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CT Anesthesia Attending preferences ​

NOTE

The following are updated statements directly from each attending

Abrams ​

  • There is no "cardiac setup" or "cardiac induction". Make a plan specific to the patient's pathophysiology and operation.
  • Call with any significant changes in vasoactive medications or the administration of blood products.
  • Ultrasound-guided line placement means you actually visualize the tip of the needle entering the vessel. Procedure efficiency is important, but you should take your time during this step.
  • Plan to reverse neuromuscular blockade prior to leaving the OR for most cases. Rare exceptions may include an open chest and/or significant ventilator support.
  • All medications should be given through the central line once it is in place.
  • Do not use propofol as an antihypertensive medication.

Ahlgren ​

  • Know your patient and discuss induction with attending or fellow the night before.
  • Know optimal hemodynamics for valvular disorders.
  • Like ketamine for induction.
  • When any doubt of easy airway securement- use a CMAC. CMAC for all double lumen tube placements.
  • Pre-induction a-line if you are going to use an a-line (why not have it for a hemodynamically significant part of the case (induction)).
  • Put TEE probe in before central line placement and always use ultrasound for line placement- if you are struggling with the a-line- use an ultrasound- don't turn your patient into a bruised mess.
  • When in doubt of bleeding risk- use a MAC- more access is always better.
    • Consider contralateral cordis for additional access for redos.
  • When doing lines, untangling IVs, etc- watch the patient.
  • MAP above 60 at all times.
  • Doesn't care how paralyzed pt is, as long as reversible and doesn't move unless waking up for extubation.
  • Defib pads on for all redos, mitral stenosis, VADs, heart transplants, left main dx or left main equivalent.
  • Levophed poppers 12.8 mcg/mL should be available for most cases- along with standard poppers.
  • Have ketamine for most cases.
  • If you don't understand something- ask.
  • If you have never done something- ask before you do it.

Alber ​

  • Have clear patient history and anesthetic plan when you call the night before.
    • Especially their ICU course and consultant input
  • Induction with midazolam/fentanyl/sevo/muscle relaxant.
    • Doesnt prefer etomidate, propofol okay for most cardiac patients
  • Discuss +/-PAC, especially in ‘healthy’ patients
  • Avoid circumferential taping on arterial line arm boards
  • Look at the pictures of imaging studies (you learn so much, and sometimes find things the radiologist maybe didn’t think was important for us)
  • Make sure the ear isn’t folded over in the donut in lateral cases

Grae ​

  • Wants inpatients seen and consented the day before.
  • Look for antibodies on type and screen so case is not delayed due to difficult cross match.
  • Call the night before the case to discuss the plan for the day. Have clear induction, drip, line, blood availability, etc. plans when you call to tell her about the patient.
  • Likes Standard Narcotic bag with 20 ml Fentanyl, 10 ml Versed, +/- Ketamine to supplement the bag.
  • A-line before induction for all cardiac cases and lung transplants. For first start cases, arterial line should be placed early enough to ensure we are in the room and ready to induce on time. No strong preference pre-op versus in room, just wants it done on time.
  • Defib pads on for all redo’s, aortic stenosis, left main (or equivalent) lesions, and patients with inactivated ICDs. If in doubt, place defib pads on patient.
  • If patient has pacemaker or AICD, have a plan to manage it peri-operatively.
  • Call for all significant intra-operative events or questions, even if you think you can handle it. She may or may not come but needs to stay in the loop.
  • Start Precedex without bolus after hemodynamically stable off bypass, unless earlier administration is discussed with her during case planning.
  • Place OGT after TEE probe removed but before transporting to ICU and ensure all stopcocks and lines are cleaned up and capped. Cleanliness and organization will earn bonus points.
  • Has low threshold for Belmont. When in doubt, have it around.
  • Consider EJ PIV if difficult IV access.

Kowalsky ​

  • If you have never done something or have questions at any time, please call or ask before you do it. Communicate all major CPB-related events (heparin in, warming, cross clamp off, etc.) as well as hemodynamic, oxygenation/ventilation issues or other concerns to either fellow or attending so everyone is in the loop even if you think you can handle it.
  • Please have inpatients seen and consented day prior to surgery.
  • Work to ensure no delays from anesthesia side. Consent and arterial line in pre-op early with US guidance and room setup appropriately for smooth transition through start of case. - Easily preventable delays are primarily related to blood bank and CIED management. Blood bank needs two samples for release of pRBCs. Ensure appropriate timing/phase of care for labs as they require two samples prior to releasing RBCs and pre-op may not see this order if you place them after patient has checked in. Blood bank may require phone call if antibodies are present.
  • It is often easiest to staff bigger cases on the phone or, even better, in person day prior. I am happy to text and find a time that is mutually convenient but please at least try to reach out earlier rather than later. Unfortunately, there are no standard cases so having a shared gameplan for the day is beneficial and understanding the reasoning behind a plan is part of the education for the day.
  • When staffing cases, try to keep your presentation brief and follow the order of the case (something like relevant pt info and proposed surgical plan, pre-op labs/meds/blood ordering, monitors, induction, lines and infusions planned, pre/intra/post-CPB, any other special concerns, etc)
  • Defib pads on for all cardiac cases. Ensure safe plan for patient with ICD deactivated coming to OR, often easiest to deactivate in the OR for heart transplants or those with high-risk hemodynamic lesions or frequent shocks.
  • For lung transplants, call CTICU RT at 87452 for inhaled nitric oxide and Pharmacy early during setup to get access to continuous antibiotics and immunosuppressive agents as these are the usual hangup.
  • Standard bag + ketamine 100 mg + cardiac narc bag for cardiac cases. Ketamine 50 mg for most thoracic cases. It only takes a few seconds to pull extra medications up so please don’t pull up medications that we have not discussed or anticipate using.
  • Normal geometry VL (CMAC or Glidescope) for all double lumen ETTs and available for any airway that looks remotely challenging.

