anesthesia for coronary artery bypass surgery

Anesthesia for Anesthesia for Coronary Artery Coronary Artery Bypass SurgeryBypass Surgery

Vincent Conte, MDVincent Conte, MDClinical Assistant ProfessorClinical Assistant Professor

FIU College of Nursing FIU College of Nursing Anesthesiology Nursing ProgramAnesthesiology Nursing Program

CardiopulmonaryCardiopulmonary

Bypass Bypass

MachineMachine

Cardiopulmonary BypassCardiopulmonary Bypass

CPB is accomplished through the use CPB is accomplished through the use of a CPB Pump/machineof a CPB Pump/machine

Its basic function is to act like the Its basic function is to act like the heart and lungs while the heart is heart and lungs while the heart is made still for surgery to proceedmade still for surgery to proceed

The main difference is that the flow The main difference is that the flow from the pump is NON-PULSATILE vs. from the pump is NON-PULSATILE vs. normal pulsatile flow from the heartnormal pulsatile flow from the heart

Cardiopulmonary BypassCardiopulmonary Bypass

CPB is characterized by gravity CPB is characterized by gravity drainage of blood from the venae drainage of blood from the venae cavae into an OXYGENATOR followed cavae into an OXYGENATOR followed by its return to the arterial system, by its return to the arterial system, usually the ascending aorta, by usually the ascending aorta, by means of a ROLLER PUMPmeans of a ROLLER PUMP

In the presence of a competent In the presence of a competent Aortic Valve, the heart is excluded Aortic Valve, the heart is excluded from the patient’s circulationfrom the patient’s circulation

CPBCPB

If the aortic valve is NOT competent, If the aortic valve is NOT competent, then the aorta must be CROSS-then the aorta must be CROSS-CLAMPED between the valve and the CLAMPED between the valve and the INFLOW cannulaINFLOW cannula

If this step is NOT done, then blood If this step is NOT done, then blood would flow into the heart and the would flow into the heart and the heart would NOT be isolated from the heart would NOT be isolated from the circuit and work would be impossible circuit and work would be impossible to proceed to proceed

CPBCPB When the heart is isolated from the When the heart is isolated from the

circulation, Total Cardiopulmonary Bypass circulation, Total Cardiopulmonary Bypass is present and ventilation of the lungs is no is present and ventilation of the lungs is no longer necessary to maintain oxygenationlonger necessary to maintain oxygenation

At this point the ventilator can be turned At this point the ventilator can be turned off and the reservoir bag is usually off and the reservoir bag is usually removed with your pop off valve in the removed with your pop off valve in the wide open position wide open position

The circuit is open to room air pressure so The circuit is open to room air pressure so no pressure can build in the lungs, making no pressure can build in the lungs, making them expand and getting in the way of the them expand and getting in the way of the surgical fieldsurgical field

CPBCPB

The CPB machine has five basic The CPB machine has five basic components:components:

1)1) A VENOUS RESERVOIRA VENOUS RESERVOIR

2)2) An OXYGENATORAn OXYGENATOR

3)3) A HEAT EXCHANGERA HEAT EXCHANGER

4)4) A MAIN PUMPA MAIN PUMP

5)5) An ARTERIAL FILTERAn ARTERIAL FILTER

CPBCPB

Prior to its use, the CPB machine Prior to its use, the CPB machine must be primed with fluid (1200-must be primed with fluid (1200-1800 mL) that is devoid of bubbles1800 mL) that is devoid of bubbles

Usually a balanced salt solution is Usually a balanced salt solution is used to flush the machine, but used to flush the machine, but sometimes Albumin or Hespan is sometimes Albumin or Hespan is addedadded

Blood is also used as a priming Blood is also used as a priming solution for small pediatric patients solution for small pediatric patients or for anemic adult patientsor for anemic adult patients

CPBCPB

At the onset of bypass, hemodilution At the onset of bypass, hemodilution usually decreases the hematocrit to usually decreases the hematocrit to about 22-25% in most patientsabout 22-25% in most patients

That is why in the more critically ill or That is why in the more critically ill or anemic patients, blood is used for anemic patients, blood is used for priming the CPB machine to avoid priming the CPB machine to avoid too drastic a drop in hematocrit and too drastic a drop in hematocrit and consequently compromising O2 consequently compromising O2 delivery and leading to Ischemiadelivery and leading to Ischemia

ReservoirReservoir

The reservoir of the CPB machine The reservoir of the CPB machine receives blood from the patient via receives blood from the patient via one or two venous cannulas placed one or two venous cannulas placed into the Right atrium or the Superior into the Right atrium or the Superior and Inferior vena cavaeand Inferior vena cavae

Blood flows to the reservoir by Blood flows to the reservoir by gravity drainage so depending on the gravity drainage so depending on the rate of flow, you may see the pump rate of flow, you may see the pump tech raise or lower the reservoir at tech raise or lower the reservoir at different times during the casedifferent times during the case

OxygenatorOxygenator

Blood comes from the bottom of the Blood comes from the bottom of the reservoir and passes next through the reservoir and passes next through the OXYGENATOROXYGENATOR

There is a blood:gas interface and oxygen There is a blood:gas interface and oxygen is bubbled through the blood as it flows is bubbled through the blood as it flows passed the interfacepassed the interface

A volatile anesthetic is also frequently A volatile anesthetic is also frequently added at the oxygenator gas inlet to allow added at the oxygenator gas inlet to allow for control of BP while the patient is on the for control of BP while the patient is on the CPB machineCPB machine

OxygenatorOxygenator

CO2 is usually eliminated at the same CO2 is usually eliminated at the same site as where the O2 is added by site as where the O2 is added by allowing it to flow down its concentration allowing it to flow down its concentration gradientgradient

There is usually a regulator that allows There is usually a regulator that allows the pump tech to set the concentration the pump tech to set the concentration of O2 at the point of mixing so as they of O2 at the point of mixing so as they monitor the PaO2 by ABG analysis, they monitor the PaO2 by ABG analysis, they can adjust the O2 flow to maximize can adjust the O2 flow to maximize PaO2 as neededPaO2 as needed

Heat ExchangerHeat Exchanger

Blood from the oxygenator enters the Blood from the oxygenator enters the heat exchanger heat exchanger

The blood is then either cooled or The blood is then either cooled or warmed depending on the warmed depending on the temperature of the water flowing temperature of the water flowing through the exchanger (4-42 degrees through the exchanger (4-42 degrees C)C)

Heat transfer occurs by conductionHeat transfer occurs by conduction To cool the blood, ice is added to the To cool the blood, ice is added to the

outer chamber of the heat exchangerouter chamber of the heat exchanger


The blood is cooled to lower body The blood is cooled to lower body temperature during bypasstemperature during bypass

Lowering of body temperature Lowering of body temperature decreases O2 consumption so in case decreases O2 consumption so in case there is an interruption in blood flow, there is an interruption in blood flow, there will be less chance of ischemia there will be less chance of ischemia occurring during the interruptionoccurring during the interruption

There is also a protective effect on There is also a protective effect on the brain during the period of the brain during the period of hypothermiahypothermia


Once the surgery is complete then Once the surgery is complete then the heat exchanger has a heating the heat exchanger has a heating coil that is then used to warm the coil that is then used to warm the blood back to normal body blood back to normal body temperaturetemperature

Because gas solubility decreases as Because gas solubility decreases as blood temp rises, there is a filter built blood temp rises, there is a filter built into the distal end of the heat into the distal end of the heat exchanger to catch any bubbles that exchanger to catch any bubbles that may form during rewarmingmay form during rewarming

Main PumpMain Pump

Modern CPB machines use either an Modern CPB machines use either an electrically driven double-arm roller electrically driven double-arm roller pump or a centrifugal pumppump or a centrifugal pump

The pump is used to propel blood The pump is used to propel blood through the CPB circuitthrough the CPB circuit

Roller pumps produce flow by Roller pumps produce flow by compressing large-bore tubing in the compressing large-bore tubing in the main pumping chamber as the head main pumping chamber as the head turns turns

Main PumpMain Pump

The constant speed of the rollers pumps The constant speed of the rollers pumps blood regardless of the resistance blood regardless of the resistance encountered and produces a continuous encountered and produces a continuous non-pulsatile flownon-pulsatile flow

Flow is directly proportional to the number Flow is directly proportional to the number of revolutions per minuteof revolutions per minute

There are usually battery backups in case There are usually battery backups in case of power failure and most roller pumps of power failure and most roller pumps have a hand crank built in just in case of have a hand crank built in just in case of complete failurecomplete failure

Main PumpMain Pump

Centrifugal pumps consist of a series Centrifugal pumps consist of a series of cones in a plastic housingof cones in a plastic housing

As the cones spin, the centrifugal As the cones spin, the centrifugal forces created propel the blood from forces created propel the blood from the centrally located inlet to the the centrally located inlet to the peripheryperiphery

