent, PIV, pre-op assessment, procuring epidural supplies and actual placement. Please plan to arrive early enough to anticipate any difficulties and to ensure that the case can start on time (7:30 am in the OR M/Th/F, 8:30 am Tu, 9:30 am Weds). Attempts by CRNAs are at the discretion of the attending and as time allows. Please adhere to ASRA and BIDMC guidelines for anticoagulation while placing any neuraxial procedures. Epidurals for all subsequent cases are performed by the regional team. Communication is essential to avoid unnecessary procedures, complications and case cancellations. • Workflow and postop pain management: Generally, all nerve blocks and epidurals are placed in pre-op holding. Full monitoring including ECG leads, pulse oximetry and BP cuff is mandatory for placement. A timeout is required with the holding area RN. The patient is required to have a working IV prior to time out. Patient can be pre-medicated for anxiolysis if all the pre-operative paperwork has been completed. Please double check if that's the case during the time out with the holding RN. • If a case is not booked with a block or an epidural, please discuss with the surgeon and the regional team if you think your patient is a good candidate for regional anesthesia as early as possible. This includes patients who may need an epidural or block post- operatively. By far, the biggest challenge to placing an epidural or a peripheral nerve block post-operatively is the patient consent. If you anticipate that your scheduled case will change drastically (for example: diagnostic laparoscopy to become ex-lap or VATS to become an open thoracotomy), please preemptively consent patient for the regional interventions.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
For first start cases you are expected to help with IV placement at 6:45 am or as soon as the holding RN completes intake paperwork. This helps optimize workflow and ensure the on time start of the cases. • Afterhours Regional Anesthesia: You may wish for your patient to have regional interventions in off hours (evenings and on call). The availability of regional team may be limited during those times. If it is a scheduled case on the weekday that is happening after 5 pm, the regional team will try to make arrangements for your patient with floor managers and late staff to provide regional service. In specific circumstances, the Acute Pain Service team on call (resident + attending) may come back to the hospital for regional placement or may help co-ordinate placement with available staff. Starting Friday 5 pm and through the weekend the regional service is covered by Chronic Pain Service attendings with various comfort levels for performing regional procedures. They do not routinely place regional anesthesia for patients while on call. You may choose to place an epidural or a regional anesthetic yourself, but please contact the APS/CPS service to ensure that there is a follow up for the patient if catheter is to be left inserted. Please follow standard guidelines during placement, including monitoring, anti- coagulation, marking, time out, and consents. • All patients with a nerve catheter or an epidural catheter are followed by the Acute Pain Service (APS) team post-op. The APS team can be contacted via the pager system online or by paging 3PAIN (37246).
G. ICU PATIENTS • ICU Patients are transported to the OR directly from the ICU by the surgical and anesthesia teams. Location of ICU patients is noted on the OR Whiteboard and can also be confirmed with the OR front desk. • Handoff about patient specifics should be obtained from the ICU team at bedside. • Complete anesthesia consent (this is often done by the call team the night before) and finalize the PAE • Supplies to take to the ICU for patient pickup include a transport monitor (can use the same brick that is being used in the ICU), IV fluids with anesthesia tubing and any necessary meds. Anesthesiologists can choose to use the ICU IV pumps or the OR pumps for infusion meds. • Transport monitoring should include a full set of monitors. Patients who require assisted ventilation can be ventilated using an AmbuBag (PEEP valves available in the ICU). In the case of significant ventilatory support, consider using the ICU ventilator. • The Floor Manager or Float Intensivist (listed on Daily Call Team) can help with any questions or resources needed • As noted above, patients who need ICU level of care postop can go directly to the ICU or the PACU. These patients should be transported with full monitoring, and handoff given to the ICU team. Talis workstations are located in all ICUs.
H. NURSE PRACTITIONERS (NPS): • NPs are assigned to Shapiro and Feldberg holding/preop, GI3, GI4, WPC, ECT and Thursday Cardioversions. As our team members in these locations the NPs optimize
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
workflow by doing pre-anesthesia evaluations, placing IVs and readying patients for blocks. • In the East ORs, the NPs prioritize preops and IV placements for cases where attendings assigned solo, cases assigned to the floor manager and any patients needing blocks.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
I. ANESTHESIA TECHNICIAN SUPPORT • Our support team includes Talis Support, Clinical Engineering and Anesthesia Technicians on both East and West Campuses in the operating rooms and remote locations
• Anesthesia techs turn over ORs between cases including replacing suction, the anesthesia circuit/bag and replacing the anesthesia tray. A standard anesthesia tray contains a Mac3 blade+handle, a #9 oral airway and 7.0 and 7.5 endotracheal tubes. Other supplies can be found in the OR, on supply carts or in the tech workroom as shown below. • Coverage hours for the anesthesia techs are as listed below. The on-call teams are responsible for turnover during off-hours. Details of supplies and turnover will be covered during orientation.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
• A comprehensive list, pager/contact information and most updated hours are available via a link in the bottom-right corner of the Anesthesia Intranet (see screenshot below). • Information on equipment can be found on Anesthesia Intranet EducationInService Media
J. EQUIPMENT
West Shapiro Feldberg Aline kit and supplies Each OR; vascular cart b/w OR 5& 7 Workroom Workroom CVL Kit Vascular cart b/w OR 5&7; OR 15 Shapiro Workroom Workroom MH Cart Main hallway by OR 15 Feldberg Workroom Feldberg Workroom McGraths Workroom Workroom+ORs Workroom+ORs Glidescope Workroom Workroom Workroom Airway cart Workroom Feldberg Workroom Workroom Spinal Cart/Supplies Workroom Workroom Workroom
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Ultrasound Preop and outside workroom Workroom Workroom
• Please sign out McGrath videoscopes, Glidescopes and the Airway Carts using the sign out sheets in the workrooms • More information on signing out equipment and decontamination is on the Intranet • Equipment Codes: Epidural Pumps: 1-5-9 Bluebell/Anesthesia Equipment Carts: 3-1-2 Bluebell/Anesthesia Cart in East IR: 3-1-2-3-1-2 East Anesthesia Workrooms: 3-1-2 Feldberg Equipment Room (between OR 1 and 2) 3-1-2-3-1-2
VII. WEST ANESTHESIA SUPPLIES
Stocking Carts located outside of West ORs # 8, 14 & 12a
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
West Workroom: vivasight double lumen tube; regular double lumen tubes
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
West Workroom: Belmont and level 1 supplies; cook catheters; spare pumps & transport monitors, airway supplies and blades
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Shapiro Workroom #1: MH Filters, ultrasound covers, gray top ultrasound wipes, McGrath disposable blades, glidescope disposable blades
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Shapiro Workroom #2: angio needles, epidural needles, spinal needles, anesthesia tray set-up supplies, anesthesia turnover trays
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Shapiro Workroom # 3: anesthesia circuits, spinal & epidural kits, pillows and betadine, ecg stickers, bare huggers, suction canisters and tubing, syringes
VIII. REMOTE LOCATIONS
This is a quick introduction to the out of OR anesthesia locations. More info can be found at the links below or in discussion with the section/division chiefs.
A. ELECTROCONVULSIVE THERAPY (ECT) Department Liaison: Sapna Govindan MD Patients: Outpatients Location: Deaconess 2 Workflow: NP helps with preops/IVs. Usually solo attending. Patients recover in procedure bays. Most common anesthetic: GA with mask airway, methohexital/succinylcholine for induction
B. WEST CT SCAN Section Head, Radiology Liason: Leo Tsay MD
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Patients: Outpatients/Same day admits Location: West/Rosenberg Clinical Center, 3rd Floor Workflow: Patients come to preop holding on 5th floor. Anesthesia machine and bluebell anesthesia cart set up by anesthesia tech. Need to take drug box from the main Omnicell. Recovery in 5th floor PACU. Most common anesthetic: GA with ETT
C. WEST IR Section Head, Radiology Liason: Leo Tsay MD Patients: Outpatients, same day admits or inpatients Location: West/Rosenberg Clinical Center, 3rd Floor Workflow: Patients come to preop holding on 5th floor. Both IR suits equipped with an Omnicell and an anesthesia machine. Recovery in 5th floor PACU. Most common anesthetic: GA with ETT, sometimes MAC Of note: On Fridays, IR has a block noted on the schedule as “East/West Angio”. The team assigned to this block provides anesthesia for IR cases on both campuses as needed.
D. INTERVENTIONAL NEURORADIOLOGY (INR) Neuroanesthesia Division Chief: Samir Kendale MD Patients: Same day admits and emergency Code Stroke cases Location: West/Rosenberg Clinical Center, 3rd Floor Workflow: Patients come to preop holding on 5th floor. Equipped with anesthesia machine and Omnicell and extra anesthesia supplies. Recovery in 5th floor PACU. Most common anesthetic: GA with ETT for aneurysm interventions Of note: Code Stroke cases go directly to the interventional suite from the ED. These can be either MAC or GETA cases. More info on INR case setups can be found here.
E. MRI Section Head, Radiology Liason: Leo Tsay MD Patients: Mostly inpatients, some outpatients Location: West/Rosenberg Clinical Center, Basement Workflow: Patients come to preop holding on 5th floor. Anesthesia machine and bluebell anesthesia cart set up by anesthesia tech. Need to take drug box from the main Omnicell. Paper charting. Recovery in 5th floor PACU. Most common anesthetic: MAC or GA Of note: All precautions with MRI apply, including special monitors and precautions around ferromagnetic objects. For difficult airway consider induction/extubation in preop/PACU. Will need a transport monitor.
F. EAST IR Section Head, Radiology Liason: Leo Tsay MD Patients: Almost always inpatient add-on cases Location: East/Feldberg, 3rd Floor
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Workflow: Patients come to radiology holding that is adjacent to the IR suite. Anesthesia machine and bluebell anesthesia cart set up by anesthesia tech. Need to take drug box from the main Omnicell. Recovery in Feldberg PACU. Most common anesthetic: GA with ETT, sometimes MAC Of note: On Fridays, IR has a block noted on the schedule as “East/West Angio”. The team assigned to this block provides anesthesia for IR cases on both campuses as needed.
G. ELECTROPHYSIOLOGY (EP) Section Head, EP: Sankalp Sehgal, MD Patients: Same day admits Location: West/Rosenberg Clinical Center, 4th Floor Workflow: Patients come to cath lab holding that is adjacent to the EP suites/cath lab. Rooms are equipped with anesthesia machine and Omnicell and. Recovery in 5th floor PACU for GA, and cath lab for MAC cases. Usually we have 2-3 rooms per day in EP. Most common anesthetic: GA with ETT or MAC Of note: Pulmonary vein isolation (PVI) usually done with jet ventilation. Rooms are equipped with a Monsoon jet ventilator.
H. CATH LAB HOLDING- THURSDAY CV/TEE ASSIGNMENT Patients: Outpatients, some inpatients Location: West/Rosenberg Clinical Center, 4th Floor Workflow: Cardiology has a block for cardioversions and TEEs on Thursdays. Patients come to cath lab holding. NP helps with preops and IVs. Cardioversions done in cath lab holding area bays, TEEs done in procedure room. Talis available at both locations, nurses will provide propofol and other meds as requested. Some clinicians prefer to also bring a standard anesthesia box from the main Omnicell. Patients recover in cath lab. Most common anesthetic: Propofol sedation
I. GI Division Chief: Soumya Mahapatra MD • WPC Patients: Outpatients, some inpatients largely for EGD, Colonoscopies Location: West, Farr building 1st floor Workflow: Common holding and recovery area. Prepped by GI nurses. Anesthesia NPs help with preops, IVs as needed. Provide anesthesia in two endoscopy suites, both equipped with anesthesia machine, Omnicell and Talis. Following anesthetic, recover in WPC if MAC used. Recover in OR PACU (5th floor) if any concerns or GA with ETT used with inhalational agents.
Most common anesthetic: Propofol sedation
• Stoneman 3/GI3 Patients: Outpatients, some inpatients largely for EGD, Colonoscopies Location: East campus, 3rd floor of Stoneman building, across hallway from Feldberg ORs.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Workflow: Anesthesia NPs help with preops and IVs as needed. Both endoscopy suites equipped with anesthesia machine, Omnicell and Talis. Following anesthetic, recover in GI3. Recover in OR PACU (5th floor) if any concerns or GA with ETT used with inhalational agents. Most common anesthetic: Propofol sedation
• Stoneman 4/GI4 Patients: Mix of outpatients, inpatients and transfers from other hospitals for advanced endoscopy (for example ERCP and EUS) Location: East campus, 4th floor of Stoneman building, across hallway from Anesthesia Sandbox • Workflow: Anesthesia NPs help with preops and IVs as needed. Three endoscopy suites equipped with anesthesia machine, Omnicell and Talis. Usually one attending with 3 CRNAs. Following anesthetic, recover in GI3. Recover in OR PACU (5th floor) if any concerns or GA with ETT used with inhalational agents.
IX. CALL
A. WEEKDAY LATE CALL • Late call attendings stay past 5pm to complete both scheduled cases and add-ons. Determination of assignments are made by the Floor Manager until 5pm, and the overnight West and East call attendings thereafter • Late 1 and Late 2 call attendings are assigned to a specific campus and do not “cross the street” ie switch campuses • Late 3, 4, 5 and the 4-11 attending can be asked to provide anesthesia on either campus. • The Late 5 attending is backup for the overnight attendings, and remains on pager call overnight to be called back in if needed. Points are given both for holding the pager and hours worked. • Call relief is explained in detail here.
B. WEEKEND CALL (NOT OVERNIGHT) • Weekend Day: This is a fixed shift from 7am to no later than 5pm. During this time, the weekend day anesthesiologist can be asked to provide anesthesia solo, supervise residents/fellows, help with call team breaks or any other tasks that the call attending needs assistance with. • Late 3: Weekend Late 3 is on pager call from Friday 5pm to Monday 7am. Late 3 may be called in to either East or West campus if needed. Points are given both for holding the pager and hours worked. • East Call: East call on weekends is a pager call. The on-call anesthesiologist will be notified by the OR desk of any OR or remote cases on East campus. Points are given both for holding the pager and hours worked.
