UNIT 6

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Section One: Background

1. Discuss the four basic densities and their radiologic/ pathologic correlations.

2. Demonstrate an understanding of the fundamental physics and potential hazards of the following imaging techniques:

a. X-irradiation, including plain radiographic films, mammography, fluoroscopy, angiography, and computed axial tomography (CAT)

b. Ultrasound

c. Nuclear medicine

d. Magnetic resonance imaging (MRI)

e. Positron emission tomography (PET)

3. Discuss the specific patient preparations for the aforementioned radiological studies, including oral intake restrictions and bowel preparative regimens.

Section Two: Diagnostic Studies

1. Discuss the following typical plain radiographs utilized to evaluate blunt and penetrating trauma, and identify cardinal features of commonly injured organs:

a. Spine radiographs

b. Chest radiographs

c. Kidney-ureter-bladder radiographs

d. Pelvis radiographs

2. Develop a strong foundation in the interpretation of chest radiographs, particularly involving a consistent, systematic, and reproducible approach to their interpretation.

3. Recognize radiologic findings that may be associated with age-related normal variations and degenerative processes.

4. Identify practical adjustments that may be necessary for the radiographic examination of the geriatric patient, considering:

a. Physical and/or behavioral patient conditions that may limit or modify the procedure

b. Stressful rigors of some radiographic examinations

c. Influence of patient anxiety

d. Patient positioning issues which may lead to suboptimal imaging, such as immobilization devices

5. Summarize the components of an acute abdominal series in the evaluation of a potentially acute surgical abdomen. Be prepared to identify typical radiographic abnormalities and their implications, including pneumoperitoneum and calcification.

6. Select the appropriate preoperative studies utilized to diagnose surgical pathology occurring in the following organ systems:

a. Central nervous system

b. Thorax

c. Cardiovascular system

d. Peripheral vascular system

e. Gastrointestinal system

f. Genitourinary system

g. Retroperitoneum

h. Musculoskeletal system

i. Vascular

j. Breast

7. Recognize the potential applications and limitations of the following common imaging modalities utilized to diagnose surgical lesions:

a. Computed axial tomography

b. Ultrasound

c. Magnetic resonance imaging

d. Nuclear Medicine

8. Given a specific clinical condition, identify the most efficacious imaging stratagem to confirm or dismiss the working diagnosis.

9. Formulate a therapeutic plan based on variable imaging outcomes, being cognizant of:

a. Atypical manifestation of common disease

b. Realistic limitations of the radiologic study

c. Discrepancies in clinical and radiographic findings

10. Analyze the applications and limitations of commonly utilized radioisotopic studies, including:

a. Bleeding scans

b. Thyroid and parathyroid imaging

c. Ventilation/perfusion scans

11. Utilize the radiologist as a consultant to:

a. Review studies

b. Recommend the most appropriate or additional studies

c. Provide diagnostic intervention

d. Provide therapeutic intervention

Section Three: Therapeutic Radiology

1. Discuss the use of radioisotopes in the treatment of appropriate conditions, including:

a. Endocrine disorders b. Oncologic disorders

2. Assess the potential utility, limitations, and complications of interventional radiological procedures in various clinical settings.

3. Discuss the technical approaches and limitations of fine-needle and needle-core biopsies of masses performed using radiologic guidance.

4. Summarize the indications, limitations, and risks of interventional procedures for peripheral vascular disease, including angioplasty, stents, and thrombolytic therapy.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

1. Demonstrate a practical knowledge of basic radiographic interpretation

2. Identify appropriate imaging modalities given various clinical situations.

3. Recognize and communicate potential patient-specific conditions, including allergic, which may impact on the safety and efficacy of radiographic evaluation.

4. Obtain appropriate preparatory studies for selected radiographic procedures.

Senior Level:

1. Supervise and/or request pertinent radiographic investigations in diagnostic evaluation.

2. Teach junior-level residents radiologic principles and pitfalls.

3. Identify the utility of adjunct imaging modalities to better define surgical conditions.

4. Recognize interventional radiological procedures that may provide definitive or complementary treatment of surgical conditions.

