Perfusionist doing anesthesiologist’s work during bypass?

[ButchC]

I realize this isn’t a good way to introduce myself. I’m a third year med student considering anesthesiology. I’m rotating through surgery now and saw my first bypass case. I was quite surprised by what I saw. I’m really not trying to be a troll here. It just seems that the anesthesiologist didn’t have much to do while the patient was on the bypass machine and instead the patient’s well-being was placed squarely in the perfusionist’s hands. During this time, the anesthesiologist was either out of the room with a resident sitting in the chair, or was in the room sitting in his chair not doing much. I saw the perfusionist administer blood products, push drugs including pressors, and adjust the amount of isoflurane going into the patient’s blood from the vaporizor on the bypass machine - all of this without any direction from the surgeon or anesthesiologist. She ordered blood gases, interpreted them, and made adjustments to the machine accordingly on her own. She did - I hate to say it - what I thought would be the anesthesiologist’s job. Am I missing something here? How is it that this kind of incredibly important work and medical decision-making can be left to a technician, rather than be the responsibility of the anesthesiologist? If ever there was a task that would fall under the skill of an anesthesiologist, managing a patient’s oxygenation, perfusion, and other metabolic functions during a bypass would be it. Is the perfusionist just following pre-determined parameters set by the surgeon and anesthesiologist? It certainly didn’t seem that way to me. Or is it that operating a heart-lung machine is far more easy and than it appears to be? I looked up the kind of training that becoming a perfusionist requires, and apparently it is merely a 1 to 2 year program after college. Am I missing something here?

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[BLADEMDA]

I realize this isn’t a good way to introduce myself. I’m a third year med student considering anesthesiology. I’m rotating through surgery now and saw my first bypass case. I was quite surprised by what I saw. I’m really not trying to be a troll here. It just seems that the anesthesiologist didn’t have much to do while the patient was on the bypass machine and instead the patient’s well-being was placed squarely in the perfusionist’s hands. During this time, the anesthesiologist was either out of the room with a resident sitting in the chair, or was in the room sitting in his chair not doing much. I saw the perfusionist administer blood products, push drugs including pressors, and adjust the amount of isoflurane going into the patient’s blood from the vaporizor on the bypass machine - all of this without any direction from the surgeon or anesthesiologist. She ordered blood gases, interpreted them, and made adjustments to the machine accordingly on her own. She did - I hate to say it - what I thought would be the anesthesiologist’s job. Am I missing something here? How is it that this kind of incredibly important work and medical decision-making can be left to a technician, rather than be the responsibility of the anesthesiologist? If ever there was a task that would fall under the skill of an anesthesiologist, managing a patient’s oxygenation, perfusion, and other metabolic functions during a bypass would be it. Is the perfusionist just following pre-determined parameters set by the surgeon and anesthesiologist? It certainly didn’t seem that way to me. Or is it that operating a heart-lung machine is far more easy and than it appears to be? I looked up the kind of training that becoming a perfusionist requires, and apparently it is merely a 1 to 2 year program after college. Am I missing something here?

You are way off base here. A perfusionist isn't doing my job ever; but, since you don't really know what we do you think turning a dial on the ISO vaporizer and giving some Phenylephrine is anesthesia.

The perfusionist follows a simple protocol. If anything goes awry in the room the Cardiac Surgeon and Anesthesiologist deal with the situation.

Why are you so concerned that the perfusionist actually does something while on CPB?
That's his/her job in the room.

Are you worried when the PA finishes the operation and/or closes the chest for the surgeon?

 

[Bertelman]

You are way off base here. A perfusionist isn't doing my job ever; but, since you don't really know what we do you think turning a dial on the ISO vaporizer and giving some Phenylephrine is anesthesia.

The perfusionist follows a simple protocol. If anything goes awry in the room the Cardiac Surgeon and Anesthesiologist deal with the situation.

Why are you so concerned that the perfusionist actually does something while on CPB?
That's his/her job in the room.

Are you worried when the PA finishes the operation and/or closes the chest for the surgeon?

He's not that far off base.

