Clinical Rotations

Preoperative Care

Anesthesia residents at UC Irvine Medical Center spend a one-month block during their CA-1 year working in the preoperative clinic under the supervision of an attending. The objective of this rotation is to become familiar with all aspects of pre-surgical management of common patient problems.

Residents will work in conjunction with the Center for Perioperative Care team, which consists of a full-time faculty member, a CRNA, and support staff. The clinic is open from 7am to 5pm on weekdays, and the rotating resident will see patients in clinic, perform telephone interviews, and act as a consultant to surgical services.

The specific objectives of this rotation are that the resident will:

• Build a solid working knowledge of pre-procedure management and risk stratification
• Be able to consult patients regarding their anesthetic options and the various risks and benefits of each
• Perform problem-based, focused pre-surgical laboratory and other testing and determine when such testing is warranted
• Be able to consult with surgeons and other medical staff regarding the management and optimization of their patients

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Cardiovascular Anesthesia

We perform a wide spectrum of adult cardiac surgical procedures at UC Irvine Medical Center, including coronary artery bypass procedures on and off cardiopulmonary bypass, valve repairs and replacement, open and endovascular repairs of aortic dissections and aneurysms and congenital cardiac defect repairs. As a tertiary care center, our patients are usually complicated and high risk compared to the local community hospitals.

All of our cardiac anesthesia operating rooms are state-of-the-art. Transesophageal echocardiography is routinely utilized for cardiac surgical procedures and as of June, 2008 we have 3D TEE capabilities.

Residents are trained in evaluating a patient with heart disease, cardiovascular physiology, placing and interpreting invasive monitors (PA catheters), TEE, cardiopulmonary bypass, circulatory arrest and ventricular assist devices.

In addition to the procedures performed in the main ORs, we also provide anesthesia services for procedures performed in the cardiac cath lab, neonatal intensive care units and electrophysiologic interventions. Senior residents can rotate at Cedars-Sinai Medical Center on a month-long customized cardiac rotation.

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Obstetric Anesthesia

The division of Obstetric Anesthesia at the UC Irvine Medical Center is a core component of residency training and anesthesia care.

The Labor and Delivery suites at UC Irvine Medical Center have an average of 120 deliveries per month. Additionally, there are two dedicated operating rooms for OB cases. Although the number of total deliveries is modest, there are large numbers of high risk obstetric patients because of our Newborn Intensive Care Unit (NICU). The 30-bed NICU at UC Irvine is one of only two Level III Newborn Intensive Care Units in Orange County and the team has vast experience in taking care of sick newborns. Partly for that reason, UC Irvine Medical center takes many referrals of high risk parturients from other community hospitals. We routinely manage high risk conditions such as prematurity, pre-eclampsia/eclampsia, labile diabetes mellitus, placenta accreta, and both maternal and fetal cardiac problems.

The anesthesia department provides 24 hour coverage for labor analgesia, cesarean sections, and post-partum procedures. The rate of epidural analgesia for labor and vaginal delivery was 77 % in 2007, ninety-five percent of which was performed under epidural or spinal anesthesia. Since UC Irvine Medical Center has high number of sick mothers, it is sometimes necessary to place invasive monitors and perform extensive volume resuscitation.

Each anesthesiology resident spends one month on OB anesthesia rotation in the CA-1 year and acquires basic knowledge of OB and neuraxial anesthesia, specifically epidural anesthesia, and spinal anesthesia. He or she will be closely supervised by attending staff and receive hand-on teaching. Each resident then spends another month at the Cedar-Sinai Hospital during the CA-2 year to refine techniques. Finally, in the CA-3 year, there is an option of a 3 month rotation at Long Beach Memorial Medical Center for additional OB anesthesia experience for residents interested in an OB emphasis.

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Pediatric Anesthesia

Anesthesia for neonates, infants, and children requires an understanding of the manner in which pediatric patients differ, anatomically, psychologically, physiologically and pharmacologically, from adults, and how these differences affect the anesthesiologist’s ability to maintain homeostasis and provide necessary operative conditions during surgery and the post-anesthetic recovery period.