In contrast to roller pumps, these In contrast to roller pumps, these pumps are less traumatic to blood pumps are less traumatic to blood and blood elementsand blood elements

Arterial FilterArterial Filter

Particulate matter (thrombi, fat Particulate matter (thrombi, fat globules, calcium, tissue debris) enters globules, calcium, tissue debris) enters the CPB circuit with alarming regularitythe CPB circuit with alarming regularity

A final in-line arterial filter is mandatory A final in-line arterial filter is mandatory to prevent systemic embolismto prevent systemic embolism

Once filtered, the propelled blood Once filtered, the propelled blood returns to the patient, usually via a returns to the patient, usually via a cannula in the ascending aortacannula in the ascending aorta

Accessory Pumps & Accessory Pumps & DevicesDevices

Several accessory devices are Several accessory devices are usually incorporated into the CPB usually incorporated into the CPB pump:pump:

1)1) Cardiotomy SuctionCardiotomy Suction

2)2) Left Ventricular VentLeft Ventricular Vent

3)3) Cardioplegia PumpCardioplegia Pump

Cardiotomy SuctionCardiotomy Suction

This suction aspirates blood from the This suction aspirates blood from the surgical field during CPB and returns surgical field during CPB and returns the blood back to the main reservoirthe blood back to the main reservoir

It is at a lower suction pressure than It is at a lower suction pressure than that from the wall so it produces less that from the wall so it produces less trauma to the red cells and blood trauma to the red cells and blood elements and they can safely be elements and they can safely be recirculated back into the pump and recirculated back into the pump and back into the patientback into the patient

Left Ventricular VentLeft Ventricular Vent With time, even after institution of total With time, even after institution of total

bypass, blood accumulates in the left bypass, blood accumulates in the left ventricle as a result of residual pulmonary ventricle as a result of residual pulmonary blood flow from bronchial arteriesblood flow from bronchial arteries

Distention of the left ventricle Distention of the left ventricle compromises myocardial preservation and compromises myocardial preservation and requires decompression (venting)requires decompression (venting)

The blood aspirated by the vent pump The blood aspirated by the vent pump normally passes through a filter and is normally passes through a filter and is returned to the venous reservoirreturned to the venous reservoir

Cardioplegia PumpCardioplegia Pump

Cardioplegia (a high concentrated K+ Cardioplegia (a high concentrated K+ solution used to stop the heart from solution used to stop the heart from contracting) is most often contracting) is most often administered via an accessory pump administered via an accessory pump on the CPB machineon the CPB machine

This pump usually has its own heat This pump usually has its own heat exchanger associated with itexchanger associated with it

This solution is the key factor that This solution is the key factor that stops the heart for surgery to proceedstops the heart for surgery to proceed

Systemic Systemic HypothermiaHypothermia

HypothermiaHypothermia

Intentional hypothermia is routinely Intentional hypothermia is routinely used following initiation of CPBused following initiation of CPB

Core body temp. is usually reduced Core body temp. is usually reduced to 20-32 degrees Cto 20-32 degrees C

Metabolic O2 demands are generally Metabolic O2 demands are generally cut in half with each reduction of 10 cut in half with each reduction of 10 degrees C in body tempdegrees C in body temp


Profound hypothermia to 15-18 Profound hypothermia to 15-18 degrees C allows total circulatory degrees C allows total circulatory arrest for complex repairs of the arrest for complex repairs of the aorta for up to 60 min.aorta for up to 60 min.

During that time, both the heart AND During that time, both the heart AND CPB pump are stoppedCPB pump are stopped

Hypothermia is NOT w/o its problems Hypothermia is NOT w/o its problems howeverhowever


Profound hypothermia can be Profound hypothermia can be associated with:associated with:

1)1) Platelet dysfunctionPlatelet dysfunction

2)2) Reduced serum ionized CalciumReduced serum ionized Calcium

3)3) Reversible coagulopathyReversible coagulopathy

4)4) Depression of myocardial Depression of myocardial contractilitycontractility

MyocardialMyocardial

PreservationPreservation

Myocardial PreservationMyocardial Preservation

Optimal surgical results depend on Optimal surgical results depend on prevention of myocardial damage prevention of myocardial damage and maintenance of normal cellular and maintenance of normal cellular integrity and function during CPBintegrity and function during CPB

Nearly ALL patients sustain some Nearly ALL patients sustain some myocardial damage during CPBmyocardial damage during CPB

Proper preservation techniques can Proper preservation techniques can keep this damage to a minimumkeep this damage to a minimum

Myocardial PreservationMyocardial Preservation Inadequate myocardial preservation Inadequate myocardial preservation

usually manifests at the end of CPB as a usually manifests at the end of CPB as a persistently LOW CO, EKG signs of persistently LOW CO, EKG signs of ischemia, or cardiac arrhythmiasischemia, or cardiac arrhythmias

Aortic cross-clamping during CPB Aortic cross-clamping during CPB completely cuts off coronary blood flowcompletely cuts off coronary blood flow

Although no studies have really been done Although no studies have really been done to determine an optimal time for cross-to determine an optimal time for cross-clamping, it is believed that cross-clamp clamping, it is believed that cross-clamp times GREATER than 120 min. are times GREATER than 120 min. are generally considered as undesirablegenerally considered as undesirable

Myocardial PreservationMyocardial Preservation

The most widely used method or The most widely used method or arresting the myocardium and arresting the myocardium and decreasing O2 demand is through decreasing O2 demand is through the use of a solution high in K+ the use of a solution high in K+ called “Cardioplegia”called “Cardioplegia”

Following initiation of CPB, induction Following initiation of CPB, induction of hypothermia and cross-clamping of hypothermia and cross-clamping of the aorta, the coronary circulation of the aorta, the coronary circulation is periodically perfused with cold is periodically perfused with cold cardioplegiacardioplegia

CardioplegiaCardioplegia

The resultant increase in extracellular K+The resultant increase in extracellular K+

eventually leads to the INACTIVATION of eventually leads to the INACTIVATION of the fast Na+ channels, basically paralyzing the fast Na+ channels, basically paralyzing the myocardiumthe myocardium

Basically with the temperature reduced Basically with the temperature reduced and the tissues paralyzed, the myocardial and the tissues paralyzed, the myocardial O2 demand is approx. 1/20O2 demand is approx. 1/20thth of its normal of its normal requirement and in this condition the requirement and in this condition the tissue can survive with minimal O2 tissue can survive with minimal O2 supplied to itsupplied to it


Although the exact composition varies Although the exact composition varies from center to center, basically the from center to center, basically the composition of cardioplegia is the composition of cardioplegia is the same; approx. 10-40mEq/L of K+same; approx. 10-40mEq/L of K+

Small amounts of calcium and Small amounts of calcium and magnesium are added to help maintain magnesium are added to help maintain cellular integrity and sodium cellular integrity and sodium concentrations are usually kept less concentrations are usually kept less than normal serum Na+ (<140 mEq/L)than normal serum Na+ (<140 mEq/L)


Since the cardioplegia cannot reach areas of Since the cardioplegia cannot reach areas of the heart that are distal to the coronary the heart that are distal to the coronary artery obstructions, many surgeons also artery obstructions, many surgeons also administer cardioplegia retrograde through administer cardioplegia retrograde through a coronary sinus catheter and back through a coronary sinus catheter and back through the venous systemthe venous system

Some studies have reported that the Some studies have reported that the combination of antegrade and retrograde combination of antegrade and retrograde cardioplegia is FAR superior at protecting cardioplegia is FAR superior at protecting the myocardium as compared to only the myocardium as compared to only antegrade administrationantegrade administration

CardioplegiaCardioplegia Cardioplegia is usually administered every Cardioplegia is usually administered every

20-30 minutes while the patient is on CPB20-30 minutes while the patient is on CPB Excessive cardioplegia can result in an Excessive cardioplegia can result in an

absence of electrical activity, AV absence of electrical activity, AV conduction blockade, or a poorly conduction blockade, or a poorly contracting heart at the conclusion of CPBcontracting heart at the conclusion of CPB

There is often a period of “Wash Out” There is often a period of “Wash Out” needed after long cases at which time the needed after long cases at which time the heart is allowed to return beating while heart is allowed to return beating while still on partial CPB to allow excess still on partial CPB to allow excess cardioplegia and cellular byproducts to cardioplegia and cellular byproducts to become eliminated and allow the become eliminated and allow the myocardium to contract fully and without myocardium to contract fully and without any depressionany depression

Monitoring andMonitoring and

IV AccessIV Access

MonitoringMonitoring The following monitors are usually used during a The following monitors are usually used during a

CABG procedure:CABG procedure:1)1) EKG (at least a minimum of 2 leads, II and V5)EKG (at least a minimum of 2 leads, II and V5)2)2) O2 SatO2 Sat3)3) BP CuffBP Cuff4)4) TempTemp5)5) EtCO2EtCO26)6) A-line (for ABG’s and continuous BP; placed A-line (for ABG’s and continuous BP; placed

