northeast anaesthetic learning group

Northeast Anaesthetic Learning Group

Specialist Registrar Scheme

Index

1. Overview of registrar experience 2

2. Obstetrics 133. Critical Care Medicine 244. ENT, Maxillo-Facial, Dental and Plastic Surgery 365. Acute and Chronic Pain 556. Eye Surgery 687. Day Surgery 748. Neuro-Anaesthesia 779. Thoracic and Cardiac Anaesthesia 8610. Anaesthesia for Vascular Surgery 9911. Paediatric Anaesthesia 104

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1. Registrar experience

Speciality Block Duration of Experience

First year Specialist Registrar Final Fellowship YearObstetric unit 4 weeksIntensive care unit 4 weeksMaxillo-facial surgery 4 weeksPaediatric Anaesthesia 4 weeksUrology 4 weeksCardiac 4 weeksNeuro 4 weeksENT / Eyes 4 weeksGeneral Surgery 4 weeksChronic & Acute Pain 4 weeksSpecific Teaching Modules:Examination training practical and theoretical. 1 monthExamination leave 2 weeks

Second year Specialist Registrar Optional experience YearGeneral anesthetic practice 3 monthsSpecialised Anaesthetic Practice eg ITU 3 monthsResearch - Day time release 6 monthsSpecial experience alternative 1 year

Third year Specialist Registrar General experience YearPaediatric Anaesthesia [ inc. neonates] 3 monthsCardiac & Thoracic Anaesthesia 2 monthsNeuro - Anaesthesia 2 monthsAcute & Chronic Pain 2 monthObstetric Anaesthesia 1 monthITU / Trauma / Transfer 2 months

Speciality BlockSpecial Experience module A 6 monthsSpecial Experience module B 6 months

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Year 3 First year Specialist RegistrarLearning plan

Clinical Skills List

Skilled in:emergency anaesthesiaelective anaesthesia for major surgeryACLS / ACLS + APLSComprehensive obstetric careAcute & Chronic pain controlGeneral Intensive careInvasive procedures and non-theatre based anaesthesia

Competent:Advanced ITU / Complex obstetric cases

Learning:Complex monitoring methods - Awareness / evoked potentials etcMajor complex anaesthetic areas - Cardiac & Neuro & Neonates

Theoretical Skills List

Skilled in:self awareness - clinically & academicallyin the evaluation of current advances in anaesthetic practicein the preparation for the final FRCA

Competent:in developing CMEin teaching small groupsin the assessment of SHOs years 1 & 2

Learning:administration & management issuesinvolvment in the Rota organisation

Communication Skills List:

Skilled:Clinical scenario presentationVerbal & written presentationPresentation skills for Vivas

Competent:Small group teaching and assessmentleading tutorials

Learning:to teach anaesthetic skills & knowledge to experienced SHOsto develop appraisal skills

Local Assessment:

Pass the final FRCA examinationCompleted successfully the ACLS / APLS / ATLSCompletion of the Diploma course

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First year Specialist RegistrarClinical Experience

Objectives of Training:

To become a skilled member of the 2nd On-Call rota.To become skilled in emergency anaesthesiaTo maintain skills in caring for the unconscious patientTo maintain skills in IV access, and airway controlTo maintain skills in providing effective pain controlTo become skilled in providing epidural / spinal anaesthesiaTo become competent in providing anaesthetic care for ASA 4+ patientsTo learn cardiac & neuro anaesthesia

Specific Clinical Experience

The exposure to all sub-specialities of anaesthesia before the attempt at the final FRCA is necessary - providing that adequate theoretical and clinical teaching has been achieved.The content of these modules can easily be met by longer / shorter blocks, and there is no reason for them not to be combined. The experience in ITU, obstetrics, cardiac, neuro and paediatric anaesthesia must be in blocks. The remaining half of the timetable can be flexibly organised and monitored by means of the logbook.

If a modular system is chosen the relative lengths of experience should be:

Speciality Block Duration of ModuleObstetric unit 4 weeksIntensive care unit 4 weeksMaxillo-facial surgery 4 weeksPaediatric Anaesthesia 4 weeksUrology 4 weeksCardiac 4 weeksNeuro 4 weeksENT / Eyes 4 weeksGeneral Surgery 4 weeksChronic & Acute Pain 4 weeks

Specific Teaching Modules1 Examination training - practical & theoretical - 1 month2 Examination leave 2 weeks

NB: No more than 70% of the week can be dedicated to these formal guidelines.Allowance for holidays, study leave and post On-call time is mandatory.

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Year 4 Second year Specialist Registrar (Optional experience year)Learning plan

Trainees may present a wide variety of programmes for approval as options.1. A remedial programme aimed at the FRCA or some deficiency.2. Appropriate experience of another speciality.3. Appropriate research experience.4. Appropriate experience in another centre.

Clinical Skills List Consolidation of clinical skills & the development of special interests.Skilled in delegation of tasks to the appropriate on call colleague.Development of additional skills in specialised techniques eg echocardiography.


Consolidation of educational skills & the development of research skillsFurther attempts at the final FRCA if necessaryDevelop an understanding of educational & basic scientific researchUndertake a project [6 months]


Able to lead and direct effectivelyDeveloping skills in changing established practice

Local Assessment:

RITA

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Second year Specialist Registrar Clinical Experience


To maintain all transferable skills To become competent in the management of medically compromised patients To learn research methodology, and teaching methodology To seek experience in another region or overseas.

Specific Clinical Experience -

This year may be necessary for remedial attempts at the final FRCA, but for the majority of trainees it should be used to provide for theirindividual development in anaesthesia and to allow ‘time out’ for research, or the completion of a Diploma Course for example.The content of these modules can easily be met by longer / shorter blocks, and there is no reason for them not to be combined.

Trainees can offer any plan of work for consideration.


Speciality Block Duration of ExperienceGeneral anaesthetic practice 3 monthsSpecialised Anaesthetic Practice eg ITU 3 monthsResearch - Day time release 6 months

Specific Teaching Modules1 2


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Year 5 Third year Specialist RegistrarLearning plan


Consolidation of clinical skillsExperience of the major anaesthetic sub-specialities


Skilled:Continuing self assessment & education

Competent: Developing management skills

Learning:Financial / contracting issues


Skilled:Teaching transferable skillsIndividualised education of colleagues & other trainees Competent:Self presentation

Local Assessment:

Appraisal by Regional Panel Membership of a speciality association

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Third year Specialist Registrar (‘General Experience’ Year)Clinical Experience


To maintain and consolidate all transferable skillsTo become skilled in the management of medically compromised patientsTo become skilled in the management of an anaesthetic departmentTo become skilled in training and teachingTo become competent in negotiation skills


This year should provide, within a stable time and geographical frame, experience in all of the major specialitites of anaesthesia.

The time allocated to each area reflects the wieghting of the Regional Working Party for General Specialist training - the time to develop high level skills is provided in the year 4. The arrangement of this year must be modular.


Speciality Block Duration of ModulePaediatric Anaesthesia [ inc. neonates] 3 monthsCardiac & Thoracic Anaesthesia 2 monthsNeuro - Anaesthesia 2 monthsAcute & Chronic Pain 2 monthObstetric Anaesthesia 1 monthITU / Trauma / Transfer 2 months


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Year 6 Fourth year Specialist Registrar (Special experience year)Learning plan


Highly skilled in two [ rarely one] speciality areas


Completely able in CMEExpertise in medical education - able to start a small teaching unit


Skilled in negotiationpolitically awareSkilled in interview & pre-interview presentation

Local Assessment:

CCSTAppointable to a small teaching hospitalAppointable to a Post CCST Fellowship in a major speciality

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Fourth year Specialist Registrar (‘Special Experience’ Year)Clinical Experience


To maintain and consolidate all transferable skills To become highly skilled in the management of two areas of specialised anaesthetic practice. To become skilled in the management of an anaesthetic department To become skilled in training and teaching To become skilled in interview techniques - for either Post CCST fellowships or NHS Consultant Posts To become competent in negotiation skills


This year should provide, within a stable time and geographical frame, experience in two of the major specialitites of anaesthesia [ for some specialty areas - ITU and Cardiac anaesthesia - a full year based in all of the regions units will be needed. However, the CCST requirements relating to dual registration of training time must be taken into account when planning these long modules].

Speciality Block Duration of ModuleSpecial Experience module A 6 monthsSpecial Experience module B 6 months


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Further training for those intending a career in Obstetric Anaesthesia.

1. Optional year Those interested could take either all or part of their optional year in a course of study which relates to obstetric anaesthetic practice. Possible options are:

1. Experience as an SHO in an obstetric or neonatal post.2. Experience in a suitable unit elsewhere in the UK or overseas.3. Research relating to obstetric anaesthesia.4. Teaching or management training with emphasis on obstetrics.

A trainee could present a proposal of any sort for consideration.

2. Special experience year. The trainee would spend up to six months in obstetric anaesthetic practice. They would present a proposal to a supervisor who would oversee their training throughout this period.

Further training for those intending a career in Intensive Care.

1. Optional year Those interested could take either all or part of their optional year in a course of study which relates to intensive care practice. Possible options are:

1. Experience as an SHO in an appropriate post.2. Experience in a suitable unit elsewhere in the UK or overseas.3. Research relating to intensive care.4. Teaching or management training with emphasis on the ITU.


2. Special experience year. The trainee would spend up to six months in intensive care. They would present a proposal to a supervisor who would oversee their training throughout this period. The trainee could spend a year in a specialised ITU post.

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2. Obstetric Anaesthesia and Analgesia

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Specific obstetric anaesthetic Experience

For all trainees:

Second three months 1 week10-18 months 6 weeks1st year Specialist Registrar 4 weeks3rd year Specialist Registrar 4 weeks

For specialist obstetric anaesthetists:

Research opportunity etc. 1 year4th year Specialist Registrar 6 months

The practice of specialist obstetric anaesthesia is taught by a series of full time secondments combined with repeated experience of obstetric practice in the course of day to day work. It is important that some of the uncommitted day time work throughout training is spent on obstetric anaesthesia and that there is continuous experience of on call work in the maternity unit.

Special experience blocks:

During special experience blocks the equivalent to a whole working week should be devoted to the maternity unit so that the trainee can become part of the maternity team.

Second three months:

A week of obstetric observation is provided at this point so that trainees learn something of the place of obstetric anaesthetic in the tasks of the anaesthetic department.

6-18 months:The six week attachment to the obstetric unit should be provided at this time. By the end of this attachment the trainee should be competent to provide anaesthetic cover for the maternity unit. He or she will continue to be on call for obstetric units as required throughout their training. Emphasis should be placed on continuity of care, planning of obstetric care and the team approach to care in childbirth.

1st year Specialist Registrar:A four week attachment allows the trainee to have more experience of continuity in maternity care. Specific learning objectives are directed towards the management of obstetric complications.

3rd year Specialist Registrar:In this attachment trainees complete their training in the management of high dependency and critical care in obstetrics. They should also consider the issues of organising and managing an obstetric anaesthetic service.Trainees proposing a speciality interest in obstetric anaesthesia will undertake further attachments in the final registrar year.

Units offering experience:

SHO attachments can be to any recognised obstetric unit.

The first year Specialist Registrar attachment must be to a unit which runs a separate continuous obstetric call service, has more than 1500 deliveries per annum and offers an on demand obstetric analgesia service. Such units should also have a lead obstetric anaesthetic consultant with sessions devoted to the service, hold combined morbidity meetings and keep obstetric audit records.

The third year Specialist Registrar attachment must be to a unit with over 3000 deliveries per annum and specialised critical care facilities for obstetrics. Special care facilities should include the routine care of severely ill neonates.

Training for those expressing a speciality interest in obstetrics will continue under the supervision of a named obstetric anaesthetic specialist.

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First year SHOSecond three months 1 week - IntroductionObstetric Learning Plan

Theoretical Knowledge

Learning:

Normal labourPain relief in labourAnaesthesia for caesarean section

Communication Skills List

Learning:The role of maternal choice in obstetric analgesia.History taking ExaminationsDiscussion of options - pain relief in labourfor Caesarean sectionConsent

Local Assessment

Informal feedback

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First year SHOSecond three months 1 weekObstetric Clinical experience


One weeks introduction to obstetric anaesthesia

Objectives of Training

Introduction to obstetric analgesic practiceIntroduction to anaesthesia for caesarean section

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Second year SHO10-18 months 6 weeksObstetric Learning Plan


Learning:

The mechanisms of pain in relation to labour.Relevant anatomy of the pelvis and perineum. Nerve supply of abdomen, pelvis and perineum.Anatomy of the vertebral column, spinal cord and meninges.Indications and contraindications of epidural anaesthesia.The effect of epidural anaesthesia on the mother, the labour and the baby.Epidural anaesthesia in abnormal delivery (breech, malpresentations, previous section, trial of labour).The anatomy and functions of the placenta.Gas exchange across the placenta, double Bohr and Haldane effects, foetal haemoglobin.The changes in maternal physiology with pregnancy.Changes in foetal circulation at birth.The effects of drugs on the foetus.The patho-physiology of PIH and eclampsia.Understand the mechanism of action of oxytocics and prostaglandin.Fetal monitoring in labour.Anaesthesia in early pregnancy.Medical diseases complicating pregnancy.Antenatal assessment of the pregnant woman.Anaesthesia for operative obstetrics.Emergencies in obstetrics.Maternal morbidity and mortality.Neonatal resuscitation.


