Recently I received a call from an anesthesiologist whose hospital was undergoing inspection by a surgeon. This surgeon informed the anesthesiology group members that they should not leave the operating room (O.R.) during cardiopulmonary bypass (CPB). The anesthesiologist considered it acceptable to leave the O.R. during CPB as long as he was in the immediate area. He pointed out that there is an isoflurane vaporizer on the pump and that he turns the bispectral index monitor so that the perfusionist can see it during bypass. He indicated that leaving the room during CPB was common practice in his geographic region and that this can be the only opportunity he and his colleagues get to take a break during a long workday.

A shortage of anesthesiologists and an abundance of cases understandably make us think creatively about ways to lighten our load. Although CPB typically constitutes a less busy time for anesthesiologists than the periods before and after it, many routine tasks are greatly facilitated by the presence of a member of the anesthesia care team, and some emergency situations require our constant presence. Included among the routine tasks are:

• Monitoring perfusion pressure and systemic perfusion and treating pressure disturbances with vasopressors and vasodilators;

• Monitoring anesthetic depth and administering anesthetic drugs as needed;

• Assuring the presence of adequate neuromuscular blockade and administering additional muscle relaxants as needed;

• Monitoring urine output and determining the possible need for osmotic or loop-acting diuretics or adjustments in systemic blood flow or pressure;

• Monitoring the adequacy of myocardial electrical silence during the aortic crossclamp period;
• Monitoring the adequacy of myocardial decompression;

• Using transesophageal echocardiography to assist the surgeon with air evacuation maneuvers or with venous cannula or coronary sinus catheter positioning;

• Monitoring patient temperature during cooling and rewarming;

• Making blood transfusion decisions; and

• Monitoring anticoagulation and administering heparin.

More urgent scenarios that require an anesthesia care team member include unexpected patient movement, pump circuit or oxygenator failure requiring either immediate separation from CPB or oxygenator replacement, acute aortic dissection from cannulation injury and massive air embolus.

Among the routine tasks, one can argue that the surgeon and perfusionist have sufficient expertise to handle them without anesthesiology assistance. In response I submit that the surgeon needs to focus on the heart and that the perfusionist often needs to direct full attention to the bypass circuit. Furthermore optimal management of these routine situations involves dialogue among the perfusionist, anesthesiologist and surgeon. This should not be interpreted as an insult to the perfusionist or surgeon but rather as a testimonial to the unique bedside contributions of the anesthesiology team.

If you remain unconvinced of the need for anesthesiology presence during CPB, consider the following:

Anesthesiology is the practice of medicine. On one hand, ASA is working hard on our behalf to educate the public and governmental agencies that anesthesiology is the practice of medicine. On the other hand, some (many?) among us permit perfusionists to administer the full range of anesthetic drugs in our absence. We cannot have it both ways.

Billing fraud. Billing for anesthesia services requires the constant presence of a member of the anesthesia care team throughout the conduct of all general anesthetics. CPB occurs during general anesthesia. Our absence with continued billing constitutes fraud.

Risk management. Hypothetical scenario: A patient experiences intraoperative recall during a mitral valve replacement. She sues the anesthesiologist and the surgeon, and her story checks out because she accurately describes intraoperative conversations. She alleges mental anguish and recurring nightmares. The circulating nurse testifies that no one from anesthesiology was in the operating room during most of the CPB. In his defense, the anesthesiologist testifies that this constitutes common practice at his institution and others in the area, that the perfusionist had the isoflurane vaporizer on and that CPB cases are relatively high-risk procedures for intraoperative recall. The astute plaintiff’s attorney makes easy work of the defendant anesthesiologist by asking him first if there are any clinical signs that an anesthesiologist might monitor that would prevent recall (anesthesiologist responds, “Yes”) and then asking him why he would not consider it important to be present to watch for those signs during a high-risk period for intraoperative recall. This attorney also introduces into evidence policies from ASA and from the Society of Cardiovascular Anesthesiologists that require the presence of a member of the anesthesiology care team during the administration of anesthesia and CPB.

When I was a second-year medical student, an entertaining law professor named Jon Waltz lectured our class about malpractice. When he explained the concept of res ipsi loquitor (“the thing speaks for itself”), he cited a case in which a child undergoing tonsillectomy suffered brain damage during anesthesia, ostensibly because the nurse anesthetist fell asleep. The discovery process revealed that this nurse anesthetist had been moonlighting at another hospital throughout the preceding night, unbeknownst to her primary employer. Stereotyping juries as “12 plumbers” and exaggerating for dramatic effect, Professor Waltz then indicated that “the members of the jury were climbing out of the jury box, and all they wanted to know was how many zeroes are in a million.” That was in 1971. A million does not go as far as it did in 1971 so jury members listening today to our plausible recall scenario may wish to know how many zeroes are in 10 million.

The issues are simple. We are obliged to provide a member of the anesthesia care team during general anesthesia. Cardiopulmonary bypass occurs during general anesthesia. The perfusionist and surgeon, despite their many talents, are not members of the anesthesia care team.

Figure out another way to get a lunch break. We have to be there.

Glenn P. Gravlee, M.D., is Professor, Department of Anesthesiology, Ohio State University College of Medicine and Public Health, Columbus, Ohio.