Cardiac Anesthesia: Saudi Board Anesthesia Curriculum

CARDIAC ANESTHESIA
Duration: Three months during senior residency
The Cardiac Anesthesia rotation is designed to give residents an appreciation of the issues
involved in the management of anesthesia for cardiac surgery sufficient to participate in the
perioperative care of these patients.
The resident is expected to become competent in the management of patients with

cardiovascular diseases perioperatively during this rotation. It is not intended to produce
anesthesiologists capable of independently managing anesthesia for cardiac surgery.
Objectives:
1. Medical Expert/Clinical Decision Maker
The resident will demonstrate knowledge of the basic sciences as applied to the
preoperative, intraoperative, and postoperative periods of cardiac surgery.
A. Physiology and Anatomy
The resident is expected:
a) To describe the normal coronary anatomy and variants, normal cardiac

physiology, and the effects of disease states on the normal physiology.
b) To describe the anatomy and physiology of cardiac valves, left ventricle, right
ventricle, atrial, major cardiac vessels, and circulatory system in both normal and
diseased states.
c) To describe the normal conduction pathways of the heart and its clinical
significance in disease.
d) To describe the embryologic circulation, development of the heart, and fetal

physiology as it applies to adult congenital heart disease.
e) To describe the altered respiratory physiology of the immediately postoperative

ventilated patient with significant surgical incisions and pain (sternotomy, large
abdominal incision).
f) Describe common physiological changes occurring in the postoperative period

and the impact these have on end organ function (neurologic, renal, cardiac,
hepatic, gastro-intestinal).
48 SAUDI BOARD ANESTHESIA CURRICULUM

B. Pharmacology
The resident should know:
a) Commonly prescribed medications for cardiac surgical patients, the implications

for disease, and the impact on anesthetic management.
b) Commonly used cardiac anesthetics and dosages.
c) Heparin, antiplatelet agents, and anesthetic implications.
d) Protamine for heparin reversal, along with side effects and complications.
e) Antifibrinolytic agents, mechanisms of action, and indications.
f) The use of blood products (PRBC, FFP, platelets, cryoprecipitate) and blood
alternatives (albumin, starch) as well as transfusion reactions and complications.
g) Coagulation drugs (DDAVP, activated factor 7a), their indications,

contraindications, dosages, and complications.
h) Commonly used vasodilators, vasoconstrictors, inotropic agents, and their

indications, dosages, and side effects.
i) The appropriate use of pain medications, non-steroidal anti-inflammatory drugs

and regional anesthetic techniques in cardiac surgical patients.
j) Pharmacology of perioperative risk reduction strategies (lipid lowering agents, β-

blockers, aspirin).
C. Monitoring
a) To interpret ECG for ischemia, infarction, arrhythmias, and paced rhythms, and to
recognize the limitations and the sensitivity/specificity of ECG as an ischemia
monitoring tool.
b) To demonstrate the principles of noninvasive and invasive blood pressure

monitoring and its pitfalls.
c) To acquire skills of arterial and central venous cannulation (with ultrasound),

peripheral venous cannulation, and pulmonary artery catheterization.
d) To interpret CVP and data from PA catheter (PAP, PCWP, Cardiac output) and
know it indications, complications, and management.
e) To understand the basics of introductory TEE, including techniques of probe

insertion and several basic views, and its implication and application to the
critically ill patient.
f) To understand laboratory monitoring of the coagulation system (PTT, INR,

fibrinogen) as applied to the cardiac patient.
g) To assess the adequacy of mechanical ventilation using clinical parameters and

laboratory arterial blood gas analysis.
h) To recognize the parameters used to assess intraoperative blood loss and options
to treat blood loss including medical and surgical alternatives.
i) To know the significance of temperature management in the intraoperative

period, including hypothermic techniques and the importance of normothermia
during beating heart procedures.
j) To understand the indicators of volume status, especially when weaning from

bypass, and including the findings from invasive monitors, TEE, and clinical
indicators (urine volume).
i) To use appropriate intraoperative blood work for the management of patient

care, and be aware of new monitoring devices (noninvasive CO, BIS) and their
potential applications during cardiac surgery.
D. Clinical Assessment & Management
a) To complete a detailed history, physical exam, order appropriate laboratory and

ancillary investigations, and provide a management plan for a cardiac surgical
patient.
b) To know current indications and recommendations for SBE prophylaxis.

