Anesthesiology, Perioperative and Pain Medicine

Anesthesia Preoperative Evaluation Clinic


Patient evaluated in PreOp Clinic



The Anesthesia Preoperative Evaluation Clinic provides a unique service for both the resident and the pre-surgical patient. This comprehensive clinic evaluates and determines the optimal medical preparation of the outpatient and inpatient undergoing anesthesia, especially the medically complex patient. All anesthesia residents rotate through this service in 1 week blocks during general operating room rotations. Two faculty members trained in both internal medicine and anesthesia provide an extensive educational experience in preoperative anesthesia assessment.

 

Anesthesia Simulation

From its beginnings, Stanford has been in the forefront of integrating simulation immersion into the education of future anesthesiologists as well as medical students and physicians in other specialties. Stanford was one of the first to build a full scale simulation center (VA Simulation Center), and was the first medical school to appoint an associate dean (an anesthesiologist) for simulation education. Currently the school has 3 simulation centers, one at Stanford Medical Center (Goodman Simulation Center), one at Lucile Packard Children's Hospital (Center for Advanced Pediatric Education), and one at the Palo Alto Veterans Hospital (VA Simulation Center).

The Anesthesia Department is active in developing simulation programs in:

CCM Simulation
Simulation is being used in CCM to increase the safety of central venous catheterization by holding workshops and using 'vascularized' chicken models for realistic training in the use of ultrasound/catheterization equipment. These simulations are expected to significantly increase the confidence of residents in central line placement and reduce complications.


CVC in 'vascularized' chicken model

In addition, the simulation center at the VA has an active full patient scene simulation program directed by Dr. Lighthall (see VA simulator below).

 


Mother/Baby resuscitation simulation
  



OB Simulation

Senior Anesthesia residents will participate in obstetric crisis drills on the Labor and Delivery Ward as part of their training. The drill teams are comprised of labor nurses, obstetricians, and will ultimately involve the pediatric teams. Opportunities exist for residents to participate in courses at the CAPE in a simulated delivery room where code scenarios in a parturiant model are practiced.

 


Simbaby + mobile simulation
  


Neonatal Simulaton

With the help of simulation friends at Stanford/Packard (CISL, Goodman, VA, and CAPE), Dr. Chen has developed the Pediatric Anesthesia in-Situ Simulation Program (PASS).   It is a fully functioning high fidelity simulation center on wheels designed to perform in-situ simulation.  With its primary goals as safety evaluation and education, simulations have been performed in the OR, ASC, and PACU and dozens of latent system errors were identified.  In 2007, this group was asked to put on a workshop at the Society for Pediatric Anesthesia in Phoenix to demonstrate how this technology could be used to improve safety in hospitals that don’t regularly do pediatric anesthesia or own their own simulators.  Support for these projects has come from both hospital and national grants.  Future projects include simulation to evaluate residency and faculty core competencies, fire drills, and evaluation of the new pediatric operating rooms and other locations (MRI, Cath Lab, and ER). 

 

 



Crisis Management in OR Anesthesia

The main patient simulator (one of the first of it's kind in the country) is housed at the VA Palo Alto in a 1600 square foot, state of the art facility that allows for the recreation of plausible clinical situations in a realistic setting. The simulation center can be set up like an operating room, delivery room, intensive care unit or emergency department.


Full scale OR simulator

Anesthesia residents have many opportunities to train with the state of the art patient simulator. Stanford residents take the Anesthesia Crisis Resource Management (ACRM) training course each year of their residency in a three-staged curriculum which differs in didactic content and difficulty. This course was developed at Stanford by David Gaba, Kevin Fish and Steven Howard and has been taught to Stanford residents for over ten years. The faculty has taught ACRM concepts to anesthesiologists around the world further spreading these useful lessons.

Incoming anesthesia residents will spend part of their departmental orientation (one day) at the simulation center prior to being assimilated into the operating room. This course focuses on basic concepts that will help new residents early in their training.


OR scenario with live surgeon/scrub nurse actors.

