The Department of Anesthesia is committed to the development of anesthesiologists skilled in the practice of critical care. The Surgical Neuroscience Intensive Care Unit/Cardiovascular Intensive Care Unit (SNICU/CVICU) at University of Iowa Hospitals & Clinics has been medically directed by the Department of Anesthesia since the 1970s.

The 40-bed SNICU is a major referral center for support of critically ill patients in Iowa and surrounding states. Typical SNICU patient problems include:

• Trauma
• Post-surgery
• Post-organ transplant:
  • Liver
  • Kidney
• Septic shock
• Multi-system organ failure
• Peri-operative complications
• Acute neurological injuries
  • Head injuries
  • Spine injuries
  • Stroke

The SNICU is located in close proximity to the main operating rooms and the Critical Care Laboratory, enhancing efficiency of patient care. More than 3,000 patients per year are admitted for care in the SNICU/CVICU.

The CVICU is a combined medical and surgical ICU and located one floor below the SNICU. Anesthesia trainees on this rotation cover only the surgical patients, but are immediately available to help with the management of airways or lines on the medical patients.

In both intensive care units, patient care is directed by board-certified intensivists who are physicians with primary certification in anesthesia, internal medicine, surgery, or emergency medicine. Patient care is provided directly by residents, fellows, and supported by other health care providers, including critical care nurses, pharmacists, respiratory therapists, dietitians, social workers, and physical therapists.

Mid-level practitioners (PAs and ARNPs) work with residents and fellows to facilitate safe, effective, and efficient patient care. The mid-level practitioners help residents with activities such as documentation of patient care (writing notes in the electronic medical record) and writing orders. We believe that close professional relations between specialists and optimal patient care result from this team approach to clinical service and teaching.

The didactic program emphasizes evidence-based practice and includes lectures, mechanical ventilation laboratories, journal clubs, morbidity and mortality conferences. Residents get significant experience in critical care procedures, including emergency airway management, mechanical ventilation, fiberoptic bronchoscopy, echocardiography, and broad aspects of hemodynamic monitoring. With graded levels of responsibility during the training process, residents develop the expertise and confidence to handle any patient care emergency in the OR or in the ICU.

The first several weeks of anesthesia training are spent working very closely with fellow trainees and anesthesia faculty. The case selection is aimed to provide basic experience in patient evaluation, anesthetic selection, and anesthetic management.

You will develop competence in:

• Airway management, including;
  • Bag-mask ventilation
  • Direct laryngoscopy with placement of oral and nasal endotracheal tubes
  • LMA placement

Typical cases include:

• Laparoscopic cholecystectomy
• Plastic surgery procedures
• Hysterectomy
• Thyroidectomy
• Bowel resection
• Ureteroscopy/cystoscopy
• Electroconvulsive therapy (ECT)
• Bone fracture repair

Case selection is expanded over the first several months to include a broader variety of patient disease states and more complicated surgical procedures (for example, cases prone to acid-base abnormalities and significant blood loss).

Skills learned include:

• Subarachnoid blocks
• Placement of intra-arterial catheters
• Central venous catheters
• Combined epidural-general anesthetics

New patient positions (lateral, prone and beach chair) are included. By the end of basic anesthesia training, you will be prepared to take on the subspecialties.

UI Stead Family Children's Hospital opened in April 2017. This hospital is physically connected to the UI Hospitals & Clinics and includes 8 pediatric operating rooms, a 5-room procedural sedation suite, and 2 pediatric cath labs.

In 2017-2018 we provided anesthesia care for more than 8,800 children. Our team includes 16 pediatric anesthesia faculty (most are fellowship trained) and 8 core CRNAs.

The variety of medical and surgical diseases encountered in our patient population exposes residents to a wide spectrum of patient care challenges from healthy children having outpatient procedures to premature neonates undergoing complex surgical procedures. The care of these patients extends from the preoperative evaluation and education of the family to intraoperative planning and patient management to postoperative care (including pain management).

