ABA Cardiac Anesth common mistakes
ABA Cardiac Anesth · Understand the traps and how to avoid them.
Accepts the pulmonary artery catheter's displayed wedge pressure as left ventricular preload without inspecting the waveform for a true wedged position, balloon inflation timing, and end-expiratory measurement.
The monitor presents a single authoritative number, so a partially wedged or overwedged tracing is indistinguishable at a glance; candidates trained to trend numbers rather than interrogate waveforms fall into this under time pressure.
What to do instead
Before acting on a wedge pressure, confirm the tracing transitions from pulmonary artery to wedge with balloon inflation, measure at end-expiration, and corroborate with TEE findings and the clinical picture; if the value contradicts the physiology, distrust the value, not the physiology.
Selects vasoactive drugs by habit-for example giving phenylephrine for every episode of hypotension-rather than linking the drug to the dominant pathophysiology (vasoplegia, depressed contractility, right ventricular failure, dynamic LVOT obstruction).
Pattern recognition from familiar operating room scenarios replaces mechanistic reasoning, and phenylephrine is the reflex first syringe in many cardiac rooms, so the default answer feels safe.
What to do instead
Practice a short bedside algorithm that names the problem first (SVR, contractility, RV afterload, obstruction, preload), then chooses the drug class that addresses it, and rehearse cases in which phenylephrine would be harmful, such as RV failure or a fixed cardiac output state.
Answers cardiopulmonary bypass questions by reciting the sequence of conduct-of-bypass steps (heparinize, cannulate, initiate, cool, cross-clamp, cardioplegia, rewarm, wean) without connecting each step to its physiologic consequence.
Protocol lists are easy to memorize and feel complete, so candidates stop at the checklist and never build the causal chain that examiners are actually testing.
What to do instead
For each bypass step, write one sentence on the consequence (hemodilution and oxygen-carrying capacity, inflammatory activation, embolic load, dilutional and consumptive coagulopathy, reperfusion injury) and practice explaining a bypass event entirely in terms of mechanism and management.
Stratifies perioperative risk using left ventricular ejection fraction alone, ignoring right ventricular function, severity and hemodynamic behavior of valvular lesions, pulmonary hypertension, frailty, and the urgency of surgery.
Ejection fraction is the number most reliably reported and most heavily emphasized in training, so it becomes a proxy for the whole risk assessment and other modifiers are never elicited.
What to do instead
Use a structured preoperative framework that explicitly lists ventricular function (both sides), valve lesion severity and symptom class, pulmonary pressures, coronary anatomy and stent status, comorbidities and frailty, and procedural urgency, and practice stating how each item changes management.
Treats early postoperative hypotension in the cardiac surgical patient with empirical fluid boluses before excluding tamponade, active bleeding, graft or valve dysfunction, and vasoplegia.
Hypotension after bypass is frequently hypovolemic and fluid is immediately available, so the first response is reflexive; tamponade and graft failure are uncommon enough that they are not considered until late.
What to do instead
Run a fixed sequence for post-bypass hypotension: check the chest tubes and drain output, confirm the waveform and filling pressures, perform a focused TEE, review hemoglobin, coagulation, and electrolytes, and only then give a defined fluid challenge with a reassessment endpoint.
Applies adult hemodynamic targets and drug dosing to neonates and infants with congenital heart disease, for example assuming supplemental oxygen is always beneficial in a patient with a balanced single-ventricle circulation.
Adult cardiac training dominates the mental model, and oxygen is treated as universally good, so the shunt physiology that makes oxygen a pulmonary vasodilator and systemic-to-pulmonary flow regulator is not applied.
What to do instead
For each congenital lesion, state the shunt direction, the balance of pulmonary and systemic blood flow, and the intended target saturation before choosing ventilation, oxygen, or vasoactive therapy; rehearse single-ventricle, Tetralogy of Fallot, and left-sided obstructive lesion scenarios separately.
Answers patient safety and quality improvement questions with generic commitments to 'speak up' or 'communicate better' instead of naming concrete mechanisms, tools, and metrics.
Safety content is perceived as soft and self-evident, so candidates do not study it the way they study physiology, and they have no specific instrument, bundle, or database at hand.
What to do instead
Memorize a small set of named tools and how each is measured-surgical safety checklist, structured handoff, simulation and crisis resource management training, Morbidity and Mortality conference, registry benchmarking, and process measures such as antibiotic timing or reintubation rates-and practice attaching one to each scenario.
Performs an incomplete intraoperative TEE examination, routinely omitting the midesophageal ascending aortic views, the pulmonary vein and left atrial appendage views, and the deep transgastric views when asked to evaluate a structure.
Most calls in the cardiac room are about ventricular function and valves, so the same few views are obtained repeatedly and the full protocol is never rehearsed as a complete sequence.
What to do instead
Practice the complete 28-view examination as a fixed order with a verbal label for each view, and when a structure is interrogated, state explicitly which views and which Doppler modalities are required to answer the question.
Confuses right and left ventricular afterload physiology, for example giving phenylephrine to a patient in acute right ventricular failure or using systemic vasodilators that drop systemic pressure in a patient with fixed pulmonary hypertension.
The two ventricles are taught together, and the inverse relationship between pulmonary vascular resistance and systemic vascular resistance is easy to state but hard to apply when a patient is desaturating or hypotensive.
What to do instead
Draw the RV–pulmonary circulation and LV–systemic circulation as separate circuits before answering, identify which resistance is the problem, and select therapy that lowers the correct afterload while preserving coronary perfusion pressure; include oxygen and pulmonary vasodilators as specific RV afterload reducers.
Fails to systematically assess indwelling devices and antithrombotic therapy before cardiac surgery or catheterization-leaving an ICD active, missing an LVAD's fixed-speed physiology, overlooking recent antiplatelet or anticoagulant exposure, or not planning perioperative bridging.
Attention is drawn to the primary cardiac lesion and the operative plan, and device and medication details are buried in the chart, so they are addressed only if someone happens to mention them.
What to do instead
Use a fixed preoperative checklist that covers pacemaker and ICD type and planned reprogramming, LVAD settings and anticoagulation, recent stent placement and antiplatelet therapy, anticoagulant stop and bridge plan, and renal and hematologic status, then state how each finding changes the anesthetic plan.