The pediatric anesthesia experience at the University of California, Irvine (UC Irvine ) will be comprised of an initial one month rotation at UC Irvine Medical Center (UC Irvine MC) in the CA 1 year, followed by a two month rotation at Childrens Hospital Los Angeles (CHLA) in the CA 2 year, as well as numerous opportunities to care for pediatric patients undergoing outpatient and inpatient diagnostic and surgical procedures during general OR rotations from the onset of residency training, initially paired one-on-one with a pediatric anesthesiologist. The CA 1 resident will also participate in a difficult airway workshop which includes a station devoted to the pediatric airway during the winter of the CA 1 year.

The CA 1 resident is expected to attain a basic understanding of the physiology and pathophysiology of infants and children. He/she shall demonstrate the ability to apply this knowledge in various clinical settings. The CA 2 resident will continue to build on knowledge and experience.

CA 3 Residents may elect one to five additional months at Childrens Hospital Los Angeles (CHLA). CA-3 Residents may also elect a one month rotation in the Pediatric Intensive Care Unit (PICU) at CHLA or Children’s Hospital of Orange County (CHOC), or UC Irvine Medical Center (UC Irvine MC). In addition, CA 2-3 residents, after the initial 2 month rotation at CHLA, will be assigned to high risk neonatal and pediatric patients at UC Irvine MC. Because UC Irvine MC is a high-risk obstetrical and neonatal referral center, senior residents in anesthesia have the opportunity to care for premature babies with routine as well as unusual problems. Cases include PDA ligation, laparotomy for necrotizing enterocolitis, and bowel atresias, repairs of esophageal atresia/tracheoesophageal fistula, abdominal wall defects, examination and repair of airway anomalies, repair of urological anomalies and EXIT procedures.

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Neuroanesthesia

Neuroanesthesia encompasses experiences in neurosurgical and neuro-radiological interventions in radiology suites. The neurosurgical anesthesia service has expanded over the last couple of years and provides an opportunity to gain experience in anesthetic management of complex intra- and extra-cranial neurosurgical procedures. As the first intra-op MRI center in Orange County, UC Irvine offers an opportunity for residents to learn about the challenges presented by anesthesia with this technique.

Three full time neurosurgeons operate four to five days each week. They cover a broad range of neurosurgical procedures including stereo-tactic surgery, intracranial masses, cerebrovascular diseases, pituitary techniques, spine, movement disorders, and epilepsy. Additionally, UC Irvine places implants in patients suffering from movement disorders that offer residents very valuable experience in the asleep, awake, asleep pattern of anesthesia.

Our residents also interact with neurologists & electrophysiology technicians during intra-operative monitoring of somatosensory & motor evoked potentials, EEG, electromyography, & brain stem auditory evoked potentials. Various intraoperative monitoring allows the residents to learn about managing patients with total IV techniques &/or avoiding muscle relaxants.

Residents are assigned Neuroanesthesia rotation for one month at a time and work with seven faculty from the department who manage neurosurgical cases. We continue to make changes as the need arises to offer the best education & experience in Neuroanesthesia.

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Regional Anesthesia

The regional anesthesia rotation is a one-month rotation for all CA-1 residents and may also be taken as an elective during the CA-3 year. Residents will focus on the use of regional techniques (including both neuraxial and peripheral blocks) as both primary anesthetic methodologies and as an approach to post-operative pain management.

All of the most common and useful regional blocks will be covered, including the interscalene and axillary approaches to the brachial plexus, sciatic blocks, popliteal blocks, femoral blocks, and many of the adjunctive blocks like the musculocutaneous nerve and saphenous nerve blocks. Traditional nerve-stimulator technique is utilized along with anatomic landmarks, but residents will perform most blocks using ultrasound guidance and direct visualization of the nerve.

The rotation is designed so that the regional resident will get maximum exposure to available block cases and many days the resident will be part of a "floating" block team, helping to place blocks in pre-op holding in advance of other teams taking over for the surgical portion of the case.

Below are several ultrasound images obtained during regional blocks performed at our outpatient surgery suite.

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Veterans Affairs Hospital and Ambulatory

The Veterans Affairs Long Beach Health Care System (VALBHCS is a major affiliate hospital for the University of California at Irvine. UC Irvine Anesthesiology residents have rotations at the VALBHCS in the main operating room, surgical intensive care unit, and anesthesia pain clinic. Residents have also spent time at the VALBHCS during their clinical research elective. Starting July 2008, a clinical base year for UC Irvine anesthesiology residents will be available at the VALBHCS.

