Clinical Sections

Perioperative and Adult Anesthesia

Thoracic & Peripheral Vascular Anesthesia

A rotation on the Thoracic and Peripheral Vascular (TPV) service enables residents to gain experience in the anesthetic management of high-risk patients undergoing a wide variety of surgical procedures.

Thoracic surgical procedures provide invaluable learning opportunities in the placement of double lumen tubes to provide lung isolation and surgical exposure. The physiology and management of one-lung anesthesia and proficiency in pain management for the post-thoracotomy patient are all part of the routine perioperative management of this high-risk patient population. Fiberoptic bronchoscopy is available whenever a double lumen tube is placed, providing the necessary experience and familiarity with this useful tool to assist in airway management.

Patients with peripheral vascular disease manifest varying degrees of disease severity, ranging from discrete lesions of the carotid artery to diffuse atherosclerotic involvement of their entire abdominal aorta. Therefore, the patient undergoing vascular surgery presents the anesthesia resident with a host of diagnostic and therapeutic challenges. Preoperative assessment and risk stratification are an integral aspect of this rotation. The experience with perioperative management of carotid occlusive disease typifies the amount of involvement expected by a resident while on this rotation. The resident completes a preoperative assessment, constructs an anesthetic plan, then places necessary monitors prior to performing a regional block for the carotid endarterectomy. A regional anesthetic is planned; however, the resident must be prepared to augment cerebral perfusion pressure and prepare for a general anesthetic should cerebral perfusion be deemed inadequate. Knowledge of intraoperative EEG monitoring and strategies for cerebral protection are similarly necessary.

Utilization of regional anesthetic techniques plays an integral role in this rotation, as patient population and location and nature of the surgery are well suited when these techniques are utilized. The resident will receive in-depth instruction regarding the pro's and con's of deep and superficial cervical plexus blockade for carotid endarterectomy; lumbar and thoracic epidural placement for peripheral vascular and thoracic surgery; interscalene and axillary approaches for upper extremity vascular access surgery; and ankle and femoral-sciatic blocks or spinal anesthetics for procedures on the distal lower extremity.