Jennifer D. Walker, MD, FACS

In an era when patients are more complex and procedures and technology are more advanced, a new paradigm is evolving. The cardiac and general surgical operating rooms, as well as the hybrid operating suites in the catherization labs, are mandating the Universal Protocol Checklist or “time out” or “group hug”. This simple but novel tool establishes guidelines for communication among all members of the cardiac surgical and cardiac anesthesia teams.

This concept has been successfully utilized by the airline industry for decades. The requirement of team member introduction, discussion of allergies and co-morbid conditions, the planned procedure, and potential complications empowers each member of the team to speak freely. The benefit is improved dialogue between cardiac surgery and cardiac anesthesia, a breakdown of implied barriers of communication and improved patient care.

The role of cardiac anesthesia has evolved in the cardiac operating room, cath lab, EP lab, and non-cardiac emergencies in and outside of the OR. The requirement to learn TEE is now also part of the anesthesia residency curriculum encompassing 2D TEE, epiaortic, epicardial, and 3D TEE. In addition, ultrasound guidance is used for vascular access.

Adding the performance of TEE to the responsibilities of the cardiac anesthesiologist caring for critically ill patients presents challenges related to obtaining the necessary diagnostic and echo data in a timely fashion while educating residents and fellows.

The role of the cardiac sonographer as a member of the cardiac anesthesia team in the operating room is being actively addressed by the ASE to provide education about TEE for residents and fellows while obtaining images so the anesthesia staff can focus on care of the patient and be a consultant for the TEE.

Every cardiac surgical anesthetic induction, line placement, and monitoring, and every cardiac surgical procedure has an expected pace, sequence of progression, technique, and necessary level of supervision. Staff teaching of residents is the lifeblood for academic institutions and integral to the success of any cardiac surgical program.

Residents learn at varying rates based on previous experience, teaching, innate skill, preparation and practice, and conceptualization of tasks, as well as the ability of their mentors and the environment in which the education takes place. Staff surgeons and anesthesiologists have varying personalities and philosophies about education, which can promote or hinder learning. Facilitating communication is key to a successful teaching environment. Communication is defined as a giving or exchanging of information to reach a common understanding, and consists of two phases: transmission and feedback. Communication failures in the operating room jeopardize patient safety by increasing cognitive load, interrupting routine and increasing tension.

As a cardiac surgeon and the director of education and the cardiac surgical simulation lab, I have a primary investment in the successful education of our residents in cardiac surgery and anesthesia. My operating room is run as an educational module for all levels of participants from visiting high school students to senior fellows ready to graduate. I am in the operating room as soon as the patient arrives to discuss the case with nursing, anesthesia, and residents. During the case, I wear a head camera to project the surgical field on high definition monitors so I can narrate the case and explain the anatomy, pathology, and interesting findings. I engage our anesthesia and surgical residents to teach them to consider what happens on both sides of the ether screen.

Incorporating the TEE into the flow of the operation starts at the beginning. The anesthesia resident is taught to understand the indications for probe placement and specific patient factors that may influence the performance of the TEE.

Performance of the essential parts of the TEE that may influence the order and conduct of the cannulation and operation are addressed first. The remainder of the exam is then completed by protocol. When time is limited based on the operative procedure, surgical speed, or hemodynamic compromise, alacrity must be used to obtain the necessary data in the time allotted.

I converse with anesthesia through each step of the operation to help the anesthesia resident learn to plan and anticipate parts of the operation such as lowering the blood pressure to 100 mmHg for cannulation of the aorta or opening a reoperation, anticipating transient decreases in blood pressure or ectopy with atrial and caval cannulation. I urge them to look into the operative field and to verbally communicate concerns before reacting to changing hemodynamics.

As the operation progresses, I encourage anesthesia residents and staff to look at the pathologic specimen removed or at least at the intraoperative imaging to learn to correlate the finding of the TEE and the hemodynamics from the preoperative period with the specimen (bicuspid aortic valve, destroyed leaflet in endocarditis etc).

The other role for the TEE early in the case is recognition of pathology not otherwise defined by the preoperative studies or clarification of pathology such as mechanisms of mitral insufficiency.

I have altered my operative strategy many times over the years based on these preoperative TEE or epiaortic findings: left atrial appendage clot, PFOs, PFE, mobile aortic thrombi. Similarly, I rely on the TEE for assistance to place femoral venous or arterial cannulas, assist with deairing, assess the repair or replacement of valves, evaluating wall motion, postop aortic dissection, or to place an IABP. The subtle findings of the TEE have become a standard component of cardiac surgical decision making.

Just as the increasing complexity of cardiac surgical operations makes it difficult to allow less experienced residents to perform the operations, mastery of TEE is a rigorous process. Simulation training is now available in many levels of sophistication for cardiac surgical and anesthesia resident training. TTE and TEE simulators are relatively expensive and technology is evolving, but this educational tool may become essential as an increasing number of anesthesia staff and residents focus on certification in TEE.

Independent performance of cardiac surgery does not occur during residency, nor should independent performance and interpretation of TEE. Either a trained cardiac anesthesiologist dedicated to performing the TEE, or a trained intraoperative cardiac sonographer should supervise each exam to assure accurate and timely acquisition of data and conveyance of the information in a standardized format to the surgeon.

Teaching mutual respect and comradery across the ether screen is one of the key elements in training respectful, courteous, interactive professional, and well-equipped residents. There is no room in our profession for condescending, aloof attitudes, or unilateral input. Patient care and learning are maximized with input from both teams as colleagues.

We are all working towards a common goal of educating residents, advancing our skill, improving patient care, and making our workplace enjoyable and safe. In the words of George Bernard Shaw, “the problem with communication is the ilusion that is has occurred.” Ensuring that communication has occurred helps to eliminate the problem.