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UPMC PRESBYTERIAN /MONTEFIORE
Joseph J. Quinlan, MD
Chief Anesthesiologist
Overview
UPMC Presbyterian/Montefiore (PUH/MUH) continues in its role as the largest quaternary care hospital in Western Pennsylvania. It remains the core hospital of the Department of Anesthesiology in terms of clinical activity and resident education, and is a nexus for clinical research.
The PUH/MUH Division of Anesthesiology is larger than many entire academic departments found elsewhere in the country. It is comprised of 46 faculty members who cover 40 operating rooms and up to 8 additional, non-OR anesthetizing locations. The site is staffed by 63 Certified Registered Nurse Anesthetists (CRNAs). Up to 15 residents and 10 student nurse anesthetists (SRNAs) rotate at UPMC Presbyterian at any one time. Six Certified Registered Nurse Practitioners (CNRPs) provide care throughout the site as well as at the Pre-Anesthesia Evaluation and Testing Center, which conducts pre-anesthesia consultations and evaluations.
Patient Care & Clinical Activities
In Academic Year 2007-08 (AY08), the division’s faculty supervised 33,256 anesthetics in the OR environment, representing an increase of 4.6% compared with the previous year. Procedures spanned the entire spectrum of surgical and special procedures, from combined heart-liver transplantation to anesthesia for electroconvulsive therapy. Transplantation continues to be a significant undertaking in the PUH/MUH operating rooms: a total of 481 transplants were performed during the year (a slight decrease compared with the prior year), and we continue to be the top lung transplant center in the world (107 transplants performed in AY08). Division faculty also became more involved with cases outside of the operating room environment; in AY08 9,065 cases were performed outside the OR, which is approximately 27% of the total cases managed at this site. Non-OR services were provided more frequently in the gastroenterology lab, bronchoscopy suite, electrophysiology suite, cardiac catheterization lab, and particularly the interventional radiology and MRI suite.
Education & Training
Anesthesia services at PUH/MUH are highly subspecialty-oriented. Many of the advanced subspecialty resident rotations in anesthesiology (liver transplantation, cardiac, ENT, thoracic, trauma, and neuroanesthesia) are based here. However, many novice residents and student nurse anesthetists (SRNAs) perform their first cases at PUH/MUH. Division faculty are very active in medical student and resident education – they not only teach in the OR, but deliver lectures, coordinate problem-based learning discussions (PBLDs), design and implement rotation curricula, serve on the medical student and resident education committees, interview resident applicants, and teach at the WISER Institute. There are several teaching conferences held specifically for trainees rotating at PUH. Monthly Quality Improvement Morbidity and Mortality conferences are provided by a select group of faculty, and PBLDs are conducted monthly at PUH. Subspecialty services also hold weekly or monthly conferences on topics in their subspecialty areas. Continuing Medical Education credit is awarded for these activities.
DIVISION OF CARDIOTHORACIC ANESTHESIOLOGY
UPMC PRESBYTERIAN
Erin A. Sullivan, MD
Director
Patient Care & Clinical Activities
The Division of Cardiothoracic Anesthesiology at UPMC Presbyterian provided anesthetic care for 747 cardiac surgical patients during Academic Year 2007-2008 (AY08). Surgical procedures performed included: coronary artery bypass graft (CABG), minimally invasive coronary artery bypass (MIDCAB), off-pump coronary artery bypass (OPCAB), cardiac valve replacement and repair, thoracic aorta repair/reconstruction, arrhythmia ablation, pulmonary thromboendarterectomy, repair of ventricular and atrial septal defects, removal of cardiac tumors/myxomas, heart, single lung, double lung and heart-double lung transplants, and implantation of mechanical ventricular assist devices as a bridge to transplantation for patients with end-stage cardiac disease awaiting cardiac transplantation (Heartmate, Abiomed, Novacor and Thoratec devices). Division faculty implanted 39 such devices during AY08. Of the 747 cardiac surgical procedures performed in AY08, 611 were performed for acquired heart disease and 361 for conditions other than CABG.
UPMC Presbyterian continues to be recognized as a world leader for heart and lung transplantation. There were 150 transplants performed during AY08, consisting of 47 heart transplants, 37 single-lung transplants, 75 double-lung transplants, and one heart / double-lung transplant. UPMC Presbyterian was the leading center in the United States for the number of lung transplants performed during AY08 with a total of 112.
Division faculty also perform intraoperative transesophageal echocardiography (TEE) on all patients undergoing cardiac and transplant surgery. The division enjoys substantial equipment resources and has established an excellent rapport with UPMC Presbyterian echocardiologists.
Education & Training
The Division of Cardiothoracic Anesthesiology offers world class opportunities for both basic and advanced training in adult cardiac anesthesia. The majority of CA-2 residents receive their initial exposure to cardiac anesthesiology at UPMC Presbyterian. CA-3 residents are offered a three-month elective in advanced adult cardiac anesthesiology. Cardiac anesthesiology fellows (CA-4) have the opportunity to receive advanced training beyond the CA-3 year in adult and pediatric cardiothoracic anesthesiology inclusive of emergency and elective surgery, TEE, perfusion/ventricular assist device theory and operation, cardiothoracic critical care medicine, and heart/lung transplantation. Fellows who successfully complete the training program are eligible to take the PTEeXAM administered by the National Board of Medical Examiners.
