Recipes, Innovation, and Convention

Cardiac surgery and anesthesia at the VA follow a very protocolized treatment regimen. The lines, the drips, the surgical approach, and the post-operative management are standardized almost to recipes. And we don't manage patients the same way as they are managed elsewhere. We keep our patients deeply sedated the first night in the ICU where other institutions may aggressively wean sedation and try to extubate. We use extremely high doses of benzodiazepines and opiates, even up to 20mg of midazolam and 4mg of fentanyl. Why do we do this and does it make sense?

It's easy to criticize this management as old and outdated. After all, this is how cardiac anesthesia was described a decade ago. Only more recently have other hospitals pressed to extubate early, decrease ICU stay, and shorten length of time. But the VA has stuck with what's worked for it. Many reasons can be offered; perhaps our vets have a high prevalence of PTSD and trying to wake up and extubate at night leads to delirium or perhaps the VA is less cost-conscious without economic pressures to get patients out of the ICU as fast as possible. But I think the most important reason is culture. Our surgeons, nurses, and anesthesiologists have come to expect cardiac surgery courses to follow a certain arc and barring reason to change it, keeping the status quo is working with the tried and true. Compared to other things in medicine, cardiac surgery is an enterprise that benefits from standardization. While diagnostic mysteries or chronic care have uncertainties, there should be minimal uncertainty in an elective surgery. Cardiac surgery and anesthesia can be performed in many different ways, but the key is for everyone to agree on one standard process and optimizing it as best as possible.