Seres ​

  • Call him for discussion of the patient and prepare talking about: Echo data: systolic fun, diastolic fun, BP and heart rate, Cath lab data, Presence of pacemaker, Exercise tolerance and of course airway
  • Formulate plan for induction and specific medications or drips based on the above data. He asks you to select induction agents for cardiac cases based on H&P data. Examples:
  • Normal or high BP and normal EF: propofol with fentanyl
  • Normal or high BP low EF: etomidate with fentanyl
  • Low BP normal EF: etomidate with fentanyl or propofol, fentanyl with phenylephrine
  • Low BP low EF: etomidate or ketamine with fentanyl
  • He starts Dexmedetomidine infusion after induction. He uses Sedline monitor to check the depth of anesthesia and minimize the amounts of anesthetic agents during cardiac cases.
  • He gives midazolam when it is indicated, and he likes to give Dilaudid 2mg before skin incision.
  • He uses cerebral oximetry for almost all the cardiac cases in combination with the Sedline. Put the Sedline sticker first close to the eyebrow and the cerebral oximetry stickers on the free space of the forehead.
  • Prepare for doing all the lines when you work with him. He does not like to start a-line in the holding area. He puts the monitors on and pre-oxygenates the patient while you start the a-line in the OR. After induction and intubation, he inserts the TEE probe and cleans the neck while you prepare for the central line. He or the fellow will start a second IV if time is limited.
  • Patient has good veins: introducer and 2 peripheral IVs, one of them 16G.
  • Patient has poor venous access: MAC catheter and 1 peripheral IV.
  • Room preparation: he is looking for the premade syringes from pharmacy: phenylephrine, epinephrine and vasopressin.
  • Drips: carrier, phenylephrine, and epinephrine. Extra drips based on the specific history or hemodynamics during the case.
  • He is looking for your vigilance on hemodynamics: use phenylephrine and glycopyrrolate to keep SBP > 100, HR > 50.
  • Preop Aline for all first cases, all subsequent cases can have the Aline done in the room (especially for TAVRs).

Stoops ​

  • Thinks it's ridiculous this preference list exists and hopes she never has more than this for an entry

Sullivan ​

  • All inpatients need to be seen and consented the night before.
  • Resident should know the hemodynamic goals for the lesion being fixed.
  • Resident should know the medical comorbidities of the patient undergoing the surgery.
  • Resident should know the basics of the surgery being performed.
  • Resident should have an induction plan and a plan for lines.
  • Drugs to have available: epi syringes, epi infusion, NE infusion, nicardipine infusion (don't need to open it), ketamine, dobutamine (don't need to open it), milrinone (don't need to open it)
  • Prefers the ultrasound to be on the same side as the IJ that you are planning to access.
  • Prefers opiates/benzo w/ inhalational induction, especially for sick patients.
    • Does not like etomidate

Wilkey ​

  • Wants inpatients seen and consented the day before.
  • Look for antibodies on type and screen the day before the case so case is not delayed due to difficult cross match.
  • Have a clear induction plan when you call to tell her about the patient. Induction plan should be based upon patient and situation. Generally does not like propofol as primary induction agent but can be convinced in some cases. Consider having a vial of propofol available for patients who need to avoid hypertension with induction.
  • A-line before induction for all cardiac cases and lung transplants. For first start cases, arterial line should be in by 730 Tuesday through Friday and 830 on Monday. No strong preference pre-op versus in room, just wants it done on time.
  • Defib pads on for all redos and patients with inactivated ICDs.
  • If pt has pacemaker have a plan to manage it peri-operatively.
  • Put TEE probe in before central line placement and always use ultrasound for central line placement.
  • Call for all bad intra-operative events, even if you think you can handle it. She may or may not come but needs to stay in the loop.
  • Place OGT after TEE probe removed but before transporting to ICU.
  • Like PIV in the EJ if difficult IV access.
  • Like ROTEMs following complex aortic cases, redos, transplants and VADs… or anything else that has bled significantly prior to coming off bypass.