The VALBHCS O.R. rotation is a one month rotation, much of which involves the care of geriatric patients. Long Beach VAMC provides anesthesia care for more than 4000 operations a year; the average patient is age 64 and the most common ASA physical status is 3. Common co-morbidities in our patient population include hypertension, diabetes, coronary artery disease, COPD, obesity and renal insufficiency. The most common major operations are vascular, orthopedic, and urologic. One of our operating rooms is equipped with built-in fluoroscopic capability for more sophisticated procedures. With two inpatient spinal cord injury wards, the LBHCS is one of the largest spinal cord injury centers on the west coast.

Anesthesia residents on rotation have opportunities to provide anesthesia for patients undergoing major operations including abdominal, major vascular and thoracic operations. Anesthesia residents commonly insert peripheral artery catheters, central venous catheters, apply lung isolation techniques (link to “Dr. Wong Thoracic set-up” document), intubate patients with difficult or potentially difficult airways (link to “fiberoptic intubation prep” document), and perform regional anesthesia for upper and lower extremity surgery during their rotation. Residents are encouraged to express their preference for the types of operations or procedures that would like to be assigned to with the anesthesia clinical coordinator of the day, who makes out the next day’s anesthesia assignments.

A typical resident day on the Long Beach O.R. rotation begins by setting up their O.R. room, having a morning report session at 0700 where they present their most interesting case that day and listen to consults of complicated patients or index cases that are presented for discussion. A short “topic of the day” related to one of the cases or consults is presented by a faculty for resident education. Morning report ends by 0720 at which time the patients are brought into the O.R. After they are relieved from the O.R. the anesthesiology residents check the cases that they are assigned to for the next day, viewing their pre-ops and other patient information in the VA computer system.

Each faculty person is assigned a didactic topic which they will discuss, with literature reference, at some time with each resident during the rotation. The list of daily topics includes:

• Evaluation of the Geriatric Patient
• Post-op cognitive dysfunction in the elderly
• Cardiac function in the aged patient
• Respiratory Effects of Aging; Smoking and PFTs
• Aging and Renal function
• Drug Tachyphylaxis and Drug Hypersensitivity in the Elderly
• Patient positioning in the Aged patient
• Palliative and End-of Life Issues in the Aged patient
• Effects of Aging on the Pharmacology of Anesthetic Agent
s
• Anesthesia for Elderly patients with Spinal cord Injury
• Regional anesthesia dose adjustments in elderly patients
• Post-op pain management in elderly patients

The VALBHCS Anesthesiology Service is very involved with the total perioperative care of the patient, beginning with the initial pre-operative work-up of index cases to the day of anesthesia and surgery and their post-operative care. From presenting their case at morning report, then providing anesthesia, then transferring their patient to the SICU or the Surgical Step-Down unit where the SICU team, led by an Anesthesiologist-Intensivist, listens to the anesthesiology resident’s transfer of care report, anesthesiology residents have the opportunity to be involved with their patient’s perioperative care from start to finish. Residents are expected see their patients on post-op day one and write their own post-op note and encouraged to follow-up on their patients while they remain in the SICU or Step-Down areas.

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Critical Care Medicine

UC Irvine has a combined ICU at the Long Beach VA Healthcare System where our residents spend one month of their critical care rotation. This is a 16 bed open ICU where medical, cardiac, & surgical patients are managed. There are five Anesthesiologists-Intensivists who staff the unit. We are responsible for only surgical patients while medical & cardiac patients are staffed by pulmonologists & cardiologists respectively. We also staff a 9 bed open Direct Observation Unit (DOU). DOU has medical & surgical patients & we staff only surgical patients.

At present, we have anesthesia residents and surgical interns from UC Irvine who rotate through SICU/DOU. We also have 2 to 4 medical students rotating with us from UC Irvine . We utilize services of nocturnists (Fellows from various medical specialties) for evening, nights & weekend calls. We receive patients from multiple surgical services excluding neurosurgery & open cardiac operations. Our average daily census between SICU & DOU is 8 to 10 patients.

The unit is staffed by respiratory therapists with arterial blood gas laboratory, dietitians, & pharmacists based in the unit for immediate consultation. We have state of the art monitoring capabilities including continuous cardiac output, cerebral oximeter, and Bispectral Index (Processed EEG). Our staff is has dedicated teachers & our residents receive regular didactic teaching along with teaching during rounds.

The ICU rotation offers significant clinical experience & great teaching about common critical care issues. It also offers a great opportunity to coordinate patient care with the surgical colleagues on a daily basis.

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