Term
| What preoperative concerns should be addressed in the patient undergoing a cardiovascular procedure? |
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Definition
*Cardiac Cath report, taking note of number of vessels stenosed and percent of blockage
*2D Echo
*Carotid Duplex report, if significant stenosis, carotids must be fixed prior to CV surgery
*CHF
*Myocardial Infarction
*Angina
*Patient presentation and age
*Comorbidities
*Functional Status
*Lab data (Hct, PT, PTT, BUN, CR, etc)
*Diabetes- blood sugar
*Blood available 4-6 units
*Vitals, Temp-U/A
*ECG/Rhythm
*Redo CABG? May do radial artery grafting
*Note pre-op vitals/parameters
*Valvular disease (severe aortic stenosis)
*>70% blockage of LAD or 3 Vessel disease
*Check consent for possible use of radial artery and blood consent
*continue on beta blockers, antihypertensives, NTG infusions
*Coagulation (if coming from cath lab may be on gpIIbIIIa agents) |
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Term
| Procedures done prior to the start of CV case? |
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Definition
*Right Radial Arterial line (right d/t LIMA take down)
*Right IJ SGC
*CO/CI/SVO2- Calibrate SVO2 in-vitro prior to insertion
*16 or 18g PIV usually left
*SVO2 data (low SVO2 can indicate and increased metabolic rate, increased 02 extraction, or decreased oxygen supply)
*PAP data (PAP increases when pt is getting ischemic and acidotic, PHTN, Hypoxia, fluid overload.)
*Pay attention to baseline vitals and parameters!
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Term
| What is the minimum requirement for vasoactive drips? |
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Definition
*Nitro and Neo sticks
*NTG
*Amicar/Aprotinin
*Norepinephrine
*Epinephrine
*Phenylephrine
*+/- Nitroprusside
*+/- Atropine and ephedrine
*Insulin- per blood sugar results
*Should have amiodarone, milrinone, and other cardiac meds immediately available. |
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Term
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Definition
| Plasmin inhibitor, protects coagulation system while on pump (pump tears up coags) |
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Term
| When will blood sugar likely increase during open heart procedure? |
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Definition
| *when the patient is on pump. An overall system inflammatory response occurs. Keep CBG <300, goal is <250. |
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Term
| Standard room set up for open heart case |
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Definition
*IV pumps (5-6gtts)
*Pacer (check battery/settings (DDD, 80, 10,10))
*Hot line/level one (put blood tubing on hot line)
*TEE
*Three sets of ECG (ours, balloon pump, and defibrillator) tape down put on back and sides
*Standard table top materials (Airway materials, Succ)
*Blood tubing for Cordis and PIV
*VIP line- 500mL NS on minidrip with 5 gang stopcock
*Fentanyl 20mL
*Amicar 20cc (for 5g bolus)
*Pavulon 10mL (Used for vagolytic & long acting properties)
*Etomidate 10mL
*NTG 10ml x 2
*Phenylephrine 10ml x2
*CaCl and Lidocaine
*Versed 5cc (5mg)
*MgSO4 2-3g
*Heparin 30mL
*Protamine
*+/- ephedrine and atropine
*Carrier solution at end of VIP line
Arms are tucked and shoulder roll is placed
*Cables: for pressures lines (3) and SVO2 |
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Term
| What should be done when OR is entered for an open heart procedure? |
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Definition
*Start ABX w/in one hour of incision Document.
-Ancef 2gm q4 hours, if PCN allergy use Vanco
*Valves for abx Ancef q4h plus Gentamycin 180mg x1
*Ensure 3 sets of leads are taped down with 3 inch silk tape
*Reconnect and/or start CO/CI
*CI <1.8
*Secure SGC, hook up A-line, NTG on if warrented.
*Draw baseline labs, ACT (105-176) and calculate heparin dose (typical dose 300u/kg). Be sure to run prior to giving amicar.