5. Initiate radiologic consultation on complex cases to avoid potential delay in diagnosis.

The Diagnostic and Therapeutic Radiology unit was revised by Ira N. Adler, MD, and Jeffrey C. Pence, MD, from the Curriculum, third edition.

SELECTED BIBLIOGRAPHY:

Brant W, Helms C. Fundamentals of Diagnostic Radiology. Baltimore: Williams & Wilkins Co., 1998;1-1460.

Daffner RH. Clinical Radiology: The Essentials (2^nd ed). Baltimore: Williams & Wilkins, 1999;1-590.

Grainger R, Allison DJ. Grainger and Allison’s Diagnostic Radiology. New York: Churchill Livingston, Inc., 2001.

Kadell BM, Zimmerman PT, Lu DS. Radiology of the abdomen. In: Zinner MJ, Schwartz SI, Ellis H (eds), Maingot’s Abdominal Operations (10^th ed). Stamford CT: Appleton & Lange 1997;3-116.

Putman CE, Ravin CE. Textbook of Diagnostic Imaging (2^nd ed). Philadelphia: WB Saunders Co., 1994.

Rheinhold RB, Doherty FJ, Mele FM, et al. Selected technologies and general surgery. In: O’Leary JP (ed), The Physiologic Basis of Surgery (2^nd ed). Baltimore: Williams and Wilkins, 1996;618-644.

Silverman FN, Kuhn JP, Caffey J. Caffey’s Pediatric X-ray Diagnosis: An Integrated Imaging Approach (9^th ed). St. Louis: Mosby Year Book, Inc., 1993.

Web reference

http://www.rsna.org

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

Junior Level:

1. Describe general pharmacokinetic principles, including:

a. Absorption c. Metabolism

b. Distribution d. Elimination

2. Describe how aging affects the following pharmacokinetic parameters:

a. Absorption c. Metabolism

b. Distribution d. Elimination

3. Define pharmacodynamics, and explain its place in therapeutics.

4. Identify clinically significant drug interactions, including:

a. Drug-drug interactions b. Drug-nutrient interactions

5. Identify which medications are pharmacodynamically altered in elderly people.

6. Identify adverse reactions to medications from clinical and laboratory observations.

7. Describe the various pharmacological effects of giving medications via different routes of administration, including:

a. Oral e Rectal

b. Parenteral f. Inhalation

c. Topical g. Sublingual

d. Intrathecal

8. Discuss the association between increasing age and the occurrence of adverse medication reactions.

9. Identify five medication classes which are common causes of adverse medication reactions in elderly people.

10. Describe the essential components of an inpatient drug order and an outpatient prescription, including:

a. Date/time d. Schedule

b. Drug name e. Route of administration

c. Strength f. Refills or duration of therapy

11. List three reasons for reduced medication compliance in elderly people.

12. Identify the following medications for which an antidote exists, and describe how the antidote should be administered:

a. Narcotic analgesics d. Digoxin

b. Benzodiazepines e. Warfarin

c. Heparin

13. Relate the key components of a drug and allergy patient history.

14. Explain the pharmacologic profile and clinical use of the following core groups of medications:

a. Analgesics and anesthetics

b. Antibiotics

c. Cancer chemotherapeutic agents

d. Cardiovascular drugs

e. Modulators of the immune response

f. Hormones

g. Modulators of coagulation

h. Modulators of wound healing

i. Neuropsychiatric medications

j. Gastrointestinal drugs

k. Anti-inflammatory medications

l. Respiratory agents

m. Skeletal muscle relaxants

n. Blood derivatives

15. Analyze the methods for effective medication monitoring.

16. Become familiar with and utilize a variety of terms with older patients that may be used synonymously with pain, such as:

a. Burning d. Soreness

b. Discomfort e. Heaviness

c. Aching f. Tightness

17. Discuss the potential side effects associated with the medication groups listed in #14 above, and identify treatment choices for these complications.

