Neuroanesthesia

The medical center of the University of Puerto Rico Medical Sciences Campus is the primary referral center for neurosurgery in Puerto Rico. Therefore the residents are exposed to numerous neurosurgical cases, particularly those of complicated pathology.

We have two full-time attending faculty who completed a formal neuroanesthesia fellowship. The main operating room in ASEM has four neurosurgical suites and one neuroendovascular suite. Another neuroendovascular suite will be opened in May 2007. The Pediatric University Hospital reserves one operating room twice a week for elective pediatric neurosurgery.

Neurosurgical procedures seen include aneurysm clipping, hematoma evacuations, posterior fossa tumor resections, pituitary tumor resections, tethered cord surgeries, craneosinostosis, arteriovenous malformation embolizations, lumbar laminectomies, spinal fusions and other spine surgeries. With these neurosurgical procedures, residents learn increased intracranial pressure management, evoked potentials monitoring, and cerebral protection management.

In March 2007, we performed our first awake craniotomy for tumor resection with dexmetomidine in Puerto Rico which will be published regionally. We are committed to resident education and strive to make this neuroanesthesia rotation a rewarding experience.

Pediatric Anesthesia

Our pediatric operating rooms are located at The University of Puerto Rico Pediatric Hospital. This is the only pediatric surgical referral center for the Island and the Caribbean. We perform approximately 3,000 pediatric cases per year that range from complex procedures to same day surgery.

All pediatric surgical subspecialties are represented, including general pediatric and neonatal surgery, otolaryngology, urology, gynecology, orthopedic surgery, ophthalmology, oral surgery, dental surgery, plastic surgery, and neurosurgery. Cardiovascular procedures are performed across the street in The Puerto Rico Cardiovascular Center.

The residents are exposed to a wide variety of procedures that include: complex airway management with devices and fiber optic scopes, central venous and arterial lines, caudal blocks, epidural catheters, neonatal spinal anesthesia and more.

The overall general objective is to develop the knowledge and skills, to provide state-of-the-art pediatric anesthesia care in most situations likely to be encountered in future practice.

We look forward to working with you and hope that you have an enjoyable and educational experience.

Pain Management

The University of Puerto Rico School of Medicine and the Department of Anesthesiology are involved with patient in the peri-operative period. The Acute Pain Management Service was created in August 2005 by Francisco Lebrón, MD and Carlos Buxo, MD.

This service is provided to patients upon request by the surgeon or anesthesiologist involved in the surgical procedure via a pain management consult. Other times a non-surgical service, including Internal Medicine and its subspecialties, also requests consults on a 24 hour/ 7 days a week on call basis. Consults for acute postoperative pain management are for patient-controlled analgesia (PCA), epidural infusions, intrathecal infusions, or continuous regional nerve block infusions as well as recommendations for in-hospital management and discharge planning for patients on chronic opioid treatment or patients with cancer pain. The Pain Service should be contacted at pager 787-440-2809 by the nursing staff for any pain management consult.

Patient-controlled analgesia affords the patient an alternative to traditional methods of pain management. PCA provides a means for self-administration of a physician’s prescribed dose of a narcotic, on demand, providing a consistent level of pain relief. PCA offers reliable analgesia, a measure of control over timing and frequency of narcotic injections while decreasing dependence on nursing administration of narcotics. This will help to eliminate the peaks and troughs associated with the pain/comfort/sedation cycle.

Epidural and intrathecal analgesia are proven to be beneficial for patients in the acute postoperative period after major abdominal, thoracic, or lower extremity surgery. This modality provides a continuous infusion of local anesthetic and opioids. The patient is able to ambulate, and the respiratory and gastrointestinal function returns to baseline earlier when compared to patients without epidural analgesia.

Continuous peripheral nerve block anesthesia offers many clinical advantages that contribute to both an improved patient outcome and overall lower healthcare costs. Peripheral nerve blocks provide excellent anesthesia and postoperative pain relief, fewer side effects than general anesthesia, and facilitate early physical activity. They are associated with reduced use of opioids for postoperative pain, fewer postoperative complications, and earlier discharges. This is particularly desirable and effective in elderly and high-risk patients undergoing a wide variety of surgical procedures, particularly on the upper and lower extremity.