C. PAGER CALL
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
• Transplant, cardiac and pain are call pools that are separate from the OR call pool. These are pager calls and attendings come in if called by the OR desk. • As noted above, Late 3 and East call are weekend pager calls.
D. OVERNIGHT CALL • Weekdays: East and West overnight call start at 4:30pm and end at 7am the following morning. The on-call attending receives signout from the Floor Manager at the beginning of their call and hands off to the Floor Manager at the end of their call. • Weekends: West call is a 24 hour call on Saturdays, Sundays and OR holidays. The call starts and ends at 7am. East call is a pager call on weekends and holidays. • Team: Following relief of the late call CRNAs and attendings, the West call team that stays in-house consists of the attending and two residents Following relief of the late call CRNAs, residents and attendings, the East campus overnight attending is on call solo • Resources: West—The on-call ICU attending (almost always anesthesia critical care) is inhouse overnight East—the OB anesthesia attending is inhouse overnight Anesthesia AOC—Member of senior leadership who is available at all times to answer any questions related to clinical resources or policies
X. OVERNIGHT CALL RESPONSIBILITIES
A. CASES • The on-call team completes both scheduled and add-on cases. The overnight attending on West campus typically supervises two residents. The overnight attending on East campus supervises residents or CRNAs initially, then transitions to providing anesthetic care solo. • The on-call anesthesiologist must communicate with the charge/resource nurse to determine number of ORs that can run concurrently and the plan for add-on cases • On West campus, one OR (usually OR 15) must always be set up as a trauma OR. The trauma room is set up by either the PACU or float resident. If OR 15 is being used, a different OR is set up as the trauma room after discussion with the OR charge/resource nurse.
B. PACU COVERAGE • West PACU is covered by the PACU resident and the Float Intensivist attending during the day. The on-call West anesthesia attending will get PACU signout from the float ICU attending. The PACU is covered by the PACU resident initially, then the float resident and subsequently the overnight call team. • Both East PACUs (Shapiro and Feldberg) are covered by the Floor Manager during the day. The on-call East anesthesia attending will receive signout on any active issues and covers the PACU overnight
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
• ICU Boarders in the PACU on both campuses are covered by the respective ICU teams overnight, ie the ICU Call attending on West Campus and the Finard ICU/MICU attending on East campus
C. LATE CALL RELIEF • Starting at 4:30pm the on-call attending on each campus takes over floor management responsibilities. Details of late call relief are as noted in East Late Call Relief and West Late Call Relief. • The on-call attending is responsible for ensuring fair and timely relief of the late-call team as detailed here. • Dinner breaks should ideally be provided to all residents, CRNAs and attendings who are expected to stay past 7pm. • The East and West overnight attendings should continually communicate with each other to ensure fair relief of late call staff
D. CODE BLUE COVERAGE • Both East and West call attendings and the West call residents carry code pagers and respond to “Anesthesia Stat” and “Code Blue” pages Anesthesia Stat is a respiratory or cardiac arrest only in an ICU or cath lab. All other cardiopulmonary arrests at the Medical Center, including isolated respiratory arrests, are called Code Blue • On East campus, both the OB attending and the East attending respond to codes overnight. If the overnight attending is solo in an OR, they should communicate this with the OB attending in case of a code blue call • Similarly on West campus, both the West overnight on-call anesthesiologist and the ICU attending respond to all code events • The anesthesia team’s responsibility at Code Blue events is advanced airway management usually endotracheal intubation. The respiratory therapists are usually assisting with BMV at the time of our arrival and also bring airway supplies including a McGrath video laryngoscope. Meds (if needed) are provided by pharmacists. • All intubations must be documented in the medical record (OMR note) and can be billed using the blue cards in the anesthesia offices
E. OTHER RESPONSIBILITIES • Urgent/elective intubations in the medical ICUs: All standard supplies will be available at bedside. As noted above, all intubations must be documented as procedures in OMR and a blue card can be used to bill for the procedure • Sick calls: Any staff calling in sick for the subsequent day is asked to notify the West call attending. The overnight attending should attempt to find appropriate coverage for the sick call, but can defer to the floor manager for the next day. • Preops: Add-on inpatient preops for the following day are done by the float resident and the on-call residents (as able) to identify any major issues and ensure adequate preop testing is completed • Weekend ICU Postops: Per regulations, we are required to complete postops checks on ICU patients. These can be completed by the on-call residents as able on weekends only.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
SCORE: ADMINISTRATIVE INFORMATION
I. EXECUTIVE LEADERSHIP Daniel Talmor, MD, MPH Dawn Ferrazza, MA Chair Chief Administrative Officer Yamins 210 (East Campus) Yamins 210 (East Campus)
Philip Hess, MD Alan Lisbon, MD Executive Vice Chair Executive Vice Chair, Emeritus Feldberg 407
J. Michael Haering, MD Rikante Kveraga, MD Vice Chair, Clinical Services Vice Chair, Network South Rosenberg 470 Site Chief, Needham
John D. Mitchell, MD S. Krish Ramachandran, MD Vice Chair, Education Vice Chair, Quality, Safety and Dir. Center for Educaiton Innovation Research, Technology and Program Director, Innovation in Anesthesia Perioperative Quality and Safety Rosenberg 470 fellowship Yamins 210 Todd Sarge, MD Dr. Shaz Shaefi Vice Chair, Critical Care Vice Chair of Professional Affairs Medicine Program Director, Rosenberg 6th floor Neurocritical Care fellowship Neurology fellowship CLS 6th floor Eswar Sundar, MBBS Simon Robson, MBChB, PhD Director Clinical Operations – Vice Chair, Research East Campus Director, Center for Inflammation CLS 4th floor
Rami Burstein, PhD Vice Chair, Neuroscience CLS 6th floor
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
II. DIVISION DIRECTORS
Samir Kendale, MD Lisa Kunze, MD, PhD Division Director, Division Director, Neuroanesthesia Orthopedic Anesthesia
Yunping Li, MD Soumya Mahapatra, MD Division Director, Division Dir. Obstetric Anesthesia GI Anesthesia
Feroze Mahmood, MD Robina Matyal, MD Division Director, Division Director, Cardiac Anesthesia Vascular Anesthesia Director, Perioperative Echocardiography
Richard Pollard, MD Andrey Rakalin, MD Division Director, Division Director, PAT Clinic Regional Anesthesia Director, Quality Improvement Program Dir. Regional Anesthesia Program Dir. Neuro Fellowship Fellowship
Max Schaefer, MD Tom Simopoulos, MD Division Director, Division Director, Thoracic Anesthesia Pain Medicine
Jason Wakakuwa, MD Sugantha Sundar, MBBS Division Director, Director of Professional Affairs Transplant Anesthesia Director of Center on Professional and Peer Support
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
III. ADMINISTRATIVE DEPARTMENTS
BILLING AND CODING (ANESTHESIA FINANCIAL SERVICES) Administrative Team members: Shannon Cameron Cathy Manzelli Executive Director of Revenue Supervisor, Payment Posting Cycle, HMFP
Tracy Blake Caitlin Parece CCS-P Senior Manager of Supervisor Accounts Receivable Operations & Human Resources
Aaron Banner-Goodspeed Carmen Saralegui, RHIT, CPC, CGSC Senior Manager Revenue Coding & Compliance Manager Integrity
Ed Kelly Patricia Varitimos, CPC, CANPC Supervisor - Chart Flow Manager of Revenue Cycle
Michael Kurey AR Data & Payer Relations Manager
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
COMMUNICATIONS Administrative Team members: Heather Derocher Ann Plasso Director, Communications and Communications Specialist Special Projects Yamins 210 (East Campus) Yamins 210 (East Campus) [email protected]
Beth Hill Project Administrator, Communications Westborough (offsite)
The role of the communications team is to help keep you connected to your coworkers and help you stay informed about the important work, accomplishments and interesting activities happening in our large and complex department. We also plan a variety of special events throughout the year.
What we work on:
• Publishing a monthly departmental newsletter • Plan and coordinate dept. events and parties including our annual Anesthesia Week Celebration. • Maintain our employee database • Create and maintain departmental pages on the BIDMC intranet and BIDMC.org website • Maintain face-sheets for all department divisions • Produce a departmental biennial report • Manage departmental social media accounts (Twitter: @BIDMCAnesthesia and Instagram: bidmc_anesthesia) • Spearhead departmental marketing campaigns • Announce new employees • Communicate departmental strategic goals and objectives • Maintain list of research publications
Feel free to contact us if you want to learn more about what we do, submit news for our newsletter, or discuss other communication needs.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
FINANCE Administrative Team members: Patricia Stevens Richard Lynch Executive Director of Finance Sr. Budget Analyst Yamins 210 (East Campus) Yamins 210 (East Campus) [email protected]
Ahmet Akcay Jackie Thompson Financial Administrator Sr. Accounts Payable Specialist Yamins 210 (East Campus) Yamins 210 (East Campus)
MEDICAL EDUCATION
Clinical Team members: John D. Mitchell, MD Ola Awolesi, MD Vice Chair, Education Anethesia Clerkships Director, Center for Education Research, Technology and Innovation in Anesthesia (CERTAIN) Rosenberg 470 [email protected] Ruma Bose, MD, MBBS Lauren Buhl, MD, PhD Program Director, Associate Program Director, Adult Cardiothoracic Fellowship Anesthesia Residency
Phil Hess, MD Yunping Li, MD Executive Vice Chair, Division Director, Anesthesia Program Director, Obstetric Anesthesia Obstetric Anesthesiology Associate Program Director, Fellowship Obstetric Anesthesiology Fellowship
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Robina Matyal, MD Sara Neves, MD Division Director, Program Director, Vascular Anesthesia Anesthesia Residency Program Director, Advanced Perioperative Ultrasound and Clinical Anesthesia Ameeka Pannu, MD Richard Pollard, MD Program Director, Division Director, Critical Care Anesthesia PAT Clinic Fellowship Director, Quality Improvement Program Director, Neuro Fellowship
Rakalin Andrey, MD S. Krish Ramachandran, MD Program Director, Vice Chair, Quality, Safety and Regional Anesthesia fellowship Innovation Program Director, Perioperative Quality and Safety fellowship Paragi Rana, MD Lindsay Rubenstein, MD Program Director , Associate Program Director, Pain Medicine Fellowship Mentoring/Diversity
Dr. Shaz Shaefi Eswar Sundar, MD Vice Chair of Professional Affairs Program Director Program Director, Anesthesia for Outpatient Surgery Neurocritical Care fellowship Fellowship Neurology fellowship
Leo Tsay, MD Daniel Walsh, MD Anesthesia Rotation – BIDMC Director, In-house Departments ICU BID-Plymouth Associate Program Director, Didactics
Dr. Scott Zimmer Director of Wellness, Anesthesia Categorical Internships Yamins 210 (East Campus)
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Administrative Team members: Mary Jane Cahill Kimberley Brown Manager, Medical Education Fellowship Program Coordinator Programs Yamins 210 Yamins 210 [email protected] Michael Chen Roxanne Erekson Anesthesia Education Lab Residency/Fellowship Program Assistant Coordinator Yamins 210 Yamins 210
Ron Mayes Alexandra Toussaint Program Administrator, Residency/Fellowship Program Continuing Medical Education Coordinator Yamins 210 Yamins 210
Vanessa Wong Project/Grant Coordinator, Education Rosenberg 470
Graduate medical education is the crucial step of professional development between medical school and autonomous clinical practice. It is in this vital phase of the continuum of medical education that residents learn to provide optimal patient care under the supervision of faculty members who not only instruct, but serve as role models of excellence, compassion, professionalism, and scholarship.
Our educational mission is to develop leaders in our profession through excellent clinical experience, strong mentorship, innovative teaching curricula, and a flexible program of unique offerings that can be adapted to meet each learner’s needs. This is accomplished via a relentless pursuit of excellence through continuous quality improvement and creativity grounded in sound educational theory and evidence.
Feel free to contact us if you want to learn more about what we do.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
PROFESSIONAL AFFAIRS Clinical Team members: Dr. Shaz Shaefi Dr. Scott Zimmer Vice Chair of Professional Director of Wellness Affairs Yamins 210 (East Campus) Program Director, Neurocritical Care fellowship Neurology fellowship CLS 6th floor [email protected] Lindsay Rubenstein, MD Associate Program Director, Mentoring/Diversity
Administrative Team members: Susan Kilbride Nora McCarthy Director of Professional Affairs Project Administrator - Professional and Recruitment Affairs and Recruitment Yamins 210 (East Campus) Yamins 210 (East Campus) [email protected]
Diane Baranowski Taneshia Pina Credentialing Administrator – Program Administrator – Professional Credentialing, Privileging and Affairs Enrollment Yamins 210 (East Campus) Westborough (offsite)
Yvette Dusabe Letisha Phillips Administrative Coordinator – Project Administrator - Credentialing, Credentialing, Professional Privileging and Enrollment Affairs and Recruitment Yamins 210 (East Campus) Rosenberg 470 (West Campus)
Rosanna Kelleher Recruiter - Professional Affairs, Physician and CRNA Recruiter Westborough (offsite)
The name of Professional Affairs reflects and encompasses the existing inclusive nature of our department, while also supporting the future goals of cultivating contractual, experiential and emotional objectives of all our people.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Vision Our vision is to empower departmental members to discover and pursue a path to a fulfilling career, so they may realize their full potential.
Mission Our mission is to educate and support departmental members to develop sustainably as fulfilled, balanced and valued professionals.
Ambition We recognize value and promote well-being in every person in our department by equitably supporting, cultivating and empowering personal growth and career development.