Learning:How to discuss anaesthetic management in pregnancy with patients.Working with midwives as independent professionals.The team approach to management of labour.Keeping proper obstetric analgesia records.

Local Assessment

Able to establish an epidural for management of pain in an uncomplicated labour.Able to give a safe anaesthetic for caesarean section, both GA and Regional.Assessment of communication skills.Ability to keep good quality records.

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SHO6-18 months 6 weeksObstetric Clinical Experience


Six weeks experience in an obstetric unit with over 1500 deliveries per annum. Must have a designated anaesthetist in charge of obstetric anaesthesia. Must have at least 5 consultant sessions allocated to obstetrics. Must run an on request obstetric epidural service. Practical exposure to neonatal resuscitation if no previous experience in this area.

The trainee will begin obstetric anaesthetic first on call during this six week secondment. He or she will then continue to be on call for obstetrics as required throughout their training.

The substantial part of this training time must be during consultant obstetric anaesthetist sessions.


Ability to manage pain relief in labour.Administration of general and regional anaesthesia for obstetric routine and emergency cases.To become competent to be 1st on call for obstetrics.

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Third Year TraineeFirst year Specialist Registrar 4 weeksObstetric Learning Plan


Skilled in:All aspects of planning and managing pain relief in labour.Regional anaesthesia for labour and operative obstetrics.Management of complications of regional anaesthesia in obstetrics.Management of anaesthesia for Caesarean section, regional and general.Spinal anaesthesia.Anaesthesia for operative vaginal delivery.Anaesthesia for retained placenta.

Competent in:Managing ante-partum haemorrhage.Managing post partum haemorrhage.The management of patients with PIH/pre-eclampsiaCoping with intercurrent maternal disease.Understanding the problems of the at risk baby.Severe obstetric haemorrhage.Obstetric anaesthetic management of multiple birth.

Learning:High dependency care in obstetrics.Dealing with the high risk patient (mother and baby)Neonatal resuscitation.Diagnosis and management of severe pre-eclampsia.


Skilled:

How to discuss anaesthetic management in pregnancy with patients.Working with midwives as independent professionals.The team approach to management of labour.Keeping proper obstetric analgesia records.

Competent:

Presentation of a case study.Presentation to multi-disciplinary meeting.Personal Time Management and Prioritisation.

Local Assessment

Formal feedback from consultants.

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Third year TraineeFirst Year Specialist Registrar 4 weeksObstetric Clinical experience

Specific Clinical Experience - Module

Four weeks experience with responsibilities developing from those of the previous year.At least one of the main attachments should be in a unit with more than 3000 deliveries per year.


To become a competent member of the team for obstetric care.To recognise and manage common complications and exercise proper judgement in asking for help.To consolidate management of obstetric anaesthesia.To be able to supervise and teach a less experienced trainees.

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Fifth year TraineeThird Year Specialist Registrar 4 weeksObstetric Learning Plan


Skilled in:The anatomy, physiology, pathology and pharmacology of labour.

Competent:Use of audit.

Learning:The pathophysiology of major complications in obstetrics.Legal aspects of record keeping.


Skilled in:Obstetric anaesthetic care.Management of pain in labour.

Competent in:Management of major complications of childbirth.Management of obstetric high dependency.Management of severe pre-eclampsia and eclampsia.Resuscitation and preparation for transfer of critically ill mother.

Learning:Intensive care of the obstetric patient including transfer.Life threatening liver, kidney and heart failure in pregnancy.


Skilled in:As aspects of communicating with obstetric patients.All aspects of communicating with obstetric are team.

Competent:Communicating with relatives when things are going wrong.Record keeping and audit.

Learning:How to organise systems and protocols for team care.Completing the cycle in obstetric anaesthetic audit.Role of obstetric anaesthetist in antenatal education.Dealing with complaints.

Local Assessment

Informal feedback with consultants.

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Fifth year TraineeThird year Specialist Registrar 4 weeksClinical experience


The placement should be in a centre with tertiary referrals for obstetrics and high level Special Care facilities for babies.

Obstetric of Training

To be a skilled member of the obstetric care team.To learn how to run an obstetric anaesthetic in a large and small obstetric unit.Management of patients in obstetric high dependency.Management of obstetric patients in ITU.

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Further training for those intending a career in Obstetric Anaesthesia

Second Year Registrar

Those interested could apply to pursue an optional course of study during part or all of their SpR 2 year. Possible options are:

Experience as an SHO in an obstetric or neonatal post.Experience in a suitable unit elsewhere in the UK or overseas.Research relating to obstetric anaesthesia.Teaching of management training with emphasis on obstetrics.Management of obstetric anaesthetic service.


Fourth Year SpR

The trainee would spend up to six months in obstetric anaesthetic practice. They would present a proposal to a supervisor who would oversee their training throughout this period.

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3. Critical Care Medicine

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Specific Intensive Care Experience

For all trainees:

Second three months 3 weeks7-9 months 4 weeks10-18 months 4 weeks18-24 months 6 weeks1st Year Specialist Registrar 4 weeks3rd Year Specialist Registrar 8 weeks

For specialist Intensivists:

Research opportunity etc. 1 year4th Year Specialist Registrar 6 months or 1 year

The practice of Intensive Care Medicine is taught by a series of full time secondments combined with intermittent periods of on-call attachments during other periods.

Specialist Experience Blocks

Second Three Months

This is primarily an orientation period. The trainee will be expected to accompany an SHO working on the Unit to learn something of the day to day functioning of an Intensive Care Unit. In addition, he will accompany the member of the ICU team who attends cardiac arrest and trauma calls to observe and practice immediate care of the critically ill patient. There will be a strong emphasise on formal teaching, aiming to complement training in general anaesthesia as much as possible.

The general learning objectives for this attachment are:-

To learn to recognise and assess the sick patientTo be competent at immediate care provision

Months 7-9

During this attachment the trainee will start to become an active member of the ICU team. Though still not on the on call team, he will function as the day resident for the ICU, working closely with a more senior SHO. The trainee will be responsible for the maintenance of the medical records for specific patients and will be responsible for ensuring hand-over of these patients to the on-call team. This attachment will involve the presentation of a case (with discussion) at a departmental meeting. The general learning objectives for this period are

To learn the management of the elective postoperative patientTo learn skills required to function as “on-call” resident for ICU

Months 10-18

The trainee will commence ICU on-call during this attachment and will play a more active role on the ICU during the day, including the informal teaching of junior SHO’s. In addition, he will carry the cardiac arrest bleep and will be available for trauma calls and ward referrals. Assessment of this module will involve a critical review of recent ICU literature at a departmental journal club. The general learning objectives of this block are:

To learn management of the emergency post-operative patientTo learn the management of a patient with single organ failureTo learn advanced Intensive Care techniques

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Months 18-24

This 6 week attachment is an opportunity for the SHO to consolidate his ICU teaching and experience. He will be a fully functional member of the ICU team during both day and night. It is suggested that each trainee should consider preparing a piece of work for submission for the NEICS Trainees Prize. This could be done individually or as a group. The general learning objectives for this attachment are:

To learn to recognise the patient for whom ICU admission is beneficial.To learn management of the multi-organ failure patient.To be introduced to the principles of management of the critically ill child or obstetric patientTo be introduced to the management of death/withdrawal of active therapy.

SpR Year 1

This is a 4 week attachment which will precede the final FRCA. Though he will function as ICU resident on-call at night, the trainee will be encouraged to accept more responsible duties during the day. He will be expected to start taking the working ward round in the morning under the supervision of an ICU consultant - the assessment of this module will take the form of managing a working ward round. In addition, ward referrals will be made through him and he will be encouraged to assess and manage the patient prior to admission to the ICU (with appropriate levels of supervision). He will carry the trauma bleep and will be actively involved in the management of the patient during the golden hour. The general learning objectives of this attachment are:

To learn the management of the multi-trauma patient.To learn the principles of ethics and the law in the ICU.To learn the principles of man-power management.To learn the principles of the routine running of an ICU.

SpR Year 3

During this 2 month attachment to the ICU, the trainee will be expected to learn about the provision of Intensive Care services within the hospital. He will receive teaching on aspects of management and budgeting skills and will be encouraged to demonstrate manpower management and delegation skills. He will play a more supervisory role on the ICU and will now be 2nd on call for the ICU at night. In addition, the trainee will be encouraged to play an active role in the teaching and training of SHOs and SpR 1 trainees. Assessment of this module involves the management of a teaching ward round and preparation of an item for submission for the NEICS Trainees Prize - again this can be an individual piece of work or the result of a group investigation. The general learning objectives for this attachment are:

To learn the management of the teaching ward round.2. To learn the principles of management and financial issues.

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First Year SHO (4-6 months) - 3 Week PeriodLearning plan for Intensive Care Medicine

Clinical Skills List:

Competent in: Immediate care of the critically ill patient (i.e. first 20 mins)A B C skillsACLS treatment algorithmsLearning:Recognition and assessment of the sick patientInterpretation of clinical data: ABG, biochemistry, haematology (including acquired coagulopathy), CXR, ECG Obtaining and maintaining a safe airway in the ICU patient. Fluid balance and sedation/analgesia in ICU patients

Theoretical Skills List:

Learning:Physiology and Pharmacology as relevant to ITU:Cardiovascular Sedation and AnalgesiaRespiratory Oxygen therapyRenal Neuromuscular blocking agentsInvasive monitoring - normal values and waveforms

Communication Skills

Competent in:Hand-over of the uncomplicated ICU patient to colleaguesMaintenance of good, accurate ICU clinical records

Learning:Case presentationCommunication with other health-care professionals

Local AssessmentNo formal assessment apart from feed-back interview at end of attachment

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Second Year SHO (7-9 months) - 4 Week PeriodLearning Plan


Skilled in:Immediate care of the critically ill patient (first 20 mins)Interpretation of clinical dataAseptic techniqueMaintenance of good clinical records

Competent in:Recognition and assessment of the sick patientInsertion of arterial cathetersFluid balance and sedation/analgesia in ICU patients

Learning:Management of the elective (uncomplicated) post-operative patientEstablishing an airway - oro-tracheal versus naso-trachealCommencing mechanical ventilationSetting up and checking an ICU ventilator, syringe pumps and volumetric devicesRecognition of the need for advanced investigations e.g. CT scan, ultrasound etc.The use of blood and blood products on ICUInsertion of central venous cathetersChest drain insertion, vascular access catheters (inc. TPN lines)


Competent in:Basic Physiology and Pharmacology as relevant to ITUInvasive monitoring - normal values and waveforms

Learning:Further physiology and pharmacology Hepatic Inotropes - indication for useNeurological Infection control and antibiotic policiesTemperature control Nutrition - enteral and TPNPathophysiology in ICU - an introduction to single-organ failurerespiratory failurecardiac failurerenal failureInvasive monitoring - abnormal values and waveformsModes of ventilation - IPPV, SIMV, Pressure Controlled, PEEP, CPAPMonitoring of respiratory mechanics during mechanical ventilationScoring systems and their place in the ICU


Skilled in:Hand-over to colleagues of uncomplicated patientsMaintenance of good accurate clinical records

Competent in:Hand-over to colleagues of complex patientsCase presentationLearning:Patient and relative interviews.

Local Assessment:

Case presentation to departmental meeting.

