Division of Pulmonary Medicine

Moses Heart Center Unit (CSICU) Fellowship Rotation

Fellowship Rotation 

The objective is to train housestaff in didactic and technical aspects of post-operative management of patients after cardiothoracic surgery, as well as in acute cardiac medical care. This includes management of surgical complications, pacemakers, arrhythmias, and coagulation disorders and post-operative respiratory and renal insufficiency.

The fellows are expected to go to the OR at least once per week, get a working knowledge of the cardiopulmonary bypass for the intra-operative and post-operative management and of anesthetic techniques applicable to cardiovascular illness.

The rounds are at 6:30 AM and 8:00 PM everyday. The fellows are encouraged to attend the Chairman's rounds in Moses CSICU on Saturday at 8:00 AM. The fellows are required to attend the Monday Cardiothoracic Conference is at 7:00 AM, and are encouraged to attend the Cardiac Cath Conference and Cardiology Grand Rounds. Critical Care Medicine provides a monthly conference on Monday morning dealing with in-depth review of a Critical Care topic relevant to acute cardiac care. The in-house call for this rotation is every fourth night.

The most frequent diagnoses at the time of admission to the CSICU are coronary artery bypass graft, valvular surgery and thoracic surgery. In addition, there is a rapidly expanding heart transplant program and a ventricular assist device (VAD) program. The fellows are exposed to management of perioperative cardiac failure and cardiogenic shock, post-operative emergencies including cardiac tamponade and hemorrhage, severe respiratory failure and renal failure. Acute cardiac medical intensive care diagnoses include myocardial infarction, unstable angina, cardiogenic shock and complex arrhthymias.

Goals and Objectives 

Goal: 

The educational purpose of this rotation is to develop full competence in evaluation, diagnosis and treatment of patients with severe cardiac disease requiring medical and surgical correction and critical care support.

The principle teaching method is thorough case management of all patients including history, physical exam, and interpretation of laboratory tests and cardiorespiratory physiology data. Teaching rounds, unit based conferences for both clinical and administrative management, increased involvement in house staff instruction, and mastery of technical aspects of major required procedures are mandatory. Fellows are required to prepare for teaching rounds by supplementing case based understanding with review of major textbooks and current peer reviewed literature.

Fellows are required to attend all curriculum conferences, and competently prepare their presentations under faculty supervision while on this rotation.

Faculty will provide supervision to fellows on site from 7am through 12 midnight every day.

Objective: 

To instruct the fellows in staffing and directing a university hospital heart transplant cardiothoracic ICU using large volume of support technologies including IABP, ECMO, and VAD.

  • PATIENT CARE: competent coordination and leadership of a university hospital heart center intensive care unit
  • MEDICAL KNOWLEDGE: state-of-the-art diagnostic and therapeutic knowledge with focus on cardiac physiology and organ support
  • PROFESSIONALISM: ethical and compassionate care delivery in a collaborative practice model
  • INTERPERSONAL SKILLS: highly effective interpersonal communication directed at developing a leadership profile and consensus while standardizing care
  • PRACTICE BASED LEARNING AND IMPROVEMENT: data collection and analysis in a highly competitive surgical specialty field
  • SYSTEMS BASED PRACTICE: effective delivery of academic cardiothoracic intensive care

