10 things to know about anesthesia and heart surgery

american society of anesthesiologistsA guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

February is American Heart Month. Unfortunately, heart disease is a major problem in the United States that can result in surgery. In addition to discussing your procedure with your surgeon, you want to be sure to discuss your anesthesia care with your physician anesthesiologist.

Here are 10 key questions and answers to help guide you through anesthesia for cardiac surgery.

1. Who is my anesthesia provider? It is critical to know who will be in charge of your anesthesia care during your heart surgery. Your anesthesia care team will be led by a physician anesthesiologist. It is fairly common for a nurse anesthetist, anesthesia assistant, anesthesiology resident or fellow to be part of the anesthesia care team, acting under the supervision of a physician anesthesiologist. Before your surgery, we encourage you to ask who will provide your anesthesia care and to share honest health information with him or her.

2. What does a physician anesthesiologist do? Your anesthesia team is responsible for monitoring all the changes in heart rate, blood pressure, and generally the delivery of blood and oxygen to your organs while simultaneously rendering you unconscious and relaxed during your operation, so you are pain-free and relaxed.  The anesthetic will gradually wear off and you will wake up in the intensive care unit.

3. What is my chance of a complication during the procedure? Based on the type of procedure and your overall health at the time of surgery, the Society of Thoracic Surgeons offers a Risk Calculator to estimate risk of a specific heart surgery. We can use this calculator to determine risk scores based on patient history and procedure details. The chances of a complication occurring vary greatly depending on factors such as patient heart history, age, body mass index and so forth. While rare, complications when placing a breathing tube, echocardiogram (special monitor to visualize your heart) or blood pressure monitoring line may occur.

4. Should I take my blood pressure medications on the day of surgery? Every institution has slightly different recommendations for blood pressure management in the days before surgery. In general, we recommend that you take your blood pressure medications as scheduled, particularly if you are on a class of medicines known as beta-blockers, the generic names of which end mostly in –olol, like metoprolol. There are a couple classes of medications, in particular angiotensin-receptor blockers (e.g., losartan) and ACE-inhibitors (e.g., lisinopril), that can cause dangerous drops in blood pressure when used with some anesthetic medications. You will probably be told to skip these medicines the day of your surgery. If you are diabetic, you should not take your oral diabetes pill the morning of surgery.  If you inject regular insulin or long-acting insulin at home, ask your doctors during your preoperative visit how to manage your medications on the morning of surgery. As far as blood thinners, you need to discuss this directly with your surgeon and cardiologist prior to coming to the hospital for procedure.

5. What if I have a pacemaker or defibrillator? If you have an identification card that explains the device, bring it with you on the day of surgery and tell the team when your device was checked last. This may provide vital information to help your anesthesia care team manage your device and understand why it was placed. Report any change in your symptoms to your doctors.

6.  What if I’m really nervous before my surgery? Many patients get a little (or a lot) nervous the morning of surgery. We offer an anti-anxiety medication to patients as we escort you to the operating room. This medicine relaxes you.

7. What exactly does the “heart-lung machine” do? Under normal circumstances, our heart accepts blood from our veins and pumps it to the lungs where it becomes oxygenated. Once full of oxygen, the blood returns from the lungs back to the heart, and the heart pumps it to the rest of the body. Most patients having heart surgery will be placed on the “heart-lung machine” or bypass machine, which provides oxygen to the blood and pumps it throughout the body while the surgical team performs your surgery.

8. Who decides if I need a blood transfusion, and what are the risks? If your blood level falls to dangerously low levels, or if there is evidence of low oxygen levels or low blood pressure, we may administer red blood cells to help you. For complex procedures or those that require long periods of time on the heart-lung machine, patients may have trouble clotting after being taken off the machine. We may need to transfuse blood proteins or platelets to help you clot better and prevent further bleeding.

9. Will I wake up in pain afterward? Patient comfort and safety are physician anesthesiologists’ top priorities. Most of the strong pain medicines slow your breathing, so we balance keeping you comfortable with monitoring your breathing. Physician anesthesiologists work with a large variety of medications to treat pain, so we will work to ease your pain if you are not comfortable when you emerge from anesthesia.

10.Will my mind work the same after my heart surgery? Postoperative cognitive dysfunction (POCD) is the term used to describe a possible decline in memory, quick thinking or change in behavior that may occur after cardiac surgery with general anesthesia. Some patients may experience this condition for a few days or weeks after surgery, but most are back to normal within two to three months. Staying as healthy as possible before the surgery and getting mobile quickly after the procedure may reduce the likelihood of infections and other complications.

We recommend you speak openly with your physician anesthesiologist about any questions or concerns you have prior to surgery. We are committed to making your operation safe and as comfortable as possible. Our goal is to quickly get you back on your feet.

Kent B. Berg and Gregory M. Janelle are anesthesiologists.

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