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Second Year SHO (10-18 months) - 4 Weeks PeriodLearning Plan Intensive Care Medicine


Skilled in:Immediate care of the critically ill patient (first 20 mins)Recognition and assessment of the sick patientInterpretation of clinical dataInsertion of arterial cathetersFluid balance and sedation/analgesia in ICU patients

Competent in:Management of the elective (uncomplicated) post-operative patientEstablishing an airway - oro-tracheal versus naso-trachealInsertion of central venous cathetersCommencing mechanical ventilationSetting up and checking an ICU ventilator, syringe pumps and volumetric devicesRecognition of the need for advanced investigations e.g. CT scan, ultrasound etc.The use of blood and blood products on ICUChest drain insertion, vascular access catheters (inc. TPN lines)

Learning:Management of the emergency post-operative patientManagement of the single organ failure patientPreparation for and management of the intra-hospital transfer of a critically ill patientAdvanced airway management - mini-tracheostomy, percutaneous tracheostomyInsertion and use of pulmonary flotation cathetersIndications for and insertion of trans-venous pacemaker wiresManagement of post-resuscitation phase - including cerebral protectionWeaning from mechanical ventilation


Skilled in:Physiology and Pharmacology as relevant to ITUInvasive monitoring - normal values and waveformsCompetent in:Pathophysiology in ICU - single-organ failureModes of ventilation - IPPV, SIMV, CPAP, PEEP.Invasive monitoring - abnormal values and waveformsMonitoring of respiratory mechanics during mechanical ventilation Scoring systems and their place in the ICULearning:Pathophysiology in ICU - single-organ failure continued:Neurological failure including encephalopathies CoagulopathiesHepatic failure Pathophysiology:multi-organ failure Sepsis syndrome/septic shockARDSInotropes - application Organ support techniques - CVVH, CVVHD, IABP, ECMOAdvanced modes of ventilation- pressure controlled, pressure support, inverse ratio, BIPAP/APRV, HFJV.Ethical and legal issues as relevant to ICU - introduction

Communication Skills ListSkilled in:Patient hand-over to colleagues. Case presentation. Maintenance of good accurate clinical recordsCompetent in:Patient/relative interviews. Communication with other health-care professionalsLearning:Teaching Stage I ICU trainees

Local AssessmentCritical review of paper(s) from recent ITU literature

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Second Year SHO (18-24 months) - 6 Week PeriodLearning Plan Intensive Care Medicine


Skilled in:Immediate care of the critically ill patient (first 20 mins)Recognition and assessment of the sick patientManagement of the elective (uncomplicated) post-operative patientEstablishing an airway - oro-tracheal versus naso-trachealCommencing mechanical ventilationInterpretation of clinical dataRecognition of the need for advanced investigations e.g. CT scan, ultrasound etc.Insertion of arterial and central venous cathetersFluid balance and sedation/analgesia in ICU patientsSetting up and checking an ICU ventilator, syringe pumps and volumetric devicesThe use of blood and blood products on ICUChest drain insertion, vascular access catheters (inc. TPN lines)

Competent in:Management of the emergency post-operative patientManagement of the single organ failure patientPreparation for and management of the intra-hospital transfer of a critically ill patientInsertion and use of pulmonary flotation cathetersIndications for and insertion of trans-venous pacemaker wiresManagement of post-resuscitation phase - including cerebral protection

Learning:Recognition of the patient who will benefit from ICU admissionRecognition of the patient for whom further ICU management is futileManagement of the multi-organ failure patientManagement of the brain dead organ donorManagement of the near-drowning, drug and substance overdose patientPreparation for and management of the inter-hospital transfer of a critically ill patientAdvanced airway management - mini-tracheostomy, percutaneous tracheostomyWeaning from mechanical ventilation

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Skilled in:Physiology and Pharmacology as relevant to ITUInvasive monitoring - normal values and waveforms, abnormal values and waveformsPathophysiology in ICU - single-organ failureModes of ventilation - IPPV, SIMV, , CPAP, PEEP.Monitoring of respiratory mechanics during mechanical ventilationScoring systems and their place in the ICU

Competent in:Pathophysiology - multi-organ failureInotropes - application Organ support techniques - CVVH, CVVHD, IABP, ECMOAdvanced modes of ventilation- pressure controlled, pressure support, inverse ratio,BIPAP/APRV, HFJV.

Learning:Physiology, pathophysiology and pharmacology in paediatric and obstetric ICU practiceEthical and legal issues as relevant to ICU Indications for Brain Death TestingHazards of electrical and other equipment on the ICU.


Skilled in:Patient hand-over to colleaguesCase presentationMaintenance of good accurate clinical recordsPatient/relative interviewsCommunication with other health-care professionals

Competent in:Teaching Stage I trainees

LearningCommunication with relatives - breaking bad newsCommunication with Coroners Officers and other official bodies.

Local AssessmentEntry for the NEICS Trainees Prize (or equivalent)

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First Year Specialist Registrar- 12 Weeks in 3 PeriodsLearning Plan Intensive Care Medicine


Skilled in:Recognition and assessment of the sick patientManagement of the elective (uncomplicated) post-operative patientManagement of the emergency post-operative patientManagement of the single organ failure patientEstablishing an airway - oro-tracheal versus naso-trachealCommencing mechanical ventilationInterpretation of clinical dataRecognition of the need for advanced investigations e.g. CT scan, ultrasound etc.Insertion of arterial and central venous cathetersInsertion and use of pulmonary flotation cathetersFluid balance and sedation/analgesia in ICU patientsSetting up and checking an ICU ventilator, syringe pumps and volumetric devicesThe use of blood and blood products on ICUChest drain insertion, vascular access catheters (inc. TPN lines)Indications for and insertion of trans-venous pacemaker wiresManagement of post-resuscitation phase - including cerebral protection

Competent in:Recognition of the patient who will benefit from ICU admissionPreparation for and management of the inter-hospital transfer of a critically ill patientRecognition of the patient for whom further ICU management is futileManagement of the brain dead organ donorManagement of the near-drowning, drug and substance overdose patientWeaning from mechanical ventilation

Learning:Management of the multi-organ failure patientManagement of the sick child and the critically ill obstetric patient(in combination with training in obstetric and paediatric anaesthesia)Management of the post-operative cardiothoracic patient(in combination with training in cardiothoracic anaesthesia)Management of the multi-trauma patient principles, initial assessment and immediate management, including triageidentification and immediate treatment of life threatening injuriesneurological assessment, role of ICP monitoring and management of raised ICPassessment and management of burns and their physiological consequencesrecognition and management of fat embolismDiagnostic and therapeutic fibreoptic bronchoscopy

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Skilled in:Physiology and Pharmacology as relevant to ITUInvasive monitoring - normal values and waveforms, abnormal values and waveformsPathophysiology in ICU - single-organ failureModes of ventilation - IPPV, SIMV, CPAP, PEEP.Advanced modes of ventilation- pressure controlled pressure support, inverse ratio, BIPAP/APRV, HFJV.Monitoring of respiratory mechanics during mechanical ventilationInotropes - application Organ support techniques - CVVH, CVVHD, IABP, ECMOScoring systems and their place in the ICU

Competent in:Pathophysiology - multi-organ failureIndications for Brain Death Testing

Learning:Physiology, pathophysiology and pharmacology in paediatric practice, obstetrics.Ethical and legal issues as relevant to ICU.


Skilled in:Patient hand-over to colleaguesCase presentationMaintenance of good accurate clinical recordsPatient/relative interviewsCommunication with other health-care professionalsTeaching Stage I trainees

Competent in:Communication with relatives - breaking bad newsCommunication with Coroners Officers and other official bodies

Learning:Management of the working ward roundManpower management

Local AssessmentSuccess in the FRCAManagement of a working ward round

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Third Year Specialist Registrar (General Experience Year) - 8 Weeks PeriodLearning Plan Intensive Care Medicine


Skilled in:Recognition and assessment of the sick patientRecognition of the patient who will benefit from ICU admissionRecognition of the patient for whom further ICU management is futileManagement of the elective (uncomplicated) post-operative patientManagement of the emergency post-operative patientManagement of the single organ failure patientManagement of the near-drowning, drug and substance overdose patientEstablishing an airway - oro-tracheal versus naso-trachealCommencing mechanical ventilationInterpretation of clinical dataRecognition of the need for advanced investigations e.g. CT scan, ultrasound etc.Insertion of arterial and central venous cathetersInsertion and use of pulmonary flotation cathetersFluid balance and sedation/analgesia in ICU patientsThe use of blood and blood products on ICUChest drain insertion, vascular access catheters (inc. TPN lines)Indications for and insertion of trans-venous pacemaker wiresSetting up and checking an ICU ventilator, syringe pumps and volumetric devicesPreparation for and management of the intra-hospital transfer of a critically ill patientManagement of post-resuscitation phase - including cerebral protection

Competent in:Management of the multi-organ failure patientBrain death testingWeaning from mechanical ventilation

Learning:Management of the sick child and the critically ill obstetric patient (in combination with training in obstetric and paediatric anaesthesia)Management of the post-operative cardiothoracic patient (in combination with training in cardiothoracic anaesthesia)Management of the multi-trauma patientprinciples, initial assessment and immediate management, including triageidentification and immediate treatment of life threatening injuriesneurological assessment, role of ICP monitoring and management of raised ICPassessment and management of burns and their physiological consequencesrecognition and management of fat embolism Diagnostic and therapeutic fibreoptic bronchoscopyManagement of the brain dead organ donor

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Skilled in:Physiology and Pharmacology as relevant to ITUInvasive monitoring - normal values and waveforms, abnormal values and waveformsPathophysiology in ICU - single-organ failure and multi-organ failureModes of ventilation - IPPV, SIMV, CPAP, PEEP.Advanced modes of ventilation- pressure controlled, pressure support, inverse ratio, BIPAP/APRV, HFJV.Monitoring of respiratory mechanics during mechanical ventilationInotropes - application Organ support techniques - CVVH, CVVHD, IABP, ECMOScoring systems and their place in the ICUPhysiology, pathophysiology and pharmacology in paediatric practice, obstetricsIndications for Brain Death TestingHazards of electrical and other equipment on the ICU

Learning:Ethical and legal issues as relevant to ICUManagement and budgeting skills on the ICU


Skilled in:Patient hand-over to colleaguesCase presentationMaintenance of good accurate clinical recordsPatient/relative interviewsCommunication with other health-care professionalsCommunication with relatives - breaking bad news, withdrawing treatmentCommunication with Coroners Officers and other official bodiesTeaching Stage I trainees

Competent in:Management of the working ward round

Learning:Manpower management, delegation skillsManagement of the teaching ward round

AssessmentEntry for the NEICS Trainees PrizeManagement of a Teaching ward roundOrganisation of a departmental journal club meeting, including presentation

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4. Anaesthesia for ENT, Maxillo-Facial, Oral, Dental and Plastic surgery

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Training in anaesthesia for ENT, maxillo-facial, oral, dental and plastic surgical sub-specialities.

These specialities have been grouped together because they are complementary and in many regards require similar and complementary skills. Initial training places emphasis on complex airway management skills; later training focuses on speciality operations and apparatus.

At the SHO level it is suggested that these specialities are taught in dedicated blocks. This is so that consistent experience of airway and paediatric skills can be obtained. It must be stressed however that some of the general experience in the form of non teaching lists which the trainee does at other times should be in these areas and will form part of their learning plan.

It is particularly important that trainees understand the treatment of emergencies in these areas and whilst the basic principles can be taught in theatre during routine lists experience will arise during on call time. Theatre teaching should therefore prepare the trainee to be able to handle dire emergencies.

Formal training has been limited to the first three years of the training scheme as it is felt that a working skill should have developed in all curriculum areas by that time. Extensive reinforcement and revision should continue throughout the last three years of training.

Specific experience for ENT, Maxillo-facial, Plastic, Oral and Dental anaesthesia.

SHO 1-3 Months 1 week ENTSHO 3-6 Months 4 weeks Combined ENT/Oral/Max-FacSHO 9-18 Months 4 weeks combined ENT/Max-Fac/PlasticSHO 18-24 Months 4 weeks Combined Plastic/Oral/Max-FacSHO 18-24 Months 2 weeks DentalSpR 1 Year 3 4 weeks ENT

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First Year SHO Learning planENT / Maxillo-facial / oral / dental / plasticsFirst three months

One weeks observation and practice of ENT anaesthesia

The trainee should be allocated to ENT lists which are largely concerned with short operations needing shared airway techniques. ENT lists include a number of children and this period of is important in the paediatric anaesthesia training programme.


Learning:Oral and nasal intubation.Spontaneous breathing intubated patients.How to deal with paediatric patients.Managing recovery when the airway is contaminated.Positioning for shared access surgery.Monitoring the patient when there is no access to the head during surgery.


Learning:The use of specialised endo-tracheal tubes.Design features of specialised tubes.


Learning:Talking to children.

Local Assessment

Informal

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First year SHO Clinical ExperienceENT / Maxillo-facial / Oral/ Dental/ PlasticsFirst Three Months

One weeks observation and practice of ENT anaesthesia

Objectives of training

To learn about the problems of sharing the airway with the surgeon.To learn how to protect the contaminated airway throughout surgery and recovery.To begin learning about the special problems of paediatric anaesthesia.


Anaesthesia for operations such as: tonsillectomy, adenoidectomy, SMR, laryngoscopy etc.Adult and paediatric patients

Supervision:Trainees should work with direct senior supervision, preferably by consultants.

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First Year SHO Learning planSecond three monthsENT / Maxillo-facial / oral / dental / plastics

Four weeks combined ENT, Maxillo-facial, Oral and Dental Anaesthesia

The principal objective of this period of training is to learn how to manage a variety of patients for operations in and around the airway. A good balance of specialities should be seen to ensure a comprehensive training.


Learning:Skills of nasal intubation.Shared airway management.The surgical repertoire of these subspecialties including tonsillectomy, adenoids,polyps, SMR,grommets.Spontaneous breathing intubated patients.How to deal with paediatric patients.Managing recovery when the airway is contaminated.Positioning for shared access surgery.Monitoring the patient when there is no access to the head during surgery.


Learning:Shared airway problems.The use of specialised endo-tracheal tubes: armoured, Rae, tubes for laser surgery, etc..Design features of specialised tubes.


Learning:Talking to children.

Local Assessment

Informal

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First Year SHO Clinical ExperienceSecond three monthsENT / Maxillo-facial / Oral / Dental / Plastics

Four weeks combined ENT, Oral and Dental Anaesthesia


To learn about the problems of sharing the airway with the surgeon.To learn about the pre-operative assessment of patients for shared airway surgery.To learn how to protect the contaminated airway throughout surgery and recovery.To begin learning about the special problems of paediatric anaesthesia.To learn about post-operative pain relief in ENT and dental surgery.To learn about the complications of ENT and dental surgery.To learn about day and ambulatory surgery.