PREOP)PREOP)7)7) SG Cath (w/ or w/o fiberoptics to calculate CO and SG Cath (w/ or w/o fiberoptics to calculate CO and

to sample Mixed Venous blood or to get a to sample Mixed Venous blood or to get a continuous readout of MVO2 Sat)continuous readout of MVO2 Sat)

8)8) TEETEE9)9) BISBIS

IV AccessIV Access In the preop suite prior to induction, the In the preop suite prior to induction, the

nurses or MD’s usually place AT LEAST nurses or MD’s usually place AT LEAST an 18g, preferably a 16g, IV Cathan 18g, preferably a 16g, IV Cath

Once the IV Cath is placed, Once the IV Cath is placed, premedication can be given and then premedication can be given and then the A-line is placedthe A-line is placed

This is the minimum needed prior to This is the minimum needed prior to inductioninduction

In sicker patients, an Introducer and an In sicker patients, an Introducer and an SG cath need to be placed as well SG cath need to be placed as well ALLALL prior to induction of anesthesiaprior to induction of anesthesia

Induction Induction

& &

MaintenanceMaintenance

PremedicationPremedication

The choice AND amount of The choice AND amount of premedication is dependant on the premedication is dependant on the degree of myocardial disease that is degree of myocardial disease that is present preoppresent preop

Patients with an EF <40% should be Patients with an EF <40% should be given preop medications slowly and given preop medications slowly and carefully since they are much more carefully since they are much more sensitive to the hypotensive effects sensitive to the hypotensive effects of the medsof the meds

PremedicationPremedication

The usual preop cocktail at Baptist The usual preop cocktail at Baptist PRIOR to A-line placement was:PRIOR to A-line placement was:

1)1) Versed 2-6 mg as tolerated IVVersed 2-6 mg as tolerated IV

2)2) Fentanyl 1-2 cc as tolerated IVFentanyl 1-2 cc as tolerated IV

3)3) Robinul 0.2 IVRobinul 0.2 IV

4)4) O2 NC @ 3-5L/Min (ALL patients)O2 NC @ 3-5L/Min (ALL patients)

InductionInduction

For ELECTIVE procedures, induction For ELECTIVE procedures, induction of GA should be done in a slow, of GA should be done in a slow, smooth, controlled fashion, often smooth, controlled fashion, often referred to as a cardiac inductionreferred to as a cardiac induction

Many studies have been done that Many studies have been done that have shown no difference in long-have shown no difference in long-term outcomes when different term outcomes when different anesthetic techniques are comparedanesthetic techniques are compared

InductionInduction

It should be emphasized that anesthetic It should be emphasized that anesthetic dose requirements are extremely variable dose requirements are extremely variable and generally are INVERSELY related to and generally are INVERSELY related to ventricular functionventricular function

Severely compromised patients should be Severely compromised patients should be given agents in small doses, slowly and in given agents in small doses, slowly and in incrementsincrements

In those cases, Etomidate or Ketamine In those cases, Etomidate or Ketamine may be your drugs of choice since they may be your drugs of choice since they are both associated with the least amount are both associated with the least amount of myocardial depressionof myocardial depression

InductionInduction

Several techniques are available for Several techniques are available for your use:your use:

1)1) High Dose Opioid AnesthesiaHigh Dose Opioid Anesthesia

2)2) Total Intravenous Anesthesia (TIVA)Total Intravenous Anesthesia (TIVA)

3)3) Mixed Intravenous/Inhalation Mixed Intravenous/Inhalation AnesthesiaAnesthesia

High Dose NarcoticsHigh Dose Narcotics

High dose opioid techniques were High dose opioid techniques were developed to circumvent the developed to circumvent the myocardial depression seen with the myocardial depression seen with the older inhalational agentsolder inhalational agents

Dose ranges are as follows:Dose ranges are as follows:

Fentanyl 50-100 mcg/kgFentanyl 50-100 mcg/kg

Sufenta 15-25 mcg/kgSufenta 15-25 mcg/kg

High Dose NarcoticsHigh Dose Narcotics Drawbacks to this technique are:Drawbacks to this technique are:1)1) PROLONGED postop respiratory PROLONGED postop respiratory

depression (12-24 hrs)depression (12-24 hrs)2)2) Very high incidence of patient Very high incidence of patient

awarenessawareness3)3) Often fails to control the hypertensive Often fails to control the hypertensive

response to stimulation in many response to stimulation in many patients with good LVFpatients with good LVF

4)4) Rigidity during IntubationRigidity during Intubation5)5) Postop IleusPostop Ileus

TIVATIVA TIVA techniques were developed for cost TIVA techniques were developed for cost

containment reasons since with these containment reasons since with these techniques, patients were extubated techniques, patients were extubated earlier, had shorter ICU stays, and had earlier, had shorter ICU stays, and had earlier hospital dischargeearlier hospital discharge

This technique usually employs induction This technique usually employs induction with a bolus of Propofol (0.5-1.5mg/kg with a bolus of Propofol (0.5-1.5mg/kg depending on Vent. Function)depending on Vent. Function)

This is usually followed by a Propofol This is usually followed by a Propofol infusion between 25-100mcg/kg/min infusion between 25-100mcg/kg/min depending on BP response to stimulidepending on BP response to stimuli

TIVATIVA

Usually, Remifentanil is added Usually, Remifentanil is added (1mcg/kg bolus) followed by an (1mcg/kg bolus) followed by an infusion of 0.25-1mcg/kg/mininfusion of 0.25-1mcg/kg/min

Since Remifentanil has such a short Since Remifentanil has such a short half life, it needs to be D/C’ed at the half life, it needs to be D/C’ed at the end of the case and usually MS is end of the case and usually MS is given for postop pain control (5-10 given for postop pain control (5-10 mg boluses titrated to BP and pulse)mg boluses titrated to BP and pulse)

Mixed IV/Inhalation Mixed IV/Inhalation AnesthesiaAnesthesia

Renewed interest in volatile Renewed interest in volatile anesthetics came about following anesthetics came about following several studies that demonstrated a several studies that demonstrated a protective effect of volatile protective effect of volatile anesthetics on ischemic myocardiumanesthetics on ischemic myocardium

This is especially valuable since the This is especially valuable since the newer volatile anesthetics have newer volatile anesthetics have much less myocardial depression much less myocardial depression than the older agents havethan the older agents have

Mixed AnesthesiaMixed Anesthesia

Induction is usually done with Induction is usually done with Propofol (0.5-1.5 mg/kg) or Propofol (0.5-1.5 mg/kg) or Etomidate (0.1-0.3 mg/kg)Etomidate (0.1-0.3 mg/kg)

Thiopental can also be used as an Thiopental can also be used as an induction agent (1-2 mg/kg)induction agent (1-2 mg/kg)

Narcotics are given in smaller doses Narcotics are given in smaller doses (Fentanyl 1-2 mcg/kg; Sufenta 0.25-(Fentanyl 1-2 mcg/kg; Sufenta 0.25-0.5 mcg/kg)0.5 mcg/kg)

Mixed AnesthesiaMixed Anesthesia A volatile anesthetic (0.5-1.5 MAC) is also A volatile anesthetic (0.5-1.5 MAC) is also

administered for maintenance of anesthesia administered for maintenance of anesthesia and to blunt the sympathetic response to and to blunt the sympathetic response to stimuli (Sevo or Iso)stimuli (Sevo or Iso)

Some clinicians also administer a low-dose Some clinicians also administer a low-dose propofol infusion (25-50 mcg/kg/min) for propofol infusion (25-50 mcg/kg/min) for maintenance as wellmaintenance as well

Couple all of this with a shorter acting Couple all of this with a shorter acting muscle relaxant (Zem or Nimbex) and you muscle relaxant (Zem or Nimbex) and you can usually wake up the patient and can usually wake up the patient and extubate them within 1-2 hours after extubate them within 1-2 hours after surgery)surgery)

Mixed AnesthesiaMixed Anesthesia

OF NOTE:OF NOTE: N2O is usually avoided N2O is usually avoided during Cardiac surgery that uses CPB during Cardiac surgery that uses CPB to avoid enlarging any bubbles that to avoid enlarging any bubbles that may enter into the circulation during may enter into the circulation during the procedurethe procedure

Other TechniquesOther Techniques

The combination of Ketamine (1-2 The combination of Ketamine (1-2 mg/kg for induction) with or w/o mg/kg for induction) with or w/o Versed (0.05-0.1mg/kg) for induction Versed (0.05-0.1mg/kg) for induction can also be used in patients with can also be used in patients with depressed ventricular functiondepressed ventricular function

This is usually followed by LOW dose This is usually followed by LOW dose narcotics (Fentanyl 0.5-1 mcg/kg) narcotics (Fentanyl 0.5-1 mcg/kg) and low dose volatile anesthetics and low dose volatile anesthetics (0.5 MAC) to provide amnesia during (0.5 MAC) to provide amnesia during the procedurethe procedure

Other TechniquesOther Techniques

If needed, additional boluses of Ketamine If needed, additional boluses of Ketamine (0.5-2 mg/kg) may be given during the (0.5-2 mg/kg) may be given during the procedure as dictated by the BIS reading if procedure as dictated by the BIS reading if the patient cannot tolerate the small doses the patient cannot tolerate the small doses of narcotics or the small doses of of narcotics or the small doses of inhalational agentsinhalational agents

In patients with severely depressed In patients with severely depressed ventricular function, Etomidate and O2 can ventricular function, Etomidate and O2 can be used as the sole anesthetic and be used as the sole anesthetic and additional boluses of Etomidate given also additional boluses of Etomidate given also dictated by the BIS readingdictated by the BIS reading

BreakBreak

Time!!!Time!!!

