The cardiac anesthesia service at St. Elizabeth's Medical Center is an active tertiary care unit performing 400 to 500 surgical procedures. Our service specializes in adult cardiac surgical procedures with two dedicated operating rooms. We have a challenging case mix, including coronary bypass, valve repair and replacements and re-operative procedures. Our patients are primarily high-risk with multi-system disease. Our cardiac surgical procedures are increasingly more complex with the advent of multiple arterial bypass grafts, off-pump coronary artery bypass procedures (OPCAB) and mini-thoracotomy bypass (MIDCAB). We are expanding our minimally invasive bypass program and now perform three and four vessel OPCAB when appropriate. For post-coronary bypass patients, a protocol using gene therapy with vascular endothelial growth factor (VEGF) has been developed. Until now, these patients were considered inoperable, but with this new FDA-approved technique, we can provide an innovative way to treat refractory angina in these.
The Department of Anesthesiology and Pain Medicine is in the forefront of fast tracking cardiac surgical patients during their recovery. We have an active program of early extubation, efficient care protocols and reduced length of stay for our cardiac surgical patients. We participate in and benchmark our performance against the National Society of Thoracic Surgeons (STS) database. We use invasive monitoring, including pulmonary artery catheters, continuous cardiac output (CCO) and mixed venous oximetry. Intraoperative transesophageal electrocardiography (TEE) is performed on all cardiac procedures.
Staff anesthesiologists are assigned one-on-one with the residents for each cardiac surgical procedure. The junior residents (CA-1 and CA-2) have a two-month rotation in cardiac anesthesia. They are expected to evaluate all assigned cases and discuss them with staff members. At the end of this rotation, the resident should be facile with the insertion and use of pulmonary artery catheters and comfortable with the principles of hemodynamic management of cardiac surgical patients.
CA-3 residents, demonstrating a keen interest in cardiovascular anesthesia, have an opportunity to select advanced (two- to six-month) clinical time in cardiac anesthesia. The residents are expected to be well versed in cardiac physiology and pharmacology, the management of CPB, and understand the principles of myocardial preservation. The residents can expect to develop a basic understanding of intraoperative tracheoesophageal echocardiography and may participate in clinical research projects. The residents participate in cardiac call on nights and weekends and share call with the cardiac anesthesia fellow.
In July 1993, St. Margaret's Center for Women and Infants opened on the St. Elizabeth's Medical Center campus. The center treats both routine and high-risk parturient patients from eastern Massachusetts. Residents are exposed to many patients with pregnancy-induced hypertension, multiple gestation, prematurity, diabetes, and other medical and obstetrical problems.
St. Elizabeth's provides full training in obstetric anesthesia. The introduction to this area begins in the classroom as new residents are taught the physiologic and pharmacologic characteristics of parturient patients.
CA-1 residents are assigned to the obstetric suite for a one-month rotation during which they administer all the anesthetics requested. Lectures and case conferences on obstetric anesthesia take place throughout the year. All residents have additional experience in administering obstetric anesthetics as part of their on-call responsibilities during their tenure at St. Elizabeth's Medical Center.
Most cesarean sections are performed with the patient under spinal anesthesia, whereas most of the vaginal deliveries in which anesthesia is used involve an epidural block. During a typical three-year residency, each resident participates in approximately 175 deliveries, for more than are offered during a one-month rotation even at a high-volume obstetric hospital. Opportunities exist for residents to participate in faculty clinical research projects in obstetric anesthesia.
The St. Elizabeth's Medical Center Pain Management Center is a comprehensive multidisciplinary pain center providing services for patients with acute, chronic non-malignant and malignant pain, and palliative pain care. Residents have the opportunity to treat acute and post-operative pain through the use of patient-controlled analgesia delivered intravenously as well as to the neuraxis, subarachnoid and epidural narcotics, continuous or long-acting selective nerve blockade, and oral as well as transdermal analgesics.
Training in chronic non-malignant pain management in the outpatient center includes the specialties of anesthesia, medicine, neurology, psychology, and psychiatry. Patients are provided with an individualized pain management treatment plan after comprehensive multidisciplinary review has been completed. Treatment plans may include one or more disciplines.
Typical modalities might include physical therapy, behavioral and cognitive therapies, epidural injections, myofascial injections, and sympathetic nerve blocks. State-of-the-art techniques that may be utilized include chemical or thermal neurolysis (cryoanalgesia or radiofrequency), spinal cord stimulation, and implantation of intrathecal narcotic delivery systems. Residents become familiar with applying the appropriate modalities to reduce and control the pain associated with most painful conditions.
Critical Care/Intensive Care
The Lahey Clinic, located approximately 15 miles from St. Elizabeth's Medical Center, is the site for ICU training. Typically, residents are scheduled for a two-month rotation during the second year with an additional month in the third year. The Department of Surgical Critical Care is truly multidisciplinary, comprised of three physicians representing anesthesiology, surgery, and internal medicine/pulmonary medicine. The members of the department are responsible for providing 24-hour-a-day staff coverage in an 18-bed surgical intensive care unit. They offer a stimulating educational environment for fellows, residents, medical students, nurses and paramedical personnel. The anesthesia resident rotation is specifically designed to provide a broad clinical experience in the care of the critically ill and injured patient. The educational program consists of daily bedside teaching, organized didactic lectures, and directed study, utilizing recommended texts and an assigned reading list. On completion of the rotation, the resident will have acquired the fundamental knowledge and technical skills necessary to diagnose and manage acute life-threatening single-organ dysfunction as well as complex multisystem failure.
During their second year of training, residents acquire two months of neuroanesthesia training one month at the Lahey Clinic and one month at St. Elizabeth’s. Ample experience is offered in providing anesthesia for intracranial tumors, aneurysms, shunts and other neurosurgical procedures. On the days when neurosurgical procedures are not scheduled, the residents are assigned either thoracic or major vascular procedures.
In keeping with the national trend, surgery at St. Elizabeth's Medical Center is being performed more frequently on an outpatient basis. The residents evaluate most of the ambulatory patients preoperatively a few days before the scheduled surgery and appropriate laboratory investigations ordered. A copy of the work-up and laboratory reports are then made available to the residents who are assigned to anesthetize these patients. Residents are taught anesthetic techniques and the use of appropriate drugs with pharmacokinetic profiles that achieve the goal of having the patient discharged from the hospital in a safe and comfortable manner.
Post Anesthesia Care Unit
A structured one-month postanesthesia care experience combines direct patient care in the post anesthesia care unit with responsibilities for management of acute postsurgical pain, hemodynamic changes, and emergencies related to the post anesthesia care patient.