Clinical Sections

VA Medical Center

The VA Connecticut Anesthesiology Service is an integral part of the educational and academic mission of Yale University. VA Connecticut was established in June 1995 to create an integrated healthcare network for Connecticut's veterans. The West Haven campus represents the main acute care facility that is linked to ambulatory care facilities in Newington, Groton, Stamford, Waterbury, Winsted, and Windham. In addition to serving Connecticut veterans, we are part of a service network that spans the New England region. Patients from New York to Maine are referred to our facility for coronary artery bypass surgery and chronic pain management services.

Teaching Activities

Anesthesiology residents rotate to the West Haven Campus on a monthly basis. The VA Anesthesiology Service also provides educational programs for surgical and internal medicine subspecialty residents as well as medical/paramedical students. The Veteran population offers complex challenges (e.g. advanced age and multi-system disease) to the anesthesiologists. Additionally, the diverse surgical caseload includes cardiac, thoracic, and major vascular procedures. The VA attending staff provides the Yale resident a combined academic and technical tutorial, both in perioperative patient care and chronic pain management.

The Preoperative Evaluation Clinic has been expanded and continues to provide a rich educational environment as well as quality clinical care. In addition, the clinic has been successful in reducing day-of-surgery preoperative assessments and associated delays and cancellations.

Intraoperative teaching at the VA consists of one-on-one tutorials that have become a departmental favorite for Yale residents. Invasive monitoring techniques, including transesophageal echocardiography, are frequently employed during general surgical and open heart procedures. Regional anesthesia is often chosen to either supplement or supplant general anesthesia. Regional anesthesia teaching includes peripheral nerve blocks, plexus blockade (cervical/brachial/lumbar) and single-shot/continuous epidural and spinal techniques. Postoperative management of pain includes selective neural blockade and the use of traditional parenteral opiates or continuous epidural narcotic infusions.

The VA CT Pain Management Clinic provides a comprehensive approach to complex pain problems. We provide a broad array of nerve blocks and alternative treatment strategies including the integration of Primary Care, Pain Psychology, and Physical Therapy services. Our goal is to develop a more structured multidisciplinary program including a "Pain Rehabilitation Program", which is managed by Dr. Michael J. Robbins, Director, Pain Management Services. The Pain Service provides didactic teaching and a "hands on approach" in which residents can fulfill their ASA requirements and gain experience as consultants in pain management.

The VA CT Anesthesiology Service conducts weekly literature based conferences and Problem Based Learning Discussions of controversial anesthetic topics on Friday mornings. The final Friday of each month is dedicated to morbidity and mortality conferences and quality improvement activities.

Research Activites

The Veterans Administration is committed to the advancement of medical care through basic science and clinical research. As part of this commitment, the Section's research activities focus on the development of new technologies to improve patient safety as well as reduce the cost of perioperative care. Current projects include:

Intraoperative Transesophageal Echocardiography
Albert C. Perrino, MD, Pamela E. Gray, M.D.  

Transesophageal echocardiography offers a less invasive method for cardiovascular monitoring during general anesthesia. The utility and accuracy of a variety of echocardiographic measures of left ventricular performance (e.g., pressure area relationships and automated border detection) are under evaluation. Doppler methods to monitor cardiac output in the surgical patient are also being explored.

Continuous Fick Cardiac Output Monitoring
Albert C. Perrino, Jr., M.D., Wilfred E. Lewis, M.D.  

In conjunction with the Novametrics Corporation we are exploring the use of a Fick technique to calculate cardiac output.

Cardiac Output Monitoring During Inotropic Stimulation
Albert C. Perrino,Jr., M.D., Wilfred E. Lewis, M.D.  

Transesophageal Echocardiography, thermodilution, the Fick technique (in conjunction with Novametrics Corporation), and descending aortic flow monitoring (in conjunction with Arrow International) are currently being evaluated in the setting of intraoperative inotropic stimulation.

These research efforts are focused on the effects of various drugs (especially adenosine) on pathologic cardiac processes. The effects of adenosine on cardiac fibroblast functions that are key to the development of reactive fibrosis and cardiac remodeling are of particular interest. The ultimate goal of these studies is to increase our knowledge of the role of cardiac fibroblasts in these disease processes. Such knowledge may ultimately lead to better therapeutic interventions in those patients with chronic hypertensive heart disease or suffering from post-infarct myocardial dysfunction. Molecular biologic techniques on cultured cardiac cells are used to examine intracellular mechanisms of action.

Lidocaine's Effects on Lung Fibroblasts
S Akhtar, M Eghbali-Webb  

Based on the evidence that local anesthetic have anti-inflammatory properties, we are investigating the effects of local anesthetics on lung fibroblasts. We have demonstrated that lidocaine can inhibit growth factor -induced DNA synthesis and are now in the process of elucidating the mechanism.

Effects of by hypoxia in pulmonary cells
S Akhtar, P Ray  

We attempted to ivestigate the differential effect of hypoxia on the various pulmonary cells and the mechanism underlying the differential effects of hypoxia.

A Phase III, Randomized, Controlled, Open-label, Multi-Center, Parallel Group Study Designed to Evaluate the Safety and Efficacy of Poly SFH-P Injection in the Total Elimination of Allogenic Red Cell Transfusion.
A Perrino, Jr., M.D., M Hartmannsgruber, M.D., P Gray, M.D., S Akhtar, MD  

Co-investigators in a Phase III trail to determine the efficacy of synthetic hemoglobin in patients undergoing infra-renal AAA repair.

Correlation of a Department of Veterans Affairs National Inpatient Pharmacy database with the medical record in patients undergoing surgery at VA CT Healthcare System, West Haven
S Akhtar, A Perrino, M London

Develop an in vitro model to study the effects of cardiac surgery on human endothelial cells
S Akhtar, M Sadeghi (Medicine), G Tellides (Surgery), in collaboration with Depts of Surgery and Internal Medicine  

We are attempting to develop an in vitro model to study multiple gene activation in endothelial cells in response to cardiopulmonary bypass. This model will help is study in future the effects of specific therapeutic strategies and possible no relation with clinical outcomes.

Effects of statins on inflammatory response and endothelial cell activation in patients who undergo cardiopulmonary bypass for revascularization (in collaboration with Depts of Surgery and Internal Medicine)
S Akhtar, M Sadeghi (Medicine), G Tellides (Surgery)  

Statins have anti-inflammatory properties. This project attempts to study the effects of statins in modulating inflammatory response to cardiopulmonary bypass.