2: Education for Anesthesia in Patients with Congenital Cardiac Disease


CHAPTER 2
Education for Anesthesia in Patients with Congenital Cardiac Disease


Viviane G. Nasr1 and Nina Deutsch2


1 Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA


2 Department of Anesthesiology, Academic Affairs Children’s National Hospital, Professor of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington DC, USA


Introduction


Pediatric cardiac anesthesiology has developed as a sub‐subspecialty of anesthesiology over the past 50 years. It has been practiced since the first patent ductus arteriosus (PDA) was ligated by the cardiac surgeon Dr. Robert Gross in 1938. Initially, in the 1970s and 1980s, anesthesiologists interested in practicing pediatric cardiac anesthesia would spend additional months during residency training or as a staff member gaining experience in anesthesia care for these patients, the apprenticeship model. With further advances in surgical and catheter‐based interventions and technologies in patients with congenital heart disease (CHD), pediatric cardiac anesthesiology has evolved in parallel with pediatric cardiac surgery and pediatric cardiology as a distinct field. The evolution of this specialty has led to the establishment in 2005 of a dedicated professional society, the Congenital Cardiac Anesthesia Society (CCAS).


Before the advent of CCAS, there were very few resources in terms of providing training and experience in the specific field of pediatric cardiac anesthesia. The board of directors along with other pediatric anesthesiologists addressed the lack of training criteria in congenital cardiac anesthesia and have developed the resources that we have today culminated in recognition by ACGME [1].


Why teach and learn congenital cardiac anesthesia?


Pediatric cardiac anesthesiology encompasses the care of neonates, infants, children, and adults with CHD and pediatric patients with acquired heart disease. Initially, practitioners interested in the field used to spend varying amounts of additional training time during their anesthesiology residency or as faculty members. However, the fields of congenital cardiac surgery and congenital cardiology have made significant strides which required ever‐increasing advances in the anesthetic care of these patients. While the subspecialty initially grew in concert with pediatric anesthesiology and adult cardiac anesthesiology programs, pediatric cardiac anesthesiology is now a distinct field which requires a unique fund of knowledge and skillset beyond that possessed by either the pediatric anesthesiologist or adult cardiac anesthesiologist alone.


In order to successfully care for patients with CHD and pediatric patients with acquired heart disease, it is necessary to gain expertise in the perioperative care of all forms of CHD from the simple to the most complex, and the pediatric acquired heart lesions. This includes a comprehensive understanding of congenital and acquired cardiovascular anatomy and pathophysiology. In addition, mastery of patient care along the continuum of care from the preoperative planning period, through the operative procedure itself, and through the postoperative recovery must be appreciated. In light of the wide spectrum of congenital cardiovascular anomalies and each condition having unique management considerations, the pediatric cardiac anesthesiologist must be adept at developing and executing an individualized perioperative anesthetic plan. Importantly, pediatric cardiac anesthesiologists must also master complex procedural skills to care for these patients with abnormal anatomy and physiology which go beyond those used to care for the patient with a normal cardiovascular system.


Today, an estimated 40,000 live births/year in the United States are affected with CHD [2]. These patients present for cardiac and noncardiac procedures. Given the increasing demands for well‐trained pediatric cardiac anesthesiologists, it is essential that a cohort of comprehensively trained practitioners of this craft be consistently produced. This is the only viable pathway to further advance the key objectives of providing improved clinical care and enhanced patient safety [3–5].


The current model


In 2010, leaders in pediatric cardiac anesthesiology in the United States recognized the need for a standardized educational approach to the training of pediatric cardiac anesthesiologists, and accordingly several program guidelines were developed [6]. In 2014, the Pediatric Anesthesia Leadership Council (PALC) in conjunction with the CCAS recognized the need for a formalized training pathway [7]. They specifically recommended that pediatric cardiac anesthesiology be an additional 12‐month second‐year advanced fellowship following pediatric anesthesia. This recommendation clearly recognizes that attaining skills to become a competent pediatric cardiac anesthesiologist requires training beyond a standard pediatric anesthesia fellowship. In 2018, specific training milestones required during fellowship training were established by the CCAS leadership [8].


At present, the total number of 12‐month positions offered is 28. Figure 2.1A and B represent the number of programs and trainees over time. While the structure of these fellowship programs mostly follows the published guidelines as noted above, it is acknowledged by CCAS leadership, program directors, and individual pediatric cardiac anesthesiologists that central oversight of program quality is needed for educational and training consistency. Hence, as cardiology and cardiac surgery have done previously, the subspecialty has moved forward, aiming for a standardized approach to fellowship training with ACGME oversight (Figure 2.2).