A balance of ENT, oral and dental surgery.

Supervision:Trainees should continue to be supervised directly wherever new techniques are encountered.

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Second Year SHO Learning planNine to eighteen monthsENT / Maxillo-facial / Oral / Dental / Plastics

Four weeks combined experience

This period of experience is intended to build upon the previous periods from the point of view of airway management. In ENT the experience should develop into aural surgery and there should be an emphasis on emergency surgery in maxillo-facial and plastics. There should be experience of major head and neck surgery.


Competent :The problems of sharing the airway with the surgeon.The pre-operative assessment of patients for shared airway surgery.How to protect the contaminated airway throughout surgery and recovery.Post-operative pain relief in ENT and dental surgery.

Learning:Endotracheal intubation in difficult circumstances.Indications for tracheostomy.The complications of ENT and dental surgery.Day and ambulatory surgery.Anaesthesia for aural surgery.Beginning to learn about major head and neck surgery.An introduction to major surgery on the airway: laryngectomy etc..Control of blood pressure for major head and neck surgery.Less common procedures including laser surgery, micro-laryngeal surgery, aural surgery.Special considerations for plastic surgery.Anaesthesia for facial fractures.


Competent:In understanding the medical and surgical background of these surgical specialities.ENT emergencies: bleeding in the airway, obstruction, inhaled foreign bodies.

Learning:Safety in laser surgery.Techniques of hypotensive anaesthesia.


Competent:In discussing surgical requirements with operators In case presentation.Written and verbal communication of anaesthetic material.

Local Assessment

List assessment in a speciality area

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Second Year SHO Clinical ExperienceNine to eighteen monthsENT / Maxillo-facial / Oral / Dental / Plastics



To develop competent pre-operative anaesthetic assessment of patients for major subspecialty surgery of the head and neck. To develop an understanding of special techniques including deliberate hypotension.To develop competence as part of the on call team dealing with facial and jaw injuries.To develop more advanced airway skills in patients with difficult airway access.To learn blind intubation skills.To begin to use the fibre-optic laryngoscope.To learn to anaesthetise for tracheostomy.To develop skills in obtaining airway control in patients with upper airway obstruction.To develop skills in anaesthesia for micro-laryngeal surgery.To develop skills in ambulant dental anaesthesia.To begin to anaesthetise ENT emergencies.


This module should be presented as a block of intensive experience in these areas of head and neck surgery. It is intended that a firm foundation is laid down and that intermittent experience in these areas will continue between specific specialityattachments.

Supervision:During this period the level of supervision of the trainee should be gradually reduced. Help should still however always be available at close call.

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Second Year SHO Learning planEighteen months to two yearsENT / Maxillo-facial / Oral/ Dental/ Plastics

Maxillo-facial / Plastics



Skilled :The problems of sharing the airway with the surgeon.The pre-operative assessment of patients for shared airway surgery.How to protect the contaminated airway throughout surgery and recovery.Post-operative pain relief in plastic and maxillo-facial surgery.

Learning:Care of the very difficult airway.Use of the fibre-optic laryngoscope.Managing major reconstructive surgery.Assessing and managing major blood loss.


Competent:In understanding the medical and surgical background of these surgical specialities.

Learning:Detailed anatomy of the airway, nose, pharynx, larynx, trachea and bronchi.


Competent:In understanding the surgical background to these specialities.Deciding how to manage airway access.

Learning:Understanding the scope of major head and neck interventions.

Local Assessment

List assessment in a speciality areaEssay topics

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Second Year SHO Clinical ExperienceEighteen months to two yearsENT / Maxillo-facial / Oral/ Dental/ Plastics

Maxillo-facial / Plastics



To develop competent pre-operative anaesthetic assessment of patients for majorsubspecialty surgery of the head and neck. To develop an understanding of special techniques including deliberate hypotension.To develop competence as part of the on call team dealing with facial and jaw injuries.To develop more advanced airway skills in patients with difficult airway access.To develop skills in obtaining airway control in patients with upper airway obstruction.


This block continues head and neck and plastic surgical experience. Particular attentionshould be paid to major reconstructive surgery. Use of the fibre-optic laryngoscopeshould be taught.The trainee should be undertaking ENT emergencies if the hospital has them.

Supervision:

During this period the level of supervision of the trainee should be gradually reduced. Help should still however always be available at close call.

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Second Year SHO Learning planEighteen months to two yearsENT / Maxillo-facial / Oral/ Dental/ Plastics

Dental anaesthesia

Two weeks experience


Learning :The problems of sharing the airway with the surgeon intubated and un-intubated.The pre-operative assessment of patients for dental surgery.How to protect the contaminated airway throughout surgery and recovery.ET tube, laryngeal mask, nasal mask, nasal airway.Post-operative pain relief in dental surgery.Assessment and selection of patients for ambulant surgery.Techniques for chair side dental anaesthesia.Paediatric anaesthesia for ambulant dentistry.Complications of dental anaesthesia.The patient with truisms


Competent:In understanding the medical and surgical background of these surgical specialities.

Learning:Detailed anatomy of the airway and teeth.Dental operative repertoire.


Competent:In discussing surgical requirements with operators .In talking to children in surgery situations.Assessment of day and ambulatory surgery.In case presentation.Written and verbal communication of anaesthetic material.

Local Assessment

Informal

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Second Year SHO Clinical ExperienceEighteen months to two yearsENT / Maxillo-facial / Oral/ Dental/ Plastics

Dental Anaesthesia

Two weeks experience


To develop competent pre-operative anaesthetic assessment of patients for dentalsurgery including day stay and ambulant surgery.To learn how to give chair side anaesthetics for dental extractions.To understand anaesthesia outside the routine operating theatre environment.


Allocation should be to a variety of dental lists ranging from in patient oral surgery to ambulant dentistry in the clinic and surgery setting.Dental emergencies. Abscess, trismus, acute dental pain.

Supervision:During this period the level of supervision of the trainee should be gradually reduced. Help should still however always be available at close call.

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First Year Registrar Learning planENT / Maxillo-facial / Oral/ Dental/ Plastics

Four weeks ENT experience.

This first year registrar training can either be offered as separate blocks or as a single 12 week period. The balance of experience would then have to be carefully followed by means of the log book.


Skilled in:The problems of sharing the airway with the surgeon.The pre-operative assessment of patients for shared airway surgery.How to protect the contaminated airway throughout surgery and recovery.Post-operative pain relief in plastic and maxillo-facial surgery.

Learning:Care of the very difficult airway.Use of the fibre-optic laryngoscope.Managing major reconstructive and cancer surgery.Assessing and managing major blood loss.Laser surgery.Venturi and high frequency jet ventilation.Rigid bronchoscopy.Hypotensive anaesthesia.


Competent in:Airway management planning.

Learning:

How to deal with upper airway obstruction. Inhaled foreign body, epiglotitis, croup.Pharmacology and physiology of hypotensive surgery.Therapy of massive blood loss.


Skilled:Confers well with surgeons regarding appropriate anaesthesia.

Learning:The team approach to major head and neck surgery.

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First Year Registrar Clinical ExperienceENT / Maxillo-facial / Oral/ Dental/ Plastics

Four weeks ENT


To consolidate previous airway skills and to develop competence in more major interventions.To gain experience in new areas such as middle ear and laryngeal surgery.To extend generic skills in dealing with major surgery.

Specific Clinical experience

This experience must be offered as a block so that the trainee can concentrate on the special features of ophthalmology and ENT. It would however be appropriate to offer a12 week block with combined experience in maxillo-facial, plastics and dentalanaesthesia. Anaesthesia for common ENT procedures. Tonsillectomy, adenoids, nasal polyps etc.. Anaesthesia for rigid bronchoscopy and oesophagoscopy.Anaesthesia for mastoid surgery, tympanoplasty etc..Anaesthesia for middle ear operations.Anaesthesia for laser surgery.Major head and neck surgery including laryngectomy. ENT emergencies. Foreign body in the airway. Bleeding in the airway. Upperrespiratory obstruction.

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Six weeks oral and maxillo-facial anaesthesia


Competent in:Care of the airway in shared airway procedures.Planning appropriate anaesthetic techniques.Chair side dental anaesthesia.

Learning:Major head and neck trauma management.Anaesthesia for fixing facial fractures.Assessment of the brain injured patient.Planning major head and neck surgery.Fibre-optic laryngoscopy.Anaesthesia for major dental procedures.Chair side dentistry.


Learning:ATLS trauma team management of patients with airway and facial injury.The history of chair side dentistry and the controversies that surround it.


Learning:To co-operate in a team for major head and neck surgery.To co-operate in a team for treatment of the patient with head and neck injuries.

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Six weeks oral and maxillo-facial anaesthesia


To develop skills in maxillo-facial, oral and dental surgery.


There should be equivalent exposure to each speciality.This secondment can be combined to make a twelve week block.There should be adequate experience of chair side dentistry.

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Two weeks plastic surgery anaesthesia


Learning:Anaesthesia for plastic surgery.The range of plastic surgery.Assessment of the burned patient.Anaesthesia for burns surgery.The emergency care of the burned patient.Airway management in burns.Injuries due to explosion.


Learning:The respiratory effect of burns.Carbon monoxide poisoning.Fluid management in burned patientsATLS management in the burned patient.Infection control in burns.


Learning:The problem of the severely burned patient.Talking to patients with mutilating injuries and burns.

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Two weeks plastic surgery anaesthesia


To learn the full range of plastic surgical procedures. Malignant disease, reconstructive, cosmetic and the treatment of burns. Techniques and management plans learnt in other areas will be transferred to plastic surgery.Special attention will be paid to the management of burns.


Appropriate attachment to plastic surgical lists should be combined with someexperience of a burns unit which will usually be in a supernumerary role.

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Second, Third and Fourth Year Registrar Learning plan and Clinical Experience.ENT / Maxillo-facial / Oral/ Dental/ Plastics

Second year registrar general and optional experience

A number of options are open to trainees during this year. Most trainees will have at least part of their year dedicated to general training and during this period they will have regular experience related to these specialities. It is essential that varied experience takes place at this time.

Research could be conducted in one of these speciality areas.

Third year registrar general experience year.

There are no specific secondments to these specialities during this general experience year but ad hoc work both routine and emergency will continue.

Fourth year registrar special experience year.

During the final year trainees can opt for special experience in one or more of these specialities if they are expressing a special interest for a consultant post. A supervisor would organise a suitable work plan with the trainee.

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5. Pain Management

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Training in Pain Management

Learning about the management of acute pain and in particular post-operative pain begins immediately in the SHO training curriculum. The logical use of analgesia services in recovery units and the role of acute pain teams must be taught. Where available some experience of the work of a chronic pain consultant should be included in the week by week allocation prior to the formal 4 week secondment in the second year.

There are subsequent block secondments to pain management services. Those wishing to develop a special interest will need to opt for additional experience.

Units offering training in acute and chronic pain management

SHO’s should have experience of post-operative pain management in acute pain teams which include a Consultant in charge and pain team nurses. Where a unit with SHO training has no analgesia service a secondment to such a service should be made.

Chronic pain management must take place in a unit with access to:

1. Dedicated consultant sessions.2. An adequate workload.3. Adequate allied and ancillary staff.4. Facilities for:

imaginglaboratory servicesspecialist clinical psychology serviceoccupational therapy and rehabilitation facilitiesneurophysiological investigation

5. Opportunities for research.

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Experience in Acute and Chronic Pain Management

Grade Stage

SHO1-3 Months

Learning Acute pain and post- operative pain relief throughout this period

9-18 months Chronic pain module 4 weeks

SpR SpR 1 & 2 4 weeks acute and chronic pain.

SpR 3 2 months acute and chronic pain.

SpR 4 6 months optional special experience.

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First Year SHO Learning planAcute and Chronic Pain ManagementThe first nine months


Learning:Post-operative pain relief.Use of opioids by i.m., i.v. and s.c. routes.Use of PCA.Use of regional anaesthesia for post-op pain relief.Use of epidural opioid infusions/PCA.Use of simple analgesics / NSAID’s.Treatment of post-operative nausea and vomiting (PONV).


Learning:Pharmacology as applied to the management of pain.Physiology and pharmacology of PONV.Pharmacology of local anaesthetics.The role of the acute pain service.


Learning:Discussion of post-operative pain relief with patients when pre-op visiting.Communicating information relating to operative and post-operative pain relief to recovery ward staff.Ability to write clear directions for post-operative pain relief plan.

Local Assessment

None

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First year SHO Learning PlanAcute and chronic pain managementNine to eighteen months

Four weeks chronic pain management


Skilled in:Use of opioids by i.m., i.v. and s.c. routes.Use of PCA.Use of simple analgesics/NSAID’sTreatment of PONV.

Competent in:Use of regional anaesthesia for post-operative pain relief.

Learning:Planning the management of the patient.The use of diagnostic aids.Use of epidural opioid infusions/PCA.Principles of symptom control in Palliative Care.The clinical assessment and multi-dimensional measurement of pain, disability and quality of life.Use of diagnostic and therapeutic nerve blocks.