c) To manage medical bleeding.
d) To correct common derangements in metabolic and electrolyte disturbances in

the intraoperative period.

e) To know the basic principles of cardiac support devices including IABP and
extracorporeal membrane oxygenation.
f) To know the common pathophysiology and management of patients with

complications of:
 Coronary artery disease, acute myocardial ischemia and infarction,
complications of myocardial infarction and thrombolytic therapy
 Valvular heart disease and valve replacement or repair
 Aortic dissection, thoracic and thoracoabdominal aortic aneurysm
 Shock and the use of volume resuscitation, venodilators/constrictors,
inotropes, and lusitropes
 Emergencies requiring ACLS
 Cardiac tamponade, constrictive pericarditis
 Dilated, restrictive and obstructive cardiomyopathy, CHF, and diastolic
dysfunction
 Aberrant conduction, dysrhythmia, sudden acute and subacute ventricular
and supra-ventricular arrhythmia
 Pacemakers and the indications for and applications of the various modes
of temporary pacing
 Pneumohemothorax
 Pulmonary edema, pneumonia, CHF
 COPD, asthma, sleep apnea in the ventilated patient
 Heparin-induced thrombocytopenia and heparin resistance
 Neurologic risk stratification during CPB procedures
 Renal failure and its management
 Diabetes and endocrine control, and the implications of hyperglycemia
2. Communicator
a) To demonstrate effective communication with patients and families (description of

procedures, informed consent, anesthetic options and risks).
b) To demonstrate effective communication with OR team (cardiac surgeons, nurses,

perfusionists) and postoperative team, particularly during the initiation conduct and
removal of cardiopulmonary bypass.
c) To provide clear and concise written consultation and anesthetic records.
3. Collaborator

a) To recognize the need to utilize other specialists for the care and management of the
critical patient.
b) To foster healthy team relationships.
4. Manager
a) To manage OR time by efficiently conducting the anesthetic, continuing education,

and personal activities.
b) To make effective use of healthcare resources.
5. Health Advocate
a) To demonstrate the use of risk reduction strategies, including use of ultrasound and
sterile technique for invasive lines.
6. Scholar
a) To demonstrate commitment to continuing personal education including use of

information technology.
b) To be able to critically review cardiac anesthesia literature and to describe the

principles of research relevant to this population.
c) To assist in education of other members of the OR team.
7. Professional
a) To always demonstrate respectful and compassionate behavior toward patients, their

families, and other healthcare providers.
b) To demonstrate an appropriate sense of responsibility to themselves and their

patients.
c) To remain calm and organized in stressful or emergency situations.
d) To demonstrate appropriate interactions with colleagues and staff.

REGIONAL ANESTHESIA
Duration: 1–2 months
The aim of this rotation is to provide the resident with an extended exposure for the
attainment of a higher level of competence in various regional anesthesia techniques. This
rotation is intended to gain procedural mastery under the supervision of qualified regional
anesthesiologists.
1. Medical Expert/Clinical Decision Maker
The resident should demonstrate the understanding of anatomy, physiology, and

pharmacology. The resident should demonstrate knowledge acquisition in the following
areas:
a) Anatomy related to specific regional anesthesia technique including surface

landmarks, perineural structure, ultra sound anatomy, sensory innervation, motor
innervation, and components and details of brachial plexus, lumbar plexus, and sacral
plexus.
b) Physiology related to specific regional anesthesia techniques and disease processes,

including nerve transmission/blockade, physiologic response to acute pain, and the
patient with chronic pain at the site of surgery.
c) Pharmacology of local anesthetics, adjuvants (e.g. epinephrine, opioids, HCO3),