Pediatric cardiac anesthesia training


Curriculum development should employ a logical, systematic approach linked to specific healthcare needs. The Kern model of curriculum development for medical education could be used to develop a curriculum to teach and learn congenital cardiothoracic anesthesia [9]. This has a six‐step approach and consists of the following:



  1. Problem identification and general needs assessment
  2. Targeted needs assessment
  3. Goals and objectives
  4. Educational strategies
  5. Implementation
  6. Evaluation and feedback.

Problem identification and general needs assessment


This comprises identification and characterization of the healthcare problem:



  • Whom does it affect?
  • What does it affect?
  • What is the qualitative and quantitative importance of the effects?

As detailed above, education in anesthesia for CHD covers a wide range of lesions – uncorrected, corrected, and palliative therapies. The trainee needs to be educated in all aspects of the six core competencies related to these topics.


The following points should be addressed to obtain adequate needs assessment:



  • What proficiencies (cognitive, affective, and psychomotor skills) currently exist among learners?
    Schematic illustration of (A) Number of pediatric cardiac anesthesia programs over time; (B) number of graduating 12-month fellows per year over time.

    Figure 2.1 (A) Number of pediatric cardiac anesthesia programs over time; (B) number of graduating 12‐month fellows per year over time.

    Schematic illustration of timeline of major milestones in education and training in CHD.

    Figure 2.2 Timeline of major milestones in education and training in CHD. AAP, American Academy of Pediatrics; ACC, American College of Cardiology; ACGME, Accreditation Council for Graduate Medical Education; AHA, American Heart Association; BCH, Boston Children’s Hospital; CCAS, Congenital Cardiac Anesthesia Society; CHOP, Children’s Hospital of Philadelphia; PALC, Pediatric Anesthesia Leadership Council; SPA, Society for Pediatric Anesthesia; SPCTPD, Society of Pediatric Cardiology Training Program Directors; US, United States.


  • Previous training and experiences of fellows and residents in congenital cardiac anesthesia
  • Current training and experiences already planned for trainees
  • Resources available to learners (patients and clinical experiences, information resources, computers, audiovisual equipment, role models, teachers, mentors)
  • Perceived deficiencies and learning needs
  • Characteristics of the learners and barriers to learning and teaching.

The current state of the pediatric cardiac anesthesia training in CHD was most recently characterized in an email survey performed in 2019 addressed to program directors (n = 19). The number of pediatric cardiac anesthesia programs in the United States offering pediatric cardiac anesthesiology training has continually grown from 2 in 2000 to 8 in 2010 and to 19 in 2020 (Figure 2.1A). Similarly, the number of 12‐month fellows graduating each year has increased (Figure 2.1B).


Following graduation, the majority of trainees (75%) work either exclusively as a pediatric cardiac anesthesiologist or divide their time as a general pediatric anesthesiologist and as a pediatric cardiac anesthesiologist. Seven percent work in combined pediatric cardiac and adult cardiac anesthesia programs. The remaining 15% work in a combination of anesthesia and critical care, adult cardiac anesthesia, or other settings.


Targeted needs assessment


For the needs assessment to be an accurate reflection of what is required, it must involve the current trainees (learners) in pediatric cardiac anesthesia. Attempts should be made to assess the current strengths and weaknesses in knowledge, skills, and performance [10]. The environment in which education is currently happening needs to be evaluated as well. Is the operating room (OR) conducive to the education of some of the complex physiology or should the initial education happen in a simulated environment where the stress level of all concerned is much lower? It is vital that all the stakeholders (trainees, program directors, cardiologists, intensivists, and pediatric cardiac surgeons) are involved in the development at an early stage. Barriers and reinforcing factors that affect learning should be identified early on. Faculty development programs may be necessary to improve the quality of teaching and education in congenital cardiac anesthesia. Needs assessment should also include what resources are currently available to the trainees to facilitate learning in congenital cardiac anesthesia.


There is a dedicated body of science, knowledge, and skills related to the unique field of pediatric cardiac anesthesiology. There are chapters on the practice of pediatric cardiac anesthesia in every major anesthesia textbook, every major pediatric anesthesia textbook, and in several major cardiac surgical and pediatric interventional catheterization/electrophysiology textbooks. More importantly, there are numerous textbooks devoted entirely to the practice of pediatric cardiac anesthesia. In addition to textbooks and journals, dedicated pediatric cardiac anesthesia faculty at all the different respective programs constitute a body of knowledge and a source of education for the fellows in the field.


