Cardiac Anesthesia Section: The Adult Cardiac Surgical Patient
Section Editor: Peggy G. Duke, MD
Introduction
Cardiac anesthesiology has facilitated the rapid introduction of new cardiac surgical approaches, which have changed the landscape for cardiac surgical patients, offering options for high risk patients to undergo complex surgical procedures. Commonly, as less invasive surgical procedures have evolved, the anesthesia techniques required have become more complex and require ever-increasing anesthesiology skills. It is not by accident that now, in almost every academic center and, increasingly, in private practice settings, those anesthesiologists who practice cardiac anesthesiology are required to have both a Cardiac Anesthesiology Fellowship or be “grandfathered” by having demonstrated competence and a certification in Perioperative Transesophageal Echocardiography. TEEs are now standard for most valve surgery, major aortic procedures, adult congenital heart procedures, and open-chamber procedures and are very commonly done for coronary artery bypass, both off and on cardiopulmonary bypass.
Although, cardiologists can do intraoperative TEEs, it is far more practical for the cardiac anesthesiologist to perform the exams. Ready availability during the surgery, knowledge of the surgical procedure and the surgeon and certification for performing TEEs are assets owned by the cardiac anesthesiologist. Epiaortic exams, performed by the surgeon and the anesthesiologist are now commonly done before aortic manipulation and show promise for decreasing morbidity of embolic stroke from aortic atheroma.
New and increasing use of anticoagulants and increasing complexity for managing perioperative coagulation for cardiac surgery mandates having access to the most current knowledge.
Monitoring continues to evolve as technology improves requiring ongoing updates to one’s knowledge base.
Complex aortic surgery requires a full understanding of the exact procedure to be done, skills for management of the patient during deep hypothermic cardiac arrest, including protection of the brain, kidneys, and gastrointestinal systems.
Team-based collaboration is the key to maximizing success and minimizing errors by together establishing standardized processes and having an intimate understanding of the knowledge, capabilities and expertise of each of the team members. Having a Just Culture as the foundation upon which to build a cohesive team is paramount. This requires leadership at the highest level to embrace the concept and to apply it equitably. For many organizations, it has proven elusive. For those organizations that prosper in this new world order, the ability to achieve a Just Culture may be what differentiates the successful from the non-successful.
Not yet on the horizon of most cardiac surgeons and anesthesiologists is the concept of shared accountability for long-term outcomes as a mechanism to take quality of patient care to a much higher level and hence to improve patient outcomes. Currently, cardiac surgeons are accountable for outcomes they do not fully control, i.e., postoperative infections, postoperative ventilation times, 30 day readmission, 30 day mortality, etc. Currently, cardiac anesthesiologists have no accountability for outcomes for which they have a major impact, same ones as listed for the cardiac surgeon. Recognition that both surgeon and anesthesiologist having skin in the same game can lead to improved patient care and thus better outcomes has potential to become the “Tipping Point” for the team to become a smooth-running, well-organized, efficient, effective and high-functioning group which will add value to the enterprise, to all team members and very importantly, to the patient and patient family.
Pertinent cardiac anesthesia chapters will be added over 2016. The information provided should benefit all who have an interest in the care and well being of the adult cardiac surgical patient. Students, surgery and anesthesiology residents and fellows, surgeons, anesthesiologists, cardiac nurses, perfusionists, intensivists, and others who find these topics fascinating will gain knowledge and insight into the increasingly complex, dynamic world of the cardiac anesthesiologist and surgeon and the multifaceted roles the cardiac anesthesiologist offers to the cardiac surgeon and the cardiac patient.
Introduction
Cardiac anesthesiology has facilitated the rapid introduction of new cardiac surgical approaches, which have changed the landscape for cardiac surgical patients, offering options for high risk patients to undergo complex surgical procedures. Commonly, as less invasive surgical procedures have evolved, the anesthesia techniques required have become more complex and require ever-increasing anesthesiology skills. It is not by accident that now, in almost every academic center and, increasingly, in private practice settings, those anesthesiologists who practice cardiac anesthesiology are required to have both a Cardiac Anesthesiology Fellowship or be “grandfathered” by having demonstrated competence and a certification in Perioperative Transesophageal Echocardiography. TEEs are now standard for most valve surgery, major aortic procedures, adult congenital heart procedures, and open-chamber procedures and are very commonly done for coronary artery bypass, both off and on cardiopulmonary bypass.
Although, cardiologists can do intraoperative TEEs, it is far more practical for the cardiac anesthesiologist to perform the exams. Ready availability during the surgery, knowledge of the surgical procedure and the surgeon and certification for performing TEEs are assets owned by the cardiac anesthesiologist. Epiaortic exams, performed by the surgeon and the anesthesiologist are now commonly done before aortic manipulation and show promise for decreasing morbidity of embolic stroke from aortic atheroma.
New and increasing use of anticoagulants and increasing complexity for managing perioperative coagulation for cardiac surgery mandates having access to the most current knowledge.
Monitoring continues to evolve as technology improves requiring ongoing updates to one’s knowledge base.
Complex aortic surgery requires a full understanding of the exact procedure to be done, skills for management of the patient during deep hypothermic cardiac arrest, including protection of the brain, kidneys, and gastrointestinal systems.
Team-based collaboration is the key to maximizing success and minimizing errors by together establishing standardized processes and having an intimate understanding of the knowledge, capabilities and expertise of each of the team members. Having a Just Culture as the foundation upon which to build a cohesive team is paramount. This requires leadership at the highest level to embrace the concept and to apply it equitably. For many organizations, it has proven elusive. For those organizations that prosper in this new world order, the ability to achieve a Just Culture may be what differentiates the successful from the non-successful.
Not yet on the horizon of most cardiac surgeons and anesthesiologists is the concept of shared accountability for long-term outcomes as a mechanism to take quality of patient care to a much higher level and hence to improve patient outcomes. Currently, cardiac surgeons are accountable for outcomes they do not fully control, i.e., postoperative infections, postoperative ventilation times, 30 day readmission, 30 day mortality, etc. Currently, cardiac anesthesiologists have no accountability for outcomes for which they have a major impact, same ones as listed for the cardiac surgeon. Recognition that both surgeon and anesthesiologist having skin in the same game can lead to improved patient care and thus better outcomes has potential to become the “Tipping Point” for the team to become a smooth-running, well-organized, efficient, effective and high-functioning group which will add value to the enterprise, to all team members and very importantly, to the patient and patient family.
Pertinent cardiac anesthesia chapters will be added over 2016. The information provided should benefit all who have an interest in the care and well being of the adult cardiac surgical patient. Students, surgery and anesthesiology residents and fellows, surgeons, anesthesiologists, cardiac nurses, perfusionists, intensivists, and others who find these topics fascinating will gain knowledge and insight into the increasingly complex, dynamic world of the cardiac anesthesiologist and surgeon and the multifaceted roles the cardiac anesthesiologist offers to the cardiac surgeon and the cardiac patient.