my name is Max Feinstein and I'm an
anesthesiologist filming here in New
York City at Mount Sinai Hospital in
this video I'm going to be taking you
inside an operating room with an actual
surgery going on where the patient goes
on to cardiopulmonary bypass this video
does not provide medical advice and
while the patient is not shown and no
patient information is displayed in this
video the patient did consent to having
filming being done while the surgery was
going on this video was also approved by
Mount sinai's Department of
anesthesiology as well as the hospital's
press office if you find this video
interesting or helpful I'd really
appreciate it if you liked it and
subscribe to the channel let's Dive In
please
we are sitting here with the attending
anesthesiologist for the case Dr Benji
Salter helped me understand a little bit
about the nature of the case that we're
looking at today so today's case is an
on pump coronary artery bypass case this
is a patient with known diabetes and
coronary artery disease which is just
significantly gotten worse to the point
where the patient is experiencing
dyspnea and exertion had a positive
stress exam as well which led to a
coronary catheterization which revealed
all the vascular disease
the term on pump refers to rerouting
blood from the patient's heart and lungs
into this bypass machine run by a
specially trained perfusionist the heart
is then intentionally arrested so that
it's motionless which allows the surgeon
to then graft blood vessels from other
parts of the patient's body to go around
the diseased coronary arteries hence the
term coronary artery bypass graft or
cabbage as it's commonly referred to
what was the preparation like for this
case
the preparation for our cases always
start the night before I was able to
communicate with both my resident and my
fellow last night we spoke briefly about
hemodynamic goals the patient's medical
history the different lines monitors
that we were going to use today and we
kind of came up with a plan and then all
met again with the patient this morning
this is a very major operation and I
think that that the level of anxiety is
a lot different relative to another
surgery so it really is our
responsibility to
ease their anxiety prepare them for what
is to come both initially and then
afterwards and so I think having that
conversation and and treating them like
a family member or a friend is really
important because when they come in the
room and they see there's five other
support staff in there and they see all
the monitors and they see the
perfusionist and all their equipment
you're very very scared but I think this
is really what sets the really good
anesthesiologists from everybody else
which is our ability to establish a
rapport with our patients in addition to
meeting with the patient the
anesthesiology team prepared the room
the mnemonic Ms Maids is often used to
recall the components of an anesthesia
setup where m stands for machine check
s for suction another M for monitors
which includes pulse oximetry EKG blood
pressure which in this case will be
monitored with an arterial line placed
with ultrasound guidance
a bispectral index monitor to measure
depth of anesthesia
and a cerebral oximeter to measure
cerebral oxygen saturation the a stands
for Airway which includes a laryngoscope
that facilitates placement of an
endotracheal tube I for IV which in this
case includes special tubing with a
filter to allow safe administration of
blood products as well as a central line
that will be placed in the patient's
neck to allow for safe delivery of
vasopressors as well as central venous
pressure monitoring the D and Ms maid
stands for drugs cardiac surgery
requires preparing many medications
which I go over in more detail in the
video linked in the top right it's worth
pointing out that the anticoagulant
Heparin plays a particularly vital role
in preventing complications while on
bypass the last s in the mnemonic stands
for special equipment and in this case
we'll have electrodes attached to the
patient in case we need to deliver
shocks throughout the surgery we'll also
be using trans-esophageal
echocardiography for which cardiac
anesthesiologists are specially trained
with everything set up we now wheel the
patient back to the operating room and
start placing monitors those include
cerebral oxygen saturation as well as a
bispectral index monitor to get
pre-induction Baseline readings as well
as a pre-induction arterial line this
allows us to monitor a patient's blood
pressure continuously which is
especially important when inducing
anesthesia for patients with severe
cardiovascular disease this is a sterile
procedure that starts with administering
lidocaine to make it less uncomfortable
since the patient's awake it's common to
use ultrasound guidance although
anesthesiologists can also perform this
procedure by feel alone this is what the
continuous blood pressure waveform looks