Competent in:Pharmacology as applied to pain management.Physiology and pharmacology of PONV.Physiology and pharmacology of local anaesthetics.Role of the acute pain service.

Learning:The epidemiology and sociology of pain.An understanding of all aspects of terminal illness.Use of opioids in terminally ill patients (tolerance, ceiling, adjuvants).Introduction to chronic non-malignant pain syndromes e.g. reflex sympathetic dystrophy, phantom limb pain, post herpetic neuralgia.Use of TENS.Use of “central” analgesics ( TCA’s, anticonvulsant ).Physiology of acute pain pathways.Anatomy relating to pain.


Competent in:Hand-over of patients to recovery ward staff.Writing clear directions for post-operative pain management.

Learning:Assessment of psychological and psychiatric contributes to pain.The use of psychological methods.The use of behavioural methods of pain management.Pre-operative assessment and discussion with patient regarding use of opioid epidural infusions and PCA..

Local Assessment

Able to plan appropriate post-operative pain relief.Able to deal with PONV in a systematic fashion.

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First year SHO Clinical ExperienceAcute and chronic pain managementNine to eighteen months

Four weeks chronic pain management


An introduction to the speciality of pain management.Understanding the scope of the speciality.Understanding the work pattern of the pain specialist.The role of non medical professionals in the management of pain.


4 weeks secondment full time to a suitable pain clinic and associated services.

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First year Specialist Registrar Learning PlanAcute and chronic pain management

Four weeks acute and chronic pain managementThis secondment should be in a continuous block.


Skilled in: Use of opioids by i.m., i.v. and s.c. routes.Use of PCA.Use of simple analgesics/NSAID’sTreatment of PONV.Use of regional anaesthesia for post operative pain relief.

Competent in:Use of epidural opioids/PCA.Principles of palliative care with opioids.

Learning:Planning the management of the patient. The use of diagnostic aids.The clinical assessment and multi-dimensional measurement of pain, disability and quality of life.Treatment of reflex sympathetic dystrophy. Early recognition, Intra venous regional sympathetic block, physiotherapy.Management of phantom limb pain.Use of TENS in chronic non malignant pain.Treatment of low back pain.The role of neural blockade.The indications for and role of neuro-ablative procedures.The role of surgery.


Skilled in:Pharmacology of opioids.Physiology and pharmacology of PONV.Physiology and pharmacology of local anaesthetics.Role of the acute pain service.

Competent in:The epidemiology and sociology of pain.An understanding of all aspects of terminal illness.Use of opioids in terminally ill patients (tolerance, ceiling, adjuvants).Introduction to chronic non-malignant pain syndromes e.g. reflex sympathetic dystrophy, phantom limb pain, post herpetic neuralgia.Use of TENS.Use of “central” analgesics ( TCA’s, anticonvulsant ).Physiology of acute pain pathways.Anatomy relating to pain.

Learning:The role of the pain management unit.Multidisciplinary approach to pain management.Psychology of chronic pain behaviour.The role of individual team members (clinical psychologist, physiotherapist, pain specialist)Specific anaesthetic blocks in the treatment of pain. Lumbar sympathectomy, stellate ganglion block.

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Skilled in:Hand-over of patients to recovery ward staff.Writing clear directions for post-operative pain management.

Competent in:Pre-operative assessment and discussion with patient regarding use of opioid epidural infusions and PCA.. The use of psychological methods.

Learning:Taking an adequate pain history, carrying out appropriate examination.Talking to patients and their relatives with chronic and terminal painful conditions.The place of complimentary medicine.

Local Assessment

Managing an acute pain round with clinical nurse specialist.Informal feedback with pain specialist.

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First year Specialist Registrar Clinical ExperienceAcute and chronic pain management

Four weeks acute and chronic pain management


To consolidate previous acute pain learning.To develop practical and theoretical skills in chronic pain management.To understand the team approach to pain therapy.To learn to communicate well with patients about their pain.

Specific Clinical experience

Four weeks experience of work within a pain team. Participating fully in all aspects of the work.The opportunity to observe specific practical procedures:

peripheral and central nerve blocksepidural and subarachnoid injectionsinjection into and around jointsintrapleural techniquesneurolytic techniques as applied to peripheral nerves and nerves in the epiduraland subarachnoid spaces.thermocoagulationcryotherapypercutaneous techniques of sympathetic blockadeintravenous regional sympathetic blockadestimulation produced analgesiarelaxation techniquesimplantation of pumps and catheters

neurosurgical techniques used in pain reliefionisation therapy and chemotherapy in pain management

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Third year Specialist Registrar Learning PlanAcute and chronic pain managementEight weeks acute and chronic pain management


Skilled in:Use of opioids by i.m., i.v. and s.c. routes.Use of PCA.Use of simple analgesics/NSAID’sTreatment of PONV.Use of regional anaesthesia for post operative pain relief.Use of epidural opioids/PCA.Principles of palliative care with opioids.

Competent in:Planning the management of the patient. The use of diagnostic aids.The clinical assessment and multi-dimensional measurement of pain, disability andquality of life.Use of TENS in chronic non malignant pain.The role of neural blockade.The indications for and role of neuro-ablative procedures.The role of surgery.Treatment of reflex sympathetic dystrophy. Early recognition, Intra venous regional sympathetic block, physiotherapy.Management of phantom limb pain.Use of TENS in chronic non malignant pain.Treatment of low back pain.

Learning:Organisation of pain management unit/clinic.Organisation of pain management programme.Organisation of palliative care in home/hospital/hospice settings.Assessment of pain in children.


Skilled in:Pharmacology of opioids.Physiology and pharmacology of PONV.Physiology and pharmacology of local anaesthetics.Role of the acute pain service.Use of opioids in terminally ill patients.Physiology and pharmacology of pain pathways.Awareness of chronic non malignant pain syndromes.Use of TENS.

Competent in:The role of the pain management unit.Multidisciplinary approach to pain management.Psychology of chronic pain behaviour.The role of individual team members (clinical psychologist, physiotherapist, pain specialist)Specific anaesthetic blocks in the treatment of pain. Lumbar sympathectomy, stellate ganglion block.

Learning:Specific anaesthetic blocks in relief of pain.

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Skilled in:Hand-over of patients to recovery ward staff.Writing clear directions for post-operative pain management.Pre-operative assessment and discussion with patient regarding use of opioid epidural infusions and PCA.

Competent in:Explaining to patients.Talking to patients with chronic and terminal painful conditions.

Learning:Skills involved in management of more difficult patients. e.g. angry patients, seriously depressed patients. Talking to dying patients and their relatives.

Local Assessment

Informal feedback with pain specialist.

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Third year Specialist Registrar Clinical ExperienceAcute and chronic pain management

Eight weeks acute and chronic pain management


To understand the organisation and management of pain services.To develop skills of acute and chronic pain management.To develop skills in palliative care.To understand whether to opt for additional training in pain management.


Two months continuous secondment to a pain management service.Experience in wards , out patients, home and hospice.Experience of specific practical procedures:

peripheral and central nerve blocksepidural and subarachnoid injectionsinjection into and around jointsintrapleural techniquesneurolytic techniques as applied to peripheral nerves and nerves in the epidural and subarachnoid spaces.thermocoagulationcryotherapypercutaneous techniques of sympathetic blockadeintravenous regional sympathetic blockadestimulation produced analgesiarelaxation techniquesimplantation of pumps and catheters

neurosurgical techniques used in pain reliefionisation therapy and chemotherapy in pain management

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Second and Fourth Year Registrar Learning plan and Clinical Experience.Acute and Chronic Pain Management

Second year registrar general and optional experience

A number of options are open to trainees during this year. Most trainees will have at least part of their year dedicated to general training and during this period they could have regular experience relating to pain management. It is essential that varied experience takes place at this time.

Research could be conducted in one of these speciality areas.

Fourth year registrar special experience year.

During the final year trainees can opt for special experience in one or more of these specialities if they are expressing a special interest for a consultant post. A supervisor would organise a suitable work plan with the trainee. It would be expected that all trainees wishing to take up a consultant post with a special interest in some area of pain would undergo six months further training in pain.

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6. Anaesthesia for Eye Surgery

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Experience of Anaesthesia for Eye Surgery

Second Year SHO (9 - 18 Months) 4 WeeksFirst Year Specialist Registrar 4 Weeks

There are two periods of experience identified in the anaesthetic curriculum; during the second year as an SHO and as a first year registrar. These periods are intended for intensive training in anaesthesia for this specialty in order to fully understand the particular difficulties.

In addition ophthalmic surgery should be regularly included in the trainees work schedule in non allocated time. Trainees may feel that more experience would be advantageous to them and can organise this during optional period as second and fourth year registrars.

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Second Year SHOLearning Plan for Anaesthesia for Eye Surgery at 9-18 months4 Weeks secondment


Learning:Anaesthesia for squint surgery.Anaesthesia for cataract surgery.Anaesthesia for other techniques not including vitreo-retinal surgery.Observation of vitreo-retinal surgery.Observation of local anaesthetic techniques.Dealing with microscopes and specialised eye operating machinery.


Learning:Anatomy, techniques and complications relating to ocular regional anaesthesiaControl of intra-ocular pressure.Occulo-cardiac reflex.Ophthalmic pharmacology as related to anaesthesia.Deciding between general and local anaesthesia for eye surgery.Anaesthesia for ocular emergencies. penetrating eye injuries.Nitrous oxide free anaesthesia for vitreo-retinal surgery.Ocular disease in generalised systemic disease. Diabetes etc..Safety issues relating to lasers.


Learning:Talking to children.Discussing anaesthetic choice of local or general anaesthesia.Anaesthesia in remote sites

Local Assessment

Feedback from consultants.Possible Eye list assessment

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Second Year SHOClinical Experience of Eye Surgery at 9-18 months4 Weeks Secondment


To learn about the repertoire of ophthalmic surgeryTo learn how to give anaesthetics for eye operations of simple and intermediate difficulty.To observe more complex operations.To understand the problems of anaesthesia for children.To understand the problems of anaesthesia for the elderly.To appreciate the effect of related systemic and intercurrent disease on the management of patients for eye surgery.To observe and begin learning regional anaesthesia for ophthalmic surgery.


Four weeks experience of eye surgery.This may be a continuous secondment or be managed as day by day allocation. If the latter course is chosen attention must be paid to providing continuity of learning.

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First Year RegistrarLearning Plan for Anaesthesia for Eye Surgery 4 Weeks secondment


Skilled:Anaesthesia for squint surgery.Anaesthesia for cataract surgery.Anaesthesia for other techniques not including vitreo-retinal surgery.

Competent:Regional anaesthesia for eye surgery.Paediatric anaesthesia for eye surgery.Per-operative management of diabetes.

Learning:Anaesthesia for vitreo-retinal surgery.Ocular blocks.Management of intra-ocular pressure.Eye syndromes.


Skilled:Anatomy, techniques and complications relating to ocular regional anaesthesiaControl of intra-ocular pressure.Occulo-cardiac reflex.Ophthalmic pharmacology as related to anaesthesia.Deciding between general and local anaesthesia for eye surgery.Safety and lasers.

LearningAnaesthesia for ocular emergencies. penetrating eye injuries.Nitrous oxide free anaesthesia for vitreo-retinal surgery.Ocular disease in generalised systemic disease. Diabetes etc..


Competent:Talking to children.Discussing anaesthetic choice of local or general anaesthesia.Anaesthesia in remote sites

Learning:Planning surgery for more complex patients.Surgery for the very elderly.

Local Assessment

Feedback from consultants.

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First Year RegistrarClinical Experience of Eye Surgery4 Weeks Secondment combined with ENT


To learn how to anaesthetise for more complex operations.To learn about vitreo-retinal surgery.To understand the problems of anaesthesia for children.To understand the problems of anaesthesia for the elderly.To appreciate the effect of related systemic and intercurrent disease on the management of patients for eye surgery.To become skilled in regional anaesthesia for ophthalmic surgery.


Four weeks experience of eye surgery. This secondment is shared with ENT.This may be a continuous secondment or be managed as day by day allocation. If the latter course is chosen attention must be paid to providing continuity of learning.

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7. Anaesthesia for Day Surgery

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Learning Anaesthesia for Day Surgery

Trainees will learn about day patient surgery and surgery for ambulant patients in the course of their various experiences of speciality anaesthesia. No special provision is made to allocate trainees to blocks of day surgery work.

It is however expected that attention will be paid to the basic principles of anaesthesia for day surgery.

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Learning Plan for Day Patient Anaesthesia

Clinical Skills ListLearning:Assessment of patients as appropriate for day surgery.Appropriate and inappropriate anaesthetic techniques for day patients.Day patient procedures appropriate to all surgical specialities.Regional anaesthesia appropriate to day patients.Managing post operative analgesia in day and ambulant patients.Criteria for discharge of day surgery.Surgical and anaesthetic complications which justify keeping day patients in hospital.Paediatric day surgery.Day surgery in the elderly.


