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2.
TEAMWORK AND CRISIS RESOURCE MANAGEMENT
Scott C. Watkins, Christopher L. Cropsey, and Cory M. Furse
INTRODUCTION
used the term in the early 1970s, but it was not until the
above referenced crash investigations that CRM reached a
A healthcare team can be thought of as a distinct set of two
or more clinicians working together with specic, individual roles and tasks toward a common goal.
1,2
Teamwork
can be thought of as the dynamic behaviors, cognitions,
attitudes, and skills that allow a team to perform its stated
goal.1 Nearly two decades ago, the report To Err Is Human
from the Institute of Medicine (IOM) identied teamwork as a key target for improving the quality and safety of
patient care.
1,3
Although much progress has been made in
the years since the seminal IOM report was issued, teamwork remains as critical as ever to the safe delivery of healthcare. is may reect a concurrent shi in the delivery of
medicine from “solo” practitioners to teams of healthcare
providers.
Long before the IOM report, the eld of anesthesiology
recognized the importance of human error, and not decits
in medical knowledge and skills, in relation to anesthetic
morbidity, including breakdowns in key teamwork components such as lapses in preparation, vigilance, and the
application of existing knowledge.4 us, it should be no
surprise that anesthesiologists were the rst to adapt “crisis” resource management (CRM) to healthcare.5 Over the
last 25 years, CRM has become synonymous with a style
of team performance epitomized by healthcare providers in
high acuity, time- pressured environments such as acute care
practice.
tipping point in aviation safety.
general approach was implemented by all major commercial airlines and evolved from “cockpit” to “crew” resource
management to emphasize the role of all aircrew members
in safe operation and level the pilot- centric hierarchical cul-
6,7
ture.
Commercial airline disasters are now extremely rare,
forcing aviation safety experts to turn to direct observations
of crew behaviors and surveys of crew attitudes to measure
the continued success of CRM.
e same errors in human performance identied in
the airline crashes of the 1970s are increasingly being recognized as contributors to medical errors and disasters
in healthcare. When one considers the major advances in
medical knowledge, therapeutics, and technology over
the last few decades, it is no surprise that human error has
emerged as one of the leading contributors to medical mishaps. Consider a few of the major advances within the eld
of anesthesiology over the last few decades: the advent of
safer volatile anesthetics accompanied by widespread use of
depth of anesthesia monitors, routine use of pulse oximetry
and end- tidal carbon dioxide sensors, improved hemodynamic monitoring, and the proliferation of airway devices
making lost airways a rare occurrence. Along with these
technological advances, or possibly as a result of them, there
has been a shi toward a culture of safety within the practice of anesthesia. us, parallels between the evolution of
6,7
In the ensuing years, the
aviation safety and the safety of anesthesia are easy to draw.
EVOLUTION OF CRISIS RESOURCE
MANAGEMENT
In the 1970s, investigation into a series of commercial airline crashes highlighted “failures of interpersonal communications, decision making, and leadership” as the leading
contributors of “human error” in airline disasters.6 e term
“cockpit” resource management (CRM) was rst used by
the NASA psychologist John K. Lauber.6 Lauber initially
6
ANESTHESIA CRISIS RESOURCE
MANAGEMENT
David Gaba, one of the pioneers of CRM and the patient
safety movement in anesthesia, describes CRM as “the
articulation of principles of individual and crew behavior in ordinary and crisis situations that focuses on skills
of dynamic decision- making, interpersonal behavior, and
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evenly among team members so that no one member of the
BOX 2.1 KEY COMPONENTS OF CRISIS RESOURCE
MANAGEMENT
Call for Help
Designate a Team Leader
Establish Clear Roles
Distribute the Workload
Know the Environment
Communicate Effectively
Anticipate and Plan
Mobilize Resources Early
Allocate Attention Wisely
Use all Available Information
Use Cognitive Aids
SOURCE: Adapted from Goldhaber- Fiebert SN, Anesthesia & Analgesia. 2013.
8
team becomes task overloaded.
It is important that the team and/ or its leader know the
enironment, that is, know what resources are available and
where to obtain those resources. Resources might include
an expert clinician, a piece of equipment, transportation
for mobilizing the patient to another location, and so forth.
e assignment of team roles should be based on the individual skill and knowledge required to fulll those roles;
thus it is helpful if a team leader is familiar with his/ her
team members.