like from an arterial line next
anesthesia is carefully induced with a
combination of Fentanyl and propofol
followed by the paralytic Rock uronium
to facilitate intubation and keep the
patient's body motionless during surgery
once the patient is under general
anesthesia an endotracheal tube is
inserted to support the patient's
breathing during surgery now we get
ready to place the central line which is
a sterile procedure I notably made my
useful contribution to this case by
helping Dr standard put on hysterical
gown you're welcome
then Dr pulajal prepared a nine French
central line with a triple Lumen
catheter which is how we can safely
administer vasopressors measure central
venous pressure and deliver a fairly
substantial volumes of fluid through the
large catheter a sterile drape is placed
over the patient then using ultrasound
guidance a needle is inserted into the
patient's internal jugular vein
ultrasound helps us make certain that
the needle is in the vein not in a major
artery which could be catastrophic
not shown was the placement of a
transthoracic echocardiography probe
which helps us to confirm the proper
placement of the central line by seeing
a wire passing into the patient's heart
the catheter can then be placed over the
wire which is known as the seldinger
technique and our central line is done
with the patient under general
anesthesia and the lines in place the
surgeons can now start the case
the entire time you know we kind of keep
our heads on a swivel we're remaining
Vigilant we're really monitoring
hemodynamics uh communicating with the
surgeons about hemodynamic goals our
responsibility in addition to all that
right now is a thorough Echo exam not
only do we want to evaluate this
patient's function because they are
coming in for coronary bypass but we
want to make sure that there are no
valvular abnormalities no pathology that
wasn't expected lots of our patients
have a very thorough workup there are CT
scans there are pre-op Echoes but things
change we want to make sure there's no
new disease that was unknown prior to
starting the surgery because more often
than not it can change the course of
surgery whether that's what they're
going to address when they're actually
on pump whether it's going to change how
they cannulate all of those findings
that we see May alter the course of the
surgery as we perform the initial
echocardiography exam the surgeons are
performing several steps simultaneously
one is opening the chest which is called
a sternotomy while at the same time the
blood vessels are being harvested from
various parts of the body including the
leg the arm or the chest itself these
blood vessels will eventually be grafted
onto the heart to to bypass the diseased
coronary arteries once the blood vessels
have been harvested the team gets ready
to go onto cardiopulmonary bypass so the
heart can be stopped and operated on
part of the preparation process entails
the surgeons inserting cannulae into the
patient's major blood vessels to take
blood out of the heart run it through
the bypass machine and then return it
back to the patient's body the
anesthesia team assists the surgeons
with cannula placement by confirming
proper location on Echo a crucial safety
mechanism before going on a bypass
includes heparizing the patient which
means administering the anticoagulant
Heparin So the patient's blood doesn't
clot it's really important so that we
don't have any you know clotting
situation or you know maybe a thrombus
formation embolus during or in the pump
or on any of the membranes of the pump
or in the field we want to make sure the
patients really adequately
anticoagulated so that they're not at
risk for for any of those insults once
heparinized we can now go on to cardio
pulmonary bypass with the heart lung
machine next in order to stop the heart
so it can be operated on a solution
known as cardioplegia is routed through
the heart cardioplegia contains large
amounts of potassium which is ultimately
responsible for arresting the heart here
the EKG actually shows the heart slowing
down and then finally stopping
at this point the surgeons start to
graft the harvested blood vessels onto
the heart to bypass the diseased
coronary arteries in addition to being
the attending anesthesiologist for this
case you are also the program director
for the cardiothoracic anesthesiology
fellowship program here at Mount Sinai
Hospital what has that been like for you
this has been one of the most fantastic
experiences I've ever had in my career
we have seven current fellows we're
going to have eight in the upcoming
Academic Year
it really is an honor to be able to
bridge them between residency and when
they become attendings and and work with
them to develop their skills as
cardiothoracic anesthesiologists someone
who's just watching this video might
think that the fellow is actually the
attending the way that she's interacting
with the resident teaching pushing
medications so in my experience it's
