Multispecialty Anesthesiology

Overview

The Division of Multispecialty Anesthesiology (MSA) is the largest clinical department within the Anesthesiology Department. We provide a wide range of professional services and staffing for more than 75 anesthetizing sites, including:

• Out-of-OR locations in interventional radiology, MRI, CT, Gamma Knife^®, electrophysiology laboratory, bronchoscopy suites, GI endoscopy suites, outpatient surgery and ophthalmologic surgery
• 52 non-cardiac operating rooms at Cleveland Clinic Main Campus
• The Special Delivery Unit at Cleveland Clinic Main Campus

Our clinical expertise spans:

• Leading-edge regional anesthesia techniques (e.g., catheter techniques and TAP blocks)
• Anesthesia for high-acuity surgery (e.g., major neurological and vascular surgery)
• Perioperative services for one of the country’s busiest liver and intestinal transplantation programs
• Anesthesia for ENT, general and colorectal surgery, as well as bariatric, urological, orthopaedic, obstetric and gynecological procedures

Our Vision

Multispecialty Anesthesiology is the largest division in the Department of Anesthesiology at Cleveland Clinic Main Campus. Our division consists of 70+ anesthesiologists, 100+ certified nurse anesthetists, student nurse anesthetists, residents, fellows, technicians, directors and administrative assistants. Together, we’re a team dedicated to providing comprehensive care and outcomes.

Vision

We strive to provide compassionate, high-quality and outcome-oriented care, foster innovative research and educate tomorrow’s leaders in anesthesia and perioperative medicine.

Mission

• Provide the highest quality, compassionate care in a cost-effective manner.
• Improve patient safety in the perioperative period through research and innovation.
• Cultivate excellence through collegiality and teamwork.
• Train outstanding residents, fellows and SRNAs.
• Pursue, nurture and develop the right team members.

Values

Superb patient care is our highest priority, and we recognize that research and education are essential to achieving best practices. Our employees are our most precious resource, and we create an environment of respect, integrity and professionalism so that all can excel. We acknowledge that everyone has unique interests, strengths and abilities. We work to foster their professional development by helping them achieve excellence in clinical care, research and teaching.

The Division of Multispecialty Anesthesiology performs about 50,000 anesthetics per year, of which 40% occur in procedural areas outside the main operating room pavilion. Although our faculty is qualified to provide care for all patients, the culture of the department is to pair subspecialty training and the interests of our personnel with specific subspecialty patient populations. Thus, our subspecialty sections work more closely with our surgical colleagues to improve patient care and outcomes.

The foundation of resident education in the Department of Anesthesiology is also found in MSA. Our faculty not only prepares the trainees for their educational journey in the subspecialty areas but also organizes a significant portion of the didactic lectures, problem-based learning discussions, journal clubs, workshops and simulations. In the same context, the School of Nurse Anesthesia has its base and the majority of training for future Certified Nurse Anesthetists within MSA. A noteworthy number of MSA staff members have academic appointments within Cleveland Clinic’s Lerner College of Medicine; some are also involved in the training of medical students.

Many staff members are involved in clinical research. The division publishes approximately 70 papers per year, and at any given point in time performs, or is involved in, about 30 studies. Thousands of patients are part of these research studies. Our goal is to test perioperative interventions and improve intermediate and long-term patient outcomes. Academic and professional development are two of the most important goals of Multispecialty Anesthesiology.

Leadership

Multi Specialty Anesthesiology Physician Leadership

• Maged Argalious, MD - MSc, MBA, MEd, FASE, FASA - Chair

Section Heads

• John Seif, MD, MBA – Anesthesia for Orthopaedic Surgery
• Andrew Zura, MD – Anesthesia for ENT Surgery
• Jacek Cywinski, MD – Anesthesia for Liver and Multivisceral Transplantation
• Allen Keebler, DO – Anesthesia for General and Colorectal Surgery
• Mauricio Perilla, MD – Anesthesia for Urologic Surgery
• Nour El Hage Chehade, MD – Anesthesia for Obstetric and Gynecologic Surgery
• Dawn Schell, MD – Anesthesia for Ophthalmologic Surgery
• Omar Omar, MD – Anesthesia for Interventional Radiology
• Jessica Lovich-Sapola, MD and Sam Gumbert, MD – Anesthesia for Trauma Services