The case mix in the training programs, multidisciplinary faculty educators, and access to online journals and educational materials, including the availability of audiovisual equipment, are vital to the success of curricular delivery. The value of the hidden and informal curriculum that is currently in place should not be underestimated.


Goals and objectives


Goals and objectives must, by necessity, be specific and measurable. They should measure the knowledge (cognitive), attitude (affective), and competence (psychomotor) of the learners. The goals and objectives are currently being developed by a task force which is comprised of ACGME leadership, a pediatric anesthesiologist, an adult cardiac anesthesiologist, and representative from the Society for Pediatric Anesthesia and CCAS. The goals and objectives should reflect the relationship of the educational process to the degree of participation of the learners, as well as the faculty response to the developed curriculum. To achieve goals, the program must be structured to ensure optimal patient care while providing trainees with the opportunity to develop skills in clinical care, judgment, teaching, and research. Consideration should be given to the use of learning goal‐scoring rubrics. Meyerson et al. performed needs assessment for an errors‐based curriculum on thoracoscopic lobectomy and structured the curriculum based on their observations using a standardized checklist [11].


The following goals and objectives are valuable in the OR to achieve competency in congenital cardiac anesthesia:



  • The subspecialist in congenital cardiac anesthesiology should be proficient in providing anesthesia care for both pediatric and adult patients undergoing congenital cardiac and vascular surgery as well as anesthesia for non‐cardiac surgery.
  • The subspecialist should demonstrate and conduct a preoperative patient evaluation; and demonstrate the ability to interpret imaging, cardiovascular, and pulmonary diagnostic test data.
  • The subspecialist should be able to evaluate and understand the anesthetic management of patients undergoing non‐operative diagnostic and interventional cardiac, thoracic, and electrophysiological procedures. Examples include angiography, arrhythmia mapping and ablation, stent placements, and device closures.
  • The clinical curriculum should include competency and demonstrate cognitive proficiency in the management of cardiopulmonary bypass (CPB), pharmacological and mechanical hemodynamic support as well as extracorporeal circulation.
  • The subspecialist should be able to create a plan for postoperative critical care, including ventilatory support, extracorporeal circulatory support, and pharmacologic hemodynamic support, as well as understand the implications of pain management.
  • The subspecialist should demonstrate effective communication skills in obtaining informed consent from families, discussing any complications that may have occurred as well as providing consultations as and when necessary.
  • The subspecialist should demonstrate skills in preparing materials and presenting at multidisciplinary conferences to allied health professionals.
  • The subspecialist must demonstrate professionalism in the work environment as evidenced by the ability to show compassionate care to the patient and their diverse needs, respecting other providers, as well as complying with program, department, and institutional policies and procedures.
  • The subspecialist should understand the value of multidisciplinary teams, be able to evaluate errors, and find solutions, thereby enhancing patient safety and improving outcomes for their patients.

The didactic curriculum provided through lectures, conferences, and workshops should supplement clinical experience as necessary for the fellow to acquire the knowledge to care for cardiothoracic patients with CHD and conditions outlined in the guidelines for the minimum clinical experience for each fellow. The didactic components should include the areas in the following list, with an emphasis on how cardiothoracic diseases affect the administration of anesthesia and life support to cardiothoracic patients with CHD.


These represent guidelines for the minimum didactic experience for each fellow:



