The role of anesthesiology in cardiac surgical operations is well established. Anesthesia is also frequently required for many cardiac procedures performed by cardiologists. The level of such anesthesia can range from conscious sedation to general anesthesia. The area with likely the greatest need for anesthesia among cardiology specialties is in electrophysiology (EP), as some procedures such as cardioversion or defibrillation testing require deep sedation for pain control, while others such as complex ablation may require general anesthesia given the duration of study and need to minimize patient movement.1–4 Given the growth and complexity of EP procedures5 over the past decade as well as adoption of newer anesthesia regulations and policies, such as nonanesthesiologists no longer being able to provide deep sedation at some institutions, there has been a significant shift in recent years in anesthesia coverage for EP procedures.6 However, little quantification of these changes is available.7 Accordingly, a large US-based survey was undertaken to provide insight with regard to such activities. Both anesthesiologists and electrophysiologists were included, and the present study focuses on a comparison of the perceptions of the 2 specialties.
The study was approved by our hospitals’ Institutional Review Board, and the requirement for written consent was waived by the Institutional Review Board. A questionnaire was formulated (Figure) based on input from electrophysiologists and anesthesiologists at our institution who care for patients undergoing EP procedures. Questions were based on what these physicians thought would be important information necessary to better ascertain national trends in the area of anesthesia involvement for EP procedures. The physicians who provided input included those in national leadership positions within their society. The survey collected information on clinical role (anesthesiologist or electrophysiologist), the training status of the programs, annual case volumes, and perceived anesthesia involvement in a variety of procedures of varying complexity and average duration. Included was type of anesthesia used (ie, general endotracheal anesthesia [GETA], monitored anesthesia care [MAC], and deep sedation). The survey also ascertained the perceptions of the role of the anesthesiologist and the impact on clinical care.
On approval from the Society of Cardiovascular Anesthesiologists and the Heart Rhythm Society, an online, cross-sectional survey was administered to the US physician membership of both societies. The survey was resent to all physician members 1 month after its first distribution.
Descriptive statistics were calculated for all measures in the data across all participants. Participants’ practice characteristics and responses to questions about team structure, impact of anesthesia and physician involvement, and timing of care were also examined by specialty (anesthesia versus EP). Differences in the percent of respondents in each response category between provider types for questions about team structure, impact of anesthesia and physician involvement, and timing of care were also estimated, and the 95% Wald confidence interval with continuity correction is provided. Using the observed number of respondents in each specialty indicates that a sample size of 179 electrophysiologists and 297 anesthesiologists allows for estimation of a 2-sided 95% confidence interval around the difference in proportions selecting a specific response between provider types with a width no >0.18. All analyses were conducted in SAS v 9.4 (SAS Institute, Inc, Cary, NC).
There were 479 physicians who completed the survey. This included 297 (62%) anesthesiologists of 3604 Society of Cardiovascular Anesthesiologists members giving a response rate of 8.24%, 179 (37.4%) electrophysiologists of 1321 Heart Rhythm Society members giving a response rate of 13.6%, and 3 (0.6%) who did not report their clinical designation. A majority of respondents (56.6%) reported the teaching of residents and/or fellows in their practices, and most (62.3%) also reported having >500 invasive EP cases annually in their practice. More than 95% of responders reported that the attending anesthesiologist was accessible through the case, and there was strong consensus (92%) that involvement of an anesthesiologist improved patient satisfaction. Most respondents also reported that anesthesiologists were present at induction, case start, timeout, and emergence. A majority (55%) stated that all anesthesiologists in their group rather than solely cardiac anesthesiologists or another designated team are involved in EP cases. More than 80% of respondents reported that an attending electrophysiologist performed a majority of the cases at their institution. Information of the distribution of responders across all providers and by provider type for a subset of the survey questions is shown in Table 1.