*Careful positioning of arms (tucked with sleds)
*Know proximity of surgeon |
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Term
| What is the overall goal of induction for open heart surgery? |
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Definition
| To attenuate response to laryngoscopy and surgery without undue hypotension or tachycardia |
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Term
| What drugs can be used for induction for an open heart? |
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Definition
*High dose narcotic (Fentanyl 3-10mcg/kg or Sufenta 0.5-1mcg)
*Amnestic Versed 3-5mg or sleep dose of induction agent such as Etomidate
*Muscle Relaxation- Pavulon: long acting and Vagolytic |
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Term
| What can test anesthetic depth prior to laryngoscopy? |
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Definition
*Foley catheter insertion
*Placement of oral airway
*limit laryngoscopy to 10-15sec |
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Term
| How much fluid should be given Pre CPB and total per case? And why? |
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Definition
*Keep fluids less than 1L pre-CPB
*2L total for case
*Large amount of hemodilution occurs when patient goes on CPB |
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Term
| After induction, what parameters should be checked? What other diagnostic tool should be used? |
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Definition
*Check CO/CI, BP and HR
*Insert TEE and hang on Ether screen after it is attached. Also attach pressure transducer here. |
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Term
| What drug should be administered after induction? |
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Definition
| Amicar bolus or test dose and bolus of Aporotinin |
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Term
| What should the anesthetist observe for during surgical prep? |
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Definition
| *Pressure changes up and down when legs go up or down |
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Term
| When and how much is Amicar given? |
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Definition
5g bolus after induction
5g before going on pump
5g on pump
or
5g bolus and run infusion |
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Term
| What inhalational agent is preferred for open heart surgery? |
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Definition
| *Forane due to having the least myocardial depressant effects |
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Term
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Definition
| *No, you want a high FIO2 and it can result in expansion of possibly entrained air. |
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Term
| What are events that are high stimulation during CABG? |
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Definition
*Laryngoscopy
*Chest Incision
*Sternotomy
*Sternal Retraction
*Incision of Pericardium
*Cannulation |
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Term
| What are periods of low stimulation during CABG? |
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Definition
*Prep
*LIMA harvest
*Saphenous harvest |
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Term
| What should the surgeon asking for the LIMA bar indicate to you? |
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Definition
*That he is about to take down the LIMA and will ask for the table up and to the left.
*They may request heparin administration at this time when LIMA is clamped. |
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Term
| What is the acceptable Hct for autologous blood removal? |
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Definition
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Term
| What is the process for Autologous Blood Removal? |
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Definition
*Use large bore central line for removal
*Drain into CPD Solution Bag
*500-1000mL can be drained
*Store in Fridge
*Must leave bag connected in Jehovah Witness
*ABR sequesters platelets and clotting factors, hang up at end of case. |
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Term
| What needs to be checked before sternotomy? |
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Definition
| *Blood must be checked and in room |
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Term
| What should be done just before sternotomy? |
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Definition
*May need redosing of narcotic
*Lungs must go down with reciprocating saw |
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Term
| What is different during sternotomy with a Redo CABG? |
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Definition
*An oscillating saw is used. Lungs do not have to go down
*Very slow process can take hours to open chest |
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Term
How often is U/O recorded off CPB?
How often is U/O recorded on CPB?
Who is responsible for ensuring U/O is adequate? |
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Definition
*Every 1/2 hour
*Every 15 minutes
*Anesthesia |
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Term
Where should Heparin be administered?
When does heparinization occur and how much?
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Definition
*Must be administered centrally, aspirate prior to giving
*Heparinzation must occur before cannulation
*300u/kg or calculated using heparin dose response titration |
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Term
| How soon after heparin administration should ACT be checked what should it be? |
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Definition
*Check 3 minutes afterward
*Need ACT >500 |
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Term
| What is a possibility if the ACT is inadequately increased? What is the treatment? |
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Definition
*Anti-Thrombin III (AT3) deficiency will result in an inadequate rise in ACT following heparin admin.
*AT3 needs to be present for Heparin to work.
*Give AT3 or FFP (2u) which contains AT3. |
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Term
| If a patient has HIT what should be given instead of Heparin? |
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Definition
| *Give argatrogan or lepirudin. Pt will have open chest, not reversible, will give factor VII, FFP, Cryo, etc. |
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Term
| What is cannulated first? |
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Definition
|
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Term
| What should SBP be prior to cannulation? |
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Definition
*Approximately 100mmHg
*Use NTG or forane to bring it down |
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Term
| What are some complications of aortic cannulation? |
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Definition
*Air or atherosclerotic emboli
*Hypotension from hypovolemia (dumping)
*Dissection-cannula pressure needs to match radial pressure
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Term
| Where is cannula placed for venous cannulation? |
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Definition
| *Placed into SVC through Right atrium |
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Term
| What are the complications of venous cannulation? |
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Definition
*Massive hemorrhage
*Arrhythmias
*Air entrainment |
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Term
| Which has more blood loss potential aortic or venous cannulation? |
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Definition
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Term
When is retrograde cardioplegia indicated?
