The Anaesthesia and Intensive Care Unit of Monzino Cardiology Centre provides support for surgical and interventional activities and manages post-operative intensive care. Numerous activities, summarised below, are carried out in different fields: Anaesthesia, Loco-regional anaesthesia and pain therapy, Transoesophageal echocardiography, Anaesthetic procedures in the other Units, and Intensive Care.
In cases of complex surgery such as cardiovascular surgery, the anaesthesiologist's role is not limited to that, albeit fundamental, of administering anaesthetic drugs for surgery to be performed. Preoperative evaluation is a very important part of the service: detailed knowledge of the clinical problems of individual patients often allows dangerous situations to be foreseen, with undoubted advantages for the patient.
At the Monzino Centre, the Anaesthesia and Resuscitation Unit does, therefore, participate in the daily discussions with cardiologists and surgeons on the choice of the best clinical approach to the patient. The purely cardiological assessment is completed, when deemed necessary, with instrumental evaluations of respiratory function through the anaesthetic team’s specific equipment and knowledge.
The Unit has developed different anaesthetic techniques for the various types of surgical interventions, cardiac surgery, and major and minor vascular surgery, which take place in the four operating theatres. Patients must in fact be "protected" with appropriate techniques from "surgical stress" and post-operative pain. The aim is to prevent any reflexes triggered by these events from subjecting the heart to increased work, a condition that can become extremely dangerous in patients with heart disease, who account for almost all the patients treated.
As far as concerns cardiac surgery, the development of appropriate anaesthetic and monitoring methods has allowed an ever increasing number of coronary bypass operations to be performed using the so-called "beating heart" technique, that is, without the aid of extracorporeal circulation, in which the heart is moved and fixed in non-physiological positions for even long periods of time.
Loco-regional anaesthesia and pain therapy
Loco-regional anaesthesia has undergone great progress in recent years, driven especially by the concomitant presence of diseases that complicate the clinical picture of patients to be operated, the increase in their average age, and the growing demand from the patients themselves "not to feel bad afterwards". This technique offers several possibilities even in a field, such as cardiovascular care, in which it apparently would seems to have no space.
Thus we created, within the Anaesthesia and Resuscitation Unit, a service specifically dedicated to the use of loco-regional anaesthesia in its multiple applications: acute therapy of unstable angina, chronic therapy of refractory angina, treatment of chronic angina pain and chronic peripheral vascular pain with spinal cord stimulators.
Moreover, in association with general anaesthesia, some coronary bypass procedures are performed with the aid of continuous high thoracic epidural anaesthesia (HTEA), a technique that can control intraoperative and postoperative pain in a particularly effective way, reduce sympathetic reflexes, and obtain a useful vasodilating effect on the coronary circulation.
Major vascular surgery also makes significant use of loco-regional anaesthetic techniques. While in some cases (interventions to the abdominal or thoracic aorta) these techniques are an important complement to general anaesthesia, in the case of carotid surgery loco-regional anaesthesia allows the intervention to be performed with the patient awake, so the patient’s state of consciousness can be assessed continuously during the intervention.
During the intervention the possibility of "seeing" the heart and being able to evaluate its function at any time has led to the development of transoesophageal echocardiography as a means of intraoperative monitoring.
The Anaesthesia and Intensive Care Unit of the Cardiology Centre, thanks to active collaboration with staff of the echocardiography service, was one of the first in Italy to use this technique in a routine way. Three echocardiographs, one of which is equipped with three-dimensional software, are available to the operating theatre. All the doctors of the Unit use this equipment and are constantly updated on the evolution of this important technique.
The anaesthetist’s involvement in other Units
The expansion of invasive cardiology techniques is leading to an increasing need for the anaesthesiologist's skills in the Haemodynamics and Electrophysiology laboratories to ensure adequate control of vital functions in often very compromised patients. These procedures are often performed with conscious or deep sedation with the presence of an anaesthetist to protect the patient's clinical condition.
As a logical completion of the therapeutic process, the Anaesthesia and Resuscitation Unit also deals with Postoperative Intensive Care. Patients from the operating theatres are followed in Intensive Care, which is always entrusted to at least one of the staff members. Returning to consciousness is a delicate moment for the patient with heart disease because it triggers reflex reactions, forcing the heart to a potentially excessive oxygen consumption. The Postoperative Intensive Care area contains 11 beds, which are monitored and controlled by central data collection units. It is equipped with electro-medical devices and state-of-the-art monitoring systems. Each patient’s vital functions, i.e., respiratory and cardiocirculatory functions (invasively and non-invasively measured arterial pressure, heart rate, electrocardiogram) can be monitored continuously, integrating this information with more complex haemodynamic data such as cardiac output, pulmonary venous saturation, lung volumes, and extra-vascular pulmonary fluid.
The mechanical ventilators used, all of the latest generation, can ensure an adequate degree of adaptation to the patient's condition, displaying a large amount of data, in both numerical and graphical form, regarding the respiratory cycle, thus facilitating optimal transition to spontaneous breathing .
All clinical and instrumental data are collected electronically and stored in a digitized folder so that the data can be processed for therapeutic and research purposes. The professional skills acquired by the staff and the availability of adequate electromedical equipment allow a whole series of important diseases to be treated.
Modern devices for renal depuration (haemodiafiltration, haemodialysis, peritoneal dialysis) help patients with even seriously impaired kidney function, while artificial, enteral or parenteral nutrition protocols, sophisticated anti-decubitus mattresses and special nursing and physiotherapy programmes are used for complex patients whose stay in Intensive Care is protracted.
The research activities of the Anaesthesia and Intensive Care Unit are focused mainly on the following areas:
- the protection of renal function during heart surgery
- the development of anaesthetic techniques for minimally invasive heart surgery
- intraoperative echocardiographic monitoring.
The Unit’s doctors collaborate with the Institute of Anaesthesiology and Resuscitation of the University of Milan allowing students of the degree course in Medicine and Surgery and the post-graduates specialising in Anaesthesiology and Resuscitation to attend the Unit in rotation to obtain specific training in cardiovascular anaesthesia. The Unit also provides the logistics and tutors necessary for the preparation of theses for both undergraduates and the post-graduate specialisation trainees.
National and international scientific activities
The Unit’s doctors participate in various congresses of the main Italian and European scientific societies in the field of anaesthesiology-resuscitation. They are involved in the organisation of itinerant courses and in drafting the guidelines of the Italian Society of Anaesthesia and Resuscitation on specific topics (transoesophageal echocardiography and airway management).