Physician-Reported Anesthesia Involvement
The survey included specific questions regarding anesthesia involvement in specific procedures including simple ablation, complex ablation, placement of an implantable cardioverter-defibrillator (ICD), pacemaker placement, and cardioversion. Respondents reported ranges of proportion of cases that involved an anesthesiologist. The respondent reported distribution of the proportion of cases that involved an anesthesiologist by procedure type is shown in Table 2.
A majority of respondents (65.8%) reported an increase in anesthesia involvement over the past 2 years. Anesthesia involvement was greatest for complex ablations with >73% of respondents reporting that >80% of cases were done with anesthesia involvement. Cardioversion and ICD also had high reported levels of anesthesia involvement with 69.6% and 57% of respondents reporting anesthesia involvement in at least 60% of cases for these procedures, respectively. The lowest reported instance of anesthesia involvement was for pacemaker cases where almost half (47.5%) of respondents reported anesthesia involvement in ≤20% cases.
Physician-Reported Anesthesia Technique
The survey also included questions regarding the type of anesthesia (GETA, MAC, or deep sedation) used in specific procedures including atrial fibrillation (A fib), supraventricular tachycardia, atrioventricular node ablations, implantation of ICDs or pacemakers, and cardioversions. Again, for each procedure, respondents reported the range of the proportion of these cases in which GETA, MAC, and deep sedation were used. The percentage of cases for each procedure using the different anesthesia technique reported by study participants is shown in Table 3.
GETA was the most commonly reported anesthesia technique used during A fib with 69% of respondents reporting use of GETA in at least 80% of A fib cases. In contrast, use of GETA was limited in supraventricular tachycardia, atrioventricular node ablations, implantation of pacemaker or ICD, and cardioversions with a majority of respondents (between 60% and 89%) reporting use of these procedures in <20% of cases across these 5 procedures. Reported use of MAC and deep sedation was low across all procedures with >55% of respondents reporting use of MAC or deep sedation in <40% of cases across all procedures. MAC and deep sedation were used least in A fib cases with 80% and 82% of participants reporting use of MAC or deep sedation during A fib in <20% of cases, respectively. While the use of MAC and deep sedation appears to be limited, these techniques were reportedly used in a larger proportion of cases for cardioversion relative to other procedures. Specifically, 37% of respondents reported use of MAC and 47% reported use of deep sedation in at least 60% of cardioversion cases.
The proportion of cases in which total intravenous anesthesia (TIVA) rather than inhalation anesthesia was used was also examined. Sixty percent of respondents report using TIVA in <40% of cases, and only 21% report using TIVA in >80% of cases.
Data were also collected on the composition of the anesthesia teams involved in EP procedures. These results are summarized in Table 4. Additionally, respondents were queried as to their perception of whether or not anesthesia involvement improved patient satisfaction. There were significant differences observed between the 2 physician groups regarding the composition of the anesthesia group and whether or not the anesthesiologist is easily accessible during the case. Specifically, 51.7% of electrophysiologists reported the anesthesia group as consisting of physicians and certified registered nurse anesthetists, whereas anesthesiologists reported this structure only 36.5% of the time and more often reported having a group consisting of residents, fellows, attending physicians, and certified registered nurse anesthetists. Anesthesiologists were also more likely to report that their involvement improves patient satisfaction.
Timing of Anesthesia and EP Involvement
The 2 physician groups also had different perceptions regarding their presence during various aspects of the procedure. The survey also queried the perception of the presence of anesthesiologists and electrophysiologists at different times during the procedure. These results are summarized in Table 4. Anesthesiologists were more likely to report their presence at induction, time out, and emergence relative to electrophysiologists. Electrophysiologists were more likely to report their presence at both induction and emergence. Additionally, anesthesiologists were more likely to report that they were easily accessible during the case relative to electrophysiologists.