Where is cannula passed? |
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Definition
*When there is an incompetent aortic valve or severe stenosis of coronary arteries
*Coronary Sinus |
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Term
| What should anesthesia have ready for retrograde cardioplegia? What should be done prior to attaching line to retrograde cannula? |
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Definition
*A place to attach a pressure line passed from surgery, turn stopcock so it is reading the retrograde line.
*Be sure to flush cannula |
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Term
| What should retrograde pressure be around? |
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Definition
|
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Term
| What are complications of retrograde cardioplegia? |
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Definition
|
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Term
| What is needed for normal cardioplegia? |
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Definition
| *Competent aortic valve and patent enough coronaries for cardioplegia. |
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Term
| What indicates that the patient is on bypass? |
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Definition
| *When perfusion says "full flow" |
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Term
True or False
There is a period of ischemia until cardioplegia is administered. |
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Definition
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Term
| Once on bypass anesthesia may..... |
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Definition
*Stop ventilation
*Forane off
*Flows down
*Disconnect |
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Term
| What does anesthesia want to do with the SGC after the patient is on bypass? |
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Definition
| *Pull back the SGC 5cm d/t becoming hard in the chest when ice bath is put in |
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Term
| Can drips be shut off during bypass? |
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Definition
| *Turn off except Amicar or Trasylol |
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Term
| What needs to be redosed during CPB? |
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Definition
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Term
| What are some signs and symptoms of improper cannulation? |
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Definition
*Face flushing
*Swelling
*Dilated pupils |
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Term
| What is the goal during CPB? |
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Definition
| *Keep MAP >60 and continue to make urine |
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Term
| What should be expected Hct, K, and glucose changes during CPB? |
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Definition
*Hct will drop
*K will rise d/t cardioplegia
*Blood sugar will increase r/t insulin resistance and stress response |
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Term
| What two things does anesthesia manage during CPB? |
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Definition
*Blood sugar
*Table position
*Anesthesia also keeps an eye on U/O but perfusion manages |
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Term
| What does RAP stand for and why is it used? |
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Definition
| *Retrograde Autologous Prime. It lets blood flow back into arterial cannula to prime the line instead of priming with priming solution. Less hemodilution. |
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Term
| What drugs should absolutely not be given during CPB? |
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Definition
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Term
| What should be discussed prior to coming off pump? |
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Definition
| *The use of FFP and Plt since they take time to thaw |
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Term
| What offers myocardial protection during CPB? |
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Definition
*Cooling the patient to 30-32 degrees or "let them drift (hypothermia)
*Cardioplegia |
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Term
| What offers cerebral protection? |
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Definition
| *Hypothermia and flow provided by CPB |
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Term
| *What should be decided prior to separation from CPB? |
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Definition
*If milrinone or any non-standard drugs may be needed
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Term
| When should rewarming be started? |
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Definition
| *When distal anastomosis are done and sewing into aorta |
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Term
| What should be redosed prior to separation from CPB? |
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Definition
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Term
| What needs to be checked prior to separating from bypass? |
|
Definition
*Core temperature
*Hct >20%, K&Ca WNL, corrected metabolic status
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Term
| What will the surgeons pass to anesthesia after coming off bypass? |
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Definition
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Term
| What position will surgeon ask for before closing the pericardium and why? |
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Definition
| *Head down to assist with de-airing the heart and get rid of atelectasis |
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Term
| Since arrhythmias are one of the largest concerns when coming off bypass, what are some meds that should be given? |
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Definition
*MgSO4 2-3gm
*100mg Lidocaine
*0.5gm CaCl
*if need to shock give 20-30joules with internal paddles
*give amiodarone 150mg bolus or 300mg, run infusion 1mg/min for 6 hours and 0.5mg/min for 18 hours |
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Term
| When will ventilation resume? |
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Definition
*Prior to separation, hand vent 1st
*"give some big blows"
*Helps deair heart and get rid of atelectasis |
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Term
| What drugs should be going when the AOX is off? |
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Definition
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Term
| At what point does the CRNA resume responsibility for ventilation and hemodynamic control? |
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Definition
| *When patient separates from bypass |
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Term
| What should be obtained immediately after separation from bypass? |
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Definition
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Term
|
Definition
| *Neutralizes heparin by binding and making a complex with it. |
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Term
| How should protamine be given and what is added? What can happen with a reaction? |
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Definition
*Protamine should be given peripherally and slowly. 500-1000mg of CaCl is added to the bag to offset histamine release caused by Protamine
*Let surgeon know when the bag is half empty
*Increaesed PAP, hypotension, and tachycardia can ensue with a protamine reaction. |
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Term
| Who is at risk for a protamine reaction? How are those at risk pretreated? |
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Definition
*Men who have had vasectomies, Redos, diabetics, people who have received protamine previously.