UI Hospitals & Clinics provides anesthesia care to children for both diagnostic and therapeutic procedures from all specialties including pediatric general surgery, urology, neurosurgery, orthopedics, cardiac, ENT, ophthalmology, burns and satellite cases. Pediatric cases are performed primarily in UI Stead Family Children's Hospital, but also in the Ambulatory Surgery Center, and satellite locations (such as radiology, dermatology, cardiac cath lab and radiation therapy). Residents are exposed to regional techniques in the pediatric population and receive advanced airway training to handle difficult pediatric airways.

Senior residents also have the opportunity to participate in an international mission trip with a pediatric anesthesiologist.

Apart from their direct patient care and teaching responsibilities, the faculty is involved in several clinical studies. One interesting example is the study evaluating the neurodevelopmental effects of exposure to anesthesia at an early age. Residents are encouraged to participate in our ongoing projects.

UI anesthesia residents gain experience in the management of a large variety of neurosurgical cases. The Neurosurgical Anesthesia Division performs more than 2,100 anesthetics per year. The level of complexity ranges from the simplest lumbar laminectomy to the most complex intracranial vascular or craniovertebral/skull base procedure. These procedures may be elective or emergent.

Common neurosurgical procedures at the UI Hospitals & Clinics include:

• Supra- and infratentorial craniotomy for tumor resection
• Vascular malformations and aneurysms
• Cranioplasty
• Trans-oral resection of the odontoid process
• Spinal fusion surgery
  • Cervical
  • Thoracic
  • Lumbar
• Deep brain, peripheral nerve, and spinal cord stimulator implantation
• Minimally invasive and endoscopic procedures
• Burr holes
• Clot evacuation procedures
• Neuro-interventional procedures

Our neurosurgeons also perform a large number of procedures in children, including:

• Posterior fossa procedures
• Surgery for craniosynostosis
• Tethered cord repair
• Meningomyelocele repair
• Ventriculoperitoneal shunts

Residents on this rotation gain valuable experience performing awake and asleep fiberoptic-assisted intubation. Residents also learn to manage anesthesia in combination with specialized monitoring modalities such as processed EEG and somatosensory evoked responses.

Each year, approximately 1,100 adults and children undergo anesthesia for cardiopulmonary bypass and corrective cardiac surgery at the University of Iowa Hospitals & Clinics. During their cardiovascular anesthesia rotation, residents care for patients with ischemic, valvular, and congenital heart diseases.

Anesthesia residents are exposed to the pathophysiology of heart disease and gain familiarity with inotropic, antiarrhythmic and vasoactive medications. They evaluate critically ill patients and formulate thorough anesthetic plans for a wide variety of cardiac procedures.

Residents also gain an in-depth understanding of the complex physiology of cardiopulmonary bypass and develop proficiency with a variety of invasive monitoring techniques, including arterial pressure monitoring, central venous and pulmonary artery pressure monitoring, transesophageal echocardiography (TEE). Faculty assignments are one-on-one and allow for intensive resident/faculty interaction.

Residents on this rotation also provide anesthesia for patients undergoing thoracic surgery. Anesthetic management in these patients requires a clear understanding of "one lung" physiology and the important techniques of single lung ventilation, fiberoptic bronchoscopy, and central neural-axis analgesia.

Intra-operative TEEs are formally reviewed and interpreted each week by members of our cardiac anesthesia group. TEE reading sessions are open to all residents. Consultation is readily available from both the adult and pediatric cardiology echocardiography service.

Any anesthesia resident at Iowa has the ability to perform and interpret the number of TEE exams necessary to qualify for the Basic PTEeXAM (Basic perioperative transesophageal exam). This certification requires ABA board certification and a permanent medical license (not a training license), but a "preliminary" (Testamur) status can be achieved by passing the written exam and conducting/interpreting the required number of TEE exams. Once you complete ABA certification and have a permanent license, you can convert from Testamur to Certified status.

Didactic material is presented as part of the morning lecture series. A variety of recurring conferences are available, including pediatric surgical indications conference, adult cardiology echo conference, cardiothoracic lectures, and anesthesia TEE conference. Finally, the Department of Anesthesia has a TEE simulator that residents and fellows use to practice ECHO skills.