What we work on:
• Recruitment/Onboarding • Credentialing, Privileging and Enrollment • Appointments, annual reviews and promotions at HMS • Mentoring junior faculty • Peer support and Wellness • Diversity, Equity and Inclusion Initiatives • Performance appraisal and management • Faculty development plans
Our primary goals:
• Explore and implement, the Professional Affairs resources across the Department • Continuously evaluate and develop strategic goals for the Professional Affairs group as environments change • Facilitate work assignments to address current staff interests and career advancement • Coordinate individualized career development plans across the strategic pillars of our department • Enhance collaborations between departments that have a positive impact on a greater number of faculty
In the last two years, we have seen increasing change, stresses and extrinsic pressures in the workplace. Successfully providing opportunities for robust professional development to promote and drive retention, satisfaction, wellness and sustainability within a diverse and inclusive framework ultimately strengthen the collective department. We look forward to continuing this important work.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
QUALITY, SAFETY, INNOVATION AND INFORMATICS
Clinical Team members: S. Krish Ramachandran, MD Sugantha Sundar, MBBS Vice Chair, Quality, Safety and Director of Professional Affairs, Innovation Director of Center on Professional Program Director, and Peer Support Perioperative Quality and Safety fellowship [email protected] Sara Neves, MD Program Director, Anesthesia Residency Program Lead, Root Cause Analysis Program
Administrative Team members: Sarah Nabel, MS Director, Tom Xie, MS Quality, Safety, Innovation and IT Operations Manager Informatics [email protected]
Reshma Abraham, MPH Matt Bornstein, MS, Safety Project Management CPHIMS, SHIMSS Manager of Anesthesia Systems and Data Management
Robert “Bob” Carlin Jobe Diagne Operations Project Systems Technical Analyst I Management
Jo Ann Jordan, MS Nick Latta Senior Data Project Manager Application Analyst
Praveena Muthuraj Laura Ritter-Cox, MSN, RN-BC Application Architect Nurse Informatics Specialist
Rob Ruiz Tuyet Tran Technical Analyst Data Analyst
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
Quality, Safety, Innovation and Informatics (QSII) supports the delivery of safe and efficient patient care through processes directed at the site, division and individual level. The three foundational arms of this division aim to create more effective ways to modify both human and system drivers of quality and safety.
CLINICAL QUALITY The QSII leadership group comprises site directors, quality leaders, IT experts, project managers and support staff who are actively engaged in developing quality and safety programs, as well as research and data visualizations for both process and outcome metrics relevant to our constituencies. This- data visualization engine combines data from multiple local and organizational databases in order to link processes of care with outcomes that matter to our patients, department and organization.
Specific cross-departmental issues identified through threshold indicators are explored in depth through the Faculty Hour mechanism using multidisciplinary project team s. It is estimated that the combined efforts of these project teams continue to reduce hospital costs by several million dollars a year while enhancing patient safety. Our highly successful project management team supports clinical leadership in executing key interventions.
CLINICAL SAFETY During the past several years, we have continued to use system-based quality assurance (QA) methods to enhance the quality and safety of clinical care. This philosophy is evident in our new Morbidity and Mortality (M&M) structure, unveiled in 2019, and provides a standardized set of support tools to improve both individual and organizational learning from adverse events or close calls. Peer review is performed by the Professional Standards Committee and is designed to eva luate individual competence through Ongoing Professional Practice Evaluation standards and investigate concerns with standards of care or professionalism through Focused Professional Practice Evaluation.
INNOVATION Our innovation efforts are directed to discover improvements that will positively impact health care delivery in the perioperative environment. This work involves both quality-improvement initiatives and rigorous research projects. The results influence areas such as team and organization design, communication pathways and transitions of care, information management systems, and training and education. By virtue of being part of the Anesthesia Department, we work across all phases of the perioperative environment (pre-, intra-, and post-operative). We also strive to work across departments— Surgery, Orthopedics, Obstetrics/Gynecology, Perioperative Nursing, Pharmacy, and Healthcare Quality and Safety—to ensure our improvement and research efforts encompass the interdisciplinary nature of our perioperative work.
What we work on: • Team training (i.e. CRICO premium reduction program) • Root Cause Analysis training • Quality and Safety Education (fellows, residents and attendings) • Oversee the Fellowship in Perioperative Quality and Safety • Information Systems (Anesthesia Informations Management System, Datamart, Clinical Informatics programs, Anesthesia Department Intranet) • Innovation projects (Faculty Hour Chartered Teams)
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
SCHEDULING
Administrative Team members: Joanne Grzybinski, MBA Christine Kuhn Manager, Scheduling Schedule Administrator Operations [email protected]
Lisa McGuirk Katarzyna (Kate) Lada Scheduling Administrator, Scheduling Administrator, APHMFP APHMFP
During your day 1 Department Orientation Joanne Grzybinski will demonstrate how to access your daily schedule online as well as how to request time off, red book entries, points etc.
What we work on:
• OR scheduling • Call scheduling • Clinician Vacation • Points • Qgenda training
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
GENERAL INFO
CODES TO KNOW 1. PCA pump (159) (EQUIPMENT) 2. ICU vasopressor infusion pump (5) 3. Anesthesia workroom/blue bell (312) 4. East IR/Angio Bluebell code (312312) 5. Epidural Code – East Campus (159) 6. Rosenberg 3 West Campus closet CC-0374 (040909) 7. Feldberg Anesthesia Pump/Equipment room #FD-328 between Feldberg ORs 1 and 2 (312312)
DEPARTMENT These can be found through the Anesthesia Intranet Site: WIDE MEETINGS, LECTURES, ETC. Go to the Anesthesia Intranet Site Schedules Lecture
In the monthly view you will see the following schedule of events:
DOCUMENTS & Please log in to the BIDMC Portal and go to the Anesthesia Intranet (you will POLICIES: need to be logged in for the links below to work):
Go to Department InfoPolicies, Procedures and Guidelines: https://anesthesia.bidmc.harvard.edu/Policies/Admin_Policies.aspx
Select the area you are interested in: Administrative includes broad Department policies Residency includes documents for Residents and Interns Clinical includes most of the updated clinical policies, SOPs and guidelines for clinician use. HMFP includes some HMFP related policies (points policy and time away policy are listed here) Search option allows a simple search of the documentation. You should try to use simple terms in order to receive the most results. A search for ‘overnight call’ for instance will return one result while a search for ‘call’ will bring up most, if not all, documents related to call.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
COVID19 Protocols and Policy Manual are currently on the front page of the intranet site beneath the TALIS information.
FACULTY Below are details about how we do our faculty evaluations, our daily resident- EVALUATIONS & attending feedback, and our learning management system that we use to share FEEDBACK educational materials (Moodle).
Faculty Evaluations Our attendings are separated into groups based on birth month. At the beginning of each month, we ask all attendings to evaluate one of these groups so that all groups are evaluated by the end of the year. In addition, you will be evaluated 6 months after your start date. Residents and fellows will also provide evaluations if they work with you substantially during a certain month (this is based on their rotations).
To manage these evaluations, we use a program on our education server (anesthesiaeducation.net). When it is time to evaluate your peers (i.e. at the beginning of the month), you should receive an email from [email protected] asking you to complete the evaluations. While completing the evaluations is voluntary, we appreciate you doing them as they are used for each attending’s annual review. Your responses are reported anonymously to the Chair, so we encourage honest feedback.
Daily Feedback We have a system where residents and attendings provide daily feedback to each other. For now, this system applies only to assignments in the OR, in the ICU, or on OB when you work with at least one resident. Currently, we are using another program on our education server to collect this feedback, but the system may eventually be integrated with Talis. If you are on an applicable assignment, around noon each day, you should receive an email [email protected] asking you to provide feedback for your resident(s). Your feedback is provided to the residents anonymously (unless you mention your name) on a monthly basis. Also, your feedback is viewable by the Program Directors anonymously unless you indicate that you want the Program Director to contact you regarding the feedback.
Moodle We have an online management system (https://anesthesiaeducation.net) that we use to share materials for our educational initiatives.
One of these initiatives is our E-Journal Club curriculum: https://anesthesiaeducation.net/moodle/course/view.php?id=193
You can also view your daily feedback from residents at https://anesthesiaeducation.net/moodle/course/view.php?id=204
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
in 3-month periods; however, this may migrate over to Talis if we decide to move the system.
Please reach out to Vanessa Wong at [email protected] with any questions about this. GENERAL HR OR General HR or Workday questions for HMFP and APHMFP can be answered WORKDAY through the HMFP Human Resources email at QUESTIONS [email protected]
Susan Kilbride can also be reached out to if you have other general, non- Workday related questions. [email protected]
GRAND ROUNDS Grand Rounds is held every Wednesday in Sherman Auditorium from 7-8am. Taneshia Pina, will send out a confirmation email every Monday with topics and any other potential updates for that week’s Grand Rounds.
M&M (Mortality and Morbidity) when scheduled, is held directly after in Sherman from 8-8:30am. Jackie Villafuerte temporarily schedules cases and M&M dates.
LOCKERS Susan Kilbride will assign you a locker on East and/or West campus. Please note that you may not have a locker on both campuses. You will receive your locker assignment by email and will have the information in your orientation packet.
If you don’t have a locker on East, there are day lockers you can use in the Anesthesia Sandbox on the 4th Floor of Feldberg:
Day Lockers There are lockers on Feldberg 4 for those who DO NOT have permanent lockers on the East Campus. If you have a locker on East please do not use the day lockers; this will free them up for those who do not have permanent lockers.
The lockers in the Sandbox (Feldberg 4 Lounge) are for anesthesia attendings only and the lockers in the resident lounge are for residents and fellows only.
To lock the day lockers, close the door, Press C and choose a 4-digit code, then press the key symbol.
To unlock, press C and enter your 4-digit code, then press the key symbol.
If you have any issues with the day lockers, please contact Gidget Hunter at: [email protected] or 617-667-3112 (7-3112 internally).
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
PAGING SYSTEM On your orientation day you will receive a pager along with a small reference card with pager instructions on it. Below is a copy (front and back) of this card for reference:
PAYROLL Please reach out to Trish Stevens at [email protected] with any QUESTIONS questions re: payroll.
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
PHONE CARD NUMBERS (ROOM PHONE CARDS)
EAST CAMPUS EAST CAMPUS Feldber Preop/Holding RN/Anesth Shapiro RN/Anesth g 1 77601/78601 1 67101/67201 Feldberg 75601 2 77602/78602 2 67102/67202 Shapiro 70200 Stoneman/GI 3 77603/78603 3 67103/67203 Locations 4 77604/78604 4 67104/67204 GI 3 75444 5 77605/78605 5 67105/67205 GI 4 75459 6 77606/78606 6 67106/67206 7 77607/78607 7 67107/67207 Pharmacy 74247 8 77608/78608 8 67108/67208 Blood Bank 74480 9 77609/78609 Cysto 77622/77621 Stat Lab 75227 10 77610/78610 L&D 73077 Feld OR Core 72411 11 77611/78611 Phase I 70300 Finard ICU 73124 PACU 73905 Phase II 74790 (617) 667-XXXX (617) 632-XXXX (617) 754- Calling From Outside XXXX
WEST CAMPUS WEST CAMPUS West RN/Anesth West RN/Anesth 1 43061/43081 12a 43073/43093 Preop 43100 2 43062/43082 14 43074/43094 OR Desk 43000 3 43063/43083 15 43075/43095 PACU 42800 4 43064/43084 16 43076/43096 Blood Bank 43300 5 43065/43085 17 43077/43097 Pharmacy 43808 6 43066/43086 18 43418/43518 Stat Lab 43230 7 43067/43087 19 43368/43366 WPC 28861 IR/Angi 8 43068/43088 42552 TSICU 43130 o 9 43069/43089 INR 42663 SICU 43250 10 43070/43090 CT 42558 NeuroICU 27625 11 43071/43091 MRI 42099 CVICU-A 42900 Cath 12 43072/43092 27470 CVICU-B 42950 Lab (617) 667-XXXX (617) 632-XXXX (617) 754- Calling From Outside XXXX
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
SUPPORTING DOCUMENTS (CLINICAL)
ANESTHESIA ADMINISTRATOR ON CALL
The Anesthesia Administrator on-call (AOC) will be a member of the senior leadership team with sufficient clinical and administrative experience to serve as a resource for all members of the department. The AOC is an administrative position not a clinical one.
The AOC will be available for consultation 24/7. Issues and circumstances that might prompt a call to the AOC would include but would not be limited to the following:
1. Clinical issues or questions 2. Policy issues or questions 3. Anesthesia consent issues or questions 4. Serious adverse outcomes including death or outcomes resulting in likely permanent injury. 5. Questions regarding documentation of adverse outcomes 6. Intra/inter departmental disagreements consistent with hospital conflict escalation policies 7. COVID 19 related workflow, safety and policy questions
The departmental AOC shall be notified with activation of the following hospital emergencies or major facilities related incidents including leaks, floods, power failure, and HVAC issues that threaten clinical areas:
- Code Silver (threat with weapon) - Code Triage (disaster; requires hospital AOC activation) - Code MH - The hospital goes on diversion - PACU or ICU capacity issues
The departmental AOC will serve as a liaison to the hospital AOC consistent with the hospital conflict escalation policy.
OR CRISIS MANUAL 1. Failed Airway
2. Hypoxia
3. Bronchospasm
4. Pneumothorax Operating Room 5. Hemorrhage Crisis Checklists 6. Hypotension 7. Tachycardia – Unstable >> Do not remove book from this room << 8. Bradycardia – Unstable
The use of this manual is meant 9. Cardiac Arrest –Asystole/PEA as a guideline and reference. It is not meant to be a substitute 10. Cardiac Arrest – VF/VT for training and experience. 11. Myocardial Ischemia Color code: Blue – Respiratory 12. Malignant Hyperthermia Red – Cardiac Green - Other 13. Air Embolism – Venous Yellow – Reference 14. Transfusion Reactions
15. Local Anesthetic Toxicity
16. Anaphylaxis
17. Fire ĞƉĂƌƚŵĞŶƚŽĨŶĞƐƚŚĞƐŝĂ͕ƌŝƟĐĂůĂƌĞ ĂŶĚWĂŝŶDĞĚŝĐŝŶĞ 18. Total Spinal Anesthesia
Version 1.0 December 22, 2020 19. Appendices - References 1 1 Failed Airway 2
Two unsuccessful intubation attempts by airway expert
START
1. Call “Anesthesia STAT” and ask for an airway cart • Ask: “Who will be the eventmanager?”
2. Get difficult airway cart and video laryngoscope
3. Bag mask ventilate with FiO2 100%
4. Is ventilation adequate?
State Problem: e.g. “This is a CAN’T INTUBATE CAN’T OXYGENATE emergency!”
