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- It is often said that the anesthesiologist is the internist of the operating room (OR). By extension, the cardiac anesthesiologist becomes the OR's cardiologist. While it is certainly true that anesthesiologists must have knowledge of medicine in general and cardiology in particular, the practice of cardiac anesthesia is a unique discipline unto itself. Although cardiac anesthesiologists must have knowledge of why someone is being taken to cardiac surgery, they will not be the ones to decide if surgery is indicated or not. Rather, cardiac anesthesia staff must review the totality of the patient's cardiac and medical history to determine the best approaches to manage sick patients perioperatively. This chapter will briefly examine how someone is referred for cardiac surgery and the essential elements of preoperative evaluation necessary for patient management.
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Patients of all types present for heart surgery. From the smallest, hypoxemic infant with congenital heart disease to the 90-year-old with critical aortic stenosis, all varieties of patients undergo heart surgery. Even patients undergoing the same type of surgery can vary greatly depending upon their preoperative comorbidities and the impact their disease has had upon their cardiac function. A patient with well-preserved ventricular function presents far different challenges than an individual with a low ejection fraction. Likewise, the patient with intact renal function free of diabetes and lung disease is potentially less problematic than the person afflicted with these comorbidities. In this regard the conduct of cardiac anesthesia parallels that of any anesthetic. A patient's comorbidities are considered as the anesthetist determines the appropriate anesthetic technique, monitoring, and plan for postoperative management. What is perhaps unique about cardiac anesthesia is that so many of these comorbidities are regularly present; the "routine" cardiac surgery patient is incredibly sick both as a consequence of their primary heart disease as well as the associated illnesses which occur frequently in this patient population.
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Generally, the "routine" cardiac surgery patient is designated as an American Society of Anesthesiologists (ASA) class 4. No one undertakes cardiac surgery on a whim and as such anesthesia consent should be direct and sobering to avoid excessive optimism in patients and their families. All patients are informed of the inherent risk of death, stroke, neurological dysfunction, or renal failure. The risk/benefits of transesophageal echocardiography (TEE) should likewise be discussed with the patient preoperatively. Although the risk of stroke following bypass surgery is low (3%)1 and that of death even lower, cardiac surgery is associated with multiple postoperative morbidities including cognitive dysfunction, renal failure, gut ischemia, and potentially prolonged ICU care. Because both the surgeon and the anesthesia team influence the patient's hemodynamic performance it is often difficult to discern whether surgery or anesthesia is responsible for an adverse outcome. Ideally both the surgery and cardiac anesthesia groups function as a team sharing the joy when difficult patients are safely managed and sharing the anguish when the inevitable death or brain injury occurs. Anesthesiologists entering into cardiac anesthesia practice should be ...