Residents rotating through the intensive care unit at the VA Palo Alto will have further exposure to simulator training as it pertains to caring for the critically ill patient outside the operating room. The course entitled Improving the Management of Patient Emergency Situations (IMPES) focuses on teamwork, communication and decision-making in the complex world of the ICU.

For more information, please visit the VA Anesthesia Simulation Center webpage.

Pediatric Anesthesia

The Department of Anesthesia of the Lucile Salter Packard Children's Hospital provides care for over 7,500 infants, children, teens and young adults a year, who require anesthesia for a wide variety of surgical and medical procedures including solid organ transplantation, complex cardiac surgery, radiation therapy, and invasive radiological procedures.  The department also provides labor analgesia or surgical anesthesia for about 4,300 deliveries a year in the Johnson Center for Pregnancy and Newborn Services. The Pediatric Pain Management Service treats infants, children, and teens with acute surgical pain, pain from trauma, acute and chronic pain complicating medical diseases, and manages children with drug withdrawal or side effects from drug therapies.
The Packard Children's Hospital Department of Anesthesia is the primary pediatric teaching program for the residents of the Stanford University Department of Anesthesia. The Department also participates in the training of residents in the Department of Pediatrics, the fellows of the Pediatric Intensive Care Unit, and the air transport nurses of Stanford Life Flight.

Further information can be obtained from the Pediatric Anesthesia web site.

Obstetric Anesthesia

Obstetric Anesthesia occupies approximately two months in the Stanford Anesthesia residency, usually during the second and third years. The more than 5000 deliveries annually include a significant proportion of high-risk cases and a 30% cesarean section rate. Extensive experience is obtained in regional anesthesia with approximately 75% of laboring patients and 95% of cesarean section patients receiving regional blocks. Educational activities include a didactic tutorial program given by specialist faculty and an obstetric anesthesia journal club presented by residents and fellows. During one of the obstetric anesthesia rotations residents take Neosym, a simulator course on neonatal resuscitation where they become certified in
NALS (Neonatal Advanced Life Support). Additional obstetrical anesthesia experience is obtained at Santa Clara Valley Medical Center, with over 3500 deliveries per year.

Further information can be obtained from the Obstetric Anesthesia web site.

Cardiovascular Anesthesia

During rotations on the Cardiovascular Anesthesia service at Stanford University Hospital or the Palo Alto Veterans Administration Medical Center, the resident learns basic anesthesia for cardiac and vascular surgery as well as invasive (PA catheterization, TEE) and non-invasive cardiovascular monitoring techniques. Residents are also exposed to anesthesia for heart and heart-lung transplantation, complex reoperations, AAA stent graft, complex thoracoabdominal aortic surgery, CPB with circulatory arrest, beating-heart CABG and arryhthmia surgery.

Transesophageal Echocardiography Rotation (TEE)

Senior residents interested in cardiac anesthesia and cardiac disease enjoy our Transesophageal Echocardiography rotation for several reasons. They are taught echocardiography by board-certified cardiologists in the Stanford University Echo Laboratory. Individualized instruction using teaching videotapes as well as actual intraoperative tape recordings optimize the understanding of this exciting form of real-time monitoring of cardiac function. Two TEE machines are dedicated for fulltime use in the operating rooms for both interesting cardiac as well as noncardiac operations. Residents on this rotation split their time between using the TEE device in patients in the operating rooms with review in the Echo Lab and echo studies performed on other patients in the hospital.

Stanford University Pain Service

The Stanford University Pain Service sees about 350 patient referrals per month in a multidisciplinary pain clinic which evaluates and treats chronic pain in outpatients. An inpatient Chronic Pain Service is also active and integrates with the Acute Pain Service which consults on hospitalized post surgical patients requiring pain management. Techniques taught include diagnostic and therapeutic nerve blocks, selective spinal analgesia, patient controlled analgesia and other novel analgesic techniques. Residents are given an opportunity for 1 month rotations on each pain service.

For more information link to the Pain Service web site.