18. Identify indications for use of the following classes of medications in emergency or critical care:

a. Inotropes e. Antihypertensives

b. Pressors f. Volume expanders

c. Diuretics g. Neuromuscular blocking agents

d. Antiarrhythmics h. Analgesics

19. Explain the principles of perioperative drug use, including antimicrobial agents.

20. Summarize the management of pain through the use of appropriate pharmacologic analgesia.

21. Summarize the prophylactic and therapeutic use of anticoagulants in the surgical patient.

Senior Level:

1. Formulate pharmacotherapeutic-dosing strategies in patients with altered pharmacokinetics such as:

a. Hepatic dysfunction d. Ascites

b. Kidney dysfunction e. Short bowel

c. Cardiovascular dysfunction f. Advanced age

2. Utilize serum concentration monitoring to modify dosage regimens of medications with narrow therapeutic indices such as:

a. Aminoglycosides

b. Theophylline

c. Vancomycin

d. Phenytoin

e. Digoxin

f. Cyclosporine

3. Design, evaluate, and modify pharmacotherapeutic strategies to treat patients in complex clinical situations, including:

a. Multiple diseases c. Intensive care setting

b. Multiple medications d. Polypharmacy in the elderly

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

1. Take and record an appropriate drug and allergy history.

2. Write appropriate inpatient medication orders and outpatient prescriptions, under supervision.

3. Monitor the pharmacologic preparation of a patient for surgery.

4. Monitor the pharmacotherapeutic effects of medications.

5. Prescribe medications for patients without altered pharmacokinetic parameters.

6. Prescribe medications such as inotropes, pressors, diuretics, antiarrhythmics, and antihypertensives in emergency and critical care situations.

7. Prescribe medications pre- and post- operatively to prevent surgical complications, including infection, thromboembolic events, and stress related occurrences.

8. Prescribe and monitor appropriate analgesic therapy based on an assessment of a patient's pain.

9. Prescribe appropriate antimicrobial therapy for given surgical infections, and monitor the effectiveness of such therapy.

10. Appropriately prescribe and monitor the effects of anticoagulant therapy in surgical patients with thromboembolic disease.

11. Apply microbiology and antimicrobial knowledge in selecting appropriate therapeutic or empiric antibiotic coverage for a suspected infection.

Senior Level:

1. Manage patients in complex clinical pharmacotherapeutic situations.

2. Monitor and adjust the dose of medications (described as groupings in #14 of the first section) for patients with altered pharmacokinetics.

3. Monitor and alter the dose of selected medications based on serum concentrations.

4. Appropriately prescribe the following medications in the geriatric patient:

a. Antihypertensives d. Anticoagulants

b. Digoxin e. Analgesics

c. Benzodiazepines f. Antimicrobials

5. Monitor and alter the dose of medications listed above in the elderly patient.

The Pharmacotherapeutics unit was revised by James P. Worden, Jr., PharmD, from the Curriculum, third edition.

SELECTED BIBLIOGRAPHY:

Abrams WB, Beers MH, Berkow R (eds). Clinical pharmacology. The Merck Manual of Geriatrics (2^nd ed). Whitehouse Station, NJ: Merck Research Laboratories, Merck & Co., Inc., 1995;255-275.

AGS (American Geriatrics Society) Panel on Chronic Pain in Older Persons. The management of chronic pain in older persons. J Am Geriatr Soc 1998;46(5):635-651.

Backes WL, Moerschabaecher JM, Principles of pharmacology. In: O’Leary JP (ed), The Physiologic Basis of Surgery (2^nd ed). Baltimore: Williams and Wilkins, 1996;228-246.

Chernow B, Brater DC. The Pharmacologic Approach to the Critically Ill Patient (3^rd ed). Baltimore: Williams & Wilkins, 1994.

