What evidence recommends that cardiothoracic (cardiothoracic) anesthesiologists, specifically those experienced in circulatory arrest cardiac cases, perform these procedures?

From the Guidelines

Circulatory arrest cardiac cases should be performed by experienced cardiothoracic anesthesiologists who are skilled in managing deep hypothermic circulatory arrest (DHCA), selective cerebral perfusion techniques, and associated physiological challenges. These complex procedures require specialized knowledge and skills, including appropriate dosing of anesthetic agents during hypothermia, monitoring cerebral perfusion with near-infrared spectroscopy (NIRS) or transcranial Doppler, and implementing neuroprotective strategies such as maintaining adequate cerebral perfusion pressures (50-70 mmHg) during selective cerebral perfusion 1. Experienced cardiothoracic anesthesiologists are better equipped to manage the specific anesthetic considerations and are skilled at managing the complex hemodynamic shifts during cooling, arrest, and rewarming phases, including appropriate use of vasopressors like norepinephrine or vasopressin when needed. The improved outcomes associated with experienced providers include reduced neurological complications, better management of coagulopathy with appropriate use of antifibrinolytics (tranexamic acid 10-30 mg/kg), and more effective post-arrest care.

Some key points to consider in the management of circulatory arrest cardiac cases include:

• The use of extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue therapy for selected patients with cardiac arrest when conventional CPR is failing in settings in which it can be implemented 1
• The importance of specialized knowledge and skills in managing DHCA, selective cerebral perfusion techniques, and associated physiological challenges 1
• The need for experienced providers to manage complex hemodynamic shifts during cooling, arrest, and rewarming phases, including appropriate use of vasopressors like norepinephrine or vasopressin when needed 1
• The improved outcomes associated with experienced providers, including reduced neurological complications, better management of coagulopathy, and more effective post-arrest care 1

Overall, the evidence suggests that experienced cardiothoracic anesthesiologists are essential for the management of circulatory arrest cardiac cases, and that their specialized knowledge and skills are critical for improving patient outcomes.

From the Research

Evidence for Cardiothoracic Anesthesiologists in Circulatory Arrest Cardiac Cases

• There are several studies that discuss the importance of experience and expertise in performing circulatory arrest cardiac cases, particularly in cardiothoracic anesthesiology 2, 3, 4, 5, 6.
• A study published in the Journal of Cardiac Surgery in 1994 highlights the importance of hypothermic circulatory arrest (HCA) in operations on the thoracic aorta, and notes that measures that preserve autoregulation of cerebral blood flow help increase the margin of safety with all methods of protection 2.
• Another study published in Perfusion in 2011 discusses alternative strategies for cerebral perfusion during deep hypothermic circulatory arrest, and emphasizes the importance of establishing guidelines for best practice in circulatory arrest 3.
• A review article published in Progress in Cardiovascular Diseases in 2013 discusses the use of deep hypothermic circulatory arrest (DHCA) in aortic arch surgeries, and notes that DHCA has been shown to have outcomes equal to or better than those of antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP) 4.
• A study published in Annals of Cardiothoracic Surgery in 2013 discusses the use of DHCA in aortic arch surgery, and notes that effective cerebral protection remains the primary concern during these procedures 5.
• A review article published in Seminars in Cardiothoracic and Vascular Anesthesia in 2007 discusses the anesthetic management of adult patients undergoing deep hypothermic circulatory arrest, and highlights the importance of specific knowledge and expertise in this area 6.

Key Findings

• Experience and expertise in cardiothoracic anesthesiology are crucial in performing circulatory arrest cardiac cases 2, 3, 4, 5, 6.
• Hypothermic circulatory arrest (HCA) is an effective method of cerebral protection during operations on the thoracic aorta 2.
• Deep hypothermic circulatory arrest (DHCA) is a commonly used technique in aortic arch surgeries, and has been shown to have favorable outcomes 4, 5.
• The anesthetic management of adult patients undergoing DHCA requires specific knowledge and expertise 6.