chronic opioid use in the patient presenting for surgery.
d) Regional anesthesia equipment including needles, peripheral nerve stimulator,

ultrasound, catheters, and stimulating catheters.
e) Complications/side effects, including: IV toxicity and management of local anesthetic

overdose, neural injury, needle trauma to surrounding tissue (i.e. hematoma,
pneumothorax, dural puncture), unintended neural blockade (i.e. phrenic nerve,
epidural).
f) Contraindications related to specific regional anesthesia techniques including

infection, anticoagulation, pre-existing neural injury, increased ICP, and pulmonary
disease.
g) To perform/assist the following procedures:

o IV regional
o Spinal anesthesia

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CARDIAC ANESTHESIA

Duration: Three months during senior residency

The resident is expected to become competent in the management of patients with

1. Medical Expert/Clinical Decision Maker

A. Physiology and Anatomy

The resident is expected:

a) To describe the normal coronary anatomy and variants, normal cardiac

d) To describe the embryologic circulation, development of the heart, and fetal

e) To describe the altered respiratory physiology of the immediately postoperative

f) Describe common physiological changes occurring in the postoperative period

48 SAUDI BOARD ANESTHESIA CURRICULUM

The resident should know:

a) Commonly prescribed medications for cardiac surgical patients, the implications

b) Commonly used cardiac anesthetics and dosages.

c) Heparin, antiplatelet agents, and anesthetic implications.

e) Antifibrinolytic agents, mechanisms of action, and indications.

g) Coagulation drugs (DDAVP, activated factor 7a), their indications,

h) Commonly used vasodilators, vasoconstrictors, inotropic agents, and their

i) The appropriate use of pain medications, non-steroidal anti-inflammatory drugs

j) Pharmacology of perioperative risk reduction strategies (lipid lowering agents, β-

The resident is expected:

b) To demonstrate the principles of noninvasive and invasive blood pressure

c) To acquire skills of arterial and central venous cannulation (with ultrasound),

e) To understand the basics of introductory TEE, including techniques of probe

f) To understand laboratory monitoring of the coagulation system (PTT, INR,

g) To assess the adequacy of mechanical ventilation using clinical parameters and

i) To know the significance of temperature management in the intraoperative

j) To understand the indicators of volume status, especially when weaning from

i) To use appropriate intraoperative blood work for the management of patient

D. Clinical Assessment & Management

The resident is expected:

a) To complete a detailed history, physical exam, order appropriate laboratory and

b) To know current indications and recommendations for SBE prophylaxis.

d) To correct common derangements in metabolic and electrolyte disturbances in

50 SAUDI BOARD ANESTHESIA CURRICULUM

f) To know the common pathophysiology and management of patients with

a) To demonstrate effective communication with patients and families (description of

b) To demonstrate effective communication with OR team (cardiac surgeons, nurses,

c) To provide clear and concise written consultation and anesthetic records.

51 SAUDI BOARD ANESTHESIA CURRICULUM

b) To foster healthy team relationships.

a) To manage OR time by efficiently conducting the anesthetic, continuing education,

b) To make effective use of healthcare resources.

a) To demonstrate commitment to continuing personal education including use of

b) To be able to critically review cardiac anesthesia literature and to describe the

c) To assist in education of other members of the OR team.

a) To always demonstrate respectful and compassionate behavior toward patients, their

b) To demonstrate an appropriate sense of responsibility to themselves and their

c) To remain calm and organized in stressful or emergency situations.

d) To demonstrate appropriate interactions with colleagues and staff.

Duration: 1–2 months

1. Medical Expert/Clinical Decision Maker

The resident should demonstrate the understanding of anatomy, physiology, and

a) Anatomy related to specific regional anesthesia technique including surface

b) Physiology related to specific regional anesthesia techniques and disease processes,

c) Pharmacology of local anesthetics, adjuvants (e.g. epinephrine, opioids, HCO3),

d) Regional anesthesia equipment including needles, peripheral nerve stimulator,

e) Complications/side effects, including: IV toxicity and management of local anesthetic

f) Contraindications related to specific regional anesthesia techniques including