5. Consider “Code Surgical Airway” early. (Page ACS)
Call “Code Surgical Airway” X43000 West Campus X72411 East Campus
Version 1.0 December 22, 2020 1 1 Failed Airway 2
Two unsuccessful intubation attempts by airway expert
Ventilation
NOT ADEQUATE ADEQUATE
Optimize ventilation Switch list if Consider awakening • Reposition patient ventilation patient or alternative • Oral /nasal airway status approaches to secure • Two-handed mask changes airway Check equipment • Advanced airway by • FiO2 = 100% trained staff member • Capnography • Abort case • Circuit integrity Check ventilation
Remains NOT ADEQUATE State the emergency and say the words out loud for all team Place i-gel supraglottic members to hear. For example: airway “This is a CAN’T INTUBATE CAN’T If unsuccessful, attempt intubation using video OXYGENATE emergency” laryngoscope Prepare for surgical airway (prep neck, get cricothyroidotomy / tracheostomy kit, call for Call “Code Surgical Airway” surgeon) X43000 West Campus Re-check ventilation X72411 East Campus
Still NOT ADEQUATE Implement surgical airway
Version 1.0 December 22, 2020 2 Hypoxia 2 Unexplained oxygen desaturation 3
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?”
2. Turn FiO2 to 100% at high gas flows • Confirm inspired FiO2 = 100% on gas analyzer • Confirm presence of end-tidal CO2 and changes in capnogram morphology 3. Hand ventilate to assess compliance • Be aware of patients with ARDS/respiratory failure 4. Listen to breath sounds 5. Check • Blood pressure, PIP, pulse • ET tube position • Pulse oximeter placement • Circuit integrity: look for disconnections, kinks, holes 6. Consider actions to assess possible breathing issues • Draw arterial blood gas • Suction (to clear secretions, mucus plug) • Remove circuit and use self-inflating bag valve mask (BVM) • Bronchoscopy • Consider respiratory therapy consult (RH failure – may require nitric oxide /pharmacy consult) • Consider milrinone / espoprostenol (Vleltri) 7. Consider causes • Is airway/breathing issue suspected?
Version 1.0 December 22, 2020 2 Hypoxia 2 Unexplained Oxygen Desaturation 3
NO Airway issue suspected Circulation • Embolism Pulmonary embolus Air embolism Go to TAB 13 • Heart disease Congestive heart failure Coronary heart disease Myocardial ischemia Go to TAB 11 Cardiac tamponade Congenital / anatomical defect • Severe sepsis • If hypocalcemia associated with hypotension Go to TAB 6
Drugs / Allergy • Recent drugs given • Dose error / allergy / anaphylaxis • Dyes and abnormal hemoglobin (e.g., methemoglobin, methylene blue)
YES! Airway issue is suspected Airway / Breathing • Aspiration • Atelectasis • Bronchospasm Go to TAB 3 • Hypoventilation • Laryngospasm • Obesity / positioning • Pneumothorax Go to TAB 4 • Pulmonary edema • Right mainstem intubation • Ventilator setting, leading to auto-peep Additional DIAGNOSTIC TESTS • Fiberoptic bronchoscope • Chest x-ray • Lung ultrasound
Reconsider Your Diagnosis Version 1.0 December 22, 2020 3 Bronchospasm
Increased PIP, wheezing, increased expiratory Time, increased EtCO2,
3 upsloping capnography tracing 4 START
1. Call “Anesthesia STAT” and consider a code cart • Ask: “Who will be the eventmanager?”
2. Increase FiO2 to 100% 3. Change I:E ratio to allow for adequate exhalation • Bronchospastic patients who develop sudden hypotension may be air-trapping. Consider temporary circuit disconnect 4. Deepen anesthetic (Sevoflurane or Propofol) 5. Rule out problems with ETT (Mucous plug, mainstem intubation) 6. Give beta-2 agonists via ETT 7. If severe, give epinephrine (10 – 100 mcg IV - may repeat) • Or give Epi-Pen (Omnicell) 8. Rule out anaphylaxis: Go to TAB 16 9. Consider ECMO if available: (Page “9-ECMO”)
SUPPLEMENTAL Medications Beta-2 agonist (albuterol) Epinephrine: 10 mcg IV and escalate Ketamine: 0.2 – 1.0 mg/kg IV Hydrocortisone: 100 mg IV Nebulized racemic epinephrine
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 3 4
PAGE INTENTIONALLY LEFT BLANK
Version 1.0 December 22, 2020 4 Pneumothorax
Increased peak inspiratory pressures, tachycardia, hypotension, hypoxemia, decreased or asymmetric breath sounds, hyper-resonance of chest to percussion, tracheal deviation (late sign), increased JVD / CVP, have high
4 index of suspicion for pneumothorax in trauma patients and COPD patients 5 START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?”
2. Increase FiO2 to 100% 3. Rule out mainstem intubation 4. Consider ultrasound or STAT CXR 5. Do not delay treatment if hemodynamically unstable 6. Call for immediate chest tube / thoracostomy . Call ACS (West X43000, East X72411)
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 4 5 PAGE INTENTIONALLY LEFT BLANK
Version 1.0 December 22, 2020 5 Hemorrhage
Acute massive bleeding
START
5 1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?” 6 2. Open IV Fluids and assess adequate IV access
3. Turn FiO2 to 100% and turn down volatile anesthetics 4. Call blood bank • Activate massive transfusion protocol (see Appendix A5 Massive Transfusion Protocol) • Consider emergency release for blood/product • Assign 1 person as primary contact for blood bank • Order and give blood products (in 2:1:1 ratio of PRBC/FFP/PLT) 5. Call for Belmont or rapid infuser 6. Discuss management plan between anesthesia, surgery and nursing teams 7. Replace products early 8. Keep patient warm 9. Send labs • CBC, PT/PTT, INR, fibrinogen, lactate, arterial blood gas, ionized calcium, potassium, type and cross Consider • Placing arterial line • Electrolyte disturbances (hypocalcemia and hyperkalemia) • Damage control surgery (pack, close, resuscitate) • Reversal of anticoagulation (Go to TAB 19-A1) • Page perfusionist to set up Cell Saver
Version 1.0 December 22, 2020 5 Hemorrhage
Acute massive bleeding
DRUG DOSES and Treatments HYPOCALCEMIA Treatment Prevention: Give 500 – 1000 mg Ca gluconate per unit of PRBC or FFP 5 Give calcium to replace deficit (calcium chloride or calcium gluconate)
Calcium gluconate: 30 mg/kg IV 6 -or- Calcium chloride: 10 mg/kg IV HYPERKALEMIA Treatment Calcium gluconate: 30 mg/kg IV -or- Calcium chloride: 10 mg/kg IV Insulin: 10 units regular IV with 1 – 2 amps D50 as needed Sodium bicarbonate if pH <7.2: 1 – 2 mEq/kg slow IV PUSH
SPECIAL Patient Populations TRAUMA Tranexamic Acid • 1000 mg IV over 10 min, followed by 100 mg over the next 8 hours • Avoid acidosis, hypothermia and coagulopathy
NON-SURGICAL UNCONTROLLED BLEEDING Despite massive transfusion of FFP, PRBC, platelets and cryo: • Consider giving Recombinant Factor VIIa: 40 mcg/kg IV • PLT should be >100 (discuss with surgeon) • Surgical bleeding must be controlled • USE WITH CAUTION in patients at risk for thrombosis • DO NOT USE when pH is <7.2 • Consider giving KCENTRA (Go to TAB 19-A1)
Version 1.0 December 22, 2020 6 Hypotension
Unexplained drop in blood pressure refractory to initial treatment
START
1. Call “Anesthesia STAT” and ask for a 8. Consider Causes code cart Operative Field • Ask: “Who will be the event • Mechanical or surgical manipulation 6 manager?” • Insufflation during laparoscopy 2. Check…. • Retraction 7 • Pulse • Vagal stimulation • Blood pressure • Vascular compression • Equipment Unaccounted Blood Loss • Heart Rate • Blood in suction canister, bloody sponges, Blood on the floor, internal bleeding • Bradycardia TAB 8 Drugs/Allergy • Rhythm • Anaphylaxis TAB16 • If VF/VT TAB 10 • Recent drugs given • If Asystole/PEA TAB 9 • Dose error 3. Run IV fluids wide open • Drugs used on the field 4. Give vasopressors and titrate to • Wrong drug response Breathing • MILD: ephedrine or • Increased PEEP phenylephrine • Hypoventilation • SIGNIFICANT/REFRACTORY: • Hypoxia TAB 2 epinephrine bolus, consider • Persistent hyperventilation infusion • Pneumothorax TAB 4 5. Turn FiO2 to 100% and turn down • Pulmonary edema volatile anesthetics Circulation 6. Inspect surgical site for bleeding • Air embolism TAB 13 • (If bleeding TAB 5) • Bradycardia TAB 8 7. Consider actions • Tachycardia TAB 7 • Place patient in Trendelenburg • Bone cementing (methylmethacrylate effect) position • Myocardial Ischemia TAB 11 • Obtain additional IV access • Emboli (pulmonary, fat, septic, amniotic CO2) • Place arterial line, check • Severe sepsis electrolytes • Tamponade • TEE? • Electrolytes • Endocrine
Version 1.0 December 22, 2020 6 Hypotension
Unexplained drop in blood pressure refractory to initial treatment
DRUG DOSES and Treatments Ephedrine: 5 – 25 mg IV, repeat as needed Phenylephrine: 80 – 200 mcg IV, repeat as needed Epinephrine: BOLUS: 4 – 8 mcg IV 6 Dilute 1 mg in 10 mL (100 mcg/mL), then 1 cc in 10cc NS (10 mcg/mL)
INFUSION: 0.1 – 1 mcg/kg/min 7 HYPOCALCEMIA Treatment Prevention: Give 500 – 1000 mg calcium gluconate per unit of PRBC or FFP Give calcium to replace deficit (calcium chloride or calcium gluconate) Calcium gluconate: 30 mg/kg IV -or- Calcium chloride: 10 mg/kg IV Vasopressin: 1 – 2 Unit BOLUS INFUSION: 1 – 4 U/hr Norepinephrine: INFUSION: 8 – 30 mcg/min Hydrocortisone: 100 mg IV
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 7 Tachycardia - Unstable
Narrow complex tachycardia Wide complex tachycardia
Persistent tachycardia with hypotension, ischemic chest pain, altered mental status or shock
START
7 1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?” 8
2. Turn FiO2 to 100% and turn down volatile anesthetics 3. Analyze rhythm • If wide complex, irregular: treat as VF/VT, go to TAB 10 • Otherwise: prepare for cardioversion 4. Prepare for immediate synchronized cardioversion • Sedate all conscious patients unless deteriorating rapidly • Turn monitor / defibrillator ON, set to defibrillator mode • Place electrodes on chest • Engage synchronization mode • Look for mark/spike on the R-wave indicating synchronization mode • Adjust as necessary until SYNC markers seen with each R-wave 5. Synchronized cardioversion at appropriate energy level • Select energy level - use Table 1 on facing page for reference • Press charge button • Press and hold shock button • Check monitor; if tachycardia persists, increase energy level • Engage synchronization mode after delivery of each shock 6. Consider expert consultation
Version 1.0 December 22, 2020 7 Tachycardia - Unstable Narrow complex tachycardia Persistent tachycardia with hypotension, ischemic chest pain, altered mental status or shock
SYNCHRONIZED CARDIOVERSION energy levels
CONDITION ENERGY LEVEL (progression in Joules) Narrow complex, regular 50 – 100 – 150 - 200 Narrow complex, irregular 120 - 150 - 200 Wide Complex, regular 100 - 150 - 200 7 Wide complex, irregular Treats as VF/VT: go to TAB 10 Table 1 8 SYNCHRONIZATION UNSUCCESSFUL If cardioversion needed and impossible to synchronize shock, use high-energy unsynchronized shocks
Defibrillation doses Follow manufacturer recommendation. If unknown use highest setting: 360 J
If cardiac arrest, go to: TAB 10 Cardiac Arrest – VF/VT TAB 9 Cardiac Arrest – Asystole/PEA Wide complex tachycardia
During RESUSCITATION Airway: Assess and secure Circulation: Confirm adequate IV or intraosseous access Consider IV fluids wide open
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 8 Bradycardia - Unstable
HR < 50 bpm with hypotension, ischemic chest pain, altered mental status or shock
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?”
2. Turn FiO2 to 100% 3. Stop surgical stimulation
8 • Bradycardia secondary to insufflation: desufflate • Administer 0.4 mg glycopyrrolate, or 0.4 mg atropine.