The Department of Anesthesia provides an excellent clinical and educational experience encompassing all aspects of anesthesia for labor and delivery. Residents spend two months providing anesthesia in labor and delivery. Senior residents have the opportunity to do an OB elective.

Approximately 2,200 babies are delivered each year at the University of Iowa Hospitals & Clinics. We take care of most of eastern Iowa's high-risk obstetrical patients, including patients with congenital heart disease, diabetes, preeclampsia, multiple gestations, and premature labor. Our facilities include combined labor-delivery rooms, modern operating rooms, and an adjoining NICU (all close to the main OR). Because of this experience, our residents are familiar with the special needs of these challenging patients.

At UI Hospitals & Clinics, a high percentage of laboring patients request epidural anesthesia, and most non-emergent (and some emergent) cesarean deliveries are performed under spinal or epidural anesthesia. In addition to the regional anesthesia cases, a number of other procedures (both emergent and non-emergent) are performed under general anesthesia or conscious sedation. Residents also help with pain management for patients unable to receive regional anesthesia, use invasive hemodynamic monitoring in selected patients, and serve as consultants in the management of patients with complex medical conditions.

The resident Monday/Tuesday morning didactic curriculum covers the important topics related to OB anesthesia. In addition, there are computer-based lessons, simulations, lectures, conferences, and daily discussions during the rotation. The extensive use of regional anesthesia in labor and delivery provides ample opportunity for residents to become comfortable and proficient with spinal and epidural anesthesia. In addition, residents learn techniques such as combined spinal-epidural anesthesia, patient-controlled epidural anesthesia, "walking epidurals," and placement of epidural and intrathecal narcotics.

Over the course of a year, the regional service performs approximately 2,600 peripheral nerve blocks. The average anesthesia resident performs around 110 peripheral nerve blocks during the course of the three-year residency.

Residents are exposed to a wide variety of peripheral nerve blocks and a significant number of approaches to a given nerve block (including ultrasound-guided). Each faculty instructor brings a unique perspective to blocks, which enhances the learning opportunity for our trainees.

The regional anesthesia rotation can be viewed as two complimentary halves of a whole. The first half is in the main OR, where residents are exposed to a number of complex blocks and catheter-based regional anesthetic techniques.

The other half is the Ambulatory Surgery Center (ASC) experience where there are more blocks with a more rapid turnover. The ASC experience encourages residents to use neuraxial blocks, both epidural and intrathecal, to cover a wide variety of lower extremity procedures. The pace is much quicker in the ASC (compared to the main OR); consequently, residents become proficient and develop the ability to prioritize the order in which blocks should be performed.

Residents rotate onto the regional service during both the CA1 and CA2 years. In addition, senior residents can elect a regional rotation during their last year of training.

From the first day on the regional service, residents do blocks. Residents are given increasingly more difficult blocks as they demonstrate the ability to safely and efficiently perform blocks and explain the reasons for a given block in a particular patient. CA1 and CA2 residents spend half their time in the main OR and half in the ASC. During the CA3 elective, residents generally spend more time in the ASC.

The Department of Anesthesia is committed to the development of anesthesiologists skilled in the practice of critical care. The Surgical Neuroscience Intensive Care Unit/Cardiovascular Intensive Care Unit (SNICU/CVICU) at the University of Iowa Hospitals and Clinics has been medically directed by the Department of Anesthesia since the 1970's. The 36-bed SNICU is a major referral center for support of critically ill patients in Iowa.  Typical SNICU patient problems include: trauma, post-surgery, post-organ transplant (liver, and kidney), septic shock, multi-system organ failure, peri-operative complications, and acute neurological injuries (head and spine injuries, stroke). The SNICU is located in close proximity to the Main Operating Rooms and the Critical Care Laboratory, enhancing efficiency of patient care.