Pain is prominent in surgical patients and is not beneficial. Good pain treatment starts with assessment. Treatment needs to be individualized and multimodal. Treating pain aggressively shortens hospital stay and improves outcome. Pain treatment options include intravenous patient-controlled analgesia, thoracic and lumbar epidurals, LAs and opioids, intrathecal catheters, and peripheral block nerves. Teamwork with nurses, physicians, and other providers is required. Consult a pain specialist when pain is limiting patient progress and treatment.

Our mission is to achieve the best possible care and pain relief for our surgical and acute pain patients, to perform evidence based anesthesia and analgesia, and to optimize education, skill, and coordination of all health care providers to conduct epidural anesthesia in the most efficient, effective and safe manner possible throughout our institution.

Obstetric Anesthesia

The Division of Obstetric Anesthesia is responsible for anesthesia coverage of the Labor and Delivery Suites at the two hospitals covered by the University of Puerto Rico: the University Hospital at the Medical Sciences Campus and Federico Trilla Hospital at Carolina. The faculty provides coverage 24 hours a day, 7 days a week with resident supervision 24/7. With both hospitals, there is a good balance of exposure to normal and high risk pregnancies.

Resident education is a major mission of the rotation, done in blocks of one month with 1:1 attending supervision by subspecialty obstetric anesthesiologists. Junior residents perform their first rotation as an introduction to Obstetric Anesthesia at the Carolina University Hospital. Here they learn the basics of obstetric anesthesia by taking care of normal patients and they are taught, supervised and advised about clinical techniques (e.g. labor epidurals) and management. On a more senior level, residents perform their rotation at the University Hospital of the Medical Sciences Campus, where we are continually faced with an interesting and challenging high risk patient population.

Our scope extends beyond the provision of spinal or general anesthesia for surgical procedures. Neuraxial blockade techniques such as epidural, combined spinal- epidural, “walking epidural” and continuous spinal anesthetic techniques for labor are available.

There is on-going clinical research by our faculty and residents in the area of obstetric anesthesia.

Trauma Anesthesia

The Trauma Hospital of the University of Puerto Rico Medical Sciences Campus is the only level I trauma center in Puerto Rico, receiving trauma cases at all hours, where automobile collisions, gun-shot wounds, and penetrating injuries are above the national average. For this reason, residents graduating from the program will have ample hands on experience and clinical training in trauma anesthesia.

All aspects of perioperative trauma care are covered including preoperative emergency room evaluation and stabilization, operative trauma anesthesia care, postoperative pain management, and trauma critical care. In the operating room residents are exposed to all types of trauma surgery, including burns and penetrating and non-penetrating injuries to the head, spine, chest, abdomen, and extremities in adult and pediatric populations.

In addition, residents rotate through the trauma intensive care unit for a month.

Critical Care

The most critical patients in Puerto Rico are usually referred or transferred to the medical center at the University of Puerto Rico Medical Sciences Campus, where the intensive care units have a team of critical care specialists, nurses, and respiratory care practitioners to manage patients from medical, surgical, pediatric, and neonatal services.

Critical care anesthesia is an integral part of the anesthesiology residency training, so residents rotate through a variety of intensive care rotations—namely medical intensive care, surgical intensive care, pediatric intensive care, neonatal intensive care, neurosurgical intensive care, and trauma intensive care at various hospitals. Residents are involved in patient care from the patient’s initial evaluation in the emergency room or pre-operative holding area to the post anesthesia care unit and intensive care unit. We have attending faculty trained and board-certified in critical care medicine.

Regional Anesthesia Rotation

The Department of Anesthesiology at the University of Puerto Rico Medical Science Campus offers a four-week block rotation dedicated to regional anesthesia training for Anesthesiology residents. This rotation is at the University’s main operating rooms (ASEM). During the rotation, residents are exposed to a wide variety of regional techniques. Residents will gain proficiency in techniques such as supraclavicular, axillary, infraclavicular, interscalene, femoral, ankle and popliteal blocks. They are expected to identify anatomical landmarks for performance of regional techniques. Residents will also gain experience performing these blocks under ultrasound and/or peripheral nerve stimulator guidance. Epidural, spinal and combined spinal-epidural techniques are also taught. Management of conscious sedation as an adjunct to regional anesthesia is developed during this month. The pharmacology and clinical use of local anesthetic agents as well as the anatomy and clinical application of peripheral and neuraxial blocks are major topics of study during the rotation. The resident is eventually expected to decide independently which blocks will be appropriate for the planned procedure, which agents to use, and to defend their choice with the attending anesthesiologist.