Complex Regional Pain Syndrome I Reflex.31 | Anesthesia | Childbirth

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OBSTETRIC ANESTHESIA RESIDENT HANDBOOK    RESIDENT SCHEDULE    OPERATING ROOM SET UP    PREANESTHETIC EVALUATION    HIGH RISK CONSULT SERVICE    ASEPTIC TECHNIQUE    EPIDURAL PLACEMENT AND MAINTENANCE    COMBINED SPINAL EPIDURAL (CSE) PLACEMENT    CESAREAN DELIVERY WITH IN SITU EPIDURAL    TOPPING OFF LABOR EPIDURALS    CATHETER PULLS    SUBARACHNOID BLOCKS    COMPLICATIONS OF NEURAXIAL TECHNIQUES    OBSTETRIC ANESTHESIA CURRICULUM   RESIDENT SCHEDULE  The resident schedule is as follows: on m
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  OBSTETRIC ANESTHESIA RESIDENT HANDBOOK RESIDENT SCHEDULEOPERATING ROOM SET UPPREANESTHETIC EVALUATIONHIGH RISK CONSULT SERVICEASEPTIC TECHNIQUEEPIDURAL PLACEMENT AND MAINTENANCECOMBINED SPINAL EPIDURAL (CSE) PLACEMENTCESAREAN DELIVERY WITH IN SITU  EPIDURALTOPPING OFF LABOR EPIDURALSCATHETER PULLSSUBARACHNOID BLOCKSCOMPLICATIONS OF NEURAXIAL TECHNIQUESOBSTETRIC ANESTHESIA CURRICULUM  RESIDENT SCHEDULEThe resident schedule is as follows: on months when 2 residents are rotating on theservice, one will be designated the a.m. resident and the other will be the p.m.resident. The a.m. resident should arrive no later than 6:45 and will stay until 3 p.m.;the other resident will arrive at 11 a.m. and stay until 7 p.m. There is often a flurryof epidural placements between 6:30 and 7:00 a.m., so the early resident might consider coming earlier when possible.Each week the a.m. and p.m. resident will alternate. You are responsible for agreeingwho will be the a.m. and p.m. resident the first week and for alternating thereafter.The first day on the service both residents can arrive at 6:45 so that the more seniorresident can orient the other. When only one resident is on the rotation, he/sheshould arrive no later than 6:45 a.m. and stay until 5 p.m. In the near future, wehope to have overnight call facilities for residents, and at that time we will tweak theschedule once again to ensure optimal exposure to procedures on the L&D ward. Please note that you are responsible for contacting both Patty Burke and the staff member on L&D if you have an unanticipated emergency or illness and are unable to get to work. The same applies if you request an additional vacation day that was not srcinally scheduled. When the a.m. resident arrives, he/she should check the anesthesia machine andensure that emergency drugs and equipment for the administration of a generalanesthetic are immediately available. The cases for the day are usually posted on thewhite bulletin board; scheduled labor inductions are listed in a binder at the nursingstation or, if the patient is already in‐house, on the bulletin board. The CRNA on L&Dcan also provide updates for the day’s schedule.Daily resident duties include: attend the “safety rounds” at 7:30 a.m. each morningin the 2 nd floor neonatal conference room, when possible; fill out the pre‐anesthesiaevaluation papers on each patient requesting an epidural or scheduled for Cesareandelivery, cerclage, tubal ligation, etc. (the packet of papers is usually in the patient’schart or on the clipboard in the anesthesia work room); place epidurals onceproperly trained and prepared, and fill out all the relevant paperwork; troubleshoot and top‐off epidurals, as needed; provide neuraxial or general anesthesia foroperative procedures, remaining with the patient and charting appropriatelythroughout; attend all lectures offered by staff, colleagues, and fellows; performpostoperative visits on all patients from the preceding day (a list of patients will beprovided); and provide continuity of care for all antepartum patients (these are thepatients being observed on the floor whose status should be reassessed on a dailybasis). If two residents are available during the hours between 11 a.m. and 3 p.m.(when shifts overlap), one will be expected to run the floor, placing andtroubleshooting epidurals, while the other is in charge of surgical cases. Antepartumand postpartum visits can be divided between residents, or residents can alternatethese duties week by week.  