Reading List 

  1. Gilbert TB, McGrath BJ, Soberman M. Chest tubes: indications, placement, management, and complications. J Intensive Care Med 1993;8:73-86.
  2. Wait MA, Sharma S, Hohn J, Dal Nogare A. A randomized trial of empyema therapy. CHEST 1997;111:1548-51. Only randomized trial comparing immediate VATS to tube thoracostomy plus 3 days of daily SK (only 20 patients total). The surgical group had better primary treatment success and earlier hospital discharge, but outcomes of patients randomized to chest tube/lytics was much worse than other reported series, suggesting suboptimal management of those patients. All medical failures were salvageable with VATS.
  3. Ashbaugh DG. Empyema thoracis. Factors influencing morbidity and mortality. Chest 1991;99:1162-5. Study of 122 consecutive patients looked at the morbidity and mortality of delaying treatment of empyema. Waiting more than 3 days to place a chest tube, and more than 14 days to proceed to surgical drainage when chest tubes fail, was associated with increased morbidity and mortality.
  4. Weinstein G, Parinam S, et al. Serial Changes in Renal Function in Cardiac Surgical Patients. Ann Thorac Surg 1989;48:72.
  5. Zerr K, Furnary A, et al. Glucose Control Lowers the Risk of Wound Infection in Diabetics After Open Heart Operations. Ann Thorac Surg 1997; 63: 356.
  6. Zacharias A, Habib R. Factors Predisposing to Median Sternotomy Complications. Chest 1996; 110: 1173-1178.
  7. Brunet F, Brusset A, et al: Risk factors for deep sternal wound infections after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg 111:1200, 1996.
  8. Braxton J, Marrin CA, McGrath PD, et al: Mediastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg 70(6):2004, 2000.
  9. Moulton MJ, Crewsell LL, Mackey ME, et al: Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg 111:1037, 1996.
  10. Laub G, Riebman J, et al. The Impact of Aprotinin in Coronary Artery Bypass Graft Patency. Chest 1994; 106: 1370-1375.
  11. Kvetan V, Angus D, Gold J. Cardiac Surgery and Critical Care Medicine. New Horizons 1999; 7(4): 441-594.
  12. Ferraris VA, Ferraris SP: Risk factors for postoperative morbidity. J Thorac Cardiovasc Surg 111:731, 1996.
  13. Higgins T, Estafanous F, Lloyd F, et al: Stratification of morbidity and mortality outcome by preoperative risk factors in coronary artery bypass patients: A clinical severity score. JAMA 207:2344, 1994.
  14. Berger PB, Alderman EL, Nadel A, et al: Frequency of early occlusion and stenosis in a left internal mammary artery to left anterior descending artery bypass graft after surgery through a median sternotomy on conventional bypass: benchmark for minimally invasive direct coronary artery bypass. Circulation 100: 2353, 1999.
  15. Force T, Hibberd P, Weeks G, et al: Perioperative myocardial infarction after coronary artery bypass surgery. Circulation 82:903, 1990.
  16. Kajani M, Waxman H: Hematologic problems after open heart surgery, in Kotler M, Alfieri A (eds): Cardiac and Noncardiac Complications of Open Heart Surgery: Prevention, Diagnosis, and Treatment. Mt. Kisco, NY, Futura, 1992, p 219.
  17. Bailey JM, Levy JH, Kikura M, et al: Pharmacokinetics of intravenous milrinone in patients undergoing cardiac surgery. Anesthesiology 81:616, 1994.
  18. Lee WA, Gillinov AM, Cameron DE, et al: Centrifugal ventricular assist device for support of the failing heart after cardiac surgery. Crit Care Med 21:1186, 1993.
  19. Oz M, Rose E, Levin H: Selection criteria for placement of left ventricular assist devices. Am Heart J 129:173, 1995.
  20. Chuttani K, Tischler MD, Pandian NG, et al: Diagnosis of cardiac tamponade after cardiac surgery: relative value of clinical, echocardiographic, and hemodynamic signs. Am Heart J 127:913, 1994.
  21. Andrews TC, Reimold SC, Berlin JA, et al: Prevention of supraventricular arrhythmias after coronary artery bypass surgery. A meta-analysis of randomized controlled trials. Circulation 84[Suppl III]:III-236, 1991.
  22. Ommen SR, Odell JA, Standon MS: Atrial arrhythmias after cardiothoracic surgery. N Engl J Med 336:1429, 1997.
  23. Chung MK: Cardiac surgery: postoperative arrhythmias. Crit Care Med 28[Suppl]:N136, 2000.
  24. Cameron D: Initiation of white cell activation during cardiopulmonary bypass: cytokines and receptors. J Cardiovasc Pharmacol 27[Suppl 1]:S1, 1996.
  25. Moore FD Jr, Warner KG, Assousa S, et al: The effects of complement activation during cardiopulmonary bypass. Ann Surg 208:95, 1988.
  26. Kellerman PS: Perioperative care of the renal patient. Arch Intern Med 154:1674, 1994.
  27. Kaul TK, Crow MJ, Rajah SM, et al: Heparin administration during extracorporeal circulation. Heparin rebound and postoperative bleeding. J Thorac Cardiovasc Surg 78:95, 1979.
  28. Levi M, Cromheecke ME, de Jonge E, et al: Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant end points. Lancet 354:1940, 2000.
  29. Kreter B, Woods M: Antibiotic prophylaxis for cardiothoracic operations. Meta-analysis of thirty years of clinical trials. J Thorac Cardiovasc Surg 104:590, 1992.
  30. Puskas JD, Winston AD, Wright CE, et al: Stroke after coronary artery operation: incidence, correlates, outcome, and cost. Ann Thorac Surg 69:1053, 2000.
  31. Kuroda Y, Uchimoto R, Kaieda R, et al: Central nervous system complications after cardiac surgery: a comparison between coronary artery bypass grafting and valve surgery. Anesth Analg 76:222, 1993.
  32. Egleston CV, Wood AE, Gorey TF, et al: Gastrointestinal complications after cardiac surgery. Ann R Coll Surg Engl 75:52, 1993.
  33. Crock PA, Ley CJ, Martin IK, et al: Hormonal and metabolic changes during hypothermic coronary artery bypass surgery in diabetic and nondiabetic subjects. Diabetic Med 5:47, 1988.

Calendar

Pulmonary Fellowship Conferences occur regularly throughout the year.

info and schedule  

Contact Us

Albert Einstein College of Medicine
Price Center for Genetic & Translational Medicine
1301 Morris Park Avenue
Bronx, NY 10461

Tel: 718.678.1040
Fax: 718.678.1020

 
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