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Vascular - Thoracic Anesthesia Service
Patient Care The Division of Vascular and Thoracic Anesthesia has been a melding of faculty from many other divisions in the department who enjoy complex and challenging clinical cases. Even though each of the members has many other time commitments and responsibilities in the department, all share a dedication to providing high quality clinical care and teaching in both the vascular and thoracic operating rooms. All faculty in the Division specialize in high acuity anesthesia care. Both the vascular and thoracic sections share a similar complex, geriatric patient population. The team has been assigned into two sections based on the most frequent clinical assignments of the faculty. With increasing clinical demands in each area over the past four years, the vascular and thoracic anesthesia service has matured leading to the refinement of separate educational programs and the enhancement of clinical expertise in each area in concert with our surgical colleagues. As a result, formal separation of the two sections into two separate divisions occurred on July 1, 2005. The members of the Division of Vascular Anesthesia are: Vascular Division Director: Carol Ann Diachun, M.D. Vascular Division Members: Sanjeev Chhangani, M.D., Ruben Davila-Perez, M.D., Joseph Dooley, M.D., Stewart Lustik, M.D., J. Russell Norton, M.D., Barry Zimmerman, M.D., and Christopher Trojan, M.D. (starting September 1, 2005) The members of the Division of Thoracic Anesthesia are: Thoracic Division Co-Directors: Sanjeev Chhangani, M.D., J. Russell Norton, M.D. Thoracic Division Members: Carol Ann Diachun, M.D., Joseph Dooley, M.D., Jason Dziak, M.D., Suzanne Karan, M.D., Denham Ward, M.D., Jacek Wojtczak, M.D. Additionally, on non-cardiac workdays, the members of the cardiac division also provide excellent clinical care and teaching in the vascular and thoracic operating rooms. Patient Care:The Divisions of Vascular and Thoracic Anesthesia utilize practice guidelines or "care-maps", recently developed by both vascular and thoracic faculty, to assist all clinicians, trainees and students. This collection of documents provides instructional guides for teaching purposes and full care guides where evidence is sufficient. The practice guidelines are designed to help the practitioner(s) involved in the care of vascular and thoracic surgery patients in clinical decision-making based on scientific evidence and broad departmental consensus, and thereby improve the process and delivery of quality of care. The entire contents of these documents are annually reviewed and updated. They can be seen on the departmental intranet web-site.Vascular Anesthesia and Surgery Volumes:Vascular surgery volume remains high with over 1200 cases performed from July 2004 through June 2005. Case mix ranges from dialysis access procedures and vein-stripping to open thoracic and abdominal aortic repairs. To provide the safest care for these very sick patients, our service uses a full range of anesthesia techniques including: monitored anesthesia care and upper extremity regional blocks for dialysis access cases, ankle blocks for foot/toe amputations, superficial cervical nerve blocks for carotid surgery, as well as spinal, epidural and general anesthesia. Utilizing our specialized fluoroscopy-equipped operating room suite, we have increased our volume of the latest endovascular procedures to over 115 cases from July 2004 through June 2005. These procedures vary from basic angiograms, to stenting of carotid and peripheral arteries, to abdominal and thoracic aortic aneurysm stent repairs. Often these procedures produce less stress for patients and allow less invasive anesthetic techniques. Nearly half of the aortic cases were accomplished endovascularly during this time period.Thoracic Anesthesia and Surgery Volumes:Thoracic surgery volume remains high with over 800 cases performed from July 2004 through June 2005. Case mix includes: lung and esophageal tumor resection, lung reduction surgery, tracheal surgery, laser bronchoscopy, and video-assisted thoracoscopic surgery and laparoscopic Nissen fundoplication. Our faculty are highly proficient in the management of these challenging cases, including the use of the fiberoptic bronchoscopy and double-lumen endotracheal tubes. It is anticipated that, although changes in thoracic surgical staff have occurred, the overall surgical volume will remain at current levels.Resident Education:A formal Vascular Anesthesia rotation and Thoracic Anesthesia rotation were established four years ago. Both are two-week rotations. The Vascular Anesthesia rotation has been created to provide residents with the skills and clinical experience to care for patients requiring vascular surgical procedures. The resident must become competent as a consultant in anesthesiology in pre-anesthetic evaluation of cardiac function and evaluation of end-organ damage from many co-morbidities including diabetes mellitus, hypertension, and