  • Embryological and morphological development of the cardiothoracic structures; nomenclature of CHD
  • Pathophysiology, pharmacology, and clinical management of patients with all adult and pediatric CHD, including single ventricle lesions, septal defects, defects of semilunar and atrioventricular valves, left‐ and right‐sided obstructive lesions, transposition of the great vessels, defects of systemic and pulmonary venous return, cardiomyopathies, vascular rings, and tracheal lesions
  • Pathophysiology, pharmacology, and clinical management of patients requiring heart, lung, and heart‐lung transplantation, including immunosuppressant regimes and selection criteria
  • Non‐invasive cardiovascular evaluation: electrocardiography, echocardiography, cardiovascular computed tomography (CT), and magnetic resonance imaging (MRI)
  • Cardiac catheterization procedures and diagnostic interpretation; invasive cardiac catheterization procedures, including balloon dilatations and stent placement; device closure of septal defects, PDA and baffle leaks, and arrhythmia ablation
  • Pre‐anesthetic evaluation and preparation of pediatric and adult cardiothoracic patients
  • Pharmacokinetics and pharmacodynamics of medications prescribed for medical management of pediatric and adult cardiothoracic patients
  • Peri‐anesthetic monitoring methods, both non‐invasive and invasive, including use of ultrasound guidance: intra‐arterial, central venous, mixed venous saturation, cardiac output determination, transesophageal and epicardial echocardiography, neurological monitoring, including near‐infrared cerebral oximetry, transcranial Doppler, and processed electroencephalograms
  • Pharmacokinetics and pharmacodynamics of anesthetic medications prescribed for cardiothoracic patients. Pharmacokinetics and pharmacodynamics of medications prescribed for the management of hemodynamic instability: inotropes, chronotropes, vasoconstrictors, vasodilators
  • Extracorporeal circulation (including CPB, low‐flow CPB, deep hypothermic circulatory arrest, antegrade cerebral perfusion, extracorporeal membrane oxygenation (ECMO)), myocardial preservation, effects of extracorporeal circulation on pharmacokinetics and pharmacodynamics, cardiothoracic, respiratory, neurological, metabolic, endocrine, hematological, renal, and thermoregulatory effects of extracorporeal circulation and coagulation/anticoagulation before, during, and after extracorporeal circulation
  • Circulatory‐assist devices: left and right ventricular assist devices and biventricular assist devices
  • Pacemaker and automated internal cardiac defibrillator (AICD) insertion and modes of action
  • Perioperative ventilator management: intraoperative anesthetic and critical care unit ventilators and techniques
  • Postanesthetic critical care of pediatric cardiothoracic surgical patients
  • Pain management of pediatric and adult cardiothoracic surgical patients. Post‐anesthetic critical care of pediatric and adult cardiothoracic surgical patients
  • Research methodology and statistical analysis
  • Quality assurance and improvement
  • Ethical and legal issues
  • Practice management

What is the minimum level of anesthesia training required?



  • Subspecialty training in congenital cardiac anesthesiology should begin after satisfactory completion of a residency program in anesthesiology accredited by the ACGME or other training judged suitable by the program director and
  • Trainees should complete an ACGME‐accredited pediatric anesthesia fellowship of 12 months’ duration after anesthesia residency.
  • Alternatively, the trainees could enter the training following completion of an ACGME‐accredited adult cardiac anesthesia fellowship of 12 months’ duration after anesthesia residency if they have completed additional pediatric anesthesia rotations.

What are the ideal duration, case quantity, and scope of training?


The following represent suggested cases for the minimum clinical scope and duration of training:



  • Nine months of clinical anesthesia activity caring for patients with congenital cardiac problems in the OR, the cardiac catheterization laboratory, and other locations.
  • This experience should include a minimum of 100 anesthetic procedures, the majority of which must require CPB. At least 50 of these patients should be infants from birth to 1 year of age and should include at least 25 neonates (≤1 month of age). The trainee should also care for at least 25 adults (≥18 years of age).
  • This experience should also include a minimum of 50 patients undergoing diagnostic procedures (cardiac catheterization, echocardiography, MRI, etc.), as well as therapeutic procedures in the catheterization laboratory (arrhythmia ablation, pacemaker insertion, septal defect closure, and valve dilatation, etc.)
  • Suggested case numbers for specific lesions are described in Table 2.1 [12]
  • Adequate experience should be obtained in the preoperative evaluation of pediatric and adult cardiothoracic patients.
  • The fellow should understand how to use information from diagnostic studies and how to recognize when additional studies and/or consultations are indicated.

It is important to note that formal guidelines and case numbers are currently being developed by the ACGME task force. They will be available by end of 2021.


Table 2.1 Suggested case numbers for Anesthetic Management of Surgical Repairs and Diagnostic and Interventional Procedures


Source: Nasr et al. [11]. Reproduced with permission from Elsevier.


































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May 17, 2023 | Posted by in ANESTHESIA | Comments Off on 2: Education for Anesthesia in Patients with Congenital Cardiac Disease

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Surgical cases bypass Case numbers
 Hypoplastic left heart syndrome 3
 Transposition of great arteries 3
 Total anomalous pulmonary venous return 1
 Common atrioventricular canal 6
 Tetralogy of Fallot 5
 Ventricular/atrial septal defect 10
 Bidirectional Glenn 5
 Fontan 4
 Left ventricular assist device 1