4. Give epinephrine 10 – 50 mcg (may repeat) 9 • Consider epinephrine infusion 5. If epinephrine ineffective • Transcutaneous pacing • Transvenous pacing 6. Consider: • Turn off volatile anesthetics if patient unstable • Calling for expert consultation (cardiology) • Assessing for drug-induced causes (e.g. beta-blockers, calcium channel blockers, digoxin) • Calling for cardiology consult if myocardial ischemia suspected (e.g. EKG changes)
Version 1.0 December 22, 2020 8 Bradycardia - Unstable
HR < 50 bpm with hypotension, ischemic chest pain, altered mental status or shock
DRUG DOSES and Treatments Atropine: 0.5 mg IV, may repeat up to 3 mg total Epinephrine: 2-10 mcg/min IV Dopamine: 2 – 20 mcg/kg/min IV Glycopyrrolate: 0.1 mg IV q 2 – 3 min PRN OVERDOSE treatments Beta-blocker: Glucagon: 2 - 4 mg IV push Calcium channel blocker: Calcium chloride: 1 g IV 8 Digoxin: Digoxin Immune FAB; consult pharmacy for specific dosing
TRANSCUTANEOUS PACING Instruction 9 1. Place pacing electrodes front and back 2. Connect 3-lead ECG from pacing defibrillator to the patient 3. Turn monitor/defibrillator to PACER mode 4. Set PACER RATE (ppm) to 80/minute 5. Start at 60 mA of PACER OUTPUT and increase until electrical capture 6. Set final current to 10 mA above initial capture level 7. Confirm effective capture: (mechanical pulse, ECG)
During RESUSCITATION Airway: Assess and secure Circulation: Confirm adequate IV or intraosseous access Consider IV fluids wide open
Critical Changes If PEA develops go to TAB 9
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 9 Cardiac Arrest – Asystole/PEA
Non-shockable pulseless cardiac arrest – confirm pulse and rhythm
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?” • Say: “The top priority is high quality CPR.” 2. Put backboard under patient, supine position
3. Turn FiO2 to 100% 4. Start CPR and assessment cycle • Perform CPR and assessment cycle / consider use of LUCAS device 9 • Greater than 100 (> 100) compressions per minute
• Compression depth 2 inches: 10 • Ensure full chest recoil with minimal interruptions • 10 breaths/min: do not overinflate • Give epinephrine • Epinephrine IV every 3 - 5 minutes • Assess every 2 minutes • Check rhythm, if rhythm organized check pulse • Change CPR/compression provider • Check EtCO2 • If: < 10 mmHg, reevaluate CPR technique • If: Sudden increase > 40 mmHg, may indicate return of spontaneous circulation. ROSC. • Draw labs –ABG, electrolytes • Consider ultrasound (TTE, TEE) • If asystole/PEA continues • Resume CPR/assessment cycle (restart step 4) • Read aloud Hs & Ts (see list on facing page) • If VF/VT • Resume CPR Go to TAB 10
Version 1.0 December 22, 2020 9 Cardiac Arrest – Asystole/PEA
Non-shockable pulseless cardiac arrest – confirm pulse and rhythm
DRUG DOSES and Treatments Epinephrine: 1 mg IV, repeat every 3-5 minutes TOXIN treatment: Local anesthetic: Intralipid 100 mL IV bolus (assuming 70 kg weight) Repeat 1 – 2 times for persistent asystole Infusion 0.25 – 0.5 mL/kg/min for 30 – 60 TAB 15 Beta-blocker: Glucagon 2 – 4 mg IV push Calcium channel blocker: Calcium chloride 1 g IV HYPERKALEMIA treatment: Calcium gluconate 30 mg/kg IV 9 Calcium chloride 10 mg/kg IV
Insulin 10 units regular IV with 1 – 2 amps D50W 10 Sodium bicarbonate if pH < 7.2 1 – 2 mEq/kg slow IV push
Hs & Ts H+ Ion (Acidosis) Tamponade (Cardiac) Hyperkalemia Tension pneumothorax Hypothermia Thrombosis (Pulmonary) Hypovolemia Thrombosis (Coronary) Hypoxia Toxin (LA, β, Ca Blockers)
During CPR Airway: Assess and secure Circulation: Confirm adequate IV or intraosseous access Consider IV fluids wide open Assign roles: Chest compressions, airways, vascular access, documentation, code cart, time keeping, reader, medications
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 10 Cardiac Arrest – VF/VT
Shockable pulseless cardiac arrest – confirm pulse and rhythm
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?” • Say: “Shock the patient as soon as defibrillator arrives” 2. Put backboard under patient, supine position
3. Turn FiO2 to 100%, turn off volatile anesthetics 4. Start CPR and assessment cycle / consider use of LUCAS device • Greater than 100 (> 100) compressions per minute • Compression depth 2 inches: • Ensure full chest recoil with minimal interruptions • 10 breaths/min: do not overinflate 10 • Defibrillate • Shock at highest setting – 360 J 11 • Resume CPR immediately after shock • Give epinephrine • Epinephrine IV every 3 – 5 minutes • Consider giving antiarrhythmics for refractory VF/VT • Amiodarone preferred if available • Assess every 2 minutes • Change CPR/compression provider
• Check EtCO2 • If: < 10 mmHg, reevaluate CPR technique • If: Sudden increase > 40 mmHg, may indicate return of spontaneous circulation. ROSC. • Read aloud Hs & Ts (see list on facing page) • Check rhythm, if rhythm organized check pulse • If VF/VT, resume CPR/defibrillation/assessment cycle • If asystole/PEA Go to TAB 9 • Check labs –ABG, electrolytes Version 1.0 December 22, 2020 10 Cardiac Arrest – VF/VT
Shockable pulseless cardiac arrest – confirm pulse and rhythm
DRUG DOSES and Treatments Epinephrine: 1 mg IV, repeat every 3-5 minutes ANTIARRHYTHMICS st Amiodarone: 1 dose: 300 mg IV/IO nd 2 dose: 150 mg/IV/IO Magnesium: 1 to 2 grams IV/IO for Torsades de Pointes
DEFIBRILLATION Instructions 1. Place electrodes on chest 2. Turn defibrillator ON, set to DEFIB mode, and increase ENERGY LEVEL; Follow manufacturer recommendation; if unknown use highest setting of 360 J 3. Deliver shock, press CHARGE, then press SHOCK 10
Hs & Ts 11 H+ Ion (Acidosis) Tamponade (Cardiac) Hyperkalemia Tension pneumothorax Hypothermia Thrombosis (Pulmonary) Hypovolemia Thrombosis (Coronary) Hypoxia Toxin (LA, β, Ca Blockers)
During CPR Airway: Assess and secure Circulation: Confirm adequate IV or intraosseous access Consider IV fluids wide open Assign roles: Chest compressions, airways, vascular access, documentation, code cart, time keeping, reader, medications
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 11 Myocardial Ischemia Depression or elevation of ST segment, arrhythmias, regional wall motion abnormalities
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?”
2. Increase FiO2 to 100% 3. Check mechanical pulse and blood pressure 4. Verify ischemia (expanded or 12 lead EKG) 5. Treat ischemia • Slow heart rate (consider beta-blockers) • Optimize blood pressure • Assess volume status 6. Reassess ischemia (consider etiology) 11
7. Prepare for arrhythmias, consider placing pads 12 8. Consider TTE or TEE for monitoring volume status and regional wall motion abnormalities 9. STEMI/CARDIOLOGY Consult –STAT 10. Consider arterial line (ABG, CBC, troponins, electrolytes) 11. Consider central venous access 12. If hemodynamically unstable consider support (IABP, perfusionists) 13. Global assessment: elicit opinions
Version 1.0 December 22, 2020 11 Myocardial Ischemia Depression or elevation of ST segment, arrhythmias, regional wall motion abnormalities
DRUG DOSES and Treatments Beta-blocker: Start with esmolol 10 – 20 mg IV NTG infusion: Start at 0.3 mcg/kg/min Heparin as indicated: Discuss with surgeon / cardiologist Aspirin: 160 -325 mg PO/NG – Discuss with surgeon / cardiologist Narcotic: Morphine 2 – 4 mg IV Vasopressin: 1 – 2 unit BOLUS INFUSION: 1 – 4 units/hour Epinephrine: BOLUS: 4 – 8 mcg IV Dilute 1 mg in 10 mL (100 mcg/mL), then 1 cc in 10cc NS (10 mcg/mL) INFUSION: 0.1 – 1 mcg/kg/min Norepinephrine: INFUSION: 0.02 1 mcg/kg/min 11 Caveats 12 Hold beta-blocker for bradycardia or hypotension Hold NTG for hypotension If anemic give PRBC Discuss ASA with surgeon Treat pain with narcotics
ST Changes 0.5 mm down-sloping ST indicates ischemia 1 – 2 mm down-sloping ST indicates NSTEMI 2 mm elevation of ST indicates ischemia
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 12 Malignant Hyperthermia In presence of triggering agent: unexplained increase in EtCO2, unexplained tachycardia / tachypnea, prolonged masseter muscle spasm after succinylcholine. Hyperthermia is a late sign.
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?” 2. Get Malignant Hyperthermia cart 3. Turn off volatile anesthetics and transition to non-triggering anesthetics • DO NOT delay treatment to change circuit or CO2 absorber • Charcoal filter on inspiratory and expiratory limb of circuit • Ventilate with self-infalating bag valve mask (BVM)
• FiO2 100% • Hyperventilate patient at flows of 10 L/min or more 4. Assign dedicated person to mix Ryanodex 5. Terminate procedure if possible 6. Give Ryanodex
12 7. Place arterial line
8. Send labs –ABG, electrolytes, CK, coags, serum and urine myoglobin 13 9. Aggressive fluid resuscitation and initiate supportive care: • Cool if temperature > 39o C (Stop if < 38o C) • Lavage open body cavities, cold NG lavage, ice externally • Consider bicarbonate for suspected metabolic acidosis (pH <7.2) • Monitor urine output • Treat hyperkalemia if suspected • Treat dysrhythmias if present • DO NOT use calcium channel blockers 10. Monitor in ICU for 24 hours 11. MHAUS Emergency 24-hour Hotline – (800) MH-HYPER (644-9737)
Version 1.0 December 22, 2020 12 Malignant Hyperthermia
In presence of triggering agent: unexplained increase in EtCO2, unexplained tachycardia / tachypnea, prolonged masseter muscle spasm after succinylcholine. Hyperthermia is a late sign.
DRUG DOSES and Treatments Ryanodex Reconstitute 250 mg vial with 5 cc sterile water (shake until orange/opaque) Dose: 2.5 mg/kg = 0.05 mL/kg 70 kg patient 3.5 mL Bicarbonate: 1 – 2 mEq/kg. Slow IV push
HYPERKALEMIA Treatment: Calcium gluconate: 30 mg/kg IV Calcium chloride: 10 mg/kg Insulin: 10 units IV with 1 – 2 amps D50 IV
TRIGGERING AGENTS Inhalational Anesthetics Succinylcholine
DIFFERENTIAL DIAGNOSIS (Consider when using high doses of Ryanodex without
12 resolution of symptoms) Cardiorespiratory Iatrogenic Neurologic Toxicology 13 Hypoventilation Exogenous CO2 Meningitis IV Dye Neurotoxicity Anticholinergic Pheochromocytoma Overwarming Intracranial Bleed Syndrome Neuroleptic Cocaine, Hypoxic Endocrine Malignant Amphetamine, Encephalopathy Syndrome Salicylate withdrawal Traumatic Brain Thyrotoxicosis Sepsis Alcohol withdrawal Injury
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 13 Air Embolism - Venous
Decreased end-tidal CO2, decreased oxygen saturation, hypotension, precordial doppler (mill-wheel murmur), TEE (bubbles detected in RA/RV)
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?”
2. Turn FiO2 to 100% 3. Stop source of air entry • Fill wound / surgical field with irrigation • Lower surgical site below level of heart, if possible
• Search for entry point (including open venous lines, CO2 embolism during laparoscopy) 4. Turn off nitrous oxide 5. Consider: • Positioning patient with left side down • Continue appropriate monitoring while repositioning
13 • Placing bone wax or cement on bone edges (in neurosurgery) • Transesophageal echocardiography (TEE) if diagnosis unclear 14
• Using EtCO2 to monitor progression and resolution of embolus or for assessment of adequate cardiac output
Version 1.0 December 22, 2020 13 Air Embolism - Venous
Decreased end-tidal CO2, decreased oxygen saturation, hypotension, precordial doppler (mill-wheel murmur), TEE (bubbles detected in RA/RV)
SUPPLEMENTAL MONITORS Precordial Doppler: Place at left sternal border Listen for “mill-wheel” murmur
TTE or TEE: Look for air entrained into right side of heart Evaluate for patent foramen ovale
CRITICAL CHANGES If PEA develops go to TAB 9 13 14
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 14 Transfusion Reactions Hemolytic reactions: Fever, back / flank pain, tachycardia, tachypnea, hypotension, dark urine, disseminated intravascular coagulation (DIC) Febrile reactions: Fever, chills / rigors, headache, vomiting Anaphylactic reactions: Hypotension, urticaria / hives, wheezing, tachycardia Hypotensive reactions to Angiotensin Converting Enzyme inhibitors: Hypotension in reaction to transfusion in patients on ACE inhibitors
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?” 2. Stop transfusion
3. Increase FiO2 to 100% 4. Support blood pressure with IV fluids and vasoactive medications if needed 5. Consult BLOOD BANK if advice needed 6. If anaphylactic reaction go to TAB 16 7. Consider hypotensive reaction to Angiotensin Converting Enzyme inhibitors
14 • Treat with vasopressin bolus / infusion
8. TRALI or volume overload if evidence of lung injury (hypoxemia, pulmonary 15 edema) • May require post-operative ventilation
Version 1.0 December 22, 2020 14 Transfusion Reactions Hemolytic reactions: Fever, back / flank pain, tachycardia, tachypnea, hypotension, dark urine, disseminated intravascular coagulation (DIC) Febrile reactions: Fever, chills / rigors, headache, vomiting Anaphylactic reactions: Hypotension, urticaria / hives, wheezing, tachycardia Hypotensive reactions to Angiotensin Converting Enzyme inhibitors: Hypotension in reaction to transfusion in patients on ACE inhibitors
DRUG DOSES and Treatments Epinephrine: BOLUS: 10 – 100 mcg IV Repeat as needed Dilute 1 mg in 10 mL (100 mcg/mL), then 1 cc in 10cc NS (10 mcg/mL)
Vasopressin: BOLUS: 1 – 2 units IV INFUSION: 1 – 4 U/hr Diphenhydramine: 25 – 50 mg IV H2 Blockers: Famotidine: 20 mg IV Hydrocortisone: 100 mg IV Albuterol: 2 – 5 mg nebulized or mini-dose inhaler 14 15
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 15 Local Anesthetic Toxicity Tinnitus, metallic taste, altered mental status, fasciculations, seizures, hypotension, bradycardia, ventricular arrhythmias, cardiovascular collapse
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?”