It is important that the team leader and team members
communicate eectively using closed- loop communication
in which statements, orders, and questions are read back for
conrmation and clarity. When possible, the team leader
and followers should communicate with each other using
rst names and avoid making statements into thin air, so
that it is clear at whom each statement is directed. e team
leader should remain receptive to the questions or concerns
of all team members throughout the crisis.
During a crisis, teams should be proactive in their
thoughts and actions, that is, anticipate and plan, in order
to stay two steps ahead of the crisis and to ensure that every
team management.”5 Gaba and colleagues have taught
and studied CRM for nearly 3 decades. eir guide to
CRM includes nearly a dozen key points that any highfunctioning team of experts should consider when managing a crisis (see Box 2.1).
8
e rst, and possibly the most important, step in CRM
is calling for help. One should call for help sooner rather than
later, mobilizing more help than might be needed and ensuring that the correct type of help is obtained,; for example in the
event of a dicult or lost airway, it is best to call for help before
cardiac arrest occurs and to seek help from those with skills in
advanced airway management. Calling for a second opinion or
help from a colleague or another expert is a useful tool when
faced with a clinical dilemma or when one becomes xated on
a problem in which a solution is not readily apparent.
e order in which the remaining key components of
CRM are carried out is less important, but one might argue
that the second step should be designating a team leader.
Designating oneself as the team leader may be hard for
some, especially more junior, clinicians to do. It is important that the leader maintain a global perspective, remain
hands- o as much as possible, be capable of directing other
members of the team, and be open and receptive to feedback and input from team members. e best team leader
may not be the senior- most clinician in the room. e team
leader should establish clear roles for the remaining mem-
bers of the team and ensure that the workload is distributed
member of the team has a clear understanding of the problem, the plan, and future actions. For example, when drawing up the rst dose of epinephrine in a cardiac arrest, the
team member responsible for medications should anticipate
the potential need for a second or third dose and should
draw up those medications ahead of time. Teams should
anticipate the need for and mobilize resources early, as there
is less harm in calling for resources and not using them than
in needing a resource and not having it when the dierence
between a good and a bad outcome may be measured in
seconds. For example, when managing a dicult airway, it
is best to call for dicult airway equipment or a surgeon
skilled in cricothyrotomy before one gets into a “can’t intubate, can’t ventilate” situation.
Teams need to allocate attention wisely in order to
avoid xation on one problem/ task at the expense of missing other problems such as a change in patient condition
or at the expense of critical tasks such as the performance
of continuous chest compressions. Team leaders may wish
to assign a team member to monitor for changes in condition. Teams will want to use all available information
sources to ensure that no critical piece of the clinical puzzle is missed and to ensure that the team does not spend
too much time or xate on one single piece of the puzzle.
For example, if following intubation no end- tidal CO2 is
present it is probably best to look for other conrmation
signs of endotracheal intubation or remove the tube and
TEAMWORK AND CRISIS RESOURCE MANAGEMENT 7
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mask ventilate than it is to spend time troubleshooting
REFERENCES
a “faulty” CO2 monitor. Finally, teams should consider
using any and all available cognitive aids, such as emer-
gency manuals, checklists, or smartphone applications,
during a crisis to facilitate information retrieval and aid
clinical decision- making.
ere is clear evidence that breakdowns in teamwork
lead to increased patient morbidity.9 Unfortunately, the
evidence for how we mitigate breakdowns in teamwork is
less clear. e rarity of bad outcomes, especially in the practice of anesthesia, makes it dicult to use clinical outcomes
to measure teamwork and CRM. us, the evidence for
teamwork and CRM consist primarily of observational and
survey data.
1,9
As a result, interventions to improve teamwork and CRM in healthcare have struggled to achieve the
widespread adoption as seen in other industries.
However, the core principles that have been discussed in this chapter are widely accepted as the governing principles of best practice for delivery of high- quality
care during urgent and emergent situations throughout
the perioperative period. e reader should keep these
in mind as specic diagnoses are considered throughout
the rest of the book, as proper adherence to CRM is the
vehicle through which specic care for a particular condi-
1. Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork
improve performance in the operating room? A multilevel evaluation. Joint Commission Journal on uality and Patient Safety.
2010;36(3):133– 42.
2. Salas E, Dickinson TL, Converse SA, Tannenbaum SI. Toward an
understanding of team performance and training. In: Salas RWSE,
ed., Teams: eir Training and Performance. Norwood, NJ: Ablex;
1992:3– 29.
3. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building
a Safer Health System. Vol 6. Washington, DC: National Academies
Press; 2000.
4. Olsson G, Hallen B. Cardiac arrest during anaesthesia: a computer aided study in 250 543 anaesthetics. Acta Anaesthesiologica
Scandinavica. 1988;32(8):653– 64.
5. Gaba D. Crisis resource management and teamwork training in
anaesthesia. British Journal of Anaesthesia. 2010;105(1):3– 6.
6. Helmreich RL, Merritt AC, Wilhelm JA. e evolution of crew
resource management training in commercial aviation. International
Journal of Aviation Psychology. 1999;9(1):19– 32.
7. Gordon S, Mendenhall P, O’Connor BB. Beyond the Checklist:
What Else Health Care Can Learn from Aviation Teamwork and
Safety. Ithaca: Cornell University Press; 2012.
8. Goldhaber- Fiebert SN, Howard SK. Implementing emergency
manuals: can cognitive aids help translate best practices for patient
care during acute events? Anesthesia and Analgesia. 2013;117(5):
1149– 61.
9. Manser T. Teamwork and patient safety in dynamic domains
of healthcare: a review of the literature. Acta Anaesthesiologica
Scandinavica. 2009;53(2):143– 51.
tion (e.g., severe anaphylaxis or local anesthetic toxicity)
should be delivered.
8 PART I. CRISIS RESOURCE MANAGEMENT
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3.
COGNITIVE AIDS IN CURRENT PRACTICE
Christopher L. Cropsey, Scott C. Watkins, and Matthew D. McEvoy
INTRODUCTION
cost, and unlike soware that must be developed for a spe-
cic device or operating system, paper is universal. In addiAs noted in the prior chapter, use of a cognitive aid (CA)
is now considered to be a core component of managing
perioperative crisis events. Interestingly, the earliest known
description of a perioperative CA comes from a 1924 article by Babcock in which he describes posting a checklist for
managing emergencies on the wall of the operative theater.1
Despite this early advocacy, the use of such aids in medicine
are only now gaining widespread acceptance. Along the
way, other professions made cognitive aids an important
part of their daily performance. In e Checklist Manifesto:
How to Get ings Right, Atul Gawande describes the creation of ight checklists in the 1930s in response to the
increasing complexity of newer generation airplanes.2
Almost a century later, it has become clear that the cognitive demands posed by the complexity of the current perioperative environment, which is further increased during a
crisis situation, have exceeded the limits of human cognitive
processing. For this reason, CAs are experiencing a renaissance, with some clinicians calling for CAs to be integrated
into all aspects of clinical care in order to improve patient
care, and a number of CAs dedicated to the management
of perioperative patients have been developed and are readily available to all clinicians (See Table 3.1).3 is chapter
describes the various types of CAs, their implementation in
clinical practice, and directions for future advances.
tion, paper requires little maintenance with no batteries to
charge or soware to upgrade and thus no risk of a paper
checklist “crashing” in the midst of a crisis due to either
hardware or soware limitations. ese are important con-
siderations for those that practice in extreme environments
where reliable access to either electricity or the Internet is
limited.
Electronic formats do oer some signicant advantages
over paper. Electronic devices are able to store increasing
amounts of information on smaller devices, while the information contents of paper CA are limited by the amount of
information that can be physically contained on a card or
inside a book. Electronic devices are able to move beyond
a simple checklist and provide audiovisual prompts to users
as well as dynamic decision support in the form of active
feedback and recommendations based on the actions of the
user and the outcome of the patient. is dynamic process
is dicult, if not impossible, to replicate using paper and
opens up the possibilities of increasing levels of real- time
support for clinicians— especially as technology and articial intelligence improve.4 Finally, some electronic formats,
for example, mobile and Web- based applications, oer the
ability to push automatic updates to users as new recommendations and guidelines become available, thus ensuring that clinicians are practicing with the most current
information.
TYPES OF COGNITIVE AIDS
Modern CAs can be classied in several dierent ways,
one of which is the medium on which they are provided.