Learning:The ideals of anaesthesia and surgery in day patients.Factors affecting suitability of patients for day surgery.Theoretical considerations relating to anaesthetic agents and techniques applicable to day patients.Theoretical considerations relating to post operative analgesia in day patients.Recognition of possible and likely complications of day surgery.Design of purpose built day surgery units.Staffing and management of day surgical units.


Learning:Communicating important information to patients and carers.Screening patients for general fitness.Keeping records in day surgery.Giving discharge information to patients.Managing day surgery as a team.

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8. Neuro-Anaesthesia

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Neuro-Anaesthesia Training Programme.Northern Schools of Anaesthesia

Introduction:

The progressive development of skills in the management of patients with neurological diseases or trauma is essential to the safe practice of anaesthesia. The principles and practical aspects of this area of practice will be taught and assessed throughout the training programme. The initial periods are to enable the safe management of patients with head injuries in the 'Golden Hour', and in patients with cervical fractures.

The syllabus document of the Royal College defines the appropriate skills that need to be taught and assessed during the SHO and pre-fellowship SpR period. Further skills are necessary for those who enter the specialist modules in the SpR grade year 3, and have been defined by the Neuro-anaesthesia Working Party of the NEALG.

Programme of Training - :

Stage of training Duration of ModuleSHO - Year 1 Observation - 1 / 2 weeksSHO - Year 2 Observation - 1 / 2 weeksSpR 1 4 weeksSpR 2 - Neuro Specialist only Optional 3 months + ResearchSpR 3 2 MonthsSpR 4 - Neuro Specialist only Optional 6 - 12 Months

Notes:

These modules are an indication of the emphasis placed on these areas by the Learning Group, and for the specialist registrar years will involve placement within a Neuro-surgical Unit. A maximum of 70% of the available time should be within the speciality, while the rest of the time should be used to maintain general skills in anaesthesia.

The supervision should always be by post-fellowship anaesthetists, and in the Neurosurgical units by consultants or SpR4s.

The documentation of successful achievement in the practical and clinical skills must occur before the trainee can proceed to more complex tasks. Where there is a failure to pass the assessment, this must be recorded for the RITA forms, and the Clinical Director informed if these skills are essential to placement on the on-call rota or solo lists.

Log Books will be kept current at all times and the case-mix will be used in the latter years as evidence of practical experience as well as clinical training.

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SHO Training in Neuro-Anaesthesia - Year 1 Learning Plan

Objectives of Training:To begin to understand the principles underlying the practice of neuro-anaesthesia with especial emphasis on the effects of trauma to the head, and to the neck. This initial exposure is to allow the details of management of head injuries and neck fractures to be taught and assessed before participation on the On-Call rota occurs.


Learning the Clinical Skills of the:Principles of anaesthesia for patients with a head injuryBasic control of CPPCare of the Unconscious PatientManagement of Acute Head Injury [ including immediate resuscitation]Management of Cervical Fractures

Learning the Practical Skills of:Airway ManagementIn-Line TractionHyperventilation TechniquesDrug control of ICP - Mannitol


Consolidating basic knowledge of neuro-anatomy & neuro-physiologyDeveloping the understanding of :

The Glasgow Coma ScoreAcute Brain Injurythe control of ICPMonitoring function - EEG + EMGthe CNS effects of anaesthetic drugs


History taking from neuro patientsPresentation of a case history of a head injured patient

Assessment at the end of Year 1

MCQ - Local - to demonstrate - Understanding & Factual RecallDissertation - Local to demonstrate - Judgement & PrioritisationPractical Skills - Manikin / Theatre In-Line Traction & Intubation

Suitable Hospital Types:

Ability to care for the head injured patient for the first 20 minutes, until more experienced help arrives, is a generic skill and opportunities for teaching and assessment of these skills is not limited to those hospitals with a Neuro-Trauma service. Small teaching units may need to arrange the secondment of their SHOs for ITU observation of management of these patients, but opportunities for the immediate care, CT scanning, and preparation of the patient for transfer to the nearest neuro-surgical unit are widely available.

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SHO Training in Neuro-Anaesthesia - Year 2Learning Plan


The trainee will be part of the On-Call team, and will be responsible for the immediate care of neuro-trauma patients. This second exposure is to consolidate these skills, and to develop the skills inherent within providing safe anaesthesia for spinal surgery in the prone position, and in the Intensive Care of neuro-surgical patients.

Clinical Skills

Competent in: Management of the Acute Head InjuryManagement of the Cervical fractureCare of the unconscious patientAirway management in the Unconscious patientControl of ICP using Drugs, and VentilationAssessment of the neck, and immobilisation of cervical fractures

Learning:Care of the prone patient for spinal surgeryIntensive care of the Head Injured patientDrug and ventilation therapy of raised ICPSkills necessary for safe CT and MRI scanning Practical Skills:The safe preparation and transport of head injured patientsThe safe preparation and transport of head injured patients

Theoretical Skills:

Competent in:The understanding of the pathophysiology of neuro traumaThe effects of raised ICP and the causes / therapy of these effectsThe accurate use of the GCS in the assessment and hand-over of patients

Learning Skills in:the assessment of reflex activity - brain stem & spinal tracts.

Communication Skills:

Learning:How to talk to relatives of head injured patientsTo present such a case on the ITU ward-round

Assessment

Practical performance Skills inventoryEssay Paper Priority & JudgementLog Book Review Breadth of experience

Where there are failures within the assessment of the trainee these must be identified with the trainee and documented. The Clinical Director must be informed of these where they have an effect on the competence of the trainee to function as a safe member of the On-Call team. Where further time is thought necessary for re-training the postgraduate Dean's Department must also be informed.

Failure of the Primary FRCA DOES NOT require these measures, although the progress of the trainee to the Specialist Registrar Posts will not be possible as this forms part of the Minimum Educational Requirements for these posts.

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Specialist Registrar - Year 1 Learning PlanBased within a Neuro-Anaesthetic Unit


The primary aim of this period of training is to observe and develop those skills in neuro-anaesthesia that are defined in the syllabus of the Royal College for the Final part of the FRCA examination. There will be regional variation in the breadth of experience available, but the local teaching will cover those aspects not commonly available within the Unit.


Skilled in:Emergency head injury managementStabilisation of neuro-trauma patientsInvasive monitoring GCS scoringManipulation of CPP

Competent:Intensive care of the neuro-trauma patientITU management of multiply injured neuro-trauma patientsinterpreting CT & MRI scan data

Learning:Anaesthesia for Craniotomy and Posterior Fossa SurgeryBrain stem testingOrgan Donation protocolselective intracranial surgeryHypotensive anaesthetic techniquesAnaesthesia for supra-tentorial vascular and tumour surgeryProlonged anaesthesiaMonitoring of neurological function during anaesthesia - BAEP, CFAM, EEG etc.


Learning:Awareness of current controversies in basic neuro-anaesthesiaNeuro-anaesthesia for supra-tentorial intracranial surgerythe care of patients undergoing posterior fossa surgeryV-P Shunt surgery in childrenDrainage of acute sub-dural haemorrhage


Competent:in case presentationin Oral examination methods for the Final FRCAPresenting current data and theories relevant to neuro-anaesthetic practice

Learning skills in:Small group teaching of neuro-trauma to SHOs

Assessment

Success in the Final FRCA examinationAble to supervise an SHO for the immediate of severe head injured patientsLocal Assessment of Log Book for Clinical ExperienceLocal practical skills assessment - ATLS / APLS

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SpR year 2 - Optional Specialist TrainingBased within a Neuro-Anaesthetic Unit

These posts will be arranged following successful transition from the first specialist year, and the completion of the FRCA.

There will be an individual programme of further experience and research organised by the Director of the School. The expectation of this module is to provide an expansion in skills applicable to neuro-anaesthesia or neuro-trauma.

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Specialist Registrar - Year 3 Learning PlanBased within a Neuro-Anaesthetic Unit


This year aims to provide those specialist skills necessary for safe and competent practice in a Non-Specialist Hospital. Further training is likely to be needed to allow practice within a Neuro-Anaesthesia Unit - This will be gained within SpR year 4 for those who wish such specialisation.


Skilled in:Supra-tentorial surgery - Including aneurysm surgerySpinal Surgery - cervical + LumbarInt Invasive monitoring Monitoring & Interpretation of dataITU management of multiply injured neuro-trauma patients ensive care of the neuro-trauma patient

Competent in:Brain stem testing'Normal' posterior fossa surgery Paediatric neurosurgery - V-P shunts for exampleHypotensive anaesthetic techniquesProlonged anaesthesia

Learning:Complex posterior fossa surgery - Complex spinal surgery - Thoracic and scoliosis surgery Complex paediatric surgery - posterior fossa tumours, cranio-facial surgeryEvoked Potential recording / EEG analysis


Competent in:Management issues in providing neuro-anaesthesiaOrganisational issues within the neuro-trauma ITU Learning:Medico-legal aspects of Neuro-Anaesthesia

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Competent in:Small group teachingExamination practice for SpR1 traineesPresenting current data and theories relevant to neuro-anaesthetic practice

Learning skills in:Curriculum developmentEducational skills

Assessment:

Written:

The trainee will write a dissertation of 5,000 words on the anaesthetic management of a neuro-anaesthetic patient, and will include a comprehensive reference list, illustrations and appropriate statistical proof for his / her opinions.

Practical:

Safely and effectively organise and run a routine Neurosurgical Operating list. This will include pre-operative care, per-operative management and any teaching of junior trainees, and the immediate post-operative care of the patients. This will include the choice of HDU or ITU where necessary.

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Specialist Registrar Year 4Extended Training Module In Neuro-Anaesthesia.6 Months Minimum


To enhance the skills of the trainee to the level of a 'Specialist' anaesthetist in Neuro-anaesthesia. This will involve the exposure to all aspect of neuro-anaesthesia, and the gradual increase in responsibility for clinical and educational matters during the module.

Site Of Training:

The necessary training cannot be gained within either of the Neurosurgical Centresalone, and the trainee will have to spend a proportion of time in both teaching centres.

The duration of each portion will be assessed individually from the log book case mix,and the eventual aims of the trainee. However, the duration in any one unit will be not less that 3 months.

The Directors of the Schools, and the Lead Tutor of neuro-anaesthesia in each unit will define the content of each training module with the individual trainee before the start of the module, and at regular intervals throughout the training to assess satisfactory progress.

Clinical Fellowships in Neuro-Anaesthesia

These are likely to be made available on an individual basis for anaesthetists who have achieved their CCST, and who wish further specialist experience in neuro-anaesthesia. They will be fixed term posts, at a Junior Consultant level, within individual Trusts. The details of these posts will be determined by the Clinical Directors of the Units with the Director of the local School.

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9. Curriculum for Thoracic and Cardiac Anaesthesia

Including anaesthesia for patients with serious respiratory or cardiac disease complicating non thoracic surgery.

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Training in Anaesthesia for Thoracic and Cardiac Anaesthesia and for anaesthesia in patients with serious coexisting cardiac or respiratory disease.

Experience Of Anaesthesia for Thoracic and Cardiac Anaesthesia

Grade Stage

SHO Introductory month

1-3 Months

3-6 months

9-18 months One week observation of thoracic and cardiac anaesthesia.

18-24 months Possibility of optional experience of thoracic and cardiac anaesthesia. ( two weeks)

Specialist Year 1

Four weeks cardiac and thoracic anaesthesia.

Registrar Year 2

Optional specialist training based within a cardiothoracic unit.

Year 3 Two months thoracic and cardiac anaesthesia.

Year 4 Option of six months cardiac and thoracic anaesthesia

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First Year SHO Learning planAnaesthesia for Thoracic and Cardiac AnaesthesiaSix to Nine Months

An introduction to demystify cardiothoracic anaesthesia, to see the role of the subspecialty anaesthetist and an introduction to applied cardiorespiratory pathophysiology and pharmacology.


Learning:

Introduction to preoperative assessment of patients with cardiac and respiratory disease.Introduction to use of inotropes, vasodilators and vasoconstrictors to manipulate the heart and circulation.Introduction to invasive cardiovascular monitoring : arterial, central venous, PA including risks.Witness double-lumen intubation, rigid bronchoscopy, paravertebral nerve block.


Competent in:Basic respiratory and cardiovascular physiology.

Learning:Introduction to pharmacology of cardiovascularly active drugs: inotropes, vasoconstrictors/dilators, drugs for rhythm disturbance and heart failure.Introduction to pathophysiology of valve and coronary artery disease as relevant to anaesthesia and surgery.Introduction to pathophysiology of lung disease as relevant to anaesthesia and surgery.Introduction to tracheobronchial anatomy.


Competent in:Patient interviews.Presentation of patient assessment to colleagues.Maintenance of good clinical records.

Learning:Communication with other health care professionals.Communication of learned material to peers.

Local Assessment

Log book, attendance.

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First Year SHO Clinical ExperienceAnaesthesia for Thoracic and Cardiac AnaesthesiaSix to Nine Months


Witness preoperative anaesthetic assessment in patients undergoing cardiothoracic surgery.Introduction to the pathophysiology of cardiac disease and its relevance to anaesthesia. Introduction to the pathophysiology of lung disease and its relevance to anaesthesia.Introduction to arterial and central venous line insertion and awareness of risks.Introduction to manipulation of the cardiovascular system with inotropic and vasoactive drugs.Introduction to double-lumen intubation and rigid bronchoscopy.Interpretation of arterial blood gas results.