Cobbs EL, Duthie EH, Jr, Murphy JB (eds), Pharmacology and appropriate prescribing. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine (4th ed). Dubuque IA: Kendall/Hunt Publishing Company, 1999.

Dalen JE, Hirsch J (eds). Third ACCP consensus conference on antithrombotic therapy. Chest 1995;108:2255-5225.

De Piro JT, Talbert RL, Hayes PE, et al (eds). Pharmacotherapy: A Pathophysiologic Approach (3^rd ed). New York: Elsevier Science Publishing Co., 1997.

Evans R, Ireland G, Morley J, Sheahan S. Pharmacology and aging. In: Sanders AB (ed), Emergency Care of the Elder Person. St. Louis: Beverly Cracom Publications, 1996;29-41.

Hammerlein A, Derendorf H, Lowenthal DT. Pharmacodynamic changes in the elderly: clinical implications. Clin Pharmacokinetics 1998;35:49-64.

Hanlon JT, Schmader KE, Ruby CM, et al. Suboptimal prescribing in older patients and outpatients. J Am Geriatr Soc 2001;49:200-209.

Lamy P, Wiser TH. Pharmacotherapeutic considerations in the elderly surgical patient. In: Katlic MR (ed), Geriatric Surgery: Comprehensive Care of the Elderly Patient. Baltimore: Urban & Schwarzenberg, 1990;209-239.

Prisant LM, Moser M. Hypertension in the elderly: can we improve results of therapy? Arch Int Med 2000;160:283-289.

Rosenthal RA, Andersen DK. Physiologic considerations in the elderly surgical patient. In: Miller TA (ed). Modern Surgical Care: Physiologic Foundations and Clinical Applications (2^nd ed). St. Louis: Quality Medical Publishing, Inc., 1998;1362-1384.

Shrimp LA. Safety issues in the pharmacologic management of chronic pain in the elderly. Pharmacotherapy 1998;18:1313-1322.

Worden JP, Jr. Geriatric pharmacotherapy. Curr Surg 1996;53(9):522-526.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

1. Discuss the rationale governing the use of local, regional, and general anesthesia, including the following concepts:

a. Careful cardiovascular, respiratory, and neurologic monitoring is the mainstay of safe anesthesia

b. No specific anesthetic is inherently safer than any other; and as such, risk assessment must be considered in each case

c. Regional anesthesia may provide some advantages, including:

(1) Decreased blood loss

(2) Improved perioperative graft patency in vascular reconstruction

(3) Reduced incidence of venous thrombosis

d. Combined regional and general techniques may improve outcomes in selected patient populations:

(1) Significant cardiovascular disease and major abdominal or thoracic surgery

(2) Severe pulmonary disease and major abdominal or thoracic surgery

e. Preemptive analgesia, such as the use of epidural anesthesia, enhances perioperative comfort

2. Summarize the essential elements of the pre-anesthesia assessment, including:

a. Targeted history and physical examination (review of systems, emphasizing cardiovascular and pulmonary disease)

(1) Effects of chronic medications (anticoagulants, insulin, and antiarrhythmics)

(2) Effects of preoperative medications (narcotics, anxiolytics, and atropine)

(3) Effects of postoperative medications (including antihypertensives and antiemetics)

b. Anatomic and physiologic variables germane to anesthetic success:

(1) Airway anatomy, including the Mallampati classification.

(a). Class 1: Visualization of all oro- and hypo- pharyngeal structures

(b). Class 2: Anterior and posterior tonsillar pillars are obscured by tongue

(c). Class 3: Soft palate and base of uvula are visible

(d). Class 4: Only the soft palate is visualized

(e). Increasing Mallampati score is associated with the reduced likelihood of successful direct laryngoscopic intubation.