Medical Directors

• Wael Ali Sakr Esa, MD, PhD, MBA – Acute Pain/Regional Anesthesia
• Samuel Irefin, MD – Anesthesia for Electrophysiologic Procedures (EPS)
• Ursula Galway, MD – Postoperative Anesthesia Care Unit and Same Day Surgery
• Magdelaine Deeby, MD – Anesthesia for Endoscopy (Q3)
• Mariel Manlapaz, MD, MEd – Anesthesia for Neurological Services
• Basem Abdelmalak, MD – Anesthesia for Bronchoscopic Procedures
• Ehab Farag, MD, FRCA – Director of Clinical Research

Sections

Ambulatory Cole Eye

The Ambulatory Anesthesia Section provides anesthetic services at the Cole Eye Institute. Our goal is to give ophthalmology patients an efficient ambulatory anesthetic experience with minimal side effects.

Ambulatory anesthesia requires a unique set of focused skills. We take great pride in applying our skills and experience to serve the needs of patients by providing excellent, sophisticated ambulatory anesthesia. Additionally, the close proximity of our unit to the resources of Cleveland Clinic Main Campus allows us to care for complex medical and surgical encounters that might not normally be cared for in free-standing ambulatory surgery centers. We’re able to coordinate with other services to expedite care for patients with serious and complex medical conditions, including LVAD pumps, end-stage renal disease and complex cardiomyopathies.

Our trainees receive exposure to ambulatory anesthesia and learn the skills of rapid turnover and efficient evaluation/treatment that are required to be successful in a busy ambulatory surgery center. Accordingly, our staff are very active in the Society for Ambulatory Anesthesia (SAMBA) and are passionate about teaching the skills required to provide excellent ambulatory anesthesia care.

The Adult Medical Emergency Team (AMET)

AMET is a hospital-wide rapid response team that provides prompt medical assistance to patients, visitors and caregivers. The purpose of AMET is to intervene early in a situation to lessen the incidence of decompensation. AMET can be activated by anyone, including patients and family members. AMET consists of an LIP, a registered nurse and a respiratory therapist. The team carries equipment and medications enabling it to definitively respond to nearly any medical emergency anywhere. AMET responds to situations that include, but are not limited to, cardiopulmonary arrest, chest pain, dysrhythmia, respiratory difficulties, altered mental status and hypotension. One of the goals of AMET is to respond to a call for assistance within 10 minutes. AMET doesn’t take over care of the patient, but assists when immediate intervention is necessary, such as airway management and blood pressure support. This extensive AMET infrastructure is a major investment by Cleveland Clinic, providing patients and caregivers with the highest quality of care.

Anesthesia for Colorectal Surgery

Our anesthesia team from the Colorectal Section, led by experienced anesthesiologists, works with the nationally and internationally recognized surgeons from Cleveland Clinic’s Colorectal Surgery Department. We work closely with our surgical colleagues to ensure that our patients are optimally prepared for surgery. Together, we provide anesthesia and post-anesthesia care for patients with a wide range of diseases of the colon and rectum, including inflammatory bowel diseases, cancers, functional bowel disorders, pelvic floor dysfunctions and anorectal disorders. Every day, we take care of the patients who have their surgeries done in a conventional way or with the use of laparoscopic/robotic techniques. Our section participates in the education of anesthesia residents and student nurse anesthetists. In close collaboration with the Anesthesia Outcome Research Department, we work on research and practice-improvement projects to better care for our patients.

