A Day Fixing Pediatric Hearts
Pediatric Cardiac Anesthesia
2016 Congenital Cardiac update provided by Greg Smith, CA-3
As residents at UVA, we have a unique opportunity in our CA-3 year to do a dedicated congenital cardiac anesthesia rotation. This rotation is 3-4 weeks and is a very well structured and worthwhile experience. Residents are typically in the operating room on Monday, Thursday, and Friday for on-bypass and off-bypass congenital cardiac cases. On Tuesdays, we typically do cases in the pediatric cath lab. Wednesdays are dedicated ‘educational days’, where residents attend our department morning conferences and then attend a pediatric congenital conference where cardiologists, surgeons, and intensivists review cases that will take place the coming week. Residents often spend the rest of the day either in a pediatric cardiology clinic, or with a pediatric perfusionist, to further understand the differences between adult and pediatric cardiopulmonary bypass. There are typically 1-2 surgical cases daily – which include but are not limited to the following pathologies: VSD and ASD, tetralogy of fallot, transposition of the great arteries, palliative staging for single ventricle physiology, complete and partial AV canal, coarctation of the aorta, valvular abnormalities, outflow tract obstructions, and conduction abnormalities. Residents are expected to start and finish their own cases, but are not included in the general call pool during the rotation. Residents are typically on call for emergency congenital cardiac cases throughout the rotation. The rotation is designed to enhance the resident’s understanding of congenital cardiac anesthesia, so residents are given ample time to read about their patients and associated comorbidities throughout the rotation.
In the operating room, residents typically start their day between 0530 – 0600 to set up for the case. Medication doses have to be carefully calculated beforehand, as patients are not uncommonly 2 kg or less. We typically meet with and premed the patient around 0650 with the goal of being in the room about 0715. Unless contraindicated, we typically induce the patient by mask induction, place a peripheral IV, and then nasally intubate. Once the airway is secured, the resident places both the arterial line and the central line, which can be quite challenging in these small babies. Once lines are placed, we start our infusions, sort our lines, and place a TEE for the cardiologists to review. Due to the complexity of these cases, the resident always has a dedicated attending available throughout the entirety of case. During cardiopulmonary bypass, the attending will often discuss the pathophysiology of the congenital abnormality and provide teaching to further the resident’s understanding of the case. Bypass is also a great time to get the resident out for lunch. Coming off bypass can be rather challenging, the resident and attending will orchestrate vasoactive and inotropic infusions, manage arrhythmias as they arise, and communicate with the surgeons and perfusionists to successfully separate from bypass. As the surgeons start to close, the resident calls the PICU to give report to the receiving nurse. At the end of the case, the patient may be extubated in the operating room, or transported intubated to the PICU depending on the status of the patient. The receiving nurse will help with transport to the PICU. In the PICU, the resident and attending will provide a detailed sign-out of the patient to the receiving intensivists and cardiologists, detailing the events of the case.