Historically CAs were printed on paper, but with the
proliferation of electronic handheld devices (i.e., smartphones and tablets), novel modes of delivery have received
increased attention. ere are advantages and drawbacks to
both. Paper is attractive due to the ease of printing and low
DESIGN AND IMPLEMENTATION
Although one may assume that providing a CA of any
sort would automatically enhance outcomes, this is likely
not true, as CAs are merely tools that remain dependent
on human users for their eectiveness. Improving human
performance is a complex task that requires a change of
human behavior. Aspects of a CA’s design and usability may
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TABLE 3.1 PERIOPERATIVE COGNITIVE AIDS AND RELATED RESOURCES
Emergency Manuals Implementation Collaborative (EMIC)
http:// www.emergencymanuals.org/
Society for Pediatric Anesthesia
http:// www.pedsanesthesia.org/ wp- content/ uploads/ 2015/ 02/
Critical_ Event_ Checklists.pdf
Stanford Emergency Manual
http:// emergencymanual.stanford.edu/
Ariadne Labs OR Crisis Checklists
https:// www.ariadnelabs.org/
Checklist for Treatment of Local Anesthetic Systemic Toxicity (LAST)
https:// www.asra.com/
Malignant Hyperthermia resources:
Malignant Hyperthermia Association of the United States (MHAUS)
http:// www.mhaus.org/ healthcare- professionals
European Malignant Hyperthermia Group (EMHG)
https:// emhg.org/ nc/ home/
The Anaesthetic Crisis Manual
http:// theacm.com.au/
play an important role in its overall eectiveness through
its impact on user behavior. Once a CA is used, there is no
guarantee that it will be used correctly; this may be further
compounded by poor design, such as small text or unclear
instructions leading to confusion or even error in following
a particular algorithm. At the most basic level, many anesthesia providers will simply choose to not use an available
CA, especially if it is perceived to be dicult to use; this has
been reported both anecdotally and experimentally.
5,6
highlights the importance of proper implementation of
Tools and resources for implementing CAs into local practice. Links to
other resources.
Emergency manual dedicated to the perioperative care of the pediatric
patient. Developed by a panel of experts in pediatric anesthesia. Free
download. Available in multiple languages. There is also a mobile
application available for free download.
Emergency manual dedicated to the perioperative management of adult
patients. Includes information for 25 perioperative crises and Crisis
Resource Management resources. Free download.
Crisis checklist with information on 12 of the most common operating
room crises. Free download. Also includes resources for implementation.
Resources for the management of LAST based on expert consensus of
the American Society for Regional Anesthesia and Pain Medicine. Paper
checklist available for free download. Links to mobile applications included.
Websites includes extensive resources for the management of MH including
CAs for purchase and information on preparing one’s practice for MH crises.
A quick reference handbook with a collection of 22 life- threatening anesthetic
crises. Both paper and electronic formats available for purchase.
eective. One such model, referred to as a “leader- reader”
model, uses a dedicated “reader” to physically interface
with the CA while providing prompts to the team leader.
e purported advantage of this is that it frees the leader
from the additional cognitive load of using the CA itself.
is paradigm has been shown to improve performance
in simulations of local anesthetic toxicity and obstetric
8,9
ose interested in implementing CA into
is
emergencies.
local clinical practice should refer to the many resources on
implementation available online. (See Table3.1).
CAs into clinical practice being dependent on their usability and ultimate eectiveness. Users will be unlikely to use a
CA if it is not immediately available or if they are unaware
CONTENT
it is available at all. Furthermore, unfamiliarity with the
content of a given CA can lead to inappropriate use. For
example, the user may select a checklist for the wrong crisis
or fail to switch to a dierent checklist if the original diagnosis is revised.
7
Although popular perception may be that “anyone can
read a checklist,” in reality these should be viewed more as
medical devices, which require adequate training to use
eectively and may be most eective when used by a clinician
trained in their use. is has led to some debate about the
most appropriate user of the CA. Traditionally, checklists
were employed directly by the team leader. However, newer
research suggests that other methods of use may be more
Regardless of design, format, or method of implementation,
a CA must contain valid and reliable information, preferably based on the latest evidence- based guidelines. e content of CAs designed for perioperative crises are frequently
based on a mixture of evidence- based guidelines (advanced
cardiac life support), expert consensus (local anesthetic systemic toxicity, malignant hyperthermia), and the authors’
opinion. erefore, CA users should thoroughly assess the
information contained in CA before basing clinical decisions on the contents of a CA. Evidence- based guidelines
are frequently updated with new and dierent recommendations, so CAs based on these recommendations also need
10 PART I. CRISIS RESOURCE MANAGEMENT
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to be updated. erefore, one should ensure that the most
up- to- date CA is available and used. With the recognition
of the important role teamwork and communication play
in clinical practice, many CAs now include both technical
(i.e., medical) and nontechnical (i.e., teamwork, communication) information.