Observe rigid bronchoscopy, double-lumen intubation, paravertebral nerve block.Practice arterial and central venous cannulation.Observe anaesthetic management of patients undergoing coronary artery bypass and valve surgery.

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SHO Learning planAnaesthesia for Thoracic and Cardiac AnaesthesiaEighteen Months to Two Years

Two week optional module


Competent in:Arterial cannulation.Interpretation of invasive monitoring.

Learning:Central venous cannulation.Introduction to pain relief techniques for thoracic surgery.Introduction to rigid bronchoscopy, jet ventilation, one-lung anaesthesia, double-lumen intubation.Introduction to preoperative assessment of patients for cardiac and thoracic surgery.Introduction to role of inotropes and vasoactive drugs in patients undergoing cardiac surgery.Introduction to basic perioperative management of patients undergoing cardiac and thoracic surgery: premedication, peroperative anaesthesia, analgesia and fluid management, and postopertive analgesia, fluid management and respiratory and cardiovascular care.Anaesthesia for cardioversion.


Learning:Pathophysiology of cardiovascular disease and its relevance in patients undergoing anaesthesia for non-cardiac surgery.Pathophysiology of lung disease and its relevance in patients undergoing anaesthesia for non-thoracic surgery.Introduction to intensive support of the failing heart : pathophysiology and pharmacology.Introduction to applied physiology of one-lung ventilation.Introduction to pulmonary function tests and their relevance to the anaesthetist.Introduction to cardiac catheter data and its relevance to the anaesthetist.Pacemakers.


Competent in:Patient interviews.Communication with other health care professionals.Presentation of relevant patient data to colleagues. Maintenance of accurate clinical records.

Local Assessment

log book, attendance.

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First Year SHO Clinical ExperienceAnaesthesia for Thoracic and Cardiac AnaesthesiaEighteen Months to Two Years


To develop a better understanding of the pathophysiology of ischaemic and valvular heart disease and its application to anaesthesia for non-cardiac surgery.To develop a better understanding of the pathophysiology of respiratory disease and its application to anaesthesia for non-thoracic surgery.Introduction to paravertebral nerve block for postoperative pain relief.Introduction to thoracic epidural analgesia.Practice in rigid bronchoscopy and double-lumen intubation.Practice in use of inotropes and vasoactive drugs for cardiovascular support and manipulation.To learn about pacemakers and their relevance to the anaesthetist.To be able to conduct anaesthesia for cardioversion.


Rigid bronchoscopy. Double-lumen intubation.Paravertebral nerve block.Witness preoperative assessment and anaesthesia for patients undergoing coronary artery bypass and valve replacement surgery.Visit pacemaker clinic.Visit pulmonary function test laboratory.Observe cardiac catheterisation.

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First Year Specialist Registrar Learning planAnaesthesia for Thoracic and Cardiac Anaesthesia


Skilled in:Arterial cannulation.Interpretation of invasive monitoring.

Competent in:Central venous cannulation including pulmonary flotation catheters.

Learning:Preoperative assessment of patients for cardiac (coronary artery bypass or valve) and thoracic surgery.Anaesthesia and postoperative care for adult patients undergoing cardiac surgery including role of inotropes and vasoactive drugs. Rigid bronchoscopy, double lumen intubation.Anaesthesia for pleurectomy, mediastinoscopy, lung resection including video-assisted surgery.Jet ventilation, high frequency ventilation.


Competent in:Invasive monitoring: normal values, waveforms, physics.Basic cardiovascular and respiratory physiology and pharmacology.

Learning:Intensive support of the failing heart: pathophysiology and pharmacology including IABP.Introduction to pathophysiology of cadiopulmonary bypass.History of thoracic anaesthesia.Applied physiology of one-lung ventilation.Influence of operative position in anaesthesia.Interpretation of pulmonary function tests in the context of lung resection.High frequency positive pressure ventilation.Management of specific situations eg foreign body in airway, bronchopleural fistula.


Skilled in:Preoperative patient interviews and presentation of findings to colleagues.Communication with other health care professionals. Maintenance of accurate clinical records.

Competent in:Recognition of need for help.

Learning:Presentation of topical material to department.

Local Assessment

Presentation and critical appraisal of topical article at Journal Club.Clinical assessment of perioperative management of patient undergoing thoracic procedure requiring double-lumen intubation.

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First Year Specialist Registrar Clinical ExperienceAnaesthesia for Thoracic and Cardiac Anaesthesia


To understand the similarities and differences between “cardiac” and “non-cardiac” anaesthesia.Further understanding of the pathophysiology of heart disease and its relevance to the anaesthetist.Further understanding of the pathophysiology of respiratory disease and its relevance to the anaesthetist. Practice in rigid bronchoscopy and double-lumen intubation techniques.To develop skills in thoracic epidural and paravertebral blocks for postoperative analgesia.Practice in the use of inotropes and vasoactive agents in patients with a compromised heart.


Directly supervised pre, per and postoperative care of patients undergoing CABG and valve surgery. Directly supervised pre, per and postoperative care of patients undergoing thoracic surgery.

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Second Year Specialist Registrar - Optional Specialist Training based with a Cardiothoracic Unit

These posts will be arranged following successful transition from the first specialist year and the completion of the FRCA. There will be an individual programme of further experience and research opportunities organised by the Director of the School.

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Third Year Specialist Registrar Learning planAnaesthesia for Thoracic and Cardiac Anaesthesia


Skilled in:Arterial and central venous cannulation techniques including PA catheters.

Competent in:Manipulation of the heart and circulation with inotropes and vasoactive drugs.

Learning:Perioperative anaesthetic management of patients undergoing heart surgery (CABG, valve). Postoperative intensive care for patients following heart surgery.Assessment and management of patients undergoing major thoracic surgery.


Skilled in:Continuing self assessment and education.

Competent in:Intensive support of the failing heart: pathophysiology and pharmacology including IABP.Applied physiology of one-lung ventilation.Influence of operative position in anaesthesia.Pulmonary function tests and their application to lung resection.High frequency positive pressure ventilation.Management of specific situations eg foreign body in airway, bronchopleural fistula.

Learning: Implications for subsequent anaesthesia in patients with a heart or lung transplant.The role of echocardiography in patients with heart disease.Pathophysiology of cardiopulmonary bypass, including an introduction to the protection of the heart and brain.


Skilled in:Maintenance of good clinical records.Case presentation, communication with other health care professionals, patients and relatives.

Competent in:Teaching transferable skills.

Learning:Individualised education for trainees and non-medical staff.Manpower management.

Local Assessment

Preoperative assessment, anaesthesia and postoperative plan for patient with good left ventricular function undergoing CABG.Audit project or topic review.

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Third Year Specialist Registrar Clinical ExperienceAnaesthesia for Thoracic and Cardiac Anaesthesia


Familiarity with inotropic and vasoactive agents for cardiovascular manipulation.Understand options for intensive support of the failing heart.Experience in rigid bronchoscopy, double lumen intubation and one-lung anaesthesia, and thoracic regional analgesic techniques.Practice intensive care in patients with impaired cardiac function and multi-organ failure.Understand implications of heart or lung transplantation for subsequent anaesthesia.


Rigid bronchoscopy, double lumen intubation.Conduct anaesthesia for mediastinoscopy, pleurectomy, VAT surgery, lobectomy, pneumonectomy, oesophagogastrectomy with

distant supervision. Conduct anaesthesia for patients undergoing coronary revascularisation or valve surgery with direct supervision.Postoperative management of patients following cardiac and thoracic surgery. Intensive care management of patients with impaired cardiac function and multiorgan failure.

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Fourth Year Specialist Registrar Learning planAnaesthesia for Thoracic and Cardiac Anaesthesia


Skilled in:Cannulation techniques, manipulation of the heart and circulation with inotropic and vasodilator drugs.

Competent in:Perioperative management of uncomplicated patient for coronary revascularisation or lung resection.

Learning:Perioperative management of patients for valve disease, redo surgery, complex heart disease, aortic aneurysm, dissection or transection.Thoracic anaesthesia for laser surgery, mediastinal tumours, central airway obstruction.Anaesthesia for thoracic organ transplantation.Postoperative management of patient with failing heart and multiorgan failure. Interpretation of cardiac angiography.How to set up and run cardiopulmonary bypass.Echocardography.


Skilled in:Continuing self assessment and education.Applied physiology of one-lung ventilation.Influence of operative position in anaesthesia.Pulmonary function tests and their application to lung resection.High frequency positive pressure ventilation.Management of specific situations eg foreign body in airway, bronchopleural fistula.Intensive support of the failing heart: pathophysiology and pharmacology including IABP.

Competent in:Research method and analysis.Implications for subsequent anaesthesia in patients with a heart or lung transplant.The role of echocardiography in patients with heart disease.Pathophysiology of cardiopulmonary bypass.

Learning:Cardiac and cerebral protecion during cardiopulmonary bypass.Echocardiography.Ethical and legal issues. Management and budgeting, financial and contracting issues.


Skilled in: Discussions with patients and relatives.Case presentations to colleagues.Critical review of topical journal articles.

Competent in:Teaching transferable skills.Individualised education for trainees and non-medical staff.

Learning:Manpower management.Political awareness.Negotiating skills.Interview and preinterview presentation.

Local Assessment

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Fourth Year Specialist Registrar Clinical ExperienceAnaesthesia for Thoracic and Cardiac Anaesthesia


To become competent to take up a Consultant post specialising in cardiothoracic anaesthesia.


Individually tailored to career aims of individual but including:

Conduct anaesthesia for all types of adult and thoracic surgery with decreasing levels of supervision.Management of patients undergoing thoracic organ transplantation.Cardiothoracic Intensive Care.Paediatric Cardiothoracic Anaesthesia and Intensive care.Principles and practice of cardiopulmonary bypass and ECMO.ECG, Angiography and Echocardiography interpretation.“Special” and differential ventilation techniques.Fibreoptic and Rigid Bronchoscopy.All methods of postoperative pain relief.

Audit or research project.

Major topical review.

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10. Anaesthesia for Major Vascular Surgery

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Objectives

During vascular anaesthesia modules the trainee will learn to assess the relative risks of the vascular pathology, the risk of background cardiovascular disease, and the risks inherent in vascular surgical procedures. A rational approach to choice of preoperative investigation will be taught. The decision to operative (or not) is best undertaken following discussion between anaesthetist, surgeon, patient (and his/her relatives) and general practitioner.

The principles and practice of preoperative optimisation, anaesthesia and protocol based postoperative care on the intensive care unit will be taught

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SHO Learning Plan

The trainee will learn about the perioperative care of the patient for major surgery. Such patients may have overt or covert cardiovascular or pulmonary disease; they may need extensive surgery with potential complications such as a major haemorrhage or renal failure, and may need postoperative ventilation.


Learning:Assessment of the patient with cardiac diseaseAnaesthesia of the patient with cardiac disease for non-cardiac surgeryPlacement & management of intravascular cathertersManagement of major haemorrhageCoagulation controlPreservation of renal functionMaintenance of body temperatureOxygen therapyPain management following major surgery

Theoretical Skills ListLearning:Physiology of myocardial oxygen supply and demandPhysiology of body temperature controlRenal functionPharmacological control of the cardiovascular systemAcid-base balance

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Specialist Registrar Learning Plan (SpR 1 & 2)

The trainee must undergo the equivalent of two weeks of vascular anaesthesia. This will not necessarily be a block attatchment.The trainee will learn about the perioperative care of the patient for major vascular surgery. More detailed assessment of the relative risks of vascular/cardiac pathology and vascular surgery will be learned. The registrar will attend 6 vascular surgery operating lists and should be capable of conducting anaesthesia for aortic surgery by the time of completion of this module.


Skilled in:Placement & management of intravascular cathetersManagement of major haemorrhageCoagulation controlMaintenance of body temperatureOxygen therapyPain management following major surgery

Learning:Cardiac optimisation before aortic surgery (Starling curves)Insertion & management of thoracic epiduralsMinimising the haemodynamic impact of aortic cross-clampingManaging the metabolic consequences of aortic cross-clampingDiagnosis of perioperative myocardial ischaemia/infarction (TOE, ECG, CKMB/CLratio)


Skilled in:Physiology of myocardial oxygen supply and demandPhysiology of body temperature controlRental functionPharmacological control of the cardiovascular systemAcid base balance

Learning:Clinical scoring of cardiac risk (Goldman, Detskey, Eagle)Investigation of cardiac function (exercise ECG, DTS, DSE, ejection fractionPathophysiology of aortic cross-clamping


Learning:Communicating with surgeon at times of clamping/unclampingInstruction ICU nursing staff about strategy for postoperative care

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Specialist Registrar Learning Plan (SpR 3 & 4)

The specialist registrar in the final stages of training will already be competent in patient assessment/selection and the perioperative management of patients for vascular surgery. At this state it is appropriate to learn about development of vascular unit strategies/protocols formulated between anaesthetists, intensivists, surgeons, cardiologists and radiologists.