COPD. Residents must demonstrate appropriate formulation and safe conduct of anesthetic plan including control of postoperative pain. The didactic teaching includes 1-1 teaching by vascular anesthesia faculty in the operating room and two references: Vascular Anesthesia: A Practical Handbook by Caldicott, Lumb and McCoy, 1999; and "Vascular Anesthesia Manual". The manual reviews aortic, carotid, and peripheral vascular surgical procedures and anesthetic management including pertinent pathophysiology as well as reviews on pacemakers, hemostasis and arrhythmias. Departmental care maps and reviews of the newer endovascular procedures are also included. Our future plan is to create a simulator workshop to address anesthetic management for an open aortic cross-clamp case.The goals of the Thoracic Anesthesia rotation are to provide residents with the basic science foundation in respiratory physiology, and skills and clinical experience to care for patients requiring thoracic (non-cardiac) surgical procedures. Integral to this goal is for the resident to become competent as a consultant in anesthesiology in pre-anesthetic evaluation of pulmonary function, formulation and safe conduct of anesthetic plan including control of postoperative pain, management of one-lung anesthesia and lung isolation, and skills in fiberoptic bronchoscopy. The didactic teaching includes 1-1 teaching by the thoracic anesthesia faculty in the operating room and a reference "Thoracic Anesthesia Manual" which consists of applied respiratory physiology of one-lung anesthesia, technical aspects of lung isolation, as well as "state-of-the-art" reviews in thoracic anesthesia. Over the last two years, we added a "Thoracic Anesthesia Workshop" for the rotating residents to master fiberoptic bronchoscopy skills required in positioning and trouble-shooting double-lumen tubes as well as hands-on training with lung isolation equipment. This allows the residents to learn the concepts and reinforce their skills in a more relaxed and non-stressful environment. Our future plan is to create a video gallery of thoracic anesthesia techniques. Both rotations include pre- and post-testing as part of the evaluation process, reading assignments, and OR experience. Residents have consistently rated the rotations high for their teaching quality and utility. Additionally, during the past two years, we have added a senior resident rotation in both thoracic and vascular anesthesia. These rotations emphasize more advanced skills and more autonomy for our residents. Future Plans and Challenges:Rupture AAA Clinical Trial with Vascular SurgeryDr. Karl Illig, recently appointed as Chief of the Division of Vascular Surgery service with the departure of Dr. Richard Green in 2004, is leading a project to evaluate and treat patients with contained ruptured AAA endovascularly. There is accumulating evidence that patients with ruptured aneurysms who are repaired using endovascular (as opposed to open) techniques have a significantly lower mortality rate, in some series as low as 20% (mortality after open repair remains stubbornly at 50%). There is question, however, whether this is due to selection bias or not.The "Endo/Rupture" project involves many disciplines including emergency medicine, radiology, OR nursing, vascular surgery and anesthesia. Dr. Diachun has been integrally involved on this project and presented its details to the Anesthesia Department during 2 Grand Rounds in May 2004. Since the Endo/Rupture Protocol began in July 2004, approximately 20 patients with ruptured aneurysms have presented - only 8 possible candidates had appropriate anatomy for an endovascular repair. Of these candidates, 6 patients were repaired endovascularly. It is too early to assess results, but at least two patients with true rupture, who were repaired endovascularly, left the hospital within 72 hours of their repair and have done well since. Another with a symptomatic but nonruptured aneurysm was discharged on postoperative day one. Thus far, problems and pitfalls with the technique in the rupture setting have been identified and data collection is on-going. Additionally, the vascular service is on the final list for inclusion in a trial of endovascular repair for acute type B thoracic dissection which will expand Strong's ability to treat patients with aortic emergencies. Ultimately, using this and other initiatives, Strong's vascular surgery and anesthesia services aim to form a multidisciplinary Aortic Center to care for all patients in western New York with aortic problems with one phone call, thus becoming the quaternary aortic referral center between NYC and Cleveland. Service QI ConferenceTo review misses, near-misses, and update care plans and service, the vascular anesthesia division has proposed a quarterly service QI meeting with the vascular surgical service, anesthesia, and OR nursing. All teams are enthusiastic about this proposal with the first meeting scheduled for Fall of 2005.Resident and Faculty Education Improvement |