Non-operating room anesthesia

Endoscopy, Electrophysiology and MRI/CT/Radiology

The Non-Operating Room Anesthesia (NORA) Section at Cleveland Clinic includes the administration of anesthesia for adults outside the traditional operating room setting in the GI endoscopy suites [Q3], Electrophysiology Labs, MRI and CT scan, and Interventional Radiology. NORA was born out of an increasing demand to provide safe and efficient anesthesia services at sites outside the main operating suites. This increase in the number of cases has resulted from improved technology, a growing number of very sick patients who are often not good surgical candidates, and financial constraints while still maintaining patient and provider satisfaction. The increased complexity of cases at these sites has dictated the need for deeper levels of sedation, general anesthesia with and without airway instrumentation, and hemodynamic monitoring in non-OR settings. This is reflected in the exponential increase in the NORA cases at Cleveland Clinic. Most of these locations have been upgraded and revamped to meet the increasing demand for anesthesia services. In addition, all of these locations offer an open-access and open-scheduling policy. The anesthesiologists at these locations are charged with the preoperative, intraoperative and postoperative management. Protocols and strict selection criteria have been developed to facilitate a good match between the place, patient, procedure and the anesthesia planned.

We have scheduled block times for adult elective and inpatient MRIs four days a week. Patients can obtain all their periprocedural care within the MRI suite. Pre-anesthesia and post-anesthesia care are given by PACU-trained nurses. Two fully equipped induction rooms have been designed to enable the induction of anesthesia in a magnet-free space. We often provide anesthesia for patients with claustrophobia, chronic pain and other reasons that make completion of imaging difficult. Within the same MRI suite, Cleveland Clinic Main Campus has an Intraoperative MRI System (IMRIS). We can provide anesthesia for awake or asleep craniotomies in fully equipped pre-anesthesia, induction and operating rooms.

Here we have six Interventional Radiology (IR) procedural rooms fully equipped for invasive and noninvasive anesthesia care, four rooms for body IR and two rooms for neurointerventional procedures. Like MRI, we have scheduled block times for interventional radiology four days per week. Anesthesia consultation is often needed due to requirements for procedures like transjugular intrahepatic portosystemic shunt (TIPS), non-dilated percutaneous transhepatic cholangiogram (PTHC), sclerotherapy, aneurysm, arteriovenous malformation (AVM), tumor embolization and more. This is also true for patient comorbidities, like chronic pain, obstructive sleep apnea, stroke and others. To date, IR suites have the capacity for pre-anesthesia care, and Phase II (where patients are awake or easily arousable, hemodynamically stable, on room air with adequate oxygen saturation, and minimal pain and nausea symptoms) post-anesthesia care. Coming soon is the addition of Phase I (where patients can be somnolent, hemodynamically unstable, require supplemental oxygen/airway adjuncts, and pain and nausea interventions) post-anesthesia care unit.

Nonsurgical tumor treatment by percutaneous tumor ablation is performed by our IR and CT radiologists. The CT scanners at Cleveland Clinic Main Campus provide comprehensive procedural and anesthetic care for non-operating room cases. Pre-anesthesia care and Phase II PACU care are also available in our CT suites.

Anesthesia for Ear, Nose and Throat Surgery (ENT)

The ENT Anesthesia Section presents many challenges for the anesthesiologist, requiring adjustment to both patient and surgical needs. Some of the challenges include:

• Evaluating the patient’s airway, which can be distorted due to trauma, tumors, complex anatomy and infection
• Securing the airway using a multitude of techniques and equipment
• Sharing the patient’s airway with the surgeon
• Deciding on a plan for extubation at the end of the surgery

The section covers a variety of surgical procedures, which include thyroidectomy and parathyroidectomy, tonsillectomies and adenoidectomies, tympanomastoidectomy and cochlear implant, laser surgery of the larynx and trachea. It also covers complex head and neck cancers with reconstruction, oral and facial surgeries, laryngectomies, tracheostomies and endoscopic sinus surgeries.

The bronchoscopy suite is designed to provide an ideal environment for patient care and to accommodate our increased diagnostic and therapeutic bronchoscopy volumes. World-renowned for its expertise in bronchoscopy, Cleveland Clinic’s Advanced Diagnostic and Interventional Bronchoscopy Program leads the way in developing new diagnostic and therapeutic bronchoscopy techniques. In collaboration with the pulmonologists, our anesthesiologists co-manage patients with airway complications from lung transplantation, tracheostomy (tracheal tubes), foreign objects in the airway, aspirations, lung and metastatic cancers, inflammatory airway diseases and benign airway diseases.

Anesthesia for Liver and Multivisceral Transplantation

The Section of Anesthesia for Liver and Multivisceral Transplantation provides specialized care for solid organ abdominal transplantation, including liver, small bowel, multivisceral and combined liver-kidney recipients. Both adult and pediatric liver and bowel transplant patients are cared for by members of our team, as well as living donor liver transplant patients. Patients undergoing elective hepatobiliary (HPB) surgery are scheduled with the liver transplant anesthesiology service, as well. Common procedures for HPB patients include resection of hepatocellular carcinoma and resection of hepatic metastases of colon cancer. Members of our team are subspecialty-trained and highly experienced in providing anesthesia care for a high-acuity patient population. We use highly advanced monitoring (including but not limited to transesophageal echocardiography and thromboelastography) and protocols to provide exceptional care. Our team evaluates transplant candidates in the Preoperative Liver Transplant Clinic and participates in the Multidisciplinary Selection Committee, providing truly comprehensive perioperative care.

Anesthesia for General Surgery

In general surgery, all physicians and nurses work together closely to provide safe anesthesia care for our patients, This includes, but is not limited to, anesthesia for abdominal surgery, including liver resections, gallbladder removal, appendix removal and pancreatic surgery. Also included is anesthesia for surgery of the thyroid, parathyroid and adrenal glands. We specialize in anesthesia for multiple types of hernia repairs, too. With the addition of the acute care surgery service, we also provide anesthesia care for general surgeons who specialize in emergent and urgent surgical needs of our patients. We also participate in resident education and research. We think you will find our anesthesiologists, residents, CRNAs and SRNAs to be top-notch, and we look forward to providing you with top-tier care.

Anesthesia for Neurosurgery

The Neuroanesthesia Section is one of the largest within the Department of General Anesthesiology. Members of the section are subspecialty-trained and highly experienced in providing anesthesia care for patients with neurological disabilities, including patients undergoing a neurosurgical procedure. This section covers anesthesiology services to all neurosurgical, spine and neurointerventional operating rooms. The highly subspecialized and cutting-edge neurosurgical procedures performed by Cleveland Clinic’s skilled neurosurgical and spine surgery team are combined with the exceptional anesthetic care within the section, resulting in an outstanding patient outcome. Most of these surgical procedures have unique anesthetic considerations requiring highly skilled and knowledgeable faculty. The section has initiated the Enhanced Recovery After Surgery (ERAS) pathway to further improve our patients’ outcomes. Many faculty members in the Neuroanesthesia Section are authors and editors of textbooks and research publications in this subspecialty.

Anesthesia for Obstetric and Gynecologic Surgery

Our Anesthesia Section for Women’s Health (Obstetrics and Gynecology) cares for our patients at all stages of life. We staff the Special Delivery Unit, an obstetric unit designed to provide multidisciplinary care to mothers with complex medical conditions (such as cardiac conditions, Marfan’s syndrome and brain tumors), or those carrying infants who would need surgical intervention shortly after birth. We have a close working relationship with the maternal-fetal medicine obstetricians and neonatology teams to create an individualized care plan for each patient. We participate in the peripartum management of maternal medical issues, collaborating with the OB hospitalist. We use a neuraxial technique for analgesia/anesthesia in over 90% of our obstetric deliveries.

Our gynecology operating rooms include surgeries for endometriosis, perimenopausal bleeding and known malignancies. We will increasingly see more oncology surgery on this service. We have been using Enhanced Recovery After Surgery (ERAS) protocols to help our patients feel better sooner. An experimental protocol for uterine transplantation has just started recruiting patients at Cleveland Clinic. These cases will involve complex multidisciplinary care. Our Women’s Health anesthesia care team at Cleveland Clinic employs a broad skill set to provide care for our patients.