Skilled in:Manipulation of patient haemodynamicsDesign and implementation of perioperative patient management protocols

Learning:Transthoracic & transoesophageal ECHODoppler measurement of cardiac output

Theoretical Skills Lists

Skilled in:Patient assessment & selectionConduct of anaesthesia for major vascular surgeryPostoperative intensive care

Learning:Is there a place for coronary revascularisation?Prevention of ischaemia-reperfusion injury


Learning:Deciding patient selection strategies with the vascular surgeonDiscussing relative risks of aneurysms and surgery with patients and relatives

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11. Paediatric Anaesthesia

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Training in Anaesthesia for Children

There are a number of levels of paediatric anaesthesia training depending upon the career intention of the trainee. A full training in all aspects of paediatric anaesthesia for the anaesthetist who’s consultant post includes no special responsibility for paediatrics must be complete by the end of year 5 of training.

1. A baseline experience which is intended for a consultant with no special responsibility for childrens anaesthesia. This will include consultants in the many hospitals which have a substantial workload of childrens emergency services; but no specialised paediatric anaesthesia services. Adequate training must be achieved within the SHO years and SpR years 1 and 3.

2. Complex experience is needed for those who will work primarily in another subspeciality but in the course of which they will have responsibility for complex paediatric anaesthesia. This experience will be in the final year of training.

3. Training for sub-specialist paediatric anaesthetists. This group should also include anaesthetists with responsibility for paediatric services in general hospitals. Special training will take place in year 6 of training and also post-CCST if the unit employing the consultant feels that further training is needed.

Trainees will learn about anaesthesia for children throughout the six years of this training scheme. As each anaesthetic sub-speciality is introduced the trainee should give some thought to the application of that speciality in children. The first two years of the training scheme at the SHO level introduce paediatric anesthesia at the general level. There is no secondment to specialised paediatric units and no special involvement of paediatric anaesthetists. Children will be seen in specialities such as ENT, dentistry and ophthalmology. Between 18 months and two years into training College Tutors should try to ensure that trainees get the equivalent of 4 weeks experience of childrens anaesthesia. This is equivalent to12 operating lists which have a reasonable number of children on them or about forty children’s anaesthetics. The trainee’s log book should be examined to check that a reasonable number of children have been anaesthetised.

The four SpR years have two periods of specialist paediatric training. There is four months in year one and three months in year three. Trainees may complete training and obtain their CCST with only this quantity of training. Year SpR 1 experience can be arranged in any large hospital with childrens services by careful management and monitoring of the trainees workload. The year three experience must include a block of paediatric anaesthesia and intensive care.

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Grade Stage ExperienceSHO Experience with children is introduced as part of the day

to day work of the anaesthetic department and the level of involvement is increased throughout the two years. In the last six months as an SHO there should be opportunity for trainees to anaesthetise significant numbers of children.

Specialist Registrar

Year 1 4 weeks paediatric anaesthesia or equivalent caseload. Where specialist paediatric services exist trainees should have the opportunity to be attached to these.

Year 2 Remedial experience for those SpR’s who failed the examination (Final FRCA)Research, overseas experience etc. are possible.

Year 3 3 months paediatric anaesthetic experience. At least half in a specialist childrens service. Units with significant numbers of paediatric anaesthetics in the course of cardiac, plastic, dental or neuro anaesthesia for example can plan year 3 in a way which maximises this experience.

Year 4 Options for special experience. It will be expected that trainees intending major interests in childrens anaesthesia will undertake appropriate year 4 secondments.

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First Year SHO Learning PlanAnaesthesia for ChildrenThe First Month of training


Learning: No specific paediatric skills


Learning: Nil

Communication Skills listLearning: Nil

Local Assessment

Nil

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First Year SHO Clinical ExperienceAnaesthesia for ChildrenThe First Month of training

Objectives of TrainingNil

Specific Clinical ExperienceNone

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First Year SHO Learning PlanAnaesthesia for ChildrenThe First Three Months of Training

Trainees will observe paediatric anaesthesia and assist consultants. Their involvement will include holding facemasks, intubating and inserting i.v. canulae under supervision. They will never have responsibility for the conduct of the anaesthetic.


Learning:Observing anaesthesia in children.Simple airway management in children.Intubation of children


Learning: Simple airway equipment for children.Sizes of tubes and airways.paediatric laryngoscopes. Venepuncture.

Communication Skills list

Learning: Communication with parent and child.Learning about parents being present for anaesthetic induction.

Local AssessmentNone

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First Year SHO Clinical ExperienceAnaesthesia for ChildrenThe First Three Months


To begin learning airway management in children under direct supervisionTo start learning how to achieve i.v. access in children


None specific.Day to day contact with children and parents in the course of general anaesthetic duties.

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First Year SHO Learning PlanAnaesthesia for ChildrenThe First Six Months


Learning: Observing anaesthesia in children.Simple airway management in children.Intubation of childrenVenous access in childrenPaediatric basic life support


Learning: Simple airway equipment for children.Sizes of tubes and airways.Paediatric laryngoscopes. Venepuncture.Paediatric basic life support.Post-operative pain relief.


Learning: Communication with parent and childLearning about parents being present for anaesthetic induction.


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First Year SHO Clinical ExperienceAnaesthesia for ChildrenThe First Six Months

Objectives of TrainingTo continue developing airway management in children under direct supervision.To be effective as first on the scene in paediatric life support.To recognise the potential difficulties presented for the anaesthetist when dealing with children and to be aware of the need for help

even in apparently simple situations.

Specific Clinical ExperienceNone specific.General experience with children and parents.

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First Year SHO Learning PlanAnaesthesia for ChildrenSix to Nine Months


Competent: Paediatric basic life support

Learning: Observing anaesthesia in children.Simple airway management in children.Intubation of childrenVenous accessPaediatric basic life support


Competent: Sizes of tubes and airways.Paediatric laryngoscopes.

Learning:Simple airway equipment for children.Venepuncture.Paediatric basic life support.Post-operative pain relief.


Learning: Communication with parent, child and other staffLearning about parents being present for anaesthetic induction.


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First Year SHO Clinical ExperienceAnaesthesia for ChildrenSix to Nine Months


To continue developing airway management in children under direct supervision.To be effective as first on the scene in paediatric life support.To recognise the potential difficulties presented for the anaesthetist when dealing with children and to be aware of the need for help

even in apparently simple situations.Recognition of the importance of illness in children presenting for simple elective surgery.


Possible placements in specialties such as ENT and dentistry for paediatric anaesthetic experience.

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Second Year SHO Learning PlanAnaesthesia for ChildrenNine Months to Two Years


Competent: Paediatric basic life support.Venous access.Airway management in children over five.

Learning:Observing anaesthesia in children.Simple airway management in children aged between one and five.Intubation of children.Paediatric basic life support.


Competent: Sizes of tubes and airways.Paediatric laryngoscopes.Induction of anaesthesia.

Learning: Simple airway equipment for children.Venepuncture.Paediatric basic life supportRecognition of the ill child.Pre-operative visiting and pre-medication.Gas and i.v. induction of children.Simple fluid therapy in children.Normal fluid requirements.Paediatric pain relief for surgery.Effect of age on pharmacokinetics.The physiology of children.


Learning: Communication with parent, child and other staff.Recognition of the problems of communicating with children of different ages.Obtaining informed consent.Learning about parents being present for anaesthetic induction.

Local Assessment

None

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Second Year SHO Learning PlanAnaesthesia for ChildrenNine Months to Two Years

At this stage of training the trainee may anaesthetise fit children aged more than five for minor surgery with supervision. The supervising consultant may be within the theatre suite but not necessarily in the immediate operating theatre. Every paediatric case must be separately discussed with the supervising consultant.


To continue developing airway management in children under direct supervision.To be effective as first on the scene in paediatric life support.To recognise the potential difficulties presented for the anaesthetist when dealing with children and to be aware of the need for help

even in apparently simple situations.Recognition of the importance of illness in children presenting for simple elective surgery.Should be able to give an anaesthetic to a fit child of over 5 for simple surgery including pre-operative preparations and prescription of analgesics.To be sensitive to the role of parents and other carers in the peri-operative situation.


Possible placements for paediatric anaesthetic experience. The experience should gradually increase throughout this period of training.By two years should manage simple surgery in older children solo.ENT and ophthalmology

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First Year Specialist Registrar Learning PlanAnaesthesia for Children


Skilled in: Anaesthesia for simple surgery in fit children over 5.Basic paediatric life support.Uncomplicated pre-operative assessment.

Competent: Assessment of children.Simple fluid resuscitation.

Learning: All aspects of advanced life support in children.Neonatal resuscitation.Paediatric peripheral nerve blocks.Caudal anaesthesia.Management of upper airway obstruction.Anaesthesia in special circumstances - imaging etc.


Competent: Paediatric fluid requirements in infants and children.Paediatric advanced life support.

Learning: Pain assessment.Problems of anaesthesia for ex-premature infants.Major milestones of infancy.The Children ActProblems of Down’s syndrome.Principles of neonatal anaesthesia.Special hazards of small children.Anaesthetic implications of major congenital abnormalities.The symptoms, signs, treatment and anaesthetic implications of congenital heart disease.


Learning: Transport protocols and problemsInter-hospital referral/communication

Local Assessment

Paediatric resuscitation.Anaesthesia in a young child.

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First Year Specialist Registrar Clinical ExperienceAnaesthesia for Children

When appropriate and following discussion, trainees at this stage of training may undertake anaesthesia for children (including emergency anaesthesia) without a consultant supervisor in the hospital.


Should develop competence in anaesthesia for fit children over 12 months of age.Should understand the principles of neonatal anaesthesia.Manage uncomplicated intensive care of children.Where possible, experience of intensive care of children.

Specific Clinical ExperienceAssessment of the child with airway obstruction.Neonatal anaesthesia.Intensive care of children.

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Second Year Specialist Registrar Learning PlanAnaesthesia for Children

Either a repeat of year SpR 1 or ..Research or..Overseas experience.No local special experience attachments to paediatric anaesthesia will be available at this stage of training.Special experience of SCUBU may be available.

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Third Year Specialist Registrar Learning PlanAnaesthesia for Children

At the end of this module trainees who do not express special interest in paediatric anaesthesia will have completed their training. They should have the skills needed for a consultant post in a small hospital which has services for children. They must be competent in paediatric life support, resuscitation of shock and sepsis at all ages, management of upper airway obstruction, drowning and common poisonings. They should be above all skilled in assessment stabilisation and transport of children including neonates. They should be experienced and expert resuscitators of the newborn.


Skilled in: Routine and emergency anaesthesia for children over one year of age.Post-operative pain control.Post-operative care.

Competent: Day to day intensive care and associated procedures.

Learning: CVP and arterial line insertion and management in children.Practical skills in infants and neonates.Specialised surgery - major operations in infants and neonates such as:congenital heart diseasediaphragmatic heniatracheo-oesophageal fistulabowel atresia

Theoretical Skills list

Skilled in:Anatomy and physiology of infants and childrenPaediatric ventilators.

Competent:Fluid management in infants.

Learning:Perinatal physiology.PALS or APLS course if trainee wishes.


Skilled in:Communication with children and parents.Participating in the team approach to care.Communicating with paediatricians.

Local AssessmentAssessment will be informal but those responsible for paediatric anaesthetic teaching must be satisfied that the trainee is able to take

on the responsibilities described above.

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Third Year Specialist Registrar Clinical ExperienceAnaesthesia for Children


Consolidation of paediatric assessment, resuscitation and anaesthetic skills to non specialist consultant level.To provide a full foundation for paediatric anaesthesia speciality training.To provide opportunities for anaesthesia for neonates and infants including major surgery.To understand the requirements of consultant practice at the non-specialist level.


Neonatal surgery, pre and post-op care.Paediatric cardiac surgery.Transfer of sick children.OncologyTransplantationIntensive Care including neonates and cardiac.

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Fourth Year Specialist Registrar Learning PlanAnaesthesia for Children

The fourth year SpR may undertake further paediatric anaesthetic and critical care training.

1. To the level of DGH sub specialist. This is a consultant who will head the paediatric interest in a team of paediatric non-specialists. In addition to good paediatric skills such consultants will need to manage facilities, decide on appropriate limits for their paediatric surgical service, advise management, provide education and lead audit.

2. Towards super-specialist status in paediatric anaesthesia and intensive care. This objective may need more than another year of training to achieve.

3. To supplement the skills of a superspecialist anaesthetist in another surgical area where advanced paediatric anaesthetic ability is needed outside of the normal sphere of influence of a regional sub-speciality unit.

Each trainee must agree a programme of appropriate experience that can be six or twelve months long. This must be approved by the year four organiser and the head of school in order to make sure that training in all other sub-specialities is adequate and not being damaged by specialised training.

Each trainee must determine a list of educational targets and agree the experience needed to achieve them. Consideration should be given to overseas training or research in the agreed areas.

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Fourth Year Specialist Registrar Clinical ExperienceAnaesthesia for Children

As determined for achieving the educational objectives agreed by trainee and trainer.

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northeast anaesthetic learning group

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