*Pretreat with benedryl, zantac, and solumedrol |
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Term
| When the chest is closed what does anesthesia need to do? |
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Definition
*The lungs must be down during chest closure when wires are twisted.
*Get CO/CI immediately after closure |
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Term
| When is Aprotinin indicated? |
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Definition
*Redo CABG
*Emergency from cath lab/ICU
*Longer case- ie double valve replacement
*Coagulation problems |
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Term
| What is the goal for an emergency CABG? |
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Definition
*Goal is to maintain coronary perfusion pressure
*Time is of the essence, get them on pump! |
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Term
| What needs to be in the room prior to start of case for the pt undergoing a redo CABG? Why? |
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Definition
*6u of blood
*Higher risk of bleeding, takes longer to open chest and expose heart due to adhesions |
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Term
| What patients should a cordis not be used on? |
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Definition
*Tricuspids
*Myxoma (R atrial tumor) |
|
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Term
| What are some of the differences between a normal CABG and an off pump CABG? |
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Definition
*Same set up
*The room is warmed, along with the fluids and table
*Need more volume due to greater manipulation of heart
*Heparinization to a lesser extent (usually 8000-10000)
*"octopus" stabilizer placed |
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Term
| What needs to be monitored during the off pump CABG when shunt is placed and artery is being manipulated? |
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Definition
| *Monitor closely for ischemia |
|
|
Term
| Which goes on pump faster, a CABG or Valve? |
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Definition
|
|
Term
| What should be checked prior to and after replacement of a valve? |
|
Definition
*Valve function with a TEE
|
|
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Term
| How should stenosis be managed? What type of hypertrophy occurs with stenosis? |
|
Definition
*Keep regular, slow, and tight
*Need SVR
*Avoid nitrates and dilators, forward flow!
*Concentric hypertrophy |
|
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Term
| How should Regurg be managed? What type of hypertrophy presents with regurg? |
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Definition
*Fast, flow, and forward (increase preload, vasodilate)
*Eccentric |
|
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Term
| What problems are associated with aortic stenosis? |
|
Definition
|
|
Term
What is the size of a normal valve orifice?
Of a moderately stenosed orifice?
A severely stenosed orifice? |
|
Definition
*Normal: 2.6-3.5cm squared
*Moderate: 0.7-0.9
*Critical: <0.5 |
|
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Term
| What are different considerations for fast track hearts? |
|
Definition
*Moderate narcotic dosing
*Off vent in 1-2 hours, possibly extubate in room
*Up to chair by evening |
|
|
Term
| When is the best time to get off CPB? |
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Definition
| *The first attempt off CPB is the best one |
|
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Term
| What are some considerations if the patient can't separate from CPB? |
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Definition
*Re-heparinize based on ACT
*In any protamine was given give full dose of heparin
*More aggressive inotropic support
*IABP
*Ventricular assist device
*May leave chest open
*Re-attempt coming off |
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Term
| What are some causes of severe instability post CPB? |
|
Definition
*Inadequate revascularization
*Inadequate valve function after repair or replacement
*Coronary Spasm
*Mechanical obstruction
*Metabolic Status
*Volume Status
*Coagulation
*Emboli |
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