2. Turn FiO2 to 100% and turn down volatile anesthetics – stop local anesthetic 3. Call for Intralipid kit –(Omnicell under Lipid Emulsion) 4. Give Intralipid according to dosing on facing page 5. Treat seizure activity with benzodiazepines 6. Monitor for hemodynamic instability – treat hypotension • Consider CPR if needed 7. Variable arrhythmias: • Consider reducing epinephrine doses (< 1 mcg/kg) • Avoid vasopressin, calcium channel blockers, beta-blocker, and local anesthetics 8. If refractory to treatment, alert personnel for potential cardiopulmonary bypass
15 9. Prolonged resuscitation is expected
10. Monitor the patient post event in the ICU 16
Version 1.0 December 22, 2020 15 Local Anesthetic Toxicity Tinnitus, metallic taste, altered mental status, fasciculations, seizures, hypotension, bradycardia, ventricular arrhythmias, cardiovascular collapse
DRUG DOSES and Treatments Intralipid: Rapidly give: 1.5 mL/kg BOLUS of 20% Intralipid IV INFUSION: 0.25 mL/kg/min May increase to maximum of 0.5 mL/kg/min Note: Continue for at least 10 minutes after obtaining circulatory stability SUPPLEMENTAL Drugs: Epinephrine: BOLUS: 10 – 100 mcg IV Repeat as needed Dilute 1 mg in 10 mL (100 mcg/mL), then 1 cc in 10cc NS (10 mcg/mL)
Vasopressin: BOLUS: 1 – 2 units IV INFUSION: 1 – 4 U/hr Norepinephrine: INFUSION: 8 – 30 mcg/min 15 16
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 16 Anaphylaxis Hypotension, bronchospasm, high peak-airway pressures, decrease or lack of breath sounds, tachycardia, urticaria
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?” 2. Open IV fluids and/or give large fluid bolus 3. Remove potential causative agents
4. Turn FiO2 to 100% 5. Give epinephrine bolus (may be repeated) • Epi-pens are available in OMNICELLS– consider as first line • Dosing 300 mcg IM • Epinephrine 10 – 100 mcg IV • Start epinephrine infusion as needed 6. Establish/secure airway – potential airway edema 7. Consider: • Turning off volatile anesthetics if patient remains unstable • Vasopressin for patients with continued hypotension despite repeated doses of epinephrine • Diphenhydramine, H2 blockers, hydrocortisone • Tryptase level: (yellow top tube) Check within first hour, repeat at 4 hours and at 18– 24 hours post reaction • Histamine levels (rises within 10 minutes) • Terminate procedure 16 8. ICU admission for 24 hours post event 17
Version 1.0 December 22, 2020 16 Anaphylaxis Hypotension, bronchospasm, high peak-airway pressures, decrease or lack of breath sounds, tachycardia, urticaria
DRUG DOSES and Treatments Epinephrine: BOLUS: 10 – 100 mcg IV Repeat as needed Dilute 1 mg in 10 mL (100 mcg/mL), then 1 cc in 10cc NS (10 mcg/mL)
Vasopressin: BOLUS: 1 – 2 units IV INFUSION: 1 – 4 U/hr Diphenhydramine: 25 – 50 mg IV H2 Blockers: Famotidine: 20 mg IV Hydrocortisone: 100 mg IV Albuterol: 2 – 5 mg nebulized or mini-dose inhaler
Common CAUSATIVE Agents Neuromuscular blocking agents Antibiotics Latex products IV contrast dye Chlorhexidine surgical scrub 16 17 Reconsider Your Diagnosis
Version 1.0 December 22, 2020 17 Fire Evidence of fire (smoke, odor, flash) on patient or drapes, in patient’s airway, or in room
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?” 2. Get fire extinguisher to have as needed 3. Activate R.A.C.E. management of fire emergency • R: Move patients and assist visitors or impaired employees away from immediate danger • A: Alert others: Activate manual pull station Call front desk of OR • C: Confine: Close doors and windows Contain smoke Turn off oxygen where appropriate • E: Extinguish fire with appropriate fire extinguisher
Additional fire information in Appendix A7 • Assessing OR Fire Risk • Fire Reaction Details 17 18
Version 1.0 December 22, 2020 17 Fire Evidence of fire (smoke, odor, flash) on patient or drapes, in patient’s airway, or in room AIRWAY Fire NON-AIRWAY Fire ATTEMPT TO EXTINGUISH FIRE ATTEMPT TO EXTINGUISH FIRE • Shut off medical gases First Attempt • Disconnect ventilator • Avoid N2O and minimize FiO2 • Remove endotracheal tube • Remove drapes / all flammable materials • Remove flammable material from from patients airway • Extinguish burning materials with saline • Pour saline into airway or saline-soaked gauze • Use fire extinguisher if appropriate. If After fire extinguished equipment fire use fire extinguisher. • Re-establish ventilation using Bag DO NOT USE valve mask (BVM) with room air Alcohol-based solutions • Confirm no secondary fire o o Any liquid on or in energized • Check surgical field, drapes and electrical equipment (laser, towels electrosurgical unit (ESU), • Assess airway for injury or foreign anesthesia machine, etc.) body • Assess ETT integrity (fragments Fire PERSISTS after 1 attempt may be left in airway) • Use fire extinguisher (safe in wounds) • Consider bronchoscopy, airway humidification, bronchodilators Fire STILL PERSISTS • Assess patient status and devise • Evacuate patient ongoing management plan • Close OR door • Save involved materials/devices • Turn OFF gas supply to room for review After fire extinguished • Maintain airway / FiO2 to 100% • Assess patient for injury at site of fire, and for inhalational injury if not intubated • Confirm no secondary fire • Check surgical field, drapes and towels
17 • Assess patient status and devise ongoing management plan • Save involved materials/devices for 18 review
Version 1.0 December 22, 2020 18 Total Spinal Anesthesia After Neuraxial Anesthesia Block: Unexpected rapid rise in sensory blockade, numbness or weakness in upper extremities (hand grip weak), dyspnea, bradycardia, hypotension (or nausea/vomiting), loss of consciousness, apnea, cardiac arrest
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?”
2. Increase FiO2 to 100% 3. Give IV fluid bolus 4. Stop epidural infusion if present 5. If cardiac arrest: Start CPR • If VT/VF Go to TAB 10 • If asystole / PEA Go to TAB 9 • Support ventilation and intubate if necessary 6. Treat significant bradycardia or hypotension • Severe bradycardia: epinephrine 10 – 100 mcg IV, increase as needed (FIRST CHOICE) Go to TAB 8 • Mild bradycardia: ephedrine 5 – 10 mg, atropine 0.5 – 1 mg IV • Hypotension Go to TAB 6 7. If parturient/pregnant: Left uterine displacement, call OB and neonatology, prepare for possible emergent C-section, monitor fetal heart rate 8. Consider sedation to prevent awareness 18 19 Version 1.0 December 22, 2020 Appendix Table of Contents
Contact Phone Numbers – HELP and Consults A1 Rapid Reversal of Antiplatelet and/or Target-Specific Oral Anticoagulants A2 Delayed Emergence A3 Amniotic Fluid Embolism A4 Crisis Resource Management A5 Massive Transfusion Protocol A6 Surgical Safety Checklist A7 Assessing Operating Room Fire Risk Operating Room Fire Guidelines A8 Fall in Operating Room Guidelines A9 Instructions for Prevalon MATS / HoverJack System A10 Lucas 3 Quick Reference Guide Acknowledgements 18 19 Version 1.0 December 22, 2020 Contact Phone Numbers - HELP
EAST Campus WEST Campus
FROM OUTSIDE (617) 66X-XXXX (617) 75X-XXXX
BLOOD BANK 74480 43300
STAT LAB 75227 43230
73905 PACU 42800 Feldberg
FRONT DESK 72411 43000
STAT Help at night (West): ICU attending 1) Open paging system or Anesthesia Intranet 2) Type “ICU” into ‘On-Call Schedule Search’ 3) Find “ICU Attending On Call All Units” – these are all Anesthesia attendings except one (ER intensivist) -May also find Anesthesia Fellow/residents under ICU Fellow or ‘On Call’ TSICU/SICU Residents
Other: Late 3 attending (see Qgenda) - keep in mind this person is home call If still need further help: Consider Heart/Transplant Team
Help at night (East): East Attending or OB Team -Open Anesthesia Intranet -> Overnight tab -> East Attending and OB Attending/Residents
OB Front Desk
19 Version 1.0 December 22, 2020 Contact Phone Numbers - CONSULTS
Cardiology consult: (i.e. acute coronary syndrome) 1) Open paging system -> type “cardiology daytime” -> Page the consult fellow or consult attending for questions/consults
Pacemaker/ICD: 1) Open paging system -> type “EP” -> click “view on call now” -> page EP consult fellow between hours of 8 AM to 5 PM 2) If after 5 PM -> type “cardiology off-hours” -> Page the Fellow (first option) -One cardiology fellow is in house overnight to answer questions and provide assistance
Hint: If you know about these patients the day before, please page the EP fellow or cards consult fellow to let them know when/where you want them to meet the patient (i.e. preoperative holding 30-45 min before procedure starts)
Suspected PE: 1) Open paging system -> type “MASCOT” -> this gets on call cardiology fellow who will evaluate and contact Cards, Pulmonary, IR, Vascular, Heme/Onc, etc.
Suspected inpatient stroke: 1) Call (617) 632-1212 and ask for STROKE STAT 2) Open paging system -> type “STROKE” for ‘Stroke Fellow or Attending’
Perfusion 1) 9- ECMO (Cardiologist)
Surgical Airway Consult 1) ACS Call West X43000, East X42111
19 Version 1.0 December 22, 2020 A1 Rapid Reversal of Antiplatelet and/or Target-Specific Oral Anticoagulants Surgical-trauma patients with life threatening hemorrhage and/or intracranial hemorrhage
START
Direct Thrombin Antiplatelet Agents Factor Xa Inhibitors Inhibitors
• Aspirin • Dabigataran (Pradaxa) • Rivaroxaban (Xarelto) • Clopidogrel (Plavix) • Bivalirudin (Angiomax) • Apixaban (Eliquis) • Prasugrel (Efficient) • Agatroban PT prolonged in a • Ticagrelor (Brilinta) concentration-dependent PT may not be sensitive, PTT • Ticlopidine (Ticlid) manner; may not be prolonged by high doses, INR sensitive • Cilostazol (Pletal) can be falsely elevated
Based on TEG results, Consider prothrombin One apheresis platelet consider 2 units FFP ASAP pack complex concentrate (4- Consider DDAVP factor Kcentra) 50 Consider additional (desmopressin) 0.3 mcg/kg IV units/kg (maximum 5000 platelets if bleeding over 15 min in 50 mL NS units) IV x 1 DO NOT persists Based on TEG results, REPEAT Consider desmopressin consider Tranexamic Acid (DDAVP) 0.3 mcg/kg IV (TXA) over 15 min in 50 mL NS Laboratory Studies Load: 1 gram (over 10 min) PT/INR, Fibrinogen, PTT, Infusion: 125 mg/hr x 8 hours Hemoglobin, Platelet For Pradaxa there is an agent Type and Cross specific reversal agent – Consider Rapid TEG PRAXBIND (consult pharmacy)
Version 1.0 December 22, 2020 A1 Rapid Reversal of Antiplatelet and/or Target-Specific Oral Anticoagulants Surgical-trauma patients with life threatening hemorrhage and/or intracranial hemorrhage
START
Vitamin K Dependent Reversal
PT/INR, Fibrinogen/PTT Trauma: Hgb, PLT, Type and Cross
INR < 1.4 INR > 1.4 – 1.9 INR > 1.9
• Admit to ICU • Admit to ICU • Vitamin K 10 mg IV x 1 dose • Vitamin K 10 mg IV x 1 STAT • Give 2 units FFP Reversal Adequate • Give 2 units FFP ASAP • Prothrombin complex • If platelet <60 give I concentrate (4-factor) apheresis platelet pack (Kcentra) • If fibrinogen <100mg/dL • INR 2-4: 25 units/kg give 10 u cryoprecipitate or (Max 2500u) 2u additional FFP • INR 4-6: 35 units/kg • Repeat INR Q6h x 24h or (Max 3500u) INR < 1.4 until adequately reversed • INR >6: 50 units/kg (Max 5000u) DO NOT REPEAT • Consider platelet INR > 1.4 INR > 1.9 transfusion • Repeat INR Q 2 hours until < 1.4 Consider more • Consider TEG FFP if clinically indicated
Version 1.0 December 22, 2020 A2 Delayed Emergence Failure to return to normal consciousness in a timely fashion
START
1. Confirm all anesthetic agents (IV/inhalational) are OFF 2. Check for residual muscle relaxation • Verify NMB reversal, TOF status. 3. Consider: • Take patient to PACU/ICU intubated • NMB reversal with sugammadex (high dose vs. low dose) • Opioid reversal: Naloxone • Benzodiazepine reversal: Flumazenil • Scopolamine reversal: Physostigmine (potential cholinergic crisis, including severe bradycardia responsive to atropine) 4. Call for help 5. Neuro Exam • Look for focal neurologic deficits (pupils, asymmetric movement, gagging, etc.) • Suspect stroke (abnormal exam) obtain stat head CT 6. Check for medications swap or dosing error 7. Labs: ABG, electrolytes, glucose, temperature
Version 1.0 December 22, 2020 A2 Delayed Emergence Failure to return to normal consciousness in a timely fashion
Rule Out Other Causes Hypoxemia Hypermagnesemia Hypercarbia Hyponatremia Hypothermia Hypoglycemia Medication error
DRUG DOSES and Treatments Narcan (Naloxone): 40 mcg IV (Max 400 mcg) Flumazenil: 0.2 mg IV (Max 1 mg) Physostigmine: 1 mg IV Sugammadex doses: 4 mg/kg if TOF 1-2 post tetanic stimulation 2 mg/kg if TOF 2 twitches 16 mg/kg immediate reversal of rocuronium after induction
Version 1.0 December 22, 2020 A3 Amniotic Fluid Embolism
Respiratory distress, decreased SaO2, cardiovascular collapse, coagulopathy, disseminated intravascular coagulopathy (DIC), seizures