Critical Care Medicine

Critical Care Medicine is an important part of anesthesia residency training and takes place in the 48 bed adult intensive care units at Stanford University Hospital and the 14 bed adult unit at the Palo Alto Veteran's Administration Medical Center. A multi- disciplinary team of residents from the departments of anesthesia, medicine and surgery manage a diverse population of both medical and surgical patients. Residents become the primary physicians for these critically ill patients and are responsible for all aspects of patient care under faculty supervision. All residents receive at least 2 months of Critical Care Medicine training.

For more information see the Critcal Care Medicine website.

 

ENT / Difficult Airway Rotation

The ENT rotation gives residents significiant exposure to both simple and complex operations involving the airway. ENT anesthesia division currently includes four designated ENT anesthesiologists. A wide range of surgical ENT cases comprises major head and neck cancer surgery, laryngeal surgery including voice restoration, craniofacial plastic surgery, surgery for obstructive sleep apnea, functional endoscopic sinus surgery, major ear surgery, and combined neuro-/ENT cases for complex skull base surgery.
The ENT/Difficult airway rotation includes a carefully compiled structured
curriculum, addressing a wide variety of the airway management techniques,
and anesthetic techniques utilizing continuous infusions of different types
of opioids and total intravenous anesthesia. Airway Workshops are organized every year for junior and senior residents to enhance airway management educaiton.

Anesthesia for Thoracic Surgery




Anesthesia for Thoracic Surgery is a valuable rotation to introduce residents to managing patients with significiant pulmonary pathology and limited pulmonary reserve. During this rotation residents are also taught proper use of various endobronchial tubes and single or independent lung ventilation techniques.

Neuroanesthesia

Residency training in Neuroanesthesia at Stanford includes two rotations at Stanford Hospital / Packard Children's Hospital. Neuroanesthesia I emphasizes anesthesia for intracranial procedures, while in Neuroanesthesia II the emphasis is on anesthesia for spinal surgery, interventional radiology, and movement disorders. In addition, residents rotating through our affiliated hospitals will have further opportunities to participate in the anesthetic care of neurosurgical patients at those facilities.

Neurosurgery at Stanford is a very active and research oriented surgical service affording residents in Neuroanesthesia a unique opportunity to gain experience with a wide variety of surgical procedures and anesthetic techniques. These include hypothermic and pharmacologic brain protection, awake craniotomies, complex cerebrovascular procedures, interventional neuroradiology and electrophysiologic monitoring.

Faculty research interests include many aspects of neuroprotection, intraoperative monitoring, mechanisms of anesthetic action, pharmacokinetics, pain management and spinal cord function.

Both clinical and research fellowship positions are available.

Stanford faculty with specific interest in Neuroanesthesia include:

Regional Anesthesia

The one-month Regional Anesthesia rotation provides residents with intensive exposure to a variety of regional anesthetic techniques, with an emphasis on ambulatory surgical procedures. In addition to neuraxial anesthetics, residents will gain proficiency in many peripheral nerve block techniques, such as brachial plexus, interscalene, ankle, and popliteal blocks. Residents are supervised and instructed by faculty members with particular expertise in regional anesthesia.
In addition to this rotation, the department sponsors a yearly Regional Anesthesia Workshop, using cadaver dissection, live and inanimate models, etc to teach regional anesthesia techniques in an optimal educational environment.

Post Anesthesia Care Unit

The Post Anesthesia Care Unit (PACU) is a one month rotation available to residents who have completed six months of their anesthesia training. Residents will spend the majority of their time involved in direct patient care in the Stanford University Hospital Main OR PACU. Responsibilities include the evaluation and management of common postoperative concerns such as airway obstruction, hemodynamic instability, nausea and vomiting and pain control using a variety of techniques including epidural catheters and intravenous analgesics. In addition to the focused PACU experience, residents gain additional experience in postoperative pain management through involvement with the Stanford Acute Pain Service. Residents follow patients cared for by the Pain Service after they leave the PACU. This provides the opportunity to manage patients' ongoing postoperative pain using lumbar and thoracic epidurals, intravenous opiates, as well as other regional analgesic techniques. Dr. Cliff Schmiesing and the Pain Service Faculty provide supervision and teaching through bedside rounds, lectures, and case conferences. A comprehensive syllabus is provided.

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