AMG -Anesthesia Medical Group, P.C.

Cardiac disease is and continues to be a significant problem in the United States. Cardiac anesthesia is a subspecialty that involves the challenging medical management of patients with coronary artery disease (requiring bypass surgery) or valvular heart disease (requiring valve repair or replacement). In addition to their heart disease, cardiac patients often have other medical problems such as lung disease (COPD), hypertension, or diabetes. It is the role of the anesthesia team to take these medical problems into account and provide optimal care during surgery to try to maximize a safe outcome.

The preoperative evaluation attempts to both familiarize patients with the cardiac anesthesia care team and address any concerns and/or expectations regarding cardiac surgery. An anesthesiologist will go over your history and explain what will transpire before, during and after your surgery as it pertains to anesthesia.

You will be transported to a preoperative holding area prior to surgery. It is there that you will meet the anesthesia care team; this team is composed of an anesthesiologist and a CRNA (certified registered nurse anesthetist). The anesthesia team will review the medical records and then start an intravenous line (i.v.). Lidocaine (a local anesthetic) will be injected using a very small needle to numb the area of skin just prior to starting the i.v. A sedative (Versed) will then be administered into the i.v.; this medication will help alleviate anxiety as well as provide amnesia (it is unlikely you will remember much from this point forward until waking up in the ICU). A conscious effort is made to try to make this aspect of your care as relaxing and pain-free as possible. Narcotics are often administered in addition to the sedative to assure comfort.

An arterial line (a-line) is also inserted prior to surgery. This is an invasive catheter that is usually placed in the radial artery (at the level of the wrist where you check one’s pulse); this monitor allows the anesthesia care team to more accurately observe your blood pressure during the surgery (as opposed to a blood pressure cuff). Sometimes the cardiac surgeon will use the radial artery in one or both arms as one of the bypass grafts. In that case, the arterial line may need to be in the femoral artery (the artery that travels through the groin).

A pulmonary artery catheter may be inserted prior to surgery. This catheter is introduced through a large vein (usually the internal jugular vein in the neck) directly into the heart. This device is extremely useful in monitoring fluid pressures and heart function, both in the operating room during surgery and postoperatively in the ICU.

After all invasive lines and monitors are inserted, you will be transported to the operating room. Fresh oxygen is administered by gently placing an oxygen mask over your mouth and nose; general anesthesia is then induced by injecting medication through the i.v. It generally takes about 15-30 seconds to fall asleep after induction. A breathing tube is then inserted into the trachea and you will remain on a ventilator for the duration of surgery. General anesthesia is maintained by the delivery of anesthetic gas though the breathing tube; this is what keeps you asleep during surgery. At some facilities, a BIS monitor is used to show us how deeply asleep the patient is during surgery. This allows us to virtually assure an absence of awareness during surgery. With or without a BIS monitor, awareness is extremely RARE.

Transesophageal echocardiography (TEE) is a technique that involves using ultrasound to observe the heart. A probe (about the diameter of a finger) is inserted into the esophagus (the tube leading from the mouth to the stomach) of the patient after the patient goes off to sleep. This tool allows the anesthesiologist to visualize the heart in “real-time”; the heart’s ejection fraction (how well the heart squeezes) and valves (how well they open and/or close) can be evaluated in the operating room during surgery.

One of the main roles of the anesthesia care team during cardiac surgery is to provide an anesthetic that is as safe and stress-free to the body as possible. All of the aforementioned monitors are used continuously in association with various medications to help assure an optimal outcome.

At the end of surgery, you will be transported with monitoring to the CVICU. Most often, you will be kept asleep and on a ventilator immediately following surgery. In the past, patients have remained sedated and on a ventilator for an extended period of time following cardiac surgery; more modern anesthetic techniques have significantly reduced that time. The length of time on a ventilator can vary from person to person, but a general rule of thumb is that you will wake up 6 to 8 hours after arriving in the CVICU.