The CVICU is a combined medical and surgical ICU and located 1 floor below the SNICU.  Anesthesia trainees on this rotation cover only the surgical patients, but are immediately available to help with the management of airways or lines on the medical patients.  In addition, residents manage the airway and ventilator of adult burn unit patients requiring mechanically-assisted ventilation. 

In both units, patient care is directed by board-certified intensivists who are physicians with primary certification in anesthesia, internal medicine, surgery, trauma, emergency medicine, or neurology. Patient care is provided directly by residents and fellows and supported by other health care providers including critical care nurses, pharmacists, respiratory therapists, dietitians, social workers, and physical therapists. Finally, mid-level practitioners work with residents and fellows to facilitate safe, effective and efficient patient care. The mid-level practitioners help residents with activities such as documentation of patient care (writing notes in the electronic medical record) and order-writing. We believe that close professional relations between specialties and optimal patient care result from this team approach to clinical service and teaching.

The didactic program emphasizes evidence-based practice and includes lectures, mechanical ventilation laboratories, journal clubs, morbidity and mortality conferences. Residents get significant experience in critical care procedures, including emergency airway management, mechanical ventilation, fiberoptic bronchoscopy, echocardiography, and broad aspects of hemodynamic monitoring. With graded levels of responsibility during the training process, residents develop the expertise and confidence to handle any patient care emergency in the OR or in the ICU.

CA1 residents (later in the year) and CA2 residents are assigned two-week rotations in the PACU. The PACU resident is expected to ensure safe and efficient flow of patients through the recovery phase of anesthesia. PACU residents may be called by the nurses for problems such as airway emergencies, pain management, hemodynamic or cardiovascular alterations (for example, rhythm disturbances or ischemia), neurological changes, nausea and vomiting, and evaluation of possible post-surgical complications. They are expected to arrange for consultations for workup of postoperative problems and communicate with the anesthesia team, PACU nurse and the primary surgical service.

In addition, the PACU resident is expected to accompany the 3911 senior resident to "codes" (in the hospital) and trauma activations in the Emergency Department. Cardiac arrests and severe traumatic injuries in the Emergency Department provide valuable learning opportunities for the junior residents, teaching opportunities for the senior residents and another pair of hands to assist with patient management in less than optimal circumstances.

By the end of this rotation, residents will have the knowledge and skills to observe, recognize and treat problems that commonly occur in the PACU.

The educational experience at the Pain Management Clinic is very active and diverse. Anesthesia residents rotate for a total of 12 weeks during the CA1-CA3 years.

Residents on the Pain Medicine rotations gain experience in acute, chronic, and cancer pain management.

Chronic Pain Medicine Service

The Pain Management Clinic serves patients with a wide array of chronic benign ailments as well as cancer related pain conditions. Our clinic staff includes physicians, nurses, and a clinical pharmacist, and we work closely with psychology and physical therapy.

Residents are exposed to conservative treatments, blind and ultrasound-guided procedures (such as trigger point injections, peripheral nerve blocks, and joint injections), as well as to interventional fluoroscopically-guided procedures such as spine injections (epidurals, facets, sacroiliac joints), sympathetic blocks and chemical and thermal neurolysis. In addition, intrathecal drug delivery, spinal cord stimulation and cryoablation may be performed in select patients.

There is close collaboration with other department specialties such as neurosurgery, orthopedics, psychiatry, neurology, oncology, and palliative care.

Acute Pain/Regional Anesthesia Service

The Acute Pain/Regional Anesthesia Service actively manages postoperative pain in the in-patient setting. The service also serves as a resource when clinicians from other disciplines have complex pain questions.

Common modalities used for postoperative pain control include:

• Multimodal treatments that include intermittent, continuous intravenous drugs
  • Nurse controlled or patient controlled
• Oral medications from differed drug classes
• Thoracic and lumbar epidural catheters
• Peripheral nerve/plexus catheters

The educational program is multifaceted and includes in-depth clinical exposure, as well as teaching of medical students.