START
1. Call “Anesthesia STAT” and ask for a code cart • Ask: “Who will be the eventmanager?”
2. Turn FiO2 to 100% 3. Cardiopulmonary arrest and C-section • Plan emergent delivery • Consider TTE or TEE • Support ventilation 4. Place patient in left uterine displacement (LUD) 5. Establish large volume IV access 6. Prepare for emergent intubation 7. When possible place arterial line 8. Support circulation • IV fluids, vasopressors and inotropes 9. Anticipate massive hemorrhage and DIC 10. Consider circulatory support (Page 9-ECMO)
Version 1.0 December 22, 2020 A3 Amniotic Fluid Embolism
Respiratory distress, decreased SaO2, cardiovascular collapse, coagulopathy, disseminated intravascular coagulopathy (DIC), seizures
Rule Out Other Causes Eclampsia Hemorrhage Air embolism Aspiration Anaphylaxis Pulmonary embolism Anesthetic overdose Sepsis Cardiomyopathy/MI Local anesthetic toxicity Total spinal
Version 1.0 December 22, 2020 A4 Crisis Resource Management
Call “Anesthesia Stat”
Designate the event manager and other roles
State the diagnosis and plan out loud
1. Primary Diagnosis Group Statement • Airway (Failed, Difficult, etc.) , • Respiratory (Hypoxia, pneumothorax, etc.) • Cardiac (Ischemia, VF/VT, etc.) 2. Critical abnormality noted 3. Relevant medical or surgical history 4. Initial treatment initiated
Request input Verbal review every five minutes
Avoid fixations and critical errors in thinking
Reconsider Your Diagnosis
Version 1.0 December 22, 2020 A5 Massive Transfusion Protocol
1. Call Blood Bank West X43300, East X74480 • Inform technician of following information • Your name and Attending requesting the MTP • Patient name, gender, MRN, location
2. Cooler released to transport with component pick-up slip, or patient label. (Must have name and MRN)
1. Cooler preparation • Automatically prepared and issued every 20 minutes • First Cooler: 4 u PRBCs, 2 u FFP • All Subsequent Cooler: 4 u PRBCs, 2 u FFP, 1 dose platelets • Every 4th cooler: Cryoprecipitate prepared and issued
2. Coolers will be prepared until a call is received to stop MTP
3. Hourly tests will be requested by blood bank 1. PT, PTT, CBC, fibrinogen 2. Consider TEG
4. Complete an Emergency Release Form for emergency release products
5. Return all unused products to Blood Bank (within 12 hours)
Version 1.0 December 22, 2020 A6 Surgical Safety Checklist
Version 1.0 December 22, 2020 PAGE INTENTIONALLY LEFT BLANK
Version 1.0 December 22, 2020 A7 Assessing Operating Room Fire Risk
Version 1.0 December 22, 2020 A7 Operating Room Fire Guidelines Evidence of fire (smoke, odor, flash) on patient or drapes, in patient’s airway, or in room
START Responsible Action Responsible Action Person Person Anesthesia 1. Take charge of surgical team R: RESCUE 1. Notify Manager and Director Provider effort Floor 2. Pull fire alarm 2. Stop flow of oxygen, if Marshall/Resour 3. Inform other occupied O.R. personnel of feasible, until fire is under ce Nurse the situation; alert them of possible control evacuation. 4. If needed Identify location for evacuation At the same 1. Activate Anesthesia STAT time… 2. Notify Floor Marshall Rescue: 1. Inform circulator when to close oxygen Circulator 3. Direct incoming staff to secure Anesthesia shut-off valve. additional supplies and to Provider 2. Determine the need for evacuation. ready CO2 fire extinguisher 3. Disconnect breathing circuit from the patient and turn off the oxygen flow. At the same 1. Remove burning material from time… the patient and throw it on the Rescue: 1. Assist anesthesia provider with ventilating Surgeon floor away from the patient’s Anesthesia Tech patient during evacuation. head. This involves the 2. Obtain necessary monitoring equipment, following immediate and oxygen tank(s) and any additional coordinated actions: equipment needed to evacuate the patient. a. AP releases the drape from the IV pole Rescue: 1. Disconnect the patient from all of the b. Scrub person pushes the Surgeon, surgical equipment, i.e., cautery, drapes, mayo stand out of the way circulating insufflator, boot machine, etc. c. Circulating nurse nurse, scrub and 2. Cover the patient’s open wound with a disconnects any cords assisting steri- drape or sterile towel(s). 2. Assess patient for injury, and if personnel 3. Move patient on the O.R. bed to the any: designated area (empty O.R. or the PACU). 3. Care for patient’s injuries. A: ALARM 1. Activate RED emergency call light (West Scrub Pour saline on the drape Floor campus only) Floor 1. Pull fire alarm Marshall/Resour 2. Dial 2-1212 and report fire in (exact Marshall / 2. In collaboration with ce Nurse location: West, Feldberg, Shapiro) O.R. Resource anesthesia, turn off oxygen #___. Nurse/ valve outside of room Designee 3. Direct personnel to close all C: CONTAIN Keep the involved O.R. doors closed. doors, unplug electrical Floor devices involved, obtain Marshall/Resour extinguisher ce Nurse 4. Assign a person at the entrance of the O.R. to direct E: EXTINGUISH 1. Code Red Team will use extinguisher to put Code Red Team Code Red Team out the fire and implement fire 5. Dial 2-1212 and report fire in (Should have containment strategies. 2. Water sprinkler in the room will start (exact location: West, arrived by the Feldberg, Shapiro) O.R. #___. automatically when the temperature time…) reaches 140 degrees F. Code Red Will respond immediately at this Team time
Version 1.0 December 22, 2020 A8 Fall in Operating Room Guidelines
START
1. Assess and stabilize patient • Check patient’s breathing, pulse and blood pressure • Ensure standard monitors are functional • Check for injury such as cuts, scrapes and bruises • Consider cervical /head trauma (consider c-collar and back-board) • Stabilize patient in situ
2. Call for help with patient management / movement • Do not attempt to lift /move patient without assistance
3. Utilize Prevalon MATS/ HoverJack System to raise patient to bed • See next page
4. Consider transfer to Emergency Department for clinical evaluation of trauma s/p fall
Version 1.0 December 22, 2020 A9 Prevalon MATS/HoverJack System Guide
1. Place Prevalon MAT transfer mattress underneath patient using log- roll technique.
2. Inflate Prevalon MAT using air supply
3. Pull inflated Prevalon MAT on top of deflated Hoverjack • Assure patient is properly centered on HoverJack mat • Using buckles, secure safety straps around patient
4. Deflate Prevalon MAT by turning off air supply
5. Inflate Hoverjack System • Plug in air supply to valve #1 at patient’s feet • Once fully inflated remove air hose, valve will maintain pressure • ALWAYS INFLATE FROM THE BOTTOM • Inflate other chambers using valve #2, valve #3 and valve #4 in exact succession
6. Position bed next to inflated HoverJack. • Re-inflate Prevalon MAT and transfer patient to stretcher or bed • Transfer using the orange handles located on side of MAT • Remove safety strap that is around patient from HoverJack • Ensure team members stay at side of patient
7. If it necessary to lower patient to floor (e.g. CPR) release air by opening uppermost red deflate valve first. Then release others in sequence.
Version 1.0 December 22, 2020 A10 Lucas 3 Quick Reference Guide
Version 1.0 December 22, 2020 Acknowledgements
Please contact Dr. Richard Pollard and the QSI team at BIDMC with questions and/or clarifications regarding this book
This manual was inspired by and modified based on the following sources:
American Heart Association: Advanced Cardiac Life Support Training
Ariadne Labs. OR Crisis Checklists. Brigham & Women’s Hospital, Harvard T H Chan School of Public Health, Boston, MA
Stanford Anesthesia Cognitive Aid Group. Emergency Manual: Cognitive aids for perioperative clinical events. Creative Commons BY-NC-ND
Version 1.0 December 22, 2020 1. Failed Airway
2. Hypoxia
3. Bronchospasm
4. Pneumothorax 5. Hemorrhage Operating Room 6. Hypotension Crisis Checklists 7. Tachycardia – Unstable >> Do not remove book from this room << 8. Bradycardia – Unstable
9. Cardiac Arrest –Asystole/PEA The use of this manual is meant as a guideline and reference. 10. Cardiac Arrest – VF/VT It is not meant to be a substitute for training and experience. 11. Myocardial Ischemia Color code: 12. Malignant Hyperthermia Blue – Respiratory Red – Cardiac 13. Air Embolism – Venous Green - Other Yellow - Reference 14. Transfusion Reactions
15. Local Anesthetic Toxicity
16. Anaphylaxis
17. Fire ĞƉĂƌƚŵĞŶƚŽĨŶĞƐƚŚĞƐŝĂ͕ƌŝƟĐĂůĂƌĞ ĂŶĚWĂŝŶDĞĚŝĐŝŶĞ 18. Total Spinal Anesthesia
Version 1.0 19. Appendices - References December 22, 2020 PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS POST ANESTHESIA TRANSPORT MONITORING Beth Israel Deaconess Medical Center Department of Anesthesia and Critical Care SOP
Title: Post Anesthesia Transport Monitoring
SOP #: ANES CLN 100-015
Post Anesthesia Transport Monitoring
After an anesthetic, the patient is usually transferred to the PACU or an ICU. This guideline sets out to clarify the type of patients who will need monitoring during transportation, and the nature of monitoring required. Who needs monitoring during transportation? Monitoring during transport is mandatory for the following patients Any patient designated as needing ICU care, irrespective of whether the patient actually goes to the PACU or an ICU. Patients who are receiving vasopressors, vasodilators or inotropes. Any patient who has a pulmonary artery catheter in situ All intubated patients. An patient who has had an unstable course during the anesthetic Any patient who needs to be transported for longer than 5 minutes to the recovery area. The above list is not exhaustive and monitoring for transportation may be instituted for any patient at the discretion of the anesthesiologist.
Types of Monitoring All patients who require monitoring based on the indications above will have at a minimum pulse oximetry, EKG, and blood pressure monitored. Additional monitoring like the monitoring of the pulmonary artery catheter, CVP, ICP and IABP can be instituted at the discretion of the anesthesiologist. A patient transport monitor capable of displaying heart/pulse rate, at least one EKG wave form and systemic blood pressures must be used. The monitor must be positioned in such a way so that one member of the transportation team is able to view the screen and monitor the vital signs.
Pulse oximetry The pulse oximeter should be applied to a part of the patient’s body where good waveforms and signals can be detected. EKG A minimum of three electrodes must be applied to the patient and the EKG wave form must be satisfactory for the detection of arrhythmias. A defibrillator or pacemaker is not required for transportation in most patients except for patients who have had an unstable cardiac rhythm under anesthesia and are at risk for requiring defibrillation or pacing. Blood Pressure All patients requiring monitoring for transportation should have their blood pressure monitored. If an arterial line is available, then it may be connected to the transducer, zeroed and used. The arterial wave form along with the systolic and diastolic pressure must be visible on the monitor. If an arterial line is not available then a non invasive blood pressure cuff must be used. The cuff must be set to cycle no less frequently than once every 5 minutes. Clinical Monitoring An anesthesiologist/CRNA must be present with the patient during transportation at all times. The anesthesiologist must watch the patient constantly for inadvertent extubation, inadvertent malpositioning or removal of lines, tubes and catheters as well as constantly check for possible injury to the patient from personnel or from items on the bed.
Hand off Monitoring should only be terminated when the recovery or ICU nurse is ready to take over the patient and reinstitute monitoring. For handoff content please refer to the perioperative handoff policy 102 and 102A https://internal.bidmc.org/cms/content/BFF2BE6CA3C2436F89A247E7C33CCB19/DF712CB4C1B945B7B8 9585798C285F95.doc Documentation must be made in the computerized anesthesia record or paper record whether the patient was transported in a stable manner and what types of monitoring was used.
Owner: Eswar Sundar MD. Director of PACU
Approved by: Dr. Danny Talmor. Chair Department of Anesthesiology
Original Approved Date: 12/5/2007 1st Review Date: April 6, 2013 Review Date: April 2018 Next Review Date : December 2021
PROFESSIONAL AFFAIRS ORIENTATION FOR NEW CLINICIANS
INR CASE SETUP Cerebral aneurysm management in INR set-up
Location: INR
Lines:
PIV: Start with one 18/20 gauge IV preferably in the left arm, which will be closest to you. It is nice, but not essential, to place a second IV after induction so that you do not end up bolusing any vasoactive infusions when you give heparin or additional rocuronium. Arterial line: placed in pre-op holding, preferably in the left arm, both because it will be closest to you and because the surgical team will rarely perform the procedure via right radial access. These patients are all on anti-platelet therapy, so it is helpful to use ultrasound during placement to avoid hematoma formation.
Anesthetic: These cases are done under GA with an ETT and paralysis to avoid any chance of patient motion at the time of stent or coil positioning. Many aneurysm patients have poorly controlled hypertension, so you should have boluses of both antihypertensives (nicardipine or nitroglycerin) and pressors (phenylephrine and ephedrine) ready. If the aneurysm has already ruptured and the patient has elevated ICP, nicardipine (diluted to 200 mcg/mL) is preferrable to nitroglycerin. The procedure itself is minimally stimulating, so a low-dose phenylephrine infusion is often necessary.