been very impressive to see the level of
autonomy and Independence that fellows
get and even residents who have gotten
experience in the operating rooms I
think that that's part of the spectrum
of growing as a house staff member you
start off as a ca1 and you're not really
working independently and as you start
to grow as a ca2 and a three and you
come to cardiac and you come to thoracic
we get to kind of develop a rapport and
and as you learn you gain independence
and then as you become a fellow we have
this idea of conditional Independence
and you've already mastered general
anesthesia and that's why you're here
now is to really learn how to master
cardiac anesthesia and cardiothoracic
anesthesia so we worked very hard for
the first let's say six to nine months
in developing Independence and strength
and a foundation so that you really can
become independent by the end of the
kind of third quarter of the Year going
into the end of the year why would
someone choose to go into cardiothoracic
anesthesiology I think that in my mind
cardiothoracic anesthesia really
encompasses
so many of the things as that we that we
need to know as an anesthesiologist it
encompasses very very sick patients and
the management of their pathology
invasive monitoring whether it's central
line placement arterial line placement
trans-esophageal echocardiography which
is really important and a great tool to
have and I think it's exciting and I
think it really provides very rewarding
work to see a very sick patient improve
after surgery and then thereafter over
time one of the things that I've heard
about cardiothoracic anesthesiologists
is that they basically provide guidance
for the surgeons as they're going
through the surgery can you speak to
that a little bit let's say you're going
to do a mitral valve repair or an aortic
valve repair it really is reliant on the
anesthesiologist to tell the surgeon
what's the mechanism of the pathology so
that the surgeon can plan and and make
decisions as the surgery is continuing
what do you need to do to get prepared
to come off bypass does this patient
have a low ejection fraction are they
going to need inotropic support will
they need mechanical circulatory support
so we really start to think about not
only do they need support
hemodynamically or whatever it is but
what kind of support are they going to
have so once we've had that discussion
we all come up with a formal plan the
clamp comes off we kind of reperfuse the
heart and then we start to make
decisions based on what we're seeing how
does the function look how does the
valve repair replacement look are we
satisfied with everything do we need to
go back on bypass to repair replace
continue to work we're always
dynamically you know changing our
decision making as we go through this
whole process so we're we're prepared
with everything and uh and move forward
with that coming off of bypass
frequently entails using a temporary
pacemaker to keep the heart beating
regularly the pacemaker is typically
removed from the patient after a
relatively short period of time once the
heart is beating well on its own another
vital aspect of coming off the bypass is
reversing the anticoagulation from
Heparin which we do using a medication
called protamine that's very carefully
administered and so we come off to
bypass surgery finishes the surgeons are
done closing and the patients typically
stay intubated for a period of time and
we go up to the ICU and patients
typically are extubated within what
would you say hopefully within a couple
hours that's really the goal in our ICU
I think once they're hemodynamically
stable we're monitoring various drains
chest tube output making sure there's no
coagulopathy the sooner the better
really in our ICU they do a great job of
extubating as soon as the patient is
ready for anybody who's interested in
the cardiothoracic anesthesia program at
Mount Sinai where can they find more
information we do have a divisional
website so when you find our
departmental website you can click on
the cardiothoracic division there's a
fantastic introductory video on there
contact information for myself and for
our program coordinator we're all very
open and readily available and excited
to answer questions about the program I
really appreciate your time and the
opportunity to bring a camera inside an
operating room and film these cases even
though I'm not going into card
anesthesia it does have a spot in my
heart forgive the pun that is why I did
an extra rotation with you and it's just
great to be able to be in the operating
room and share that with my YouTube
channel so thanks a ton Benji fantastic
thanks for having me I really appreciate
it if you enjoyed this video you might
want to check out this video where I
show what it's like as a resident being
on call for cardiac anesthesia thanks
very much for watching I'll see you next
time
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