Diverse teaching activities take place:

• A weekly didactic lecture series (in collaboration with other departments)
  • Includes dedicated time for pain medicine topics
• Pain Medicine Morbidity and Mortality Conference
• Pain medicine journal club

Residents on the pain rotation take call from home approximately every sixth night. The resident on pain call is expected to come into the hospital when epidural catheter placement and/or additional analgesia are required for postoperative pain management. An attending physician is accessible for questions and available to come into the hospital if needed. The OB resident on in-house night call generally handles simple patient problems (changing the PCA settings or changing the pump battery). On weekends, the call resident and the attending pain staff round together in the mornings.

The Anesthesia Preoperative Evaluation Clinic (APEC) provides a centralized location for completion of outpatient pre-operative evaluations. This area consists of a reception area, seven examination rooms, and a shared nurse-physician work area.

APEC has been designed to provide an attractive and efficient facility for the completion of histories and physicals, anesthesia evaluations, laboratory testing, electrocardiograms, nursing assessments, and patient teaching. The APEC is staffed by a faculty anesthesiologist, a nurse anesthetist, advanced registered nurse practitioners, anesthesia residents, nurse anesthetist trainees, and registered nurses (RNs).

All patients scheduled to receive anesthesia are either seen in APEC or receive a telephone call from one of the providers or RNs. Patients who need to be seen in clinic are determined by a screening process that helps to identify those with conditions most concerning to anesthesia or those with a history of complications related to anesthesia.

On average, APEC sees 20 to 40 patients per day, which includes 5 to 10 add-ons. Patients are scheduled by the individual surgery clinics. Appointment durations are determined by the number of medications the patient is prescribed. By scheduling in this manner, patient satisfaction and efficiency are optimized.

Residents at the CA1 or CA2 level are scheduled on this two-week rotation. Trainees learn to evaluate and educate patients before surgery. Evaluation of patients may include ordering pre-operative tests, interpreting test results, and collaboration with other medical specialties.

CA2 residents have a required rotation in the Ambulatory Surgery Center (ASC), which is located adjacent (but connected by a covered walkway) to the main hospital campus. CA3 residents often take this as a senior elective.

The ASC was designed to emulate a private practice environment, implementing a teamwork approach where we all work to create a high level of patient and family satisfaction. Care is provided by anesthesiologists, CRNAs, surgeons, and nurses specially trained in outpatient perioperative care. The physical status of ASC patients ranges from healthy children and young athletes to octogenarians with a number of comorbidities.

The focus of this rotation includes safe and efficient patient care and the application of protocol-driven anesthesia to reduce variation in care and to optimize safety and patient outcomes.

Methods for accomplishing this include:

• Regional anesthesia and analgesia (spinals, epidurals, or peripheral nerve blocks)
• Application of multimodal analgesia
• Total IV anesthesia
• Avoidance of opioids
• Avoidance of post-operative nausea and vomiting

All of these items help to facilitate ambulatory anesthesia goals, including:

• Smooth timely induction
• Rapid emergence
• Post-anesthesia care unit bypass
• Excellent pain control
• Very low rates of postoperative nausea and vomiting
• High level of patient and team satisfaction

The ASC at the University of Iowa Hospitals & Clinics has 12 ORs with state-of-the-art technology; children and adults have separate care areas with private pre-op and post-op rooms. With the opening of the UI Stead Family Children's Hospital, most of the pediatric patient anesthesia has been relocated there.

CA-2 residents have a required two-week echocardiography (ECHO) rotation; CA3 residents may elect additional ECHO time.

The rotation focuses on intraoperative transesophageal echocardiography for estimation of ventricular and valvular function. Residents on the echo rotation participate in intraoperative echo assessment of cardiac surgical patients; additionally, they are encouraged to attend the weekly cardiology echo conference and participate with transthoracic and transesophageal exams in the cardiology echo clinic.

This is a popular required and elective rotation for UI residents. It is possible for residents to perform sufficiently well that they qualify for (and pass) the Basic PTE exam.

CA3 residents are required to select at least two ACA rotations.