(2) Skeletal deformities

(3) Neuromuscular diseases

(4) Aspiration risk (pregnancy, scleroderma, hiatal hernia)

c. Assigned Anesthesia Society of America class and physical status:

(1) Class 1: No organic disease

(2) Class 2: Mild to moderate systemic disease

(3) Class 3: Severe systemic disorders

(4) Class 4: Severe systemic disturbance; life threatening

(5) Class 5: Patient is moribund with little chance of survival

(6) Class E: Patient requires an emergency procedure

3. Outline the major characteristics of the pharmacokinetics and pharmacodynamics of anesthetic agents (local, volatile, opioid), considering:

a. Lipid solubility

b. Protein binding

c. Partition coefficients

4. Summarize the use and monitoring of drugs for sedation and analgesia to include:

a. Minimum anesthetic monitoring (pulse oximetry, electrocardiogram, blood pressure)

b. Advantages of scheduled postoperative analgesia versus intermittent dosing

c. Indications for patient-controlled anesthesia (PCA)

d. Importance of periodic assessment to determine:

(1) Level of consciousness

(2) Pulmonary status in sedated patients

5. Summarize the principles of administration for and compare the effectiveness of the following methods of anesthesia:

a. General c. Regional

b. Spinal d. Local

6. Describe the potential benefits of regional and local anesthesia, including:

a. Decreased respiratory depression

b. Diminished systemic effects (liver and renal toxicity)

c. Decreased direct cardiac depression

7. Outline the potential complications associated with the use of regional anesthesia, including:

a. Spinal anesthetics (headache, cerebrospinal fluid leak, meningitis)

b. Regional nerve blocks (perineural hematomas)

8. Discuss the indications for the use of muscle relaxants.

9. Analyze anesthetic monitoring techniques, to include:

a. Swan-Ganz catheters

b. Arterial lines

c. Transvenous pacemakers

d. End-tidal carbon dioxide monitoring

e. Temperature monitoring

f. Transesophageal echocardiography

10. Describe the techniques and potential complications of managing an airway, including endotracheal and nasotracheal intubation.

11. Describe and explain the most common immediate postoperative anesthetic issues:

a. Airway stability

b. Ventilation and oxygenation

c. Pain control

d. Nausea and vomiting

e. Temperature regulation

f. Hemodynamic stability

12. Analyze therapeutic options for patients with chronic pain.

13. Recognize the condition of malignant hypothermia and its management:

a. Incidence in general population (1:10,000)

b. Autosomal inheritance with variable penetrance

c. Pathophysiology of defective sarcoplasmic reticulum and secondary diminished reuptake of myoplasmic calcium leading to increased aerobic metabolism of skeletal muscle

d. Inducing medications, including inhaled anesthetics and succinylcholine

e. Hallmarks of hypermetabolism, skeletal muscle rigidity, and increased temperature

f. Therapy includes the discontinuance of anesthetic agents, dantrolene administration, and fluid resuscitation with proper physiologic monitoring.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior Level:

1. Manage the airway in adults and children, employing appropriate:

a. Physical maneuvers

b. Oral/nasal support devices

c. Suctioning techniques to maintain clear airway

2. Perform nasal and oral intubation.

3. Recognize the stages of general anesthesia and their implications, particularly in regard to airway management.

4. Recognize and treat the signs and symptoms of complications due to anesthetic agents such as:

a. Cardiovascular collapse c. Malignant hyperthermia

b. Acute metabolic disturbances

5. Perform preoperative assessment of patients.

6. Recognize risks and possible side effects of drugs used for pain control.

Senior Level:

1. Monitor patients under anesthesia, including the use of peripheral and pulmonary artery catheters.

2. Administer pre- and post- anesthesia care.

3. Apply appropriate monitoring devices.

4. Establish vascular access in a child and in an adult.

5. Manage the difficult airway, including the performance of both rigid and fiberoptic bronchoscopy.

6. Establish an emergent airway, utilizing percutaneous or surgical techniques.

The Anesthesiology unit was revised by Joshua Schwartz, MD, and Jeffrey C. Pence, MD, from the Curriculum, third edition.