In addition to the above duties, each resident is responsible for making aPowerPoint on a subject of interest for presentation during the final week on therotation. We will also assign a series of “Jackpot” questions at the beginning of therotation; we expect you to research the answers and be prepared to answer thesequestions at a designated “Jackpot” answer session each week (below is a list of resources to aid in your research). Further, when time permits, you will be expectedto take over surgical procedures already underway, relieving the CRNA andassuming responsibility for those obstetric patients in the operating suites. Finally,occasionally you will be asked to perform preoperative assessments on both “highrisk” parturients and non‐obstetric patients scheduled for outpatient surgery at Tulane Lakeside in the anesthesia preoperative evaluation clinic on the 1 st  floor.These preoperative evaluations require your familiarity with preoperativeguidelines, anesthetic implications of a variety of disease processes, and withfurther work‐up algorithms that might be necessary to optimize a patient forsurgery. The preoperative evaluation clinic provides a good learning opportunity,particularly in preparation for the Oral Boards.The L&D ward is marked by peaks and lulls; residents should take advantage of “downtime” by studying, reading, preparing the final PowerPoint presentation, andanswering the “Jackpot” questions. The third floor office has several texts andquestion books, as well as three computers with PowerPoint capacity. Please takeadvantage of these facilities for study, research, etc.Finally, a very informative and recently updated reference book to help guide youduring this rotation is Obstetric Anesthesia Handbook  by Sanjay Datta, BhavaniShankar Kodali, and Scott Segal. It is available at Amazon and other on‐linecompanies. You should also be intimately familiar with the 2007 ASA PracticeGuidelines for Obstetric Anesthesia (see  Anesthesiology  2007;106:843‐63 or simplyGoogle “ASA Obstetric Anesthesia Guidelines”; these guidelines are also printed inthe back of Chestnut’s Obstetric Anesthesia text). Other resources you may findhelpful include: Chestnut’s Obstetric Anesthesia: Principles and Practice , 4 th Ed; Clinical Anesthesiology  by Morgan, Mikhail and Murray (with particular emphasis onthe Local Anesthetics and Obstetric Anesthesia chapters); and  Anesthesia Review: AStudy Guide to Anesthesia and Basics of Anesthesia by Lorraine Sdrales and RonaldMiller (again, with emphasis on the Local Anesthetics and Obstetric Anesthesiachapters). These and other texts, including Longnecker’s  Anesthesiology  , Miller’s Anesthesia: 2­Volume Set  , and Barash’s Clinical Anesthesia are in the 3 rd floor office,although I encourage you to purchase the Obstetric Anesthesia Handbook  .OPERATING ROOM SET UPEach morning and after each case, the anesthesia machine and all equipment must be checked and left ready for any emergency that might arise.The following items must be immediately available and ready to use:    ã Anesthesia machine with breathing circuit (that has been tested for leaks) andmask  ã BP cuff, EKG, and SpO2 cable ã Laryngoscopes and blades (be sure to check each handle and blade) ã Styletted ETT of all sizes (6.0, 6.5, 7.0) ã Immediately available ephedrine, phenylephrine, and succinylcholine. Atropine,glycopyrrolate, and epinephrine should be readily accessible ã A secure, readily available induction agent and syringe ã Working suction with tip attached ã Ambu bag ã Oral airways ã Stethoscope ã A fully stocked obstetric hemorrhage cart and difficult airway cart are immediatelyavailable in the OR common areaPRE‐ANESTHETIC EVALUATIONPatients on the L&D floor are to be seen and evaluated upon nurse or obstetricianrequest. In addition, we often elect to evaluate all patients considered “high risk” assoon as possible, including patients scheduled for trial of labor after Cesarean(TOLAC), obese patients, patients with known or suspected difficult airways,multiple‐gestation parturients, severe preeclamptics, etc.A focused H&P should include age, gravid and para state, weeks gestation, anycomplications of current pregnancy, reason for C/S (if applicable), reason for priorC/S (if applicable), previous anesthetics, height, weight, allergies, comorbidities,airway, heart and lung examination, any relevant labs (platelets for a patient withknown gestational thrombocytopenia, platelet disorder, HELLP, or clinical history of bleeding; urine protein for patients with preeclampsia; blood glucose for patient with DM, etc.), NPO status, and anesthetic assessment and plan. A baseline maternalblood pressure and fetal heart tones (FHTs) should also be documented.For review of systems, it is important to evaluate whether patients withpreeclampsia have visual changes, edema, abdominal pain, headache, or any signs of easy bleeding/bruising. Ask all parturients about GERD, as well as n/v, SOB, CP, andpalpitations, when appropriate.HIGH RISK CONSULT SERVICEIn concert with the Obstetrics Department, we recently launched a high‐risk consult service. Obstetricians have been asked to identify parturients considered “high risk”and send them for an anesthesia consult in advance of the estimated date of confinement (EDC). High‐risk patients include, among others, super morbidly obesewomen with other comorbidities, patients with severe scoliosis, patients at risk forhemorrhage (previa, accreta, percreta, for example), patients with bleedingdisorders or congenital heart disease, etc. This consult service also gives us an
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