CVOR First Day Overview¶
What to Expect on Your First Day¶
Your first cardiac case will most likely be a CABG sternotomy. The room will feel busy and the setup is more involved than a general OR, but the case flow is highly predictable once you know the steps.
Before you walk in, make sure you have reviewed and understood the CVOR Case Guide.
| Read | What It Covers |
|---|---|
| CVOR Case Guide | Start here: setup → induction → bypass → separation → transport |
| Cardiac Physiology | Valves, Swan, CVP, SVO2 algorithm, Starling, EKG |
| CV Pharmacology | TXA and Amicar, milrinone, protamine, vasoplegia drugs |
| Intraoperative TEE | Standard views before you need to find them, probe technique, advanced measurements |
| Structural Heart & EP | TAVR, mitral clips, lead extractions, PFA, Watchman |
| Mechanical Support | VV/VA/VAV circuits, Impella, IABP |
| CV Test | Test of key concepts related to the CVOR, not required for SRNAs |
Keys to Success¶
- "There exists an infamous statement about opinions. Everyone has an opinion and this survival guide is mostly my opinion. Some is evidence based, but the purpose of this manual is to provide a guide to the real world application and the art of cardiac anesthesia. Many attendings and CRNAs will have differing opinions on how to induce, what pressors & inotropes to use and in what circumstances." -DF
- Communication is KEY- Learn and then use people NAMES -We use an audible read back as we complete tasks. When the surgeon asks for lungs down, we respond so the entire room can hear it “Lungs down”. Perfusion says we have “ Full flow”. We respond to them “ Thanks Jeff, my lungs are off, my gas is off, please turn your gas on”. Before we do things that could have detrimental effects at the wrong times it is standard to say what you're doing and wait to hear confirmation before actually doing it. The best examples are heparin and protamine. Surgeon asks for protamine, I get it from the nurse, hang it up and connect in line. Before I start it I say “protamine started”. I wait to hear back from the surgeon and the perfusionist. The perfusionist will usually say either “thanks” or “pump sucker off”.
Goals¶
- Provide the surgeon with the optimal surgical environment so that the PATIENT has a great outcome
- Cardiac surgery is a team sport
- Be part of the whole surgery. Stand and watch the surgeon operate
- See that ventilation is causing the lungs to intrude on his operating field and turn them off and hand bag when able
- Notice when a clamp is closed when it should be open, and when a cap is missing from a stopcock
- Understand the intraoperative surgical issues and how that may affect your post bypass echo readings and how the patient will come off bypass
- Remember, if these things are missed it is the PATIENT who is harmed not the surgeon. From nursing, to perfusion, anesthesia and surgery, we all work every day as a team to ensure that great outcomes are had for the patient
Charting¶
When it comes to charting, that is what the time on Bypass is for, only need to chart the “Events” as they occur. When our group was charting on paper most attendings had nothing written on the chart until bypass started. Please be more concerned about giving the patient and the surgeon adequate attention rather than completing the chart. We often joke about “probe-toxicity”. Probe toxicity occurs when the anesthesiologist is so focused on the TEE that one forgets to pay attention to the patient and the Blood pressure is in the toilet. Don’t let “chart toxicity” occur.
Take Away¶
IF you end up not doing Cardiac Anesthesia in the long term, please take away useful information that will help you in other areas of practice. You undoubtedly will have patients in the future with aortic stenosis for non-cardiac surgery. Wouldn’t it be nice to know how bad is bad when reading an echo? Knowing how to induce these patients will be very helpful when they arrive as emergency cases.