MuscleMuscle

RelaxantsRelaxants

Muscle RelaxantsMuscle Relaxants Muscle relaxation is necessary for Muscle relaxation is necessary for

intubation, to facilitate sternal intubation, to facilitate sternal retraction and to prevent patient retraction and to prevent patient movement and shiveringmovement and shivering

Unless airway difficulty is anticipated, Unless airway difficulty is anticipated, intubation is usually done through the intubation is usually done through the use of NON-depolarizing NMB’suse of NON-depolarizing NMB’s

The choice of agent is solely based on The choice of agent is solely based on the desired hemodynamic responsethe desired hemodynamic response

Muscle RelaxantsMuscle Relaxants

Ideally, the agent should be devoid of Ideally, the agent should be devoid of significant cardiovascular side effectssignificant cardiovascular side effects

Rocuronium and Vecuronium are Rocuronium and Vecuronium are MOST commonly usedMOST commonly used

Pancuronium can be used in patients Pancuronium can be used in patients with depressed ventricular functionwith depressed ventricular function

Atricurium should be avoided due to Atricurium should be avoided due to possible hypotension from histamine possible hypotension from histamine releaserelease

Muscle RelaxantsMuscle Relaxants

SUX should be considered for SUX should be considered for endotracheal intubation if the endotracheal intubation if the potential for difficult airway exists or potential for difficult airway exists or in full stomach inductionsin full stomach inductions

A nerve stimulator is mandatory to A nerve stimulator is mandatory to use along with ANY NMB especially if use along with ANY NMB especially if early extubation is being plannedearly extubation is being planned

BaptistBaptist

TechniquesTechniques

Baptist TechniqueBaptist Technique What my Induction technique was, is as What my Induction technique was, is as

follows:follows:1)1) Slowly in 2-3cc increments, I would give Slowly in 2-3cc increments, I would give

10cc Fentanyl as tolerated10cc Fentanyl as tolerated2)2) That would be followed with 10-15cc of That would be followed with 10-15cc of

Propofol again as tolerated and by BIS Propofol again as tolerated and by BIS readingsreadings

3)3) Then Zemuron 50mg (or Vec 10cc)Then Zemuron 50mg (or Vec 10cc)4)4) I would mask ventilate with 100% FiO2 I would mask ventilate with 100% FiO2

until paralyzed and then Intubateuntil paralyzed and then Intubate

Baptist InductionBaptist Induction

5) Again, depending on the BIS reading, if it 5) Again, depending on the BIS reading, if it was still above 60 after the was still above 60 after the Fentanyl/Propofol combo, I would ventilate Fentanyl/Propofol combo, I would ventilate with 2-3% Sevoflurane, or 0.5-1% Isoflurane with 2-3% Sevoflurane, or 0.5-1% Isoflurane until paralyzed and then intubate once my until paralyzed and then intubate once my BIS reading was below 60 (preferably 40-50)BIS reading was below 60 (preferably 40-50)

6) Men would get an 8.0 ETT and women 6) Men would get an 8.0 ETT and women would get a 7.5ETT since I would be would get a 7.5ETT since I would be anticipating postop ventilation for at least 2-anticipating postop ventilation for at least 2-3 hours3 hours

Baptist InductionBaptist Induction

7) At that point, I would set my Sevo on 7) At that point, I would set my Sevo on 2% or Iso on 1% and gown and glove 2% or Iso on 1% and gown and glove up to insert my Introducer and SG cathup to insert my Introducer and SG cath

8) During the insertion, if hypotension 8) During the insertion, if hypotension would develop, I would instruct my would develop, I would instruct my assistant to turn down/or off the gas assistant to turn down/or off the gas and give 5-10mg ephedrine or 50-and give 5-10mg ephedrine or 50-100mcg of Neo depending on the 100mcg of Neo depending on the heart rateheart rate

Baptist MaintenanceBaptist Maintenance

9) Once my SG was in place, depending on 9) Once my SG was in place, depending on the BIS reading I would dial in volatile the BIS reading I would dial in volatile agents as needed to keep it 40-50agents as needed to keep it 40-50

10) Right before STERNOTOMY I would give 10) Right before STERNOTOMY I would give another 5-10cc Fentanyl depending on the another 5-10cc Fentanyl depending on the ventricular functionventricular function

11) Right before going on bypass, I would 11) Right before going on bypass, I would give another 5-10cc Fentanyl and another give another 5-10cc Fentanyl and another FULL intubating dose of an NMB (usually FULL intubating dose of an NMB (usually Zem 50, or Vec 10mg)Zem 50, or Vec 10mg)

Baptist TechniqueBaptist Technique

12) Once it was confirmed that we were 12) Once it was confirmed that we were on FULL bypass, the vent would be on FULL bypass, the vent would be turned off, Pop-off set to full open, and turned off, Pop-off set to full open, and Reservoir bag removed and the system Reservoir bag removed and the system left open to air (I know it seems weird left open to air (I know it seems weird to TURN OF your vent but remember, to TURN OF your vent but remember, oxygenation is NOW being done by the oxygenation is NOW being done by the CPB Machine and the surgeon can’t CPB Machine and the surgeon can’t work with a pair of lungs expanding work with a pair of lungs expanding and contracting in his OR field)and contracting in his OR field)

Baptist TechniqueBaptist Technique

13) Also at that time, your Vaporizers 13) Also at that time, your Vaporizers need to be turned off completely as need to be turned off completely as wellwell

14) During bypass, I would be guided 14) During bypass, I would be guided by my BIS monitor; if it would start to by my BIS monitor; if it would start to creep up close to 50-55, I would give creep up close to 50-55, I would give another 5cc Fentanyl; if it would stay another 5cc Fentanyl; if it would stay stable at 30,40,50 I would do nothing stable at 30,40,50 I would do nothing but watch the surgery and anticipate but watch the surgery and anticipate coming off bypasscoming off bypass

Baptist Technique IIBaptist Technique II

For sicker patients or patients with poor For sicker patients or patients with poor ventricular function, I would approach the ventricular function, I would approach the situation differently:situation differently:

INDUCTION: Induction was usually done with INDUCTION: Induction was usually done with Etomidate (0.2-0.3mg/kg) followed by a Etomidate (0.2-0.3mg/kg) followed by a muscle relaxant; if that was tolerated well muscle relaxant; if that was tolerated well then Fentanyl 3-5cc was also given and then Fentanyl 3-5cc was also given and another Fentanyl 3-5cc right before another Fentanyl 3-5cc right before sternotomy OR Etomidate at half an sternotomy OR Etomidate at half an induction dose bolus right before induction dose bolus right before sternotomysternotomy

Baptist Techniques IIBaptist Techniques II

Regardless of sick or not, you always Regardless of sick or not, you always run 100% FiO2 to maximize run 100% FiO2 to maximize oxygenation to the myocardiumoxygenation to the myocardium

In the sicker patients, your entire In the sicker patients, your entire anesthetic can be Etomidate given in anesthetic can be Etomidate given in periodic boluses at the appropriate periodic boluses at the appropriate moments (Induction, Pre-sternotomy, moments (Induction, Pre-sternotomy, coming off bypass, at end before coming off bypass, at end before transfer to ICU) transfer to ICU)

Pre-BypassPre-Bypass

PeriodPeriod

Pre-bypass PeriodPre-bypass Period

Following induction and intubation, Following induction and intubation, the anesthetic course is typically the anesthetic course is typically characterized by an initial period of characterized by an initial period of minimal stimulation (prep and minimal stimulation (prep and draping) that is frequently associated draping) that is frequently associated with periods of hypotensionwith periods of hypotension

These periods of hypotension will be These periods of hypotension will be interspersed with periods of INTENSE interspersed with periods of INTENSE stimulation (Skin incision, stimulation (Skin incision, Sternotomy) that can induce Sternotomy) that can induce hypertension and tachycardiahypertension and tachycardia

Pre-bypass PeriodPre-bypass Period Your anesthetic agent(s) should be adjusted Your anesthetic agent(s) should be adjusted

appropriately IN ANTICIPATION of these appropriately IN ANTICIPATION of these periods of stimulationperiods of stimulation