FUTURE DIRECTIONS
Ultimately, despite a number of ongoing questions, it
would appear that cognitive aids— when properly design
and used— have the ability to improve the management of
crisis situations.
10– 14
ere is evidence that attitudes toward
their use are changing; the age- old stigma that a CA was
a “crutch” or a “cheat sheet” is giving way to the recognition that modern crisis situations are too complex to rely
on memory alone.15 Nonetheless, a number of outstanding issues remain. ere is a paucity of data on how to best
design a CA, and few studies have commented on usability
testing.16 Furthermore, much of the evidence for their use
is in the form of simulation assessment. Additional investigation is now needed to demonstrate an improvement
in actual patient outcomes (the so- called T2 and T3 level
testing as described by Goldhaber- Feibert et al.6) As these
hurdles are overcome, it is expected that CAs will continue
to gain wider use in the management of perioperative crises.
As the reader considers the specic diagnoses throughout the bulk of this book, they should consider how cognitive aids containing the management steps described could
be of benet in the event of them managing these particular emergencies in the clinical setting. Readers are again
directed to a number of existing resources for many of the
events in this book as shown in Table 3.1.
REFERENCES
1. Babcock WW. Resuscitation during anesthesia. Anesth Analg.
1924;3:208– 13.
2. Gawande A. e Checklist Manifesto: How to Get ings Right.
1st ed. New York, NY: Metropolitan Books; 2010.
3. Augoustides JGT, Atkins J, Koe WA. Much ado about checklists:
who says I need them and who moved my cheese? Anesth Analg.
2013;117(5):1037– 8. doi:10.1213/ ANE.0b013e31829e443a.
4. Morell RC, Cooper JB. APSF sponsors workshop on implementing emergency manuals. Anesth Patient Saf Found Newsl.
2016;30(3):68– 71.
5. Watkins SC, Anders S, Clebone A, et al. Paper or plastic? Simulation
based evaluation of two versions of a cognitive aid for managing
pediatric peri- operative critical events by anesthesia trainees: evaluation of the society for pediatric anesthesia emergency checklist.
JClin Monit Comput. 2016 Jun;30(3):275– 83.
6. Goldhaber- Fiebert SN, Howard SK. Implementing emergency
manuals: can cognitive aids help translate best practices for patient
care during acute events? Anesth Analg. 2013;117(5):1149– 61.
doi:10.1213/ ANE.0b013e318298867a.
7. Borsho D. e limitations of crisis checklists: Anesth Analg.
2014;118(6):1387– 8. doi:10.1213/ ANE.0000000000000183.
8. Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does
every code need a “reader?” Improvement of rare event management with a cognitive aid “reader” during a simulated emergency:
a pilot study. Simul Healthc J Soc Simul Healthc. 2012;7(1):1– 9.
doi:10.1097/ SIH.0b013e31822c0f20.
9. McEvoy MD, Hand WR, Stoll WD, Furse CM, Nietert PJ.
Adherence to guidelines for the management of local anesthetic
systemic toxicity is improved by an electronic decision support
tool and designated “reader.” Regional anesthesia and pain medicine 2014 Aug;39(4):299– 305. PMID: 24956454 PMC ID: PMC
4068273.
10. Harrison TK, Manser T, Howard SK, Gaba DM. Use of cognitive aids
in a simulated anesthetic crisis. Anesth Analg. 2006;103(3):551– 6.
doi:10.1213/ 01.ane.0000229718.02478.c4.
11. Low D, Clark N, Soar J, et al. A randomised control trial to determine if use of the iResus© application on a smart phone improves
the performance of an advanced life support provider in a simulated
medical emergency. Anaesthesia. 2011;66(4):255– 62. doi:10.1111/
j.1365- 2044.2011.06649.x.
12. Ziewacz JE, Arriaga AF, Bader AM, et al. Crisis checklists for the
operating room: development and pilot testing. J Am Coll Surg.
2011;213(2):212– 7.e10. doi:10.1016/ j.jamcollsurg.2011.04.031.
13. Field LC, McEvoy MD, Smalley JC, et al. Use of an electronic decision support tool improves management of simulated in- hospital
cardiac arrest. Resuscitation. 2014;85(1):138– 42. doi:10.1016/
j.resuscitation.2013.09.013.