The reason the perfusionist seems to be in control is that they have a known set of parameters which they follow. These parameters include ABG values, blood pressure and flow rates. This is learned during school and through teamwork. Different surgeons have expectations for certain cases, etc.

The beauty of a cardiac case is the way the team operates. What you thought were independent decisions by the perfusionist were actually reinforced by years of working with that team in that situation. You may have missed the cues leading the perfusionist to perform those adjustments because they are often subtle, or are single-word commands that are meaningless out of context.

Either way, you realize that no single person can both be the anesthesiologist AND the perfusionist. Their tasks overlap when going on and off bypass. The role of the perfusionist is no different than the role of an NP or PA. Make clinical decisions within their area of experience while under the supervision of a physician. Were you shocked that the perfusionist wasn't present at the beginning of the case or the end? Shocked that they were sitting in a chair seemingly "not doing much" for the majority of the OR time?

What you just experienced was a routine bypass case that ran smoothly. That's because each member of that team is very good at what they do. Fortunately, that's actually how most of our days transpire.

 

[btbam]

OP what do you think the anesthesiologist should be doing while the patient is on bypass? Do you understand why the perfusionist is controlling the Iso or giving blood products while on bypass?

 

[foxtrot]

I realize this isn't a good way to introduce myself. I'm a third year med student considering anesthesiology. I'm rotating through surgery now and saw my first bypass case. I was quite surprised by what I saw. I'm really not trying to be a troll here. It just seems that the anesthesiologist didn't have much to do while the patient was on the bypass machine and instead the patient's well-being was placed squarely in the perfusionist's hands. During this time, the anesthesiologist was either out of the room with a resident sitting in the chair, or was in the room sitting in his chair not doing much. I saw the perfusionist administer blood products, push drugs including pressors, and adjust the amount of isoflurane going into the patient's blood from the vaporizor on the bypass machine - all of this without any direction from the surgeon or anesthesiologist. She ordered blood gases, interpreted them, and made adjustments to the machine accordingly on her own. She did - I hate to say it - what I thought would be the anesthesiologist's job. Am I missing something here? How is it that this kind of incredibly important work and medical decision-making can be left to a technician, rather than be the responsibility of the anesthesiologist? If ever there was a task that would fall under the skill of an anesthesiologist, managing a patient's oxygenation, perfusion, and other metabolic functions during a bypass would be it. Is the perfusionist just following pre-determined parameters set by the surgeon and anesthesiologist? It certainly didn't seem that way to me. Or is it that operating a heart-lung machine is far more easy and than it appears to be? I looked up the kind of training that becoming a perfusionist requires, and apparently it is merely a 1 to 2 year program after college. Am I missing something here?

Why don't you trot on over to the anesthesiologist during bypass and discuss the different aspects of a CABG/valve repair (ie, going on pump, being on pump, and coming off pump), then you will learn that what the anesthesiologists does is extremely important. Cardiac anesthesia is very much a team effort. The surgeon, anesthesiologists, and perfusionists all have very important roles during the operation.

 

[periopdoc]

My job is to get them safely on pump and safely off pump. While on pump the perfusionist follows the standing orders/ protocol issued by either myself or the surgeon in the same manner that a nurse in the ICU "manages" patients while the physician is elsewhere.

A good perfusionist is extremely valuable to the team, but when things fall out of the parameters established for him/ her then the team will come together to solve the issue.

Of course I prefer off pump.


- pod

 

[proman]

I agree with what others have stated but there's more. Going on bypass, I'm there to ensure the aortic cannula is in proper position, the venous cannula are appropriately draining and that the heart is adequately arrested. Perfusionists are trained professionals and know how the nuts and bolts of operating the machines. But:
- I decide the isoflurane level (I've caught some running iso at 5% to control hypertension)
- I decide transfusion management on bypass, including hemoconcentration
- I decide electrolyte management including when to perform ultrafiltration
etc
- I decide whether is ok to come off of bypass.
We obviously work together with the surgeons and perfusionist as a team and have open communication. We also determine the protocols that they use. We ensure appropriate temperature management to avoid cerebral hyperthermia. A lot of it is subtle and done without really having to say much. A lot of institution dependent, at Duke the perfusionists had to ask us about giving more heparin.