Sternal retraction may be associated with Sternal retraction may be associated with periods of bradycardia that may need periods of bradycardia that may need treatment with ephedrine or atropinetreatment with ephedrine or atropine

Deeply anesthetized patients may have a Deeply anesthetized patients may have a gradual decrease in CO once the chest is gradual decrease in CO once the chest is opened due to decreased venous return opened due to decreased venous return since now the chest is open to normal since now the chest is open to normal atmospheric pressure and the negative atmospheric pressure and the negative intrathoracic pressure that draws blood into intrathoracic pressure that draws blood into the chest is lostthe chest is lost

Pre-bypass PeriodPre-bypass Period

Myocardial ischemia in the pre-bypass Myocardial ischemia in the pre-bypass period is often but not always period is often but not always associated with tachycardia, associated with tachycardia, hypertension, or hypotensionhypertension, or hypotension

Use of a balanced technique Use of a balanced technique incorporating narcotics AND volatile incorporating narcotics AND volatile agents can give you a better degree agents can give you a better degree of control of hemodynamic of control of hemodynamic parameters rather than using only parameters rather than using only one drug by itselfone drug by itself

SternotomySternotomy

A WORD ABOUT STERNOTOMY:A WORD ABOUT STERNOTOMY:

When it is time for sternotomy, the When it is time for sternotomy, the surgeon will give a command “LUNGS surgeon will give a command “LUNGS DOWN”; If the lungs are inflated during DOWN”; If the lungs are inflated during sternotomy he can possible slice right sternotomy he can possible slice right through themthrough them

IT IS NOT ENOUGH JUST TO TURN YOUR IT IS NOT ENOUGH JUST TO TURN YOUR VENT OFF; DISCONNECT THE “INLET” SIDE VENT OFF; DISCONNECT THE “INLET” SIDE OF THE CIRCUIT (going TO the patient) and OF THE CIRCUIT (going TO the patient) and hold it while Sternotomy is madehold it while Sternotomy is made


This serves TWO purposes:This serves TWO purposes:

1)1) Makes sure there is NO AIR going into the Makes sure there is NO AIR going into the lungslungs

2)2) You will REMEMBER that the breathing is You will REMEMBER that the breathing is off by having the circuit in YOUR HAND!!off by having the circuit in YOUR HAND!!

(A COMMON problem is forgetting to turn (A COMMON problem is forgetting to turn the vent back ON!! It really does the vent back ON!! It really does happen, so work it into your routine that happen, so work it into your routine that you always remember to turn the vent you always remember to turn the vent back on)back on)

CommunicationCommunication This is a good opportunity to bring up the This is a good opportunity to bring up the

subject of communication: ALWAYS subject of communication: ALWAYS COMMUNICATE WITH THE SURGEON AND COMMUNICATE WITH THE SURGEON AND PUMP TECHPUMP TECH

It is a good habit to get into to REPEAT It is a good habit to get into to REPEAT orders given to you by the surgeonorders given to you by the surgeon

An example is when he/she says “Lungs An example is when he/she says “Lungs Down”, you acknowledge “Lungs Down” Down”, you acknowledge “Lungs Down” both as a confirmation that you heard and both as a confirmation that you heard and also as a signal that you have done what is also as a signal that you have done what is asked of youasked of you

CommunicationCommunication

This is a good habit to have between This is a good habit to have between you and all the major players in the you and all the major players in the roomroom

Especially coming off bypass when the Especially coming off bypass when the surgeon gives you orders to start surgeon gives you orders to start drips, etc. you always acknowledge drips, etc. you always acknowledge “NTG @ 5mcgms” or “Neo/Epi @ 10cc”“NTG @ 5mcgms” or “Neo/Epi @ 10cc”

Then he knows it’s done and you have Then he knows it’s done and you have just double checked in your own head just double checked in your own head what was asked of youwhat was asked of you

SternotomySternotomy There are TWO ways to do a There are TWO ways to do a

sternotomy:sternotomy:1)1) A regular sternal saw on a “Virgin” A regular sternal saw on a “Virgin”

chestchest2)2) A “Recipricating” saw on a Redo chestA “Recipricating” saw on a Redo chestThe regular saw looks like a Jig saw with a The regular saw looks like a Jig saw with a

guard on the bladeguard on the bladeThe recipricating saw has a round wheel The recipricating saw has a round wheel

that cuts from the top down with that cuts from the top down with pressurepressure


The reason for the two saws is that The reason for the two saws is that with a REDO there may be structures with a REDO there may be structures that have healed and are “stuck” to that have healed and are “stuck” to the underside of the sternum and the underside of the sternum and with a regular saw, you will cut right with a regular saw, you will cut right through these structuresthrough these structures

The REDO saw cuts from the TOP The REDO saw cuts from the TOP down and as soon as the bone is cut down and as soon as the bone is cut through, then the surgeon stops and through, then the surgeon stops and moves down to the next spotmoves down to the next spot

Redo SternotomyRedo Sternotomy

WITH A REDO CASE: ALWAYS be WITH A REDO CASE: ALWAYS be ready for the shit to HIT THE FAN ready for the shit to HIT THE FAN after sternotomy just in case after sternotomy just in case anything vital is sawed throughanything vital is sawed through

Have your fluids ready, your heparin Have your fluids ready, your heparin ready for a STAT heparinization and ready for a STAT heparinization and be ready to go on CPB in a matter of be ready to go on CPB in a matter of minutes (even seconds if the surgeon minutes (even seconds if the surgeon is fast enough!!)is fast enough!!)

AnticoagulationAnticoagulation


Anticoagulation must be established Anticoagulation must be established prior to CPB to prevent acute DIC and prior to CPB to prevent acute DIC and formation of clots in the CPB pumpformation of clots in the CPB pump

The adequacy of anticoagulation The adequacy of anticoagulation MUST be confirmed by a test called MUST be confirmed by a test called an ACT (Activated Clotting Test)an ACT (Activated Clotting Test)

An ACT longer than 400-500 sec. is An ACT longer than 400-500 sec. is considered SAFE at most centersconsidered SAFE at most centers

AnticoagulationAnticoagulation The The Heparin doseHeparin dose that is usually given that is usually given

prior to measurement of an ACT is prior to measurement of an ACT is 300-400 300-400 U/kgU/kg

The dose of heparin is usually given at the The dose of heparin is usually given at the point in surgery where the Aortic Purse point in surgery where the Aortic Purse string sutures are being placed prior to string sutures are being placed prior to cannulationcannulation

Some surgeons prefer to administer the Some surgeons prefer to administer the heparin themselves while others leave it up heparin themselves while others leave it up to Anesthesia or the Pump techsto Anesthesia or the Pump techs

Usually the pump tech will determine the Usually the pump tech will determine the exact dose to be given and communicate it exact dose to be given and communicate it to you prior to administrationto you prior to administration


Commonly, doses of Heparin that will Commonly, doses of Heparin that will be given are between 28,000 U to be given are between 28,000 U to 40,000 U40,000 U

For this purpose, Heparin comes in a For this purpose, Heparin comes in a special vial with a concentration of special vial with a concentration of 10,000 U per 1cc instead of the 10,000 U per 1cc instead of the normal 1,000 U /ccnormal 1,000 U /cc

MAKE SURE YOU ARE USING THE MAKE SURE YOU ARE USING THE CORRECT CONCENTRATIONCORRECT CONCENTRATION

AnticoagulationAnticoagulation If need be, in an emergency, a 3.5cc If need be, in an emergency, a 3.5cc

dose of 10,000 U/cc Heparin is usually dose of 10,000 U/cc Heparin is usually sufficient to get an ACT between 400-sufficient to get an ACT between 400-500 Sec. so remember “3.5cc in an 500 Sec. so remember “3.5cc in an emergency”emergency”

If the Heparin is administered by the If the Heparin is administered by the anesthesiologist, it should normally be anesthesiologist, it should normally be administered through a Central Line and administered through a Central Line and the ACT should be measured between 3-the ACT should be measured between 3-5 min POST heparin dose being given5 min POST heparin dose being given


There are times that the surgeon will be There are times that the surgeon will be waiting for the ACT prior to beginning his waiting for the ACT prior to beginning his surgery so there may be times that you surgery so there may be times that you are pressured to HURRY the 3 min. needed are pressured to HURRY the 3 min. needed post Heparin, BUT DON’Tpost Heparin, BUT DON’T

Again if you go on bypass and the ACT was Again if you go on bypass and the ACT was not in the correct range, you can easily not in the correct range, you can easily KILL a patient and the blame will be placed KILL a patient and the blame will be placed on you so stand fast and stick to the on you so stand fast and stick to the protocolprotocol

AnticoagulationAnticoagulation Occasionally, resistance to Heparin is Occasionally, resistance to Heparin is

encountered in patients with Antithrombin encountered in patients with Antithrombin III deficiencyIII deficiency

Patients with Antithrombin III deficiency Patients with Antithrombin III deficiency will achieve normal anticoagulation after will achieve normal anticoagulation after receiving 2 U of FFPreceiving 2 U of FFP

In some instances, it may take double the In some instances, it may take double the normal dose of heparin to achieve normal normal dose of heparin to achieve normal ACT response (400-500 Sec) in some of ACT response (400-500 Sec) in some of these patients these patients

Bleeding ProphylaxisBleeding Prophylaxis Bleeding prophylaxis with Bleeding prophylaxis with

ANTIFIBRINOLYTIC AGENTS may be ANTIFIBRINOLYTIC AGENTS may be initiated before or after anticoagulationinitiated before or after anticoagulation

APROTININ therapy should be considered APROTININ therapy should be considered in patients who:in patients who:

1)1) Are undergoing a repeat operationAre undergoing a repeat operation2)2) In patients who refuse blood products In patients who refuse blood products

(i.e. Jehovah’s Witnesses)(i.e. Jehovah’s Witnesses)3)3) Who are at high risk for postop bleeding Who are at high risk for postop bleeding

because of preop therapy with Plavix, because of preop therapy with Plavix, Rheo pro, Ticlid, etc.Rheo pro, Ticlid, etc.