A large population of patients undergoing EP procedures is fragile, and many are also elderly with comorbidities and some degree of organ dysfunction. Due to the need for deep sedation and general anesthesia for these procedures in such patients, the involvement of an anesthesia service has increased and will most likely continue to increase in the future. To our knowledge, this is the first study to broadly characterize real-world perception of anesthesia involvement in EP procedures. In addition to cataloging these results, a number of opportunities are identified to improve collaboration and teamwork between the 2 medical disciplines.
This expansion of anesthesia into the realm of EP procedures has not come without challenges. Only roughly three-quarters of respondents reported having designated block time for the anesthesia service to care for patients undergoing EP procedures. Without designated block time, it is more difficult for EP services to schedule cases and makes properly staffing anesthesia services more difficult due to the uncertainty of day-to-day EP procedure volume.
The makeup of the anesthesia team also plays a vital role in these cases. Over half of the respondents reported all anesthesiologists at their institution care for patients undergoing these procedures, rather than a dedicated EP anesthesia group. Preventable errors are often due to teamwork failures,8 and it has been shown that limited interpersonal communication may be a component of errors and adverse events.9 These factors may be arguments for having a smaller group of anesthesiologists, who are familiar with these procedures and who are comfortable caring for these complicated patients.
This study also observed differences in the perception of the availability and presence of both anesthesiologists and electrophysiologists during procedures. Both specialties reported being available and present more frequently than the other specialty observed. Part of this may be lack of cognition, or the team’s collective knowledge of the roles, responsibilities, and capabilities of one another.10 By improving cognition, team performance may be enhanced and patient safety improved.
Another significant difference was noted in the reporting of the type of anesthetic utilized for the procedure. Again this may be due to a lack of cognition on the part of both parties and a lack of awareness of what the other specialty is doing. Perhaps educating electrophysiologists regarding the various definitions of anesthetic terms (MAC versus deep sedation or TIVA versus volatile), and also of the various anesthetics; and also the education of anesthesiologists regarding electrophysiological procedures would help to avoid this confusion.
While comprehensive, this study does have some limitations. The first being that it is a survey so there is bound to be a large amount of bias toward the specialty of the survey taker. This may explain why anesthesiologists reported a higher level of patient satisfaction with their involvement and also that they are more accessible and also present more frequently than their colleagues reported, and also why electrophysiologists reported their own presence at different periods in a case more frequently than anesthesiologists reported them there.
Another limitation of the survey is the lack of regional data. The survey was distributed anonymously in an attempt to increase response, thus no data were collected regarding the identity or geography of the practice.
This study is also limited by the way the questionnaire was developed. As the authors set out to document practice patterns, the questions were developed by anesthesiologists and electrocardiologists at a single institution to ascertain what they thought would be useful data. As such, validity cannot be assessed and the results should be interpreted as purely observational.
Finally, this study is limited by the low response rate of 8.24% of anesthesiologists and 13.6% of electrophysiologists. The study was sent out to the physician members of both societies with a letter explaining the purpose of the study. Follow-up to the survey was performed 1 month after the initial roll out with another letter and link to the survey. Despite this, the response rate was low for both specialties, so despite having hundreds of responses, the response may not be truly representative of both specialties.
This study helps to demonstrate that anesthesia is becoming more involved in caring for patients undergoing EP procedures; however, there are some discrepancies as to the perceptions that the specialties have toward one another. By working to improve cognition, teamwork and communication will also improve, which will inevitably lead to further increases in patient safety and overall quality of care.
Name: Eric W. Nelson, DO.
Contribution: This author helped design the study, analyze and interpret the data, draft the manuscript, and final approval of the manuscript.
Name: Erick M. Woltz, BS.
Contribution: This author helped design the study, analyze the data, and final approval of the manuscript.
Name: Bethany J. Wolf, PhD.
Contribution: This author helped analyze the data, write the manuscript, and served as the statistician.
Name: Michael R. Gold, MD, PhD.
Contribution: This author helped design the study, interpret the data, revise the draft, and final approval of the manuscript.
This manuscript was handled by: Roman M. Sniecinski, MD.
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