 

[michigangirl]

My job is to get them safely on pump and safely off pump. While on pump the perfusionist follows the standing orders/ protocol issued by either myself or the surgeon in the same manner that a nurse in the ICU "manages" patients while the physician is elsewhere.

A good perfusionist is extremely valuable to the team, but when things fall out of the parameters established for him/ her then the team will come together to solve the issue.

Of course I prefer off pump.


- pod

This.
Were you only in the OR for the bypass component of the case?

The anesthesiologist's role during a cardiac case where bypass is involved is most intense in the period up to going on pump and then when coming off. The crux of the case for anesthesia is induction (what's the physiology, where should the heart rate be? bp?)-- central lines, art lines, getting the patient completely ready for the surgical heft that's about to ensue. Coming off pump is the real deal, when everything can go completely awry, and it's the anesthesiologist's job to make sure that everything is optimized for that process with the perfusionist as proman stated, and then to make coming off pump look like its easy, performing the transesophageal echo and all. Its not easy-- and the physiology is different for each type of surgery. But most of the time, they make it look so-- it's kind of an art form, coming off pump. Different styles, same purpose-- happy patient with a better cardiac milieu.

 

[Magnus67]

Damn........we've been figured out. We really don't do anything....... Anesthesia is super easy, when its time to come off bypass all we do is flip a switch and it's smooth sailing, time to hit the golf course.

PS. The "come off bypass" switch is the second one on the left from the "anesthesia on/off" toggle , right next to the "blood pressure up/down" dial.

In the words of Keyshawn Johnson....... C'mon Man,,!!!!!!

 

[Idiopathic]

BLADE is too busy putting in 16-20 central lines per day to worry about what happens on CPB.

😉

 

[pjl]

Agree with above.
Also, you said the anesthesiologist is out of the room with a resident in the chair. Nothing wrong with that. Hopefully for the resident's sake the anesthesiologist is able to be out of the room for just about the entire operation. That should be the standard level of training.

 

[drmwvr]

I agree with what others have stated but there's more. Going on bypass, I'm there to ensure the aortic cannula is in proper position, the venous cannula are appropriately draining and that the heart is adequately arrested. Perfusionists are trained professionals and know how the nuts and bolts of operating the machines. But:
- I decide the isoflurane level (I've caught some running iso at 5% to control hypertension)
- I decide transfusion management on bypass, including hemoconcentration
- I decide electrolyte management including when to perform ultrafiltration
etc
- I decide whether is ok to come off of bypass.
We obviously work together with the surgeons and perfusionist as a team and have open communication. We also determine the protocols that they use. We ensure appropriate temperature management to avoid cerebral hyperthermia. A lot of it is subtle and done without really having to say much. A lot of institution dependent, at Duke the perfusionists had to ask us about giving more heparin.

Does your institution train perfusionists? I find myself asking why you trouble with such minutiae, unless of course you don't have competent perfusionists, that is.

 

[proman]

Does your institution train perfusionists? I find myself asking why you trouble with such minutiae, unless of course you don't have competent perfusionists, that is.

Not a training site. My institution traditionally had the surgeon directing all aspects of perfusion. It wasn't until recently that the anesthesiologists have assumed a more active role. I trouble with that minutiae because if I didn't the patient would be harmed.

 

[periopdoc]

I would not complain about having a more active role like that.

- pod

 

[proman]

I would not complain about having a more active role like that.

- pod

I'm not complaining. But I laugh at the people who think they can go take a nap on bypass. Totally unrealistic.

 

[Bertelman]

I'm not complaining. But I laugh at the people who think they can go take a nap on bypass. Totally unrealistic.

Holy Smokes, just noticed the 10 yr member banner. You've been around longer than most of the old timers people yearn for.

I bet you know Lee.

SDN must have been just a bunch of med school nerds back then.

I'll throw out the love for PMPMPMPMPDDDD, who must have been the original hSDN member when he signed up back in '01.