AprotininAprotinin Although the exact mechanism is not Although the exact mechanism is not

known, Aprotinin is an inhibitor of serine known, Aprotinin is an inhibitor of serine proteases that lead to platelet proteases that lead to platelet dysfunctiondysfunction

Its most important action is to preserve Its most important action is to preserve platelet function (adhesiveness and platelet function (adhesiveness and aggregation)aggregation)

Aprotinin therapy is highly effective in Aprotinin therapy is highly effective in reducing periop and postop blood loss reducing periop and postop blood loss and transfusion requirements (by 40-and transfusion requirements (by 40-80%)80%)

AprotininAprotinin It also seems to blunt the intense It also seems to blunt the intense

inflammatory response to CPB inflammatory response to CPB SERIOUS ALLERGIC REACTIONS can occur in a SERIOUS ALLERGIC REACTIONS can occur in a

small number of patients so a test dose of 1cc small number of patients so a test dose of 1cc is usually given to ALL patients receiving is usually given to ALL patients receiving AprotininAprotinin

The 1cc test dose is given and if there will be The 1cc test dose is given and if there will be an allergic reaction it is going to occur within an allergic reaction it is going to occur within 5 min. and manifest as drastic reductions in 5 min. and manifest as drastic reductions in BPBP

Some people have complete anaphylactic Some people have complete anaphylactic reactions that require Rx w/Epinephrinereactions that require Rx w/Epinephrine

AprotininAprotinin Reactions are also more likely to occur Reactions are also more likely to occur

upon repeat exposureupon repeat exposure Some surgeons reserve the use of Some surgeons reserve the use of

Aprotinin for difficult cases involving the Aprotinin for difficult cases involving the aorta and the replacement of part of the aorta and the replacement of part of the arch as in Aortic aneurysms or for repeat arch as in Aortic aneurysms or for repeat proceduresprocedures

Others use it routinely with ALL their cases Others use it routinely with ALL their cases as they believe that it significantly reduces as they believe that it significantly reduces the need for periop and postop transfusion the need for periop and postop transfusion requirementsrequirements

CannulationCannulation


Cannulation for CPB is a critical timeCannulation for CPB is a critical time AFTER heparinization, AORTIC AFTER heparinization, AORTIC

cannulation is usually done first so cannulation is usually done first so that if any rapid fluid infusions need that if any rapid fluid infusions need to be done to support the BP at this to be done to support the BP at this critical time, it can be done rapidlycritical time, it can be done rapidly

Next is Venous cannulation and Next is Venous cannulation and either one or two venous cannulas either one or two venous cannulas will be placedwill be placed


If one cannula is used, it will be placed in If one cannula is used, it will be placed in the Right Atriumthe Right Atrium

If two are used they will be placed in the If two are used they will be placed in the vena cavae, one Superior, the other vena cavae, one Superior, the other InferiorInferior

There can be quite a bit of blood loss There can be quite a bit of blood loss associated with venous cannulation so associated with venous cannulation so that is another reason why the aortic is that is another reason why the aortic is placed first, so any blood loss with venous placed first, so any blood loss with venous cannulation can be rapidly compensated cannulation can be rapidly compensated for through the aortic cannulafor through the aortic cannula


Venous cannulation frequently precipitates Venous cannulation frequently precipitates atrial, or less common, ventricular arrhythmiasatrial, or less common, ventricular arrhythmias

PAC’s and transient bursts of SVT’s are PAC’s and transient bursts of SVT’s are commoncommon

In rarer cases, sustained Atrial tachycardia In rarer cases, sustained Atrial tachycardia and A-fib can occur causing significant and A-fib can occur causing significant alteration in hemodynamicsalteration in hemodynamics

This is usually fixed by going on bypass and This is usually fixed by going on bypass and administering cardioplegia to quiet the heart administering cardioplegia to quiet the heart and discontinue the problem arrhythmiasand discontinue the problem arrhythmias

BypassBypass

PeriodPeriod

Bypass PeriodBypass Period

Once the cannulas are properly Once the cannulas are properly placed and secured, the ACT is placed and secured, the ACT is acceptable and the pump tech is acceptable and the pump tech is ready, CPB is initiatedready, CPB is initiated

The venous clamp and aortic clamp The venous clamp and aortic clamp are released from the pump lines and are released from the pump lines and the heart gradually begins to emptythe heart gradually begins to empty

Cardioplegia is administered to quiet Cardioplegia is administered to quiet the heart and cooling is begunthe heart and cooling is begun


Once the pump tech lets you know that Once the pump tech lets you know that you are on FULL bypass, you can shut you are on FULL bypass, you can shut down the ventilator, open the system down the ventilator, open the system to room air and NOW begin your to room air and NOW begin your preparation for coming OFF bypasspreparation for coming OFF bypass

You will need to organize your You will need to organize your emergency drugs (Neo, Ephedrine, Epi) emergency drugs (Neo, Ephedrine, Epi) and you will also need to organize your and you will also need to organize your DRIPS to be used if neededDRIPS to be used if needed


Standard Drips usually include:Standard Drips usually include:1)1) NTG and/or Nipride dripsNTG and/or Nipride drips2)2) Neosynephrine dripNeosynephrine drip3)3) Epinephrine dripEpinephrine drip4)4) A Combo Neo/Epi drip if used A Combo Neo/Epi drip if used

instead of single dripsinstead of single drips5)5) Levophed drip if usedLevophed drip if used6)6) Lidocaine drip if usedLidocaine drip if used

Bypass PeriodBypass Period ALL of these drips should be run through a ALL of these drips should be run through a

MANIFOLD with a carrier solution and MANIFOLD with a carrier solution and hooked up to a PA cath port (either distal or hooked up to a PA cath port (either distal or Infusion port)Infusion port)

You should also ready some muscle You should also ready some muscle relaxant, some Fentanyl, possibly some relaxant, some Fentanyl, possibly some VersedVersed

We had a rule that when we were coming We had a rule that when we were coming off pump we would give Versed 4-8 mg off pump we would give Versed 4-8 mg regardless of the BIS reading to prevent regardless of the BIS reading to prevent recall (a surgeon created rule that no recall (a surgeon created rule that no amount of logic could change!!!)amount of logic could change!!!)


Anesthesia during the bypass period Anesthesia during the bypass period will be guided by your BIS monitorwill be guided by your BIS monitor

Hypothermia (<34 degrees C) itself is Hypothermia (<34 degrees C) itself is usually enough anesthesia to suffice usually enough anesthesia to suffice but if your BIS starts to creep up, you but if your BIS starts to creep up, you have a multitude of choices to usehave a multitude of choices to use

Fentanyl, Etomidate, Propofol, Fentanyl, Etomidate, Propofol, Ketamine, Versed are ALL valid Ketamine, Versed are ALL valid choices to use to treat an elevated BIS choices to use to treat an elevated BIS during bypassduring bypass

Control of Blood Control of Blood PressurePressure

During bypass there may be periods During bypass there may be periods when your BIS reading is acceptable but when your BIS reading is acceptable but the BP rises. There are several options the BP rises. There are several options available to you:available to you:

1)1) Give more anesthetic regardless of the Give more anesthetic regardless of the BIS levelBIS level

2)2) Start a NTG drip or give the Pump Tech Start a NTG drip or give the Pump Tech some NTG in a syringe and they will some NTG in a syringe and they will gradually titrate it to a lower BPgradually titrate it to a lower BP

3)3) The Pump Tech can start giving their The Pump Tech can start giving their Inhalational agent via their machine Inhalational agent via their machine along with the oxygen being bubbled along with the oxygen being bubbled through the blood:gas interfacethrough the blood:gas interface

