Cardiothoracic Anesthesiology in South Africa

Cardiothoracic anesthesiology deals with the anesthesia care related to surgical procedures such as lung surgery, open heart surgery, and other procedures on the human chest. It involves perioperative care and expert manipulation of the cardiopulmonary physiology through the advanced and precise application of anesthesia, sedation and pain medication. It also involves resuscitative techniques, critical care medicine. Management of the heart-lung (cardiopulmonary bypass) machine is also undertaken by cardiothoracic anesthesiologists. This is done while the heart undergoes surgery.

Cardiothoracic anesthesiologists are medical doctors who have at least 4 years of medical school, internship for one year, at least 3 years residency in all subspecialties of anesthesiology and additional training in cardiothoracic anesthesiology.

Cardiothoracic anesthesiologists provide consultations and recommendations for patients with cardiothoracic pathology but who present for non-cardiothoracic surgery. This is because such patients have an increased danger of perioperative complications. They evaluate heart function with the help of TEE.

Cardiac procedures

coronary artery bypass surgery (CABG) both on a beating heart and on a cardiopulmonary bypass, heart valve surgery, aortic reconstruction needing deep hypothermic arrest, aortic dissection repair, mechanical ventricular assist device (VAD) placement, heart/lung transplants, lung transplants, heart transplants, thoracic aortic aneurysm repair, automatic implantable cardiac defibrillator placement, adult congenital heart surgery, cardiac pacemaker, surgical treatment of cardiac arrhythmias, complete gamut of invasive cardiologic (catheter-based).

Cardiothoracic anesthesiologists also assist in the anesthetic management of cardiac patients including ventricular assist devices (VAD), blood transfusion medicine, management of intra-aortic balloon pumps (IABP), postoperative ICU care, transthoracic echocardiography, and electrophysiology.

In addition to assisting in cardiac surgical procedures, they also assist in thoracic and vascular surgical procedures. They help manage all type of thoracic surgeries and have expertise in different techniques of lung isolation and ventilation. These include open thoracotomy, video-assisted thoracoscopic surgery (VATS), advanced airway procedures involving the trachea, bronchial blockers, advanced jet ventilation, double-lumen endotracheal tubes and univent tubes under the guidance of fiber optic bronchoscopy.

Cardiothoracic surgery is of a complex nature and therefore requires a cardiothoracic anesthesiologist. A cardiothoracic anesthesiologist has expertise in advanced monitoring techniques including cardiac output monitoring, Transcranial doppler (TCD), cerebral oximetry, Bispectral Index (BIS), invasive blood pressure, arterial blood gas analysis, jugular venous oxygen saturation, Near-infrared spectroscopy (NIRS).

Invasive procedures completed by the cardiothoracic anesthesiologists include: Echocardiography (TTE and TEE), intraspinal drainage placement, central venous cannulation (femoral, internal juggular, subclavian), arterial line placement (brachial, radial-femoral, axillary), 2D/3D transesophageal echocardiography, thoracic epidural analgesia, transvenous pacemaker placement, pulmonary artery catheter placement, fiberoptic endotracheal tube placement and advanced ultrasound guidance of vascular access.

Cardiopulmonary bypass (CPB) is a technique used during surgery whereby a heart-lung machine temporarily takes over the function of the lungs and the heart. The CPB is usually operated by a perfusionist. During surgery, the perfusionist takes over the heart function and works closely with the anesthesiologist and the surgeon. After the surgery, the patient t is separated from the CPB. The CPB can complicate the separation. Other factors that can cause complications are the patient's inherent pathology/physiology, surgical correction, and also the dynamic interaction of all three. This technique has effects on the patient's hematology, immunology and physiology and the cardiothoracic anesthesiologist must acutely manage these to ensure effective separation from CPB.