CABG:

• These are good candidates for fast tracking and early extubation. Currently, a Swan Ganz is used because of ischemic preconditioning and heart manipulation. Heparin, 10,000 u. is given at surgical request. ACT is not routinely monitored. Protamine reversal is usually required , approx 100 mg protamine.

• Etomidate, 0.2-0.3 mg/kg, provides rapid onset of hypnosis without much effect on BP.
• Etomidate will not prevent heart rate and blood pressure responses to laryngoscopy and tracheal intubation so you may need some opioid and/or esmolol, lidocaine.
• Most cath lab emergencies will have a femoral arterial line, so be prepared to add a long high pressure extension.

• Draw up 10 of LR or saline to flush infusion port of the PA catheter.
• Attach transducer apparatus to the “monster” so that transducer height changes with adjustment of table height.
• Attach Omniflow pump to infusion port of Swan Ganz with 3 stop-cocks: 1 for the opioid, 1 for the relaxant, and 1 for amicar.
• Press “start” to start the continuous cardiac output and “stat” to see the stat screen. Note that if patient height and weight are not entered and you are in the cardiac index mode, nothing will appear in the stat screen but cardiac output is still being measured.
• Use tincture of benzoin to facilitate adherence of tape when securing ET tube
• Insert orogastric tube after induction and tape into place.
• Insure that appropriate antibiotics have been given prior to incision (e.g., cefazolin 1G). Give repeat dose of cefazolin, 1 G, q6h to maintain levels. If vanco required, infuse over 1 hour; Vanco must be diluted in 200 or 250 ml before infusing.
• To deflate the lungs for median sternotomy, simply turn off the ventilator and insure that pop off valve is open. Resume ventilation once sternotomy is complete.
• Insure that the breathing filter is on the inspiratory, not the expiratory limb of the breathing circuit. The goal of the filter is to prevent transmission of any particles to the patient, not to the machine. The presence of a filter on the expiratory side exposes the patient to the risk of tension pneumothorax should any obstruction in the filter occur (which would lead to air trapping due to "stacking of breaths").
• Perform ACT and blood gas soon after induction. It is customary to sample 2 ml of arterial blood using a 3 cc syringe with needle. The perfusionist runs this test.
• Reduce tidal volume and increase respiratory rate to facilitate IMA dissection
• Administer heparin, 300 u/kg, before cannulation (surgeon should request- if not, ask). Check and confirm with surgeon and perfusionist the dose of heparin you are giving. Heparin is given via a central line. Verify blood return and note exact time of heparin administration. Three min later, draw 2 cc arterial sample for ACT- the perfusionist should be in the room when you heparinize; if not have them called. Document ACT at baseline and after heparin. Unless it is an emergency, insure ACT > 350 seconds before commencing bypass. Failure to achieve sufficient anticoagulation prior to initiating bypass results in death.
• Withdraw the PA catheter 2-5 cm within the sterile cathguard prior to going on bypass to reduce the possibility of overwedged position. To do this, firmly grasp the proximal portion of introducer before withdrawing.
• After full bypass flow attained (look for loss of pulsatile arterial flow), turn off ventilator and apply PEEP 5 cm to lungs; check drainage and perfusion of head to insure properly positioned cannula
• Stop all IVs except for continuous infusion devices
• Measure urine output every 15 min on bypass. Decreased urine output is an early sign of inadequate perfusion and aortic dissection
• Monitor MAP, temperature, BIS, and CVP during bypass. The SvO2 measure is not valid during full bypass since there is very little pulmonary artery blood flow.
• Give perfusionist syringe of phenylephrine, 100 ug/cc, to treat hypotension during bypass (MAP < 60 mmHg). Treat hypertension (MAP > 80 mmHg) with anesthetic agents and/or vasodilators, e.g., SNP 0.5-2 ug/kg/min, during bypass.
• Chart all blood gases during bypass (at least 1 per hour) and any blood products given by perfusionist. Be aware at all times of Hct, K, Ca, acid-base, and any blood products given during bypass. It is customary to transfuse if Hct is < 20% or if the bypass reservoir volume is low and Hct is < 25%.
• Draw up protamine 4 mg/kg in 30 ml syringe during rewarming phase of bypass and mark clearly. Keep in top drawer at all times until ready to administer after bypass. Perfusionist will give you an estimated protamine dose- which is just that, an estimate.
• Nitroglycerin is preferable to nitroprusside for post bypass HTN because it enhances flow through the newly constructed conduits.
• Upon resuming ventilation to atelectatic lungs prior to separation from bypass, listen to breath sounds via the esophageal stethoscope and insure adequate lung expansion. The trachea may need to be suctioned.
• Milrinone loading dose can be given via the Omniflow: draw up milrinone in 10 ml syringe, 1 mg/ml; use the intermittent mode- enter the dose (e.g, 0.05 mg/kg or 3.5 ml in 70 kg patient) and infuse over 10 min. Once the loading dose is given, the infusion can be started, if necessary, using the continuous mode.
• After bypass, administer protamine at surgeons request. The Omniflow device can be used in the intermittent mode- enter the total dose to be infused over 10-15 min and check status of line to verify when 3 cc test dose has infused. Monitor hemodynamics and continue as tolerated. The device will turn itself off once the programmed dose is complete. Addition of calcium to the protamine is rarely needed if the dose is given slowly
• Check ACT and blood gas 15 min after protamine; Be prepared to administer an additional 50-100 mg of protamine after infusion of cell saver blood, and recheck ACT as needed. Record total amount of cell saver blood given.
• If difficult pump run and problems with hypothermia, warm the room, and be prepared to treat coagulopathy. Platelet count and function can be measured using the Plateletworks test available from the critical care lab. Test tubes are kept in the workroom fridge. Use the same order form as you would for ABG
• Prepare for transport- monitor, bed, O2, Ambu bag, Arrange lines so they don’t get tangled during transport. It is worth separating out the arterial line and taping it to the arm.
• To retain SvO2 calibration values with the Baxter Vigilance monitor, press SvO2, then press transport.
• If another heart is scheduled to follow, try and start lines on second heart in recovery or another area, and draw up drugs, prepare infusions for the second case, etc during bypass

Redos

• Similar setup, use blood warmer; an extra large bore IV is usually indicated
• Have 2 units of blood in room checked during resternotomy in case of massive hemorrhage
• Amicar as with CABG (aprotinin rarely used by current surgeons)

Valves

• Similar setup as CABG. Will often use TEE, especially MR and planned MV repair.
• Avoid inserting OG or esophageal stethoscope if TEE is planned. Insert these devices only after TEE probe has been removed.
• Be prepared for deairing procedures prior to or after unclamping of the aorta- inflate and hold lungs at 30 cmH2O (Valsalva) while surgeon needles appropriate chambers, with patient in Trendelenburg position; insure full deflation of lungs after Valsalvas
• TEE may be repeated after bypass before protamine reversal

ASD (septal defects), Cardiac tumors (right sided)

• PA catheter generally avoided because of risks (tumor emboli, crossing septal defect)
• TEE may be used
• Deairing procedures as with valves

Standby Angioplasties

• Most cases will not require anesthesia and surgical intervention
• I would suggest that the following setup:
• Anesthesia machine, circuit, tubes, blades, airways and cart with resuscitation drugs
• Labelled, but empty syringes for etomidate, opioid and muscle relaxant
• Omniflow plus drips and IV tubing available, but not open or spiked
• IV, Swan and art line setup available, but not opened.

Thoracotomies, Video-assisted thoracoscopy (VATS)

• Be prepared for one lung ventilation (physiology, indications, verification, type of tubes)
• Treat hypoxemia during OLV as follows-
• insure proper tube placement and ventilation,
• FiO2 1.0, adequate tidal volume and rate,
• PIP < 35 cmH2O. If still hypoxic,
• inform surgeon and gently inflate atelectatic lung and let fall to 5 cm PEEP using CPAP circuit attached to additional O2 source.
• If still hypoxic, add 5 cm PEEP to ventilated lung.
• Thoracic or lumbar epidural morphine, 4 mg bolus and 0.5 mg/hr infusion provides good analgesia after thoracotomy, and helps prevent atelectasis and further impairment of pulmonary function (protocol # 3 with epi, Dr Kareti, Department of Pain Management). Thoracic epidural fentanyl can also be used. Addition of low concentrations of bupivacaine to the epidural may be beneficial.

Thoracic Tears, Aneurysms, Dissections

• Be prepared for large volume resuscitation. Two large bore IVs, Level 1 rapid infusor are a minimum
• Partial bypass may be used (LA-fem, LA- thoracic aorta, fem-fem, RA-fem), or deep hypothermic circulatory arrest
• If DHCA, pack the head in ice. Cerebral protection with thiopental, 5-10 mg/kg may be of some benefit. Monitor BIS - isoelectric or burst suppression; Steroids may help decrease inflammation (dexamethosone, 10 mg). Mannitol and renal dose dopamine may be useful.
• Drainage (50-75 cc) and monitoring of lumbar CSF pressures to maximize spinal cord perfusion pressure (SCPP = MAP-CSFp) may be indicated for descending thoracic aortic surgeries if heparin anticoagulation not employed.

SUGGESTED HEART ROOM SETUP FOR CABG

1. 2 EKG leads
2. 2 pulse ox
3. BIS monitor
4. Omniflow:
   • NTG 50 mg/250 ml (200 ug/ml); 0.2 ug/kg/min
   • Nipride 50 mg/250 ml
   • Diltiazem, 25 mg in 25 ml syringe; 3 mg/hr- radial artery graft only
   • LR 100 ml/hr
   • Stopcocks on lines B, C, D
   • 3 stopcocks on patient line
5. Blood line to fluid warmer
6. Regular line
7. Art line with high pressure extension
8. CVP, PA Double transducer with cables
9. CCO and SVO2 cables
10. Syringes:
    • Emergency meds:
      10 ml epi from epi bag (16 ug/ml)
      10 ml NTG from bottle (200 ug/ml)
      phenylephrine, ephedrine
      atropine, lidocaine, esmolol,
      Heparin: 30 ml syringe; Protamine: 30 ml
      
    • Anesthesia meds:
      Etomidate 10 ml, Fentanyl 30 ml, Vec 10 ml, Midazolam 5 ml
11. Regular infusion pump:
    • Vanco 1 G/hr
    • Amicar 25 G/250 ml: initial rate/hr = weight (kg); initial volume = 0.5 ml/kg
12. Syringe pumps:
    • Fentanyl, 0.05 ug/kg/min; bolus = 3 ug/kg
    • Vec, 3 ml/hr; bolus = 3 ml

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