RewarmingRewarming

Once the surgical procedure is about ¾ Once the surgical procedure is about ¾ finished, the surgeon will give the finished, the surgeon will give the command to REWARMcommand to REWARM

The blood will be warmed in the pump The blood will be warmed in the pump to approx. 39 degrees C and circulated to approx. 39 degrees C and circulated throughout the body while you watch throughout the body while you watch your temp monitors closelyyour temp monitors closely

THIS IS THE TIME OF MAXIMUM RECALLTHIS IS THE TIME OF MAXIMUM RECALL

RewarmingRewarming Over 80% of patient recall postop can be Over 80% of patient recall postop can be

traced back to the REWARMING periodtraced back to the REWARMING period Most of this data was collected prior to Most of this data was collected prior to

institution of the use of the BIS monitorinstitution of the use of the BIS monitor Now, with the BIS monitor, recall incidents Now, with the BIS monitor, recall incidents

have decreased by over 75%have decreased by over 75% Just watch your BIS and if it climbs as the Just watch your BIS and if it climbs as the

patient rewarms, administer a bolus of any patient rewarms, administer a bolus of any of the drugs that we have just previously of the drugs that we have just previously mentioned mentioned

RewarmingRewarming

If you have started with a drug then usually If you have started with a drug then usually stick to that drug, or mix and matchstick to that drug, or mix and match

Many clinicians (pre-BIS) would routinely Many clinicians (pre-BIS) would routinely administer Versed 5-10mg IV or Scopolamine administer Versed 5-10mg IV or Scopolamine 0.2-0.4mg when rewarming is initiated0.2-0.4mg when rewarming is initiated

Sweating during rewarming is NOT an Sweating during rewarming is NOT an indication of light anesthesia rather it is a indication of light anesthesia rather it is a hypothalamic reflex to perfusion with blood hypothalamic reflex to perfusion with blood at 39 degrees Cat 39 degrees C

It occurs very commonly during rewarmingIt occurs very commonly during rewarming

TerminationTermination

OfOf

CPBCPB

Termination of CPBTermination of CPB

Discontinuation of bypass is Discontinuation of bypass is accomplished by a series of necessary accomplished by a series of necessary procedures and conditions:procedures and conditions:

1)1) Rewarming must be completedRewarming must be completed

2)2) Air must be evacuated from the heart Air must be evacuated from the heart and any bypass graftsand any bypass grafts

3)3) The Aortic cross-clamp must be The Aortic cross-clamp must be removedremoved

4)4) Lung ventilation must be resumedLung ventilation must be resumed


The surgeon’s decision about when The surgeon’s decision about when to rewarm is criticalto rewarm is critical

Adequate rewarming requires time, Adequate rewarming requires time, BUT rewarming too soon removes BUT rewarming too soon removes the protective effects of hypothermiathe protective effects of hypothermia

Rapid rewarming often results in Rapid rewarming often results in large temperature gradients between large temperature gradients between well-perfused organs and peripheral well-perfused organs and peripheral vasoconstricted tissuesvasoconstricted tissues


It is a common occurrence that soon after It is a common occurrence that soon after discontinuation of CPB, there is a discontinuation of CPB, there is a significant drop in temperature as the significant drop in temperature as the peripheral locations equilibrate with the peripheral locations equilibrate with the more perfused organs to cause a lower more perfused organs to cause a lower overall body temperatureoverall body temperature

Excessively rapid rewarming can result in Excessively rapid rewarming can result in the formation of gas bubbles in the blood the formation of gas bubbles in the blood stream as the solubility of gases rapidly stream as the solubility of gases rapidly decreases with increased tempdecreases with increased temp


It is not uncommon that the heart It is not uncommon that the heart develops arrhythmias during develops arrhythmias during rewarmingrewarming

It can even go into V-fib which It can even go into V-fib which requires immediate defibrillation by requires immediate defibrillation by internal paddles at 5-10 Jinternal paddles at 5-10 J

You can assist in this process by You can assist in this process by administering Lidocaine 100-200mg administering Lidocaine 100-200mg and Magnesium 1-2gms prior to the and Magnesium 1-2gms prior to the removal of the aortic cross-clampremoval of the aortic cross-clamp


Many clinicians advocate a head-Many clinicians advocate a head-down position while intracardiac air down position while intracardiac air is being evacuated to decrease the is being evacuated to decrease the likelihood of cerebral embolilikelihood of cerebral emboli

TEE can be used to assess when the TEE can be used to assess when the intracardiac air is completely intracardiac air is completely evacuated (you can see the tiny evacuated (you can see the tiny bubbles bouncing around and can bubbles bouncing around and can watch them gradually dissipate until watch them gradually dissipate until they are gone)they are gone)


During this period you will be asked to During this period you will be asked to reinflate the lungsreinflate the lungs

Initial inflation may require higher than Initial inflation may require higher than normal insp. pressures (40-50mm H2O)normal insp. pressures (40-50mm H2O)

You should do this while using direct You should do this while using direct vision so you can see how the lungs vision so you can see how the lungs inflate and DO NOT over-inflate them inflate and DO NOT over-inflate them or you can interfere with the surgical or you can interfere with the surgical procedure or grafts that have been procedure or grafts that have been placedplaced


General guidelines for separation General guidelines for separation from CPB include the following:from CPB include the following:

1)1) The core body temperature should The core body temperature should be at least 37 degrees Cbe at least 37 degrees C

2)2) A stable rhythm (preferably sinus) A stable rhythm (preferably sinus) must be presentmust be present

3)3) The Heart rate must be adequate The Heart rate must be adequate (generally 80-100 beats/min)(generally 80-100 beats/min)


4) Lab values must be within acceptable 4) Lab values must be within acceptable limits. Significant acidosis (pH<7.20), limits. Significant acidosis (pH<7.20), hypocalcemia, and hyperkalemia hypocalcemia, and hyperkalemia (>5.5mEq/L) should be treated; (>5.5mEq/L) should be treated; hematocrit must be at least 22-25%hematocrit must be at least 22-25%

5) Adequate ventilation with 100% O2 5) Adequate ventilation with 100% O2 must have been resumedmust have been resumed

6) ALL monitors should be rechecked for 6) ALL monitors should be rechecked for proper function and recalibrated if proper function and recalibrated if necessarynecessary

Weaning from CPBWeaning from CPB Discontinuation of CPB should be gradual as Discontinuation of CPB should be gradual as

systemic arterial pressure, ventricular systemic arterial pressure, ventricular volumes and filling pressures, and CO are volumes and filling pressures, and CO are assessedassessed

Central aortic pressure can be estimated by Central aortic pressure can be estimated by palpation by the surgeonpalpation by the surgeon

Vent. Volume and contractility can be Vent. Volume and contractility can be estimated VISUALLY whereas filling pressures estimated VISUALLY whereas filling pressures are measured using the wedge pressuresare measured using the wedge pressures

CO can be measured by thermodilutionCO can be measured by thermodilution TEE also provides all of this same information TEE also provides all of this same information

by direct visualization in real-timeby direct visualization in real-time

Weaning from CPBWeaning from CPB Weaning is accomplished by progressively Weaning is accomplished by progressively

clamping the venous return line to the CPB clamping the venous return line to the CPB machine and allowing the heart to machine and allowing the heart to gradually fill and ejectgradually fill and eject

Pump flow is gradually decreased as Pump flow is gradually decreased as systemic arterial pressure risessystemic arterial pressure rises

Once the venous line is completely Once the venous line is completely occluded and the systolic arterial pressure occluded and the systolic arterial pressure is >80-90mm Hg, pump flow is stopped is >80-90mm Hg, pump flow is stopped and the patient is evaluatedand the patient is evaluated

Weaning from CPBWeaning from CPB

Most patients fall into one of the Most patients fall into one of the following four groups when coming following four groups when coming off bypass (see next slide)off bypass (see next slide)

Patients with good ventricular Patients with good ventricular function are usually quick to develop function are usually quick to develop good blood pressure and cardiac good blood pressure and cardiac output and can be separated from output and can be separated from CPB immediatelyCPB immediately


Hypovolemic patients are a mixed Hypovolemic patients are a mixed group that includes both patients with group that includes both patients with nl VF and those with varying degrees of nl VF and those with varying degrees of impairmentimpairment

Patients with pump failure emerge from Patients with pump failure emerge from CPB with a sluggish, poorly contracting CPB with a sluggish, poorly contracting heart that progressively distendsheart that progressively distends

In these cases, CPB is restarted until In these cases, CPB is restarted until adequate inotropic therapy can be adequate inotropic therapy can be used to augment function and support used to augment function and support the heart as it comes off of CPBthe heart as it comes off of CPB


In patients who have trouble coming In patients who have trouble coming off of CPB, other causes need to be off of CPB, other causes need to be investigated and eliminatedinvestigated and eliminated

