 Thank you to all the organizers of this meeting, including Kathleen Kibler. I'm very happy to be speaking to you today about the Triangle of Trust. I have no disclosures except I do have to disclose that I am a huge fan of high performance teams and high performance communication and those that use all their skill and grit to do their best to achieve great patient outcomes. At the end of a long week I sometimes like to sit back and reflect on the cases we've done and the things that went well or didn't go as well as they could have and kind of just absorb that. A few years ago I was thinking about a particular week and I thought to myself you know I really love doing this job and I was thinking about the things that made me love that job and I had this this intense appreciation for our team and how everyone comes together to do their best every day and the group the team comprised of the surgeon anesthesiologist and perfusionist has this intense connection and collaboration and great communication that really makes the job fun and it really makes our outcomes better. We take great care of patients when we collaborate intensely like that. The intraoperative contributors to outcomes and congenital heart surgery include three elements a great operation precise anesthetic and hemodynamic management and the conduct and execution of cardiopulmonary bypass that's deliberate and physiologic. The team that brings that to you includes the surgeon the anesthesiologist and the perfusionist and they make up what I like to call the triangle of trust. No one person can manage the surgery the anesthesia and hemodynamic management in the perfusion alone. We must rely on and support one another to achieve the aspired outcomes. Today we're going to explore three elements of the triangle of trust they include collaboration communication the response to the unexpected and then we'll look at some examples of the triangle in action. Collaboration involves the whole team working together with a common purpose and that involves respect shared standards and trust. These are this is respect for individuals and their contribution to the effort respect for the team and the mission this is critical. We also hold shared standards for all aspects of intraoperative care that includes bypass management blood product management basic anesthetic management and operative conduct and everybody in the team has to know how we do it and they have to live it and they have to breathe it. The third thing is trust and that's really really important this has to be part of the culture it's intentional and everyone needs to know that everyone is there to provide excellent care for the patient and also to support the team. Planning is essential and it involves a whole group before a case we need to know what the operative plan is what the cannulation sites and cannula selection will be what the anticipated depth of cooling whether we'll need special bypass bi-pass techniques like um integrate cerebral perfusion deep hypothermic circulatory arrest blood product management strategies and whether we're going to plan for an early or delayed extubation. Now for unusual or complex cases this kind of planning may take place weeks in advance we need to make sure that everybody on the team knows what the techniques we're going to use and make sure that that seems like a good idea and this kind of preparation allows high performance in a new situation. Some examples of these kind of complex cases include an 800 gram baby undergoing an arterial switch operation a five kilo baby undergoing an avisceptal defect repair without the use of any blood products or a patient with hemophilia a undergoing an arch augmentation. During cardiopulmonary bypass is when a lot of the collaboration happens. While we're on bypass the perfusionists and the anesthesiologists are working together to optimize everything optimize flow optimize pressure optimize the nears optimize the hematocrit make sure that everything is going smoothly and if things don't look so good we try to adjust them and and make things look good. If we need to involve the surgeon once appropriate steps are taken we can do that and maybe we'll adjust things after that. As one perfusionist I know is fond of saying I like to make it that the certain so the surgeon forgets that we're on bypass. Communication is very important to high performance teams and this is no exception communication can be disorganized and and disorderly or it can be concise and perfect. We want to make communication in the operating room less like a dog playing telephone and more like a fighter pilot flying in formation. Verbal communication should be clear loud scripted so that it's reproducible among teams and a read back should be employed the read back helps to confirm the accuracy and the receipt of the information. Communication is a lot easier in an environment that is quiet controlled organized and preferably there should be a line of sight between team members. The trust comes up again people need to have the psychological safety to be able to speak up they need to be comfortable to be able to raise concerns and that's something that has to be fostered and grown. Now another place that the Triangle of Trust really helps is in the response to the unexpected. This is the box and I like to talk a lot about the box and for me the box includes three things it includes a surgical field the physiologic monitors and the bypass monitors. When you know what's supposed to be in the box you can recognize when things start to deviate from the normal when you can recognize the things that deviate you can bring them back into the box before a situation gets to be unrecoverable or harm occurs. Some urgent intraoperative situations in which the Triangle of Trust and working well within this team helps to improve outcomes include a patient with Williams syndrome or a rest after induction of anesthesia, cardiac injury during sternotomy or a thrombose systemic depulmonary artery shunt in the pre-bypass period. These are all situations in which excellent collaboration, communication and response optimize performance and patient outcome. Emergency cases are also handled a lot better within this framework. When the routine is indeed routine it's easier to execute on the fly and that helps also to improve outcomes. Regular debriefings after cases or stressful situations and regular meetings are also critical this helps to that we can provide feedback and receive feedback we can grow we can improve and also the regular meetings helped so that we can disseminate information about new ideas medications equipments practice changes so that everybody is aware and there are no surprises. Now is the triangle in action the first case is a story about planning and execution it's about a nine-year-old child who is presenting for a cardiac operation on cardiopulmonary bypass and this patient had sickle cell trait. Now we know that cardiac surgery and cardiopulmonary bypass expose patients to precipitating factors for sickling but yet there's no stance that everyone believes in about how to treat them some people do nothing nothing unusual some people do a partial exchange transfusion to decrease the amount of sickle cell hemoglobin and some people do a full exchange. Our programmatic stance is to do a full exchange when initiating cardiopulmonary bypass to avoid sickling at all and the possible catastrophic outcomes. So we started planning days before the case we have a planning tool where we make calculations based on the percent hemoglobin s pre-operatively what the hematocrit is and what the hematocrit is that we want on bypass we figured out what the prime was going to be we ordered blood we talked about dosing and redosing medications including anesthetic managed anesthetic medications anti-fibrinolytics and antibiotics and we also discussed the monitoring of hemoglobin s and coagulation intra-operatively. Now when we started the the exchange we did that as we were going on to bypass we exsanguinated the patient into this bucket and then started the flow and started to flow and started the flow and then we were on full bypass we took out about two and a half liters of blood from the patient and then replaced it with our prime. When you look at the lab values you would see that we started with the hemoglobin s of 39 point something and we ended with one that was about 2% and so that is a very successful exchange transfusion. When you listen to this video though the cool thing is you can hear Blake talking and you hear communication that is concise that is informative that is clear and that is all you can hear on the video. And there's no drama it's excellent communication and it was a successful transfer exchange transfusion. This is not something we do every day but it really seemed like it was. Another opportunity to put the triangle into action is during the titration of anigrade cerebral perfusion. We use anigrade cerebral perfusion to perfuse the brain through an arterial cannula sewn onto a shunt onto either the retinominid or the carotid artery and so the brain is able to be perfused during arch augmentation like during a Norwood operation or during repair of a hypoplastic aorta. During anigrade cerebral perfusion the perfusionist and the anesthesiologist get together they look at the nears they look at transcranial Doppler flow the mean arterial pressure and we use our collective experience to titrate flow to where we want it. To be able to titrate flow this way everyone has to know how we do it what we titrate it to and that takes a great deal of communication and also preparation and the shared experience it's something that has to be taught and practiced. When you have low nears on cardiopulmonary bypass that's low cerebral oxygenation the anesthesiologist and perfusionist often get together to try to optimize the nears get it better and that includes things like increasing the flow, increasing the PACO2, increasing the mean arterial pressure, dropping the temperature if indicated and increasing the hematocrit. All of these things are communicated to the surgeon and if those things aren't working sometimes you need to look at the SVC cannula and make sure drainage is okay or the arterial cannula to make sure that it's well positioned. We all know that in many pediatric cardiac surgeries we can do it without giving blood products and when you do that you're kind of stepping out of your comfort zone a little bit and you have to have a shared way of doing it. You have to know what our standards are going to be, how we're going to improve things and have a great deal of comfort with each other that everyone is doing the right thing to try to get the patient through safely and sometimes that involves you know managing and doing without blood and sometimes that involves making the wise decision to transfuse. Lastly comes early extubation during a case where we are planning to extubate early that is in the operating room at the end of bypass the perfusionist and the anesthesiologist have to work together to control the anesthetic depth and poor communication in this area can lead to some things that we don't want like awareness under anesthesia, recall or dangerous patient movement and so that's something that really has to be worked out and checked on and a strategy developed for. I hope that I've been able to communicate to you what the Triangle of Trust means to me and my team, the Triangle of Trust that's comprised of the surgeon, anesthesiologist and perfusionist and how it contributes to improve patient safety and optimize patient outcomes. I thank you for your time and attention and again I thank the organizers for having me.