Anesthesia for Orthopaedic Surgery

The Orthopaedic Anesthesia Section is one of the busiest within the Department of General Anesthesiology. Our faculty includes highly experienced anesthesiologists who provide anesthesia care using advanced techniques tailored to the individual needs of our patients and the acuity of their illness. We provide anesthesia for all orthopaedic cases, ranging from the simplest to the most complex procedures, multidisciplinary resections and high-risk cases. Our team includes trained specialists in acute pain management. They perform various nerve blocks and utilize multimodal pain management strategies for our patients during their hospital stays. We have also initiated the Enhanced Recovery After Surgery (ERAS) pathway to further improve patient outcomes.

We continuously strive to achieve outstanding patient outcomes for all orthopaedic procedures by combining expert diagnostic methods with unparalleled, personalized anesthesia care. Many of the faculty members in the Orthopaedic Anesthesia Section are recognized authors, co-authors and textbook editors with active contributions to research publications in this subspecialty.

Anesthesia for Urologic Surgery

The Anesthesia for Urology Section supports Cleveland Clinic’s Glickman Urological and Kidney Institute, recognized worldwide for its excellence in patient care, teaching and research. Our section focuses on the perioperative management of patients who require anesthesia for urology procedures, including kidney transplants, robotic-assisted and laparoscopic procedures, urologic endoscopic procedures and complex urological reconstructive procedures. Our team is nationally recognized for excellence in education, research, and publications in national and international journals, as well as book chapters related to anesthesia and urology surgery.

Pre-Anesthesia Consultation Clinics (PACC and PACE)

With about 65,000 patients per year, the combined preoperative clinic systems (Main Campus Preoperative Anesthesia Consultation and Evaluation Clinic, or PACE, and the Pre-Anesthesia Consultation Clinic, or PACC) serve several roles. Their primary function is to ensure that patients scheduled for surgery have a thorough and appropriate preoperative evaluation to ensure the safest anesthesia and surgery possible. In collaboration with the Internal Medicine Preoperative Assessment, Consultant and Treatment (IMPACT) clinic, our team of physicians, advanced practice providers and nurse specialists work to optimize patients’ medical conditions and provide education about their upcoming surgeries. If postoperative pain is likely to be an issue, we work with the surgeon’s office to consult with the Acute Pain Management Service. PACE also works with the Department of Outcomes Research to provide patients with the opportunity to take part in clinical research studies.

Additionally, the PACE clinic has instituted several initiatives to promote patient health beyond the operating room. We work with Cleveland Clinic’s Sleep Center to screen patients for obstructive sleep apnea and refer them for further testing and treatment. We also offer referrals and support to help patients quit smoking. Most recently, we have collaborated with our allergists to offer penicillin allergy testing for patients who are documented to have an allergy but are unsure of the reaction.

Cleveland Clinic Anesthesiology resident physicians also rotate through the PACE clinic to enhance their knowledge of perioperative medicine.

Post-Anesthesia Care Unit (PACU)

The Post-Anesthesia Care Unit (PACU) is the postoperative care unit for general anesthesia at Cleveland Clinic. This is where patients go immediately after surgery, and it encompasses every surgical service. The PACU is staffed with specialized nurses trained in postoperative care, respiratory therapists and resident physicians under the medical direction of the General Anesthesiology Department staff. They work collaboratively to ensure that postoperative patients receive top-tier care and meet PACU discharge criteria before they transition to the regular nursing floor.

Clinical Research

Led by the director of research, the department publishes approximately 70 papers per year and, at any given time, performs or is involved in about 30 clinical studies. Thousands of patients are part of these research studies. Our goal is to test perioperative interventions to improve intermediate and long-term patient outcomes. With a focus on academic development, the department encourages all members to actively participate in research studies. Assistance with protocol development, manuscript editing and overall research is provided.

Education

Departmental staff members provide the majority of teaching for the institute’s core program of residents and student nurse anesthetists. Fellowships are offered in neuroanesthesia, liver transplantation and non-operating room anesthesia (NORA) — a new, innovative and unique program.

The large number and complexity of operative procedures performed at Cleveland Clinic provide our residents with abundant experience in clinical anesthesia and the opportunity to develop sub-specialization skills. Basic and clinical research opportunities further prepare residents to deliver top-quality care to patients.

We encourage you to browse our education site to learn more about our program.