Cardiac anesthesiology fellows have the opportunity to obtain extensive exposure to intraoperative TEE and develop their skill in diagnostic TEE. In addition to their intraoperative experience performing and interpreting TEEs, all cardiac anesthesiology fellows spend a minimum of one month in the echocardiography laboratory learning introductory principles of echo under the direction of the echocardiology faculty directed by Dr. William Katz. We have had several cardiology and critical care medicine fellows spend time with the cardiothoracic anesthesiology faculty in the operating rooms for the specific purpose of improving their TEE skills. Intraoperative TEE remains a fruitful area of research for UPMC Presbyterian’s cardiac anesthesiology faculty and trainees. Achievement of Testamur and Board Certification status via the PTEeXAM is strongly encouraged.
Residents and fellows receive course goals and objectives at the beginning of their clinical rotation along with a list of required reading material. The resident and cardiac fellowship didactic program consists of intraoperative clinical teaching by the cardiac anesthesiology faculty, lectures and problem-based learning discussions based on topics related to cardiac anesthesiology within the core resident lecture series, mock oral exams administered at the conclusion of the clinical rotation, and a monthly subspecialty conference moderated by a cardiac anesthesiology faculty member. This subspecialty conference follows an interactive evidence-based medicine.
DIVISION OF HEPATIC TRANSPLANTATION ANESTHESIOLOGY, UPMC PRESBYTERIAN
Raymond M. Planinsic, MD
Director
Overview
Anesthesiologists in the Division of Hepatic Transplantation Anesthesiology (HTA) are responsible for the care of patients undergoing transplantation of the liver, intestinal, and other solid organs. During Academic Year 2007-2008 (AY08), a total of 326 solid organ transplants were performed at UPMC and Children’s Hospital of Pittsburgh. In addition, the HTA Division provides anesthesiology care and work-up for patients undergoing major hepatic resections.
Patient Care & Clinical Activities
The primary responsibilities of the HTA Division include preoperative assessment of transplant candidates, participation in candidate selection, intraoperative management, and postoperative visits. Preoperative consultation of transplant candidates, led by Drs. Raymond Planinsic and Charles Boucek, is the main strength of the HTA service. HTA anesthesiologists provide hepatologists and surgeons with valuable information about extrahepatic organ function. Preoperative information is discussed at weekly HTA morbidity and mortality conferences, clinical information is exchanged on individual patients, and recommendations are presented at multidepartmental hepatic transplantation morbidity and mortality conferences.
Additionally, several members of HTA participate in the perioperative management of patients: Dr. Shushma Aggarwal studies the monitoring and management of cerebral hemodynamics and metabolism in patients with fulminant hepatic failure, Dr. Ibtesam Hilmi studies the evaluation of patients with hepatopulmonary syndrome and pulmonary hypertension, Dr. Charles Boucek serves as a consultant regarding Jehovah’s Witness patients, and Dr. Raymond Planinsic’s interests include cardiac risk assessment and coagulation and renal protection during liver transplantation.
Anesthetic management of hepatic, intestinal, and multivisceral transplantation requires both highly sophisticated monitoring and tight control of physiologic variables. An anesthesiologist carries out this management with the assistance of trainees, nurse anesthetists, and clinical technicians. Hemodynamic monitoring, right ventricular ejection fraction, right ventricular end-diastolic volume, and mixed-venous oxygen saturation are routinely determined using a pulmonary artery catheter. Two-dimensional transesophageal echocardiography also plays an important role in determining and optimizing cardiac contractility and preload.
During AY08, over 133 liver transplants and more than 193 other solid organ transplants were performed. UPMC continued to be a referral center for high-risk patients because of our diverse expertise and multidisciplinary approach to managing patients with multiple organ dysfunction. Also, UPMC performs transplants on Jehovah’s Witness patients without the use of blood, and is one of the only centers in the nation to perform transplants on HIV-positive patients. AY08 was notable for continued expansion of the adult living related kidney transplantation program at UPMC. Over 40% of kidney transplants performed in the United States are from live donors, and this trend is reflected at UPMC. A live liver donor continues to be an option for patients with end stage liver disease requiring transplantation and is available at UPMC due to the expertise of our transplant surgeons and anesthesiologists.
Education & Training
Education in the HTA service is comprised of a mandatory rotation (four weeks) for CA-2 trainees and an elective rotation (three to nine months) for CA-3 and CA-4 trainees. The teaching objectives vary with the level of training. Available fellowship training prepares graduates themselves to become a consultant and/or a director of a liver transplantation anesthesia program.
In addition to one-on-one bedside teaching, each resident attends seven didactic sessions during the rotation. Topics include cerebral hemodynamic changes in acute and chronic hepatic encephalopathy, hemodynamic alterations during liver transplantation (pulmonary hypertension), hepatopulmonary syndrome, coagulation and thromboelastography during liver transplantation, electrolyte and acid base changes during liver transplantation, hepatic physiology and pathophysiology. Residents are required to present a topic related to liver transplantation anesthesia at HTA subspecialty research meetings, and CA-3 and CA-4 trainees are encouraged to participate in research activities.
Under the leadership of Drs. Aggarwal, Planinsic and Boucek, CA-2 residents can now train at the WISER Institute in a simulation course titled “Anesthesia for Liver Transplantation.” This course has been well reviewed by the residents and is offered at the beginning of the rotation and again upon completion of their OR experience with the HTA division.
DIVISION OF NEUROANESTHESIOLOGY AND SUPPORTIVE CARE, UPMC PRESBYTERIAN
Ferenc E. Gyulai, MD
Director
Overview
The Neurosurgical Anesthesiology Division at UPMC Presbyterian (PUH) provided anesthetic care for over 6,000 neurosurgical procedures during Academic Year 2007-2008 (AY08). Anesthesia services were provided during: expanded endonasal approaches, craniotomy for tumor, retromastoid craniectomy for microvascular decompression of various cranial nerves, and spinal surgery.
Two separate Neurosurgical Intensive Care Units at PUH have continued to facilitate innovative approaches to the acute care of cerebral vascular pathologies, in addition to promoting optimal care for patients with neurotrauma and other acute neurological injury.
Patient Care & Clinical Activities
The division has become increasingly involved in the anesthetic management of patients of the Minimally Invasive endoNeurosurgery Center (MINC). MINC, led by Dr. Amin Kassam, (Chair of Neurosurgery) and Dr. Carl Snyderman (Otolaryngology), continues to expand both in case volume and uniqueness of surgical approaches. The team has pioneered cutting-edge endoscopic minimally invasive craniotomy techniques and performed close to 300 procedures in AY08. MINC consists of three components: the Cranial Nerve Disorders Program, the Endovascular Program, and the Skull Base Innovative Microneurosurgery Program. The Center for Endovascular and Exovascular Therapy is led by Dr. Michael Horowitz and provides services to treat complex neurologic vascular lesions including aneurysm embolization/clipping, arteriovenous malformation, embolization/resection and tumor embolization.
Education & Training
The division’s didactic program consists of weekly and monthly subspecialty conferences, intraoperative teaching, and a manual of guided reading. Increasing attendance at the monthly neuroanesthesia conference has fostered lively and informative discussion. Twenty-eight lectures were given in the last academic year, seven by faculty members and 21 by residents rotating through neuroanesthesia. Faculty lectures included guest lectures by neurosurgeons, neurophysiologists and neuroradiologists, which brought refreshing new perspectives and productive dialogue.
SAME DAY SERVICES, UPMC PRESBYTERIAN/MONTEFIORE
Patrick J. Forte, MD
Medical Director
Overview
Same Day Services at UPMC Presbyterian/Montefiore includes both Same Day Surgery (SDS) and the Preoperative Evaluation Center (PEC). During Academic Year 2007-2008 (AY08), 15,633 patients went through SDS either as same day admit patients (7,359) or outpatient surgery patients (8,274) and 5,453 patients were seen in the PEC, an increase of 8% over the previous academic year.
Patient Care & Clinical Activities
Most patients scheduled for outpatient surgical procedures at UPMC Presbyterian/Montefiore are cared for at the SDS unit at Montefiore Hospital. The PEC receives referrals from surgeons for prior anesthetic problems, complex medical conditions, or other patient concerns. All preoperative testing and consults are combined with a detailed pre-anesthetic history and physical examination conducted by an anesthesiology resident or nurse practitioner. An attending anesthesiologist is always available to review complicated patients or testing results with the PEC staff. The entire evaluation is then available to the patient’s attending anesthesiologist on the day of surgery in an electronically retrievable PowerNote. Patients who are not seen in the PEC are called and evaluated the day before surgery by SDS nurses. The goal of the unit is 100% patient review prior to surgery, resulting in minimal unforeseen delays and cancellations on the day of surgery. Current data shows that the patients who are seen in the PEC are significantly less likely to be delayed or cancelled on the day of surgery.
The first satellite PEC began operation in February, 2008. It is located at the UPMC South Surgery Center and provides an alternative site for patients scheduled for surgery at Presbyterian, Montefiore, Shadyside, Magee-Womens, and South Side Hospital to obtain preoperative testing and a thorough pre-anesthetic evaluation. A second satellite PEC is currently being planned for the UPMC Monroeville Surgery Center.
Education & Training
Anesthesiology faculty members at Montefiore are active in resident education by teaching principles of ambulatory, ENT, orthopedic and regional anesthesia. Residents participate in outpatient evaluations and learn a variety of regional anesthesia techniques and principles of outpatient anesthesia. The PEC will be the site of a CA-1 Preoperative Evaluation Rotation, which was recently mandated by the Accreditation Council for Graduate Medical Education (ACGME) for Anesthesiology residency programs. A monthly Montefiore subspecialty meeting highlights ambulatory anesthesia, preoperative evaluation and regional anesthesia. This meeting is attended by faculty, residents, medical students, CRNAs, and SRNAs.
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