The patient should be evaluated for The patient should be evaluated for unrecognized ischemia (kinked graft, unrecognized ischemia (kinked graft, coronary vasospasm), valvular coronary vasospasm), valvular dysfunction, shunting, or right dysfunction, shunting, or right ventricular failure (distention ventricular failure (distention primarily in the right ventricle)primarily in the right ventricle)


TEE may be used to diagnose many of TEE may be used to diagnose many of the reasons why the patient may not the reasons why the patient may not be able to come of CPB smoothly and be able to come of CPB smoothly and easilyeasily

If inotropes and afterload reduction fail If inotropes and afterload reduction fail to remedy the situation, an Intraaortic to remedy the situation, an Intraaortic balloon pump can be insertedballoon pump can be inserted

An IABP helps rest the heart and can An IABP helps rest the heart and can reduce O2 demand by approx. 50%reduce O2 demand by approx. 50%

Post-bypassPost-bypass

PeriodPeriod

Post-bypass PeriodPost-bypass Period

During the post-bypass period, bleeding is During the post-bypass period, bleeding is controlled, bypass cannulas are removed, controlled, bypass cannulas are removed, anticoagulation is reversed and the chest anticoagulation is reversed and the chest is closedis closed

Systolic pressure is usually maintained at Systolic pressure is usually maintained at 90-100 mm Hg to minimize bleeding90-100 mm Hg to minimize bleeding

Venous cannulas are removed first before Venous cannulas are removed first before the aortic cannula in case the aortic the aortic cannula in case the aortic cannula is needed for rapid infusion of cannula is needed for rapid infusion of volume or bloodvolume or blood

Post-bypass PeriodPost-bypass Period

Most patients need additional blood Most patients need additional blood volume subsequent to termination of volume subsequent to termination of CPBCPB

Administration of blood, colloids, and Administration of blood, colloids, and crystalloid fluid is guided by filling crystalloid fluid is guided by filling pressures and post bypass pressures and post bypass hematocrithematocrit

A final hematocrit of 25-30% is A final hematocrit of 25-30% is generally desirablegenerally desirable

Reversal of Reversal of AnticoagulationAnticoagulation

Once hemostasis is judged acceptable and Once hemostasis is judged acceptable and the patient continues to remain stable, the patient continues to remain stable, heparin activity is reversed with heparin activity is reversed with PROTAMINEPROTAMINE

PROTAMINE is a protein that binds to and PROTAMINE is a protein that binds to and effectively inactivates heparineffectively inactivates heparin

There are several techniques for There are several techniques for administration of Protamine, but administration of Protamine, but regardless of which technique is used, an regardless of which technique is used, an ACT is done 3-5 min. after reversal is givenACT is done 3-5 min. after reversal is given


The simplest technique to calculate the dose of The simplest technique to calculate the dose of Protamine is to base the dose of Protamine on the Protamine is to base the dose of Protamine on the dose of heparin given totaldose of heparin given total

The Protamine is given in a ratio of 1-1.3mg of The Protamine is given in a ratio of 1-1.3mg of Protamine for every 100 U of Heparin givenProtamine for every 100 U of Heparin given

The dose is usually calculated by the pump tech The dose is usually calculated by the pump tech and is reported to you for administrationand is reported to you for administration

It is usually on a CC per CC basis with the Heparin It is usually on a CC per CC basis with the Heparin (30cc of Hep given; 30cc of Protamine given)(30cc of Hep given; 30cc of Protamine given)

The concentration of Protamine is 10mg/ccThe concentration of Protamine is 10mg/cc After administration of Protamine the ACT should After administration of Protamine the ACT should

return to baselinereturn to baseline


IMPORTANT SAFETY POINT:IMPORTANT SAFETY POINT: DO NOT DO NOT draw up your Protamine until it is time to draw up your Protamine until it is time to give it EVEN if it is labeled and set asidegive it EVEN if it is labeled and set aside

If Protamine is inadvertently given prior If Protamine is inadvertently given prior to its need, it will cause massive to its need, it will cause massive coagulation within the CPB pump and coagulation within the CPB pump and tubing and lead to patient DEATH very tubing and lead to patient DEATH very quickly!!!quickly!!!

GIVE YOUR PROTAMINE THROUGH A GIVE YOUR PROTAMINE THROUGH A PERIPHERAL SITE TO AID IN DILUTIONPERIPHERAL SITE TO AID IN DILUTION

ProtamineProtamine

Protamine administration can result Protamine administration can result in a number of adverse in a number of adverse hemodynamic effectshemodynamic effects

To lessen these effects, PROTAMINE To lessen these effects, PROTAMINE SHOULD ALWAYS BE GIVEN SLOWLY SHOULD ALWAYS BE GIVEN SLOWLY (over 5-10 min)(over 5-10 min)

This will help to minimize the This will help to minimize the hypotension that can sometimes be hypotension that can sometimes be seen with Protamine administrationseen with Protamine administration

ProtamineProtamine Rapid administration of Protamine can Rapid administration of Protamine can

cause:cause:1)1) HYPOTENSION (sometimes extreme) HYPOTENSION (sometimes extreme)

from acute systemic vasodilationfrom acute systemic vasodilation2)2) Myocardial depressionMyocardial depression3)3) Marked pulmonary hypertensionMarked pulmonary hypertension4)4) Diabetics on Insulin are at a particularly Diabetics on Insulin are at a particularly

high risk for adverse reactions to high risk for adverse reactions to Protamine so be extra careful with any Protamine so be extra careful with any patient on Insulin for their DM and go patient on Insulin for their DM and go extra slow with your administrationextra slow with your administration

ProtamineProtamine

The trick I used was as follows:The trick I used was as follows:

If my protamine dose was 30cc, I would give If my protamine dose was 30cc, I would give 5cc and then draw back 5cc of Crystalloid, 5cc and then draw back 5cc of Crystalloid, wait 30 sec. and give another 5cc, draw wait 30 sec. and give another 5cc, draw back another 5cc of crystalloid, give back another 5cc of crystalloid, give another 5cc and continue the above until another 5cc and continue the above until about 5-7 minutes had passed and then I about 5-7 minutes had passed and then I would give the entire 30cc slowly over a would give the entire 30cc slowly over a minute or so since by then all I had left minute or so since by then all I had left was primarily crystalloid in the syringewas primarily crystalloid in the syringe

Persistent BleedingPersistent Bleeding Persistent bleeding following bypass Persistent bleeding following bypass

often follows long bypass periods (>2 often follows long bypass periods (>2 hrs)hrs)

There can be several different causes for There can be several different causes for postop bleeding:postop bleeding:

1)1) Inadequate surgical controlInadequate surgical control2)2) Inadequate reversal of HeparinInadequate reversal of Heparin3)3) Reheparinization from administration of Reheparinization from administration of

Heparin containing cell saver bloodHeparin containing cell saver blood4)4) Thrombocytopenia from pump Thrombocytopenia from pump

destruction of plateletsdestruction of platelets5)5) Platelet dysfunctionPlatelet dysfunction6)6) HypothermiaHypothermia

Persistent BleedingPersistent Bleeding Careful observation of the surgical field Careful observation of the surgical field

following Protamine administration will following Protamine administration will reveal if clot formation is present or notreveal if clot formation is present or not

The absence of clot formation should be The absence of clot formation should be identified and causes should be looked foridentified and causes should be looked for

Full clotting studies should be sent and Full clotting studies should be sent and appropriate action taken on the resultsappropriate action taken on the results

It is not uncommon that after long pump It is not uncommon that after long pump runs, (>2 hr) FFP and Platelets are needed runs, (>2 hr) FFP and Platelets are needed to correct clotting abnormalitiesto correct clotting abnormalities

Anesthesia Anesthesia

Following Following

CPBCPB

Anesthesia post CPBAnesthesia post CPB

Additional anesthetic agents are Additional anesthetic agents are usually needed following termination usually needed following termination of CPBof CPB

These can be:These can be:

1)1) Low dose Inhalation agentsLow dose Inhalation agents

2)2) Periodic boluses of Propofol/EtomidatePeriodic boluses of Propofol/Etomidate

3)3) Periodic boluses of narcoticsPeriodic boluses of narcotics

4)4) Re-dosing of NMB’s to prevent patient Re-dosing of NMB’s to prevent patient movementmovement

Anesthesia Post-bypassAnesthesia Post-bypass

Since you will NOT be extubating Since you will NOT be extubating your patient, do not worry about re-your patient, do not worry about re-dosing with NMB’s dosing with NMB’s

It is better to have a patient who is It is better to have a patient who is not moving than to have a patient not moving than to have a patient suddenly start to move at the end of suddenly start to move at the end of a casea case

Especially before transfer, make sure Especially before transfer, make sure that your patient is dosed with NMB’s that your patient is dosed with NMB’s and some Narcotics for sedationand some Narcotics for sedation

TransportationTransportation

Transporting patients from the OR to Transporting patients from the OR to the ICU is a hazardous processthe ICU is a hazardous process

There are many areas for potential There are many areas for potential failure and disasterfailure and disaster

Monitor black out, overdosