A Day of pre-TCV

The pre-TCV Week

Pre-TCV update provided by Pablo Kollmar, CA-2

Pre-TCV is a one week rotation done the week before you start your first cardiac rotation during CA-1 year (or beginning of CA-2 year for advanced residents). It provides the opportunity to get a handle on the workings of the heart room, solidify your procedural skills, and learn the basics of cardiac anesthesia so you can hit the ground running when you start your cardiac rotation.  The rotation is a mix of helping a senior resident set up and start cases, didactic sessions with cardiac attendings, a chance to see the role of the perfusionist during cardiac surgery, and simulation sessions.  A typical day might go something like this:

5:45 AM: The days start early on cardiac, I get there and begin to set up the room with Kathryn, one of the CA-2s on her second month of cardiac.  First case of the day is a combined CABG and aortic valve replacement (AVR). We have to set up airway stuff, central line and arterial line, pressors including epinephrine and norepinephrine, and infusions of sufentanil and aminocaproic acid.  By 6:30 we head of to the preop area to see the patient and go over some final plans with our attending for the day, Dr. Groves.

7:00 AM: We roll back to the room with the patient, get all the monitors on, and I get started on a pre-induction arterial line.  After the a-line is in we drift the patient off to sleep, and Kathryn intubates while I get all set to put in the central line. We get the patient prepped and draped and I put in the internal jugular central line.  After this we float a swan (PA catheter) so we can measure PA pressures and cardiac output. Kathryn then puts in the TEE probe and starts on an exam.

8:15 AM: The surgeons have finished prepping and draping, get the case started, and they work on taking down the internal mammary artery. Dr. Groves comes by to do some teaching about aortic stenosis findings on TEE, and I get my first chance to hold the probe and work on finding a few basic views.

9:30 AM: All of the cardiopulmonary bypass cannulae are in place, and the function of the patients heart and lungs are taken over by the perfusionist.  Isaac (the other pre-TCV resident) and I get a cup of coffee and go over some review questions about the bypass circuit with Dr. Kleiman before heading back to the OR.

11:30 AM: It time to come off bypass – one of the busiest, and most exciting moments in cardiac anesthesia.  It is a team process requiring communication between the anesthesia team, the cardiac surgeons, and perfusionists.  Things change fast, and we are processing a lot of information to make sure we are taking the patient in the right direction.  Eventually things stabilize and we are able to wean off some of the pressors, check a ROTEM, give some blood, and make sure the valve looks good on TEE.

Pablo Kollmar, CA-2

12:30 PM: It’s time to move the patient up to the TCV ICU where we give report, and then grab a quick lunch before getting things set up for our next case. I sure am glad to be having someone helping me figure this all out, as it seems like a lot is happening at once.

1:30 PM: Our second case gets started, which means an opportunity to get to do some more lines, and I feel like I’m gradually getting a hang of how this is supposed to work.  Shortly after we get everything settled Issac and I head over to the simulation center for some extra teaching on central lines and valvular pathology with Dr. Bechtel. There seems to be a lot to learn!

4:00 PM: We head home for the day. Have to rest up and do some more reading.  Sounds like we are doing an LVAD tomorrow!