Beth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine Rotation: Cardiac Anesthesia (CA-2) Goals GOALS AND OBJECTIVES With limited guidance, be able to prepare for cardiac cases With limited guidance, be able to manage perioperative cardiac patient care Objectives by Core Competency Patient Care A. Preoperative Assessment Be able to, with minimal input, perform a complete evaluation of the cardiac surgical patient o Complete a full history and physical exam o Outline the nature and extent of the patient s cardiovascular pathophysiology o Complete review, knowledge, documentation, and assessment of any and all laboratory data B. Case Preparation Take an active role in setting up a cardiac room and troubleshooting basic equipment problems With minimal faculty supervision, be able to manage the placement of intravenous and peripheral monitoring lines o Rational plan for placement location(s) o Proper sedation for line placement in cardiac surgical patients o Knowing when to ask for assistance with placement o Understanding potential complications C. Intraoperative Care Be able to, with limited guidance, develop a plan and then carry out the induction and maintenance phases of anesthesia o Medications and proper dosing o Airway management Be able to, with limited guidance, obtain central access and place monitoring lines 1
o Demonstrate proper set up o Demonstrate appropriate sterile technique o Basic troubleshooting of difficult placements and develop plans for such o Understand and treat complications related to placement With limited faculty supervision, be able to develop a basic plan for and manage separation from cardiopulmonary bypass Be able to, with limited guidance, manage and modify hemodynamics as required through the different phases of the surgical procedure Learn to manage patients undergoing minimally invasive cardiac surgeries Gain experience in placing coronary sinus and pulmonary vent catheters Be able to play a major role in coordinating and managing the transport of critically ill patients D. Post Operative Care Take an active role in providing information on the patient's course to members of the postoperative patient care team Under faculty supervision, develop a plan to manage any anesthetic complications Medical Knowledge A. Preoperative Assessment With little input, develop a rational, comprehensive anesthetic plan Begin to understand the extent and significance of co-morbidities B. Case Preparation Learn to formulate a basic plan for antifibrinolytic therapy Under faculty supervision, develop a relatively extensive and rational plan for patient monitoring o Need for pulmonary artererial catheterization. Limitations Catheter selection standard vs. oximetric vs. pacing o Need for non-standard monitoring e.g. multiple arterial catheterizations C. Intraoperative Care Begin to learn and understand basic TEE concepts o Indications and contraindications o Proper placement o Basic assessment of ventricular function o Ischemia monitoring Understand how to manage and modify hemodynamics as required through the different phases of the surgical procedure 2
Begin to understand surgical needs of patients undergoing minimally invasive cardiac surgeries Have a thorough and level appropriate understanding of the following topics o Hemodynamics and monitoring Limitations Complications Indications/contraindications Set up and use o Myocardial oxygen supply and demand o Systolic and diastolic myocardial function o Hemodynamic goals for coronary arterial, valvular, pericardial, and outflow tract pathologies o TEE (as outlined above) o Cardiovascular medications inotropes, vasopressors, vasodilators, antidysrhythmics Mechanism of action Side effects Dosing Indications o ACLS protocol o Defibrillation and cardioversion o Coagulation and anticoagulation Heparin Heparin substitutes Protamine Anti-platelet medications Heparin induced thrombocytopenia Tests of coagulation PT, PTT ACT TEG Transfusion therapy o Hypothermia o Physiology of cardiopulmonary bypass o Cardioplegia Components Methods of delivery o Surgical procedures Anesthetic requirements Time course of procedure Potential risks and complications o Pacemakers and AICDs o Physiology of single lung ventilation o Intra-aortic balloon pumps Indications Contraindications 3
Positioning Proper timing o Basic ventricular assist device physiology o Deep hypothermic circulatory arrest o Spinal cord protection during thoracic aortic surgery Practice-based Learning and Improvement Use existing literature and guidelines in developing a rational, comprehensive anesthetic plan Take an active role in presenting any complications to the Department of Anesthesia at Clinical Conference in a timely manner Take an active role in preparing a lecture on a selected topic to be presented to the Division of Cardiac Anesthesia Interpersonal and Communication Skills Take an active role in counseling and educating patients and their families on basic cardiac anesthetic issues Display the ability to effectively and coherently communicate with all members of the cardiac surgical team With minimal faculty support, give a clear, concise, and comprehensive report to nursing staff and other team members who will care for the patient post-operatively Professionalism Display compassion and respect when interacting with patients and their families Display professional behavior when interacting with all members of the cardiac surgical team Throughout the perioperative period, provide information about the patient s course to the attending anesthesiologist who cared for the patient with the resident Systems-based Practice During the preoperative assessment, with faculty guidance, consult with colleagues from other disciplines with regards to treatment plans and/or needs for further testing With faculty supervision, be able to assess the potential need for special equipment or non-standard requests o Level one o Pre-incision external defibrillation pads o Arctic sun warming device 4
o Blood bank requests Gain knowledge of cost issues when developing an anesthetic plan Take an active role in managing information during the perioperative period Take an active role in providing perioperative cardiac patient care using safe and costeffective methods Evaluation Residents will take an oral exam administered by members of the Division of Cardiac Anesthesia at the end of their rotation. This exam will follow a similar protocol as that administered by the American Board of Anesthesiology The results of this exam will become a part of the resident s evaluation of performance during their rotation 5