Blood pressure goals:
Brain Trauma Foundation recommendation for TBI patients: maintain cerebral perfusion pressure 60-70 mmHg. You will rarely have ICP monitoring, but this typically correlates to a MAP of 70-80. Surgeon preference: SBP < 140
Anticoagulation: You will be checking ACTs intra-operatively. The nurses will run the ACT machine using samples you provide off the arterial line. The surgeons will request heparin and follow-up ACTs as needed. Depending on the catheters they are using, a typical ACT goal is 250. You will not reverse with protamine at the end of the case but should make sure it is stocked in the Omnicell as it may become necessary in the event of intra-operative aneurysm rupture.
Emergence: Full paralysis is usually maintained until the surgical team is ready to seal the groin, so sugammadex is typically necessary. The anesthesia machine in INR does not have pressure support, so emergence is often abrupt. It is best to have an antihypertensive bolus ready, in- line to treat emergence hypertension, which is typically short-lived. Patient must lie flat for the first part of recovery, but you can put the bed into some reverse Trendelenberg to optimize comfort and breathing. Transport monitoring to PACU ranges from SpO2 alone to full monitors at your discretion. Print Code stroke set-up
Location: INR
Lines:
PIV: You will typically get whatever they arrive with. Lines on the left are preferable as this will be the side closest to you. Arterial line: We almost never place arterial lines in these patients, especially if they have received tPA.
Anesthetic: The first decision is whether to do MAC or GA. Retrospective studies suggested MAC may be preferrable to GA, but all randomized prospective trials have shown that outcomes with GA are equivalent to or better than outcomes with MAC. A good practice is to observe the patient in the CT scanner, if they are moving significantly or are otherwise unable to protect their airway, you should have a low threshold to do a GA. It is better to choose a GA from the start than to convert emergently in the middle of the procedure.
Blood pressure goals: Maintaining adequate blood pressure is likely more important than MAC vs. GA.
SNACC consensus recommendation: maintain SBP 140 – 180, DBP < 110
If doing a GA:
There is no prospective data to suggest that volatile agents or TIVA is preferrable. You can do whichever you are most comfortable with. It can be difficult to maintain adequate blood pressure under GA in a minimally stimulating procedure. It is helpful to maintain paralysis and the equivalent of 0.5 MAC. It is also often necessary to use norepinephrine instead of or in addition to phenylephrine, so grab both sticks on your way down to INR.
If doing a MAC:
Our traditional practice has been to give nothing but oxygen. This works in more patients than you would expect and makes it very easy to maintain adequate blood pressure. Our neurosurgeons prefer midazolam and fentanyl as first-line agents if the patient needs some sedation. Dr. Ogilvy is adamantly opposed to his code stroke patients receiving propofol while under MAC. If you find yourself needing more sedation than midazolam and fentanyl can provide, convert to GA. The other neurosurgeons are more tolerant of propofol or Precedex infusions while under MAC, but given the prospective evidence that outcomes with GA ³ outcomes with MAC, you should highly consider converting to GA rather than risk oversedation or disinhibition. Print Middle meningeal artery (MMA) embolization in INR set-up
Location: INR
Lines:
PIV: preferably in the left arm, which will be closest to you Arterial line: not needed
Anesthetic: These patients are often elderly, and the case can be done with moderate sedation using divided doses of fentanyl +/- midazolam. A light MAC with dexmedetomidine (0.2-0.4 mcg/kg/hr) and/or in small, divided boluses (4-8 mcg at a time up to a maximum total dose of 0.5 mcg/kg) is another option. Propofol is generally avoided as the risk of disinhibition is higher in these patients who are presenting with a subdural hematoma. The case will usually be booked with general anesthesia, and this is a fine option, particularly in younger, more robust patients or in patients who are uncooperative due to their TBI. Print Carotid stent in INR set-up
Location: INR
Lines:
PIV: preferably in the left arm, which will be closest to you Arterial line: placed in pre-op holding, preferably in the left arm, both because it will be closest to you and because the surgical team will sometimes perform the procedure via right radial access
Anesthetic: The surgeons want the patient to be quite awake for this procedure. Ideally, they prefer moderate sedation (midazolam and fentanyl) but need an anesthesiologist because of the nature of the procedure. Don't plan on a propofol infusion as the patient will need to follow commands and breath hold during some of the imaging runs. Drs. Thomas and Moore may tolerate propofol boluses while they are getting vascular access if necessary, but Dr. Ogilvy will prefer you to avoid propofol entirely. Dexmedetomidine as a low-dose infusion (0.2-0.4 mcg/kg/hr) and/or in small, divided boluses (4-8 mcg at a time up to a maximum total dose of 0.5 mcg/kg) is another option. Print Trigeminal radiofrequency ablation in INR set-up
Location: INR
Lines:
PIV: preferably in the left arm, which will be closest to you
Anesthetic: The surgeons will need the patient to be very sedated for initial needle placement, then quite awake to assess reproducibility of their pain, then very sedated again for the actual ablation. This is predominantly achieved with methohexital for the portions of the procedure where the patient needs to be very sedated on a background of low-dose midazolam and fentanyl.
In pre-op holding, a very small dose of midazolam (0.5 mg) and fentanyl (25 mcg) can be helpful to gauge the patient’s tolerance/sensitivity.
In the INR suite, you will place nasal cannula oxygen with CO2 monitoring on the patient with the tubing taped running between the eyes and up the forehead rather than behind the ears to avoid the surgical field. The surgeon will first administer local anesthetic with a small gauge needle with the patient awake. An additional small dose of midazolam and/or fentanyl can be helpful here. After the local infiltration, the surgeon will prepare to place the large needle and advance to the trigeminal ganglion. You should administer ~40 mg of methohexital, and when the patient is sedated, allow the surgeon to proceed. The patient may still be mildly responsive to the needle positioning, but typically won’t move. You can consider an additional 10-20 mg of methohexital if necessary but should avoid giving additional midazolam and fentanyl at this point as the patient will need to be very awake for the next part of the procedure. Once the needle is in position, you will wait for the patient to wake up from the initial methohexital bolus, and the surgeon will then ask them if their pain is reproduced with small stimulations of the needle. When the surgeon is satisfied with the needle position, you should administer an additional 30-40 mg of methohexital, and when the patient is sedated, allow the surgeon to proceed with the actual ablation. An additional small dose of midazolam and/or fentanyl can be used here if the patient is too responsive. CALL RELIEF GUIDE
Anesthesia Team: Weekday Call Relief
• The West and East Call Attendings are the de facto Floor Managers overnight once they have received board signout from the day floor managers.
• When the schedule is made, there is an attempt to balance call staff, CRNAs, and residents on both campuses.
• In general, based on case location and acuity, a Late attending will ideally cover 2 Late residents/fellows, or 3 Late CRNAs. If covering trainees, ideally a Late or Call attending covers only up to two locations. If covering only CRNAS, ideally a Late or Call attending can cover up to four CRNAs.
• At times it may be necessary to cover more rooms (up to, and never more than, 4 rooms) using a combination of residents and CRNAs.] This option should be reserved for emergencies only.
• Because of the complex nature of late afternoon/evening pairings and the endless permutations therein, the call committee recommends two parallel reminders for the order of relief, rather than explicit pairings as shown in the East and West call relief posters. The following bylaws will help facilitate decision making. The system relies on reasonable judgment, flexibility, and frequent communication.
Last updated July 2021 Anesthesia Team: Weekday Call Relief Guidelines
• Call personnel should not be relieved until ALL non-call personnel have been relieved. For example: If day staff are “stuck” on the East and the West Call Attending no longer needs the Late 1 West (who does not cross the street), Late 1 West should take over cases so that higher Lates (3, 4, 4- 11, 5) can go East to relieve the day people. Similarly, non-emergent add-on cases should NOT be started until all non-call personnel have been relieved.
• Any Late (resident or attending) with “East” or “West” after the number will remain on that campus. Any Late without a location qualifier may cross to the other campus. Thus, 7-7 CRNA, Late 3 attending, late 4 attending, late 5 attending and 4-11 attending can cross campuses as needed. Cross- campus movement is expected to be expedient, around 15 minutes.
• CRNA 7–7 and MD 4-11 do not fall into the relief order in any particular place. These are timed shifts, and the call attending must plan for their relief by 7 and 11pm respectively.
• Late Fellow may sometimes be part of the on-call/late team. There is no particular time at which the late fellow must be relieved, but should be before 9pm to stay adherent to ACGME duty hour regulations. Fellow coverage mimics resident coverage and thus, ideally an attending covering a fellow covers no more than two locations.
• The float resident is to be relieved first on the East Campus. The float resident comes in at 11am and helps with lunch breaks, preops for next day’s add on cases and relief of day residents. The float resident may be assigned to dinner breaks on the East, but should be sent to the West Campus no later than 7pm. On West, the float resident will relieve the PACU resident, can help with dinner breaks and complete preops for the next day’s add-on cases.
• All relief should be in order of number. Thereafter the floor manager may use discretion as to whether to relieve a resident, CRNA, or attending, but the expectation is that all personnel of a low number will be relieved before personnel of a higher number. [For example: a Late 2 attending should not be relieved until the Late 1 resident, Late 1 attending and Late 1.5 CRNA have been relieved]
Last updated July 2021 • Dinner breaks should be provided (30 min) to any staff, CRNAs, or residents expected to be working past 7pm, including the 4-11 attending.
• All late residents on East Campus must be relieved by 9pm in order to be compliant with ACGME duty hour regulations. PACU resident should be relieved no later than 8pm and float resident should be relieved no later than 11pm.
• East Call is expected to take over solo when down to one operating room/procedural location. However, the East Call Attending should ensure that there are no current/active issues in the PACU before providing solo anesthetic care. Should an emergency arise, that should be communicated with the OB Anesthesia attending. In addition, if an emergency arises communicate with the West Call Attending to make a Late call attending immediately available.
• 4-11 Attending can be relieved prior to 11pm if the West and East Overnight Attendings are covering all anesthesia locations. However, if the 4-11 attending is in a case close to the end of their shift, appropriate relief should be planned for 11pm. The 4-11 attending can be relieved by either the Late 5 or Overnight Call attendings.
If Late 5 has already gone home, they are expected to return to relieve the 4-11 attending. However, in some cases, the 4-11 attending may elect to stay past 11pm to complete a case. Thus, in planning 11pm relief the East or West Overnight Attending should communicate with both 4-11 and Late 5 attendings, including providing adequate time for the late 5 attending to travel back if needed.
Both 4-11 and Late 5 attendings will be compensated past 11pm using the overtime/call points system.
• NOTE: NO call personnel should go home until they or the local call attending have communicated with the cross-campus call attending to determine if there is a lower call person present who needs relief.
Please be respectful of the overnight attendings managing this complex system. Professionalism and good communication are key to navigating this tiered system . Many things are NOT reflected in PIMS (remote cases, PACU emergencies, codes/anesthesia STATs elsewhere in the hospital) and therefore PIMS does not reflect the current utilization of call personnel.
Last updated July 2021 WEST LATE CALL RELIEF West Late Call Relief Guideline
12hr/7-7 CRNA must be Late 5 should PACU Resident must relieved by 7pm. Plan relieve 4-11 at be relieved by 8pm accordingly when 11pm relieving late staff
Float resident Late 1 Late 1.5 Late 2 Late 3 Late 5 or relieves PACU Late 4 resident Attg CRNA Attg Attg 4-11
Float resident can stay West Call Attg can no later than 11pm Can be relieved earlier cover two locations by call resident if able with call residents
Communicate with the East Call Attending regularly as you relieve late call staff
Stays West: Can go either East or West: Ideal Trainee Supervision: Ideal CRNA Supervision: Late 1 West attending 12 hr (7am-7pm) CRNA An attending supervising a An attending supervising Late 1.5 West CRNA resident/fellow can cover only CRNAs can cover up to Late 2 West attending Late 3, 4, 5, 4-11 up to two locations four locations
7PM reminder 9 PM reminder 11 PM reminder --Plan for dinners for all staying past 7 All late call residents on East relieved by --Late 5 relieves 4-11 after discussion --Relieve 12 hr CRNA by 7pm 9pm compliant with duty hour regulations --Float resident must be relieved by 11pm --Plan for PACU resident relief by 8pm EAST LATE CALL RELIEF East Late Call Relief Guideline
Float resident must go Late 2 Res or Late 2 attg may be relieved first: Late 5 should West first to relieve Determined by case & relieve 4-11 at the PACU resident coverage ratio 11pm
Late 1 Late 2 Late 3 Float to Late 1.5 Late 5 or Res/Late 1 Res/Late 2 Res/Late 3 Late 4 WEST CRNA Attg Attg Attg 4-11
Late 1 Res or Late 1 attg 12hr/7-7 CRNA must be Late3 Res or Late 3 attg East Call Attending to may be relieved first: relieved by 7pm. Plan may be relieved first: take over when down Determined by case & accordingly when Determined by case & to one location after coverage ratio relieving late staff coverage ratio assessing PACU
Communicate with the West Call Attending regularly as you relieve late call staff
Stays East: Can go either East or West: Ideal Trainee Supervision: Ideal CRNA Supervision: Late 1 resident & attending 12 hr (7am-7pm) CRNA An attending supervising a An attending supervising Late 1.5 East CRNA resident/fellow can cover only CRNAs can cover up to Late 2 resident & attending Late 3, 4, 5, 4-11 up to two locations four locations
7PM reminder 9 PM reminder 11 PM reminder --Plan for dinners for all staying past 7 --Relieve all residents by 9pm to stay Late 5 should relieve 4-11 after --Relieve 12 hour CRNA by 7pm compliant with duty hour regulations discussion with 4-11