SELECTED BIBLIOGRAPHY:

Artmann SL, Giezentanner AL, Katz J. Physiology of anesthesia and pain. In: Miller TA (ed). Modern Surgical Care: Physiologic Foundations and Clinical Applications (2^nd ed). St. Louis: Quality Medical Publishing, Inc., 1998;250-273.

Hopkins PM. Malignant hyperthermia: advances in clinical management and diagnosis. B J Anes 2000;85(1):118-128.

Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. B J Anes 1997;78(5):606-617.

McLeskey CH (ed). Geriatric Anesthesiology. Baltimore: Williams & Wilkins, 1997;1-703.

Rutter TW, Tremper KK. Anesthesiology and pain management. In: Greenfield LJ, Mulholland M, Oldham KT, Zelenock GB, Lillemoe KD (eds), Surgery: Scientific Principles and Practice (2nd ed). Philadelphia: Lippincott-Raven, 1997;438-454.

Smith BE. Anesthetic considerations in elderly patients. In: Adkins RB, Jr., Scott HW, Jr. (eds), Surgical Care for the Elderly (2^nd ed). Philadelphia: Lippincott-Raven Publishers, 1998;51-76.

Thomas MA, Riopelle JM. Anesthesia. In: O’Leary JP (ed), The Physiologic Basis of Surgery (2^nd ed). Baltimore: Williams and Wilkins, 1996;602-617.

Wallace A, Layug B, Tateo I, et al. Prophylactic Atenolol reduces postoperative myocardial ischemia. Anesthesiology 1998;88(1):7-17.

Web reference

http://www.asahq.org

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

1. Summarize how the physiology of aging interacts with the effects of anesthesia, with particular attention to:

a. How high sympathetic tone, loss of beta-receptor responsiveness, and volume sensitivity to both hypovolemia and hypervolemia make blood pressure inherently unstable.

b. How increased chest wall stiffness, increased lung compliance, and increased brain sensitivity to sedative/ analgesics increase the likelihood of hypoxia, atelectasis, and pneumonia.

2. Summarize the pharmacokinetic and pharmacodynamic principles underlying the effective use of anesthetic agents, particularly how aging often leads to increased sensitivity and prolonged duration of drug effects.

3. Understand how the anesthesiologist approaches patient evaluation and the optimization of patient condition in preparation for surgery.

4. Recognize those issues important to an elderly patient when faced with the decision to have surgery, and be able to determine when mental impairment does or does not preclude the patient from providing informed consent.

5. Understand how the elderly patients are predisposed to hypothermia and how hypothermia adversely affects the risk of infection and cardiac morbidity.

6. Be familiar with the causes, diagnosis, and management of postoperative delirium.

7. Explain the principles and techniques of preemptive analgesia, including non-steroidal analgesics and peripheral nerve and field blocks.

8. Analyze and compare the hemodynamic effects, benefits, risks, and contraindications for the following advanced techniques of postoperative pain control:

a. Epidural infusions of local anesthetics and/or opioids.

b. Continuous nerve blocks

c. Intrapleural and extrapleural catheters

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

Junior and Senior Levels:

1. Assess the risk surrounding the stress of the proposed surgery relative to the benefit of the surgery, with the perspective of the physiological reserve of the patient, and be able to adjust the scope of the proposed surgery accordingly.

2. Appropriately select medications and adjust dosages for the elderly patient.

3. Recognize postoperative delirium and be able to diagnose and treat reversible causes.

4. Perform common field and nerve blocks for postoperative analgesia.

5. Establish effective dialogue with anesthesia and internal medicine colleagues for the comprehensive care of complicated patients.

The Anesthesia for the Elderly Patient unit was revised by G. Alec Rooke, MD, PhD, from the Curriculum, third edition, by G. Alec Rooke, MD, PhD.

SELECTED BIBLIOGRAPHY:

Del Guercio LRM, Cohn JD. Monitoring operative risk in the elderly. JAMA 1980;243:1350-1355.