One rotation is a general rotation with patients from any specialty of surgery. The other rotation can be another general rotation or selected from any of the surgical subspecialties.

Residents on the ACA rotation can select their own cases to get more experience in areas of interest or weakness.

Residents are expected, whenever possible, to select the more complex procedures or challenging patients.

This CA3 rotation is arguably one of the residents' favorite senior rotations. The residents complete two months of this rotation and each month is broken up into two weeks of days and two weeks of nights.

The primary role of the 3911 resident is to respond to codes, traumas, and emergent airways throughout the hospital. The 3911 resident is also available to help start both emergent and elective cases, assist with invasive line placement and help the PACU resident manage complications in the recovery room.

The 3911 resident also makes the preliminary resident OR case assignments, which ensures residents are getting an appropriate variety and complexity of cases. This responsibility is rather unique and the challenge to optimize resident learning is a matter of pride for our seniors.

Finally, both in the afternoon and overnight, the 3911 resident is responsible for running the "board" in our very busy OR. CA3 residents with faculty oversight determine priority of add-on emergency cases and assign providers. Additionally, they collaborate with the CRNA and faculty to assign relief to clinicians who are late but not on-call. Our 3911 residents are truly leaders both in the OR and throughout the hospital.

Senior residents have the opportunity for an elective cardiovascular rotation at Iowa Methodist Medical Center in Des Moines. We are privileged to have so many of our alumni practicing there and appreciate the opportunity to have our trainees learn at this off-campus site.

Senior residents typically elect a four-week rotation at Methodist. We provides an efficiency apartment close to the Methodist campus so that residents do not need to commute between Des Moines and Iowa City.

Residents typically do cardiothoracic cases and have significant autonomy. On days when there are no cardiothoracic cases, residents are expected to select other challenging rooms/cases.

This rotation enables residents to do more cardiothoracic cases, with significant autonomy and exposes residents to a true private practice anesthesia group. The rotation has been very well received and is one of the high points of the final year.

CA3 residents on this elective rotation help to orient the new CA1 or CA2 resident to OB anesthesia.

They also serve as senior mentors to the junior residents to learn the basics of patient management and procedural techniques (epidurals, spinals, combined spinal/epidurals).

Senior residents are intimately involved with emergency procedures and the more complex pregnant patients.

This CA3 rotation is designed to more closely simulate a private practice environment. It consists of a four-week block later in the CA3 year.

Three or four CA3 residents are assigned to this rotation at one time. These individuals form a “private practice” anesthesiology group. The group forms its own administration and manages its own clinical assignments.

Each week, one resident is the “master” and is charged with making the daily OR assignments, helping with breaks and lunches, and ensuring a smooth and efficient case flow.

The residents develop their own anesthetic plans and carry them out with faculty involvement limited to those activities that are CMS regulations and when medically necessary for patient safety. Faculty are specially selected for their willingness to participate and support the goals of this rotation.

POCUS (Point of Care Ultrasound) has become an important part of an anesthesiologist’s toolbox. Our department had incorporated a formal and structured POCUS rotation, taught by ultrasound trained anesthesiology intensivists, even before the ABA incorporated POCUS in the residency training requirements.

Anesthesiology residents are trained in both the skills of hands-on sonography to be able to obtain the ultrasound pictures, as well as the art of image interpretation to be able to apply the information to a clinically relevant scenario. The residents undergo both simulation/manikin as well as real patient sessions during this rotation.

These sessions are held every month and are aimed at training the residents in Transthoracic Echo (TTE), FAST, Lung and Vascular Ultrasound techniques, to become adept at obtaining images independently, and to use them for interpretation.

With the help of ultrasound machines in the SNICU, CVICU, and the PACU, along with the portable Butterfly IQ probe that connects to an iDevice, converting it to an ultrasound machine, residents develop the ability to use critical ultrasound skills in many patient care scenarios. Whether it is estimating an Ejection Fraction in the preoperative area, estimating fluid responsiveness in the ICU, or looking for intra-abdominal fluid or bleeding, ultrasound training helps our residents make better clinical decisions.