14. Arriaga AF, Bader AM, Wong JM, et al. Simulation- based trial of
surgical- crisis checklists. N Engl J Med. 2013;368(3):246– 53.
doi:10.1056/ NEJMsa1204720.
15. Krombach JW, Edwards WA, Marks JD, Radke OC. Checklists and
other cognitive aids for emergency and routine anesthesia care: a survey on the perception of anesthesia providers from a large academic
US institution. Anesthesiol Pain Med. 2015;5(4). doi:10.5812/
aamp.26300v2.
16. Marshall S. e use of cognitive aids during emergencies in anesthesia: a review of the literature. Anesth Analg. 2013;117(5):1162– 71.
doi:10.1213/ ANE.0b013e31829c397b.
COGNITIVE AIDS IN CURRENT PRACTICE 11
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PART II.
CARDIAC CRISES
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4.
INTRODUCTION TO PERIOPERATIVE CARDIAC URGENCIES
AND EMERGENCIES
Jason B. O’Neal and Andrew Shaw
ardiac arrest in the perioperative period is unique
from cardiac arrest in other scenarios, given that
C
the event is typically witnessed and real- time vital
signs are oen being monitored. is enables the responding physician to quickly formulate a focused dierential
diagnosis and develop a suitable treatment plan. In order
to establish the correct diagnosis, one must have an adequate understanding of normal cardiac physiology and of
cardiovascular pathology and the ways in which this may
adversely aect cardiac function.
e heart consists of four chambers— two atria and
two ventricles. e right and le sides of the heart each
have an atrium and ventricle. It is the dierence in mean
peripheral to mean central venous pressure that delivers
blood to the right side of the heart, which then pumps
blood into the lungs, allowing gas exchange across the
alveolar- capillary membrane. Oxygenated blood then
drains to the le side of the heart, which pumps blood
around the systemic circulation to all organs of the body.
Forward ow from the right to the le side of the heart,
across the pulmonary circulation, is ensured by two pairs
of unidirectional valves— mitral and aortic on the le, and
tricuspid and pulmonic on the right. Adequate blood ow
to the heart itself is necessary for the heart to function
properly. Blood is supplied via the le anterior descending (LAD), right coronary (RCA), and le circumex
(LCx) arteries. e le ventricle (LV) receives blood
predominantly during diastole, while the right ventricle
(RV) is perfused throughout both diastole and systole.
e conduction system in the heart coordinates electromechanical coupling as follows: e sinoatrial (SA) node
triggers a depolarization wave that spreads across the right
and le atria and, aer a brief delay, the atrioventricular
(AV) node conducts this signal forward to both ventricles
through the bundle of His.
is description may be a simplied overview of how the
heart functions, but it does provide a convenient conceptual
framework for consideration of the individual components
aecting myocardial performance. Anesthesiologists commonly discuss preload, aerload, contractility, heart rate,
and rhythm as the most important components for adequate cardiac output. Insults to any of these parameters can
be detrimental to the heart. For our purposes, and in what
follows, we identify, describe, and understand these terms
and use their denitions to assist in formulating a succinct,
direct approach to an unstable patient in the perioperative
period: Pumps, Pipes, and Preload, Vessels, Voltage, and
Valves.
e right side of the heart pumps blood to the lungs,
while the le heart pumps blood throughout the body.
When one or both of these Pumps fail, the patient may
become unstable very rapidly. Heart failure may be categorized into chronic, acute, or acute on chronic subtypes,
with an overall incidence of 1% to 6% in patients undergoing major surgery.1 is incidence is even higher in patients
with preexisting heart conditions, at up to 25% quoted
in the literature.1 Patients with chronic heart failure must
have detailed anesthetic plans prior to undergoing surgery
if morbidity is to be avoided. Fluid balance is a critical part
of this plan, and uid shis in the wrong direction can easily drive a patient with chronic heart failure into the acute
category, leading to cardiogenic shock. Several other causes
of cardiogenic shock exist, of which the more common
include cardiomyopathy, myocardial infarction (MI), and
massive pulmonary embolism (PE). Although LV failure is
the cause of most instances of cardiogenic shock, the RV
must not be overlooked, as the treatment of LV and RV failure is dierent.2 Acute trauma to the heart either from an
extrinsic process prior to surgery or possibly an iatrogenic
cause (i.e., surgical misadventure) must also be considered
when evaluating pump failure.
Pipes, or peripheral blood vessels, are natural extensions from the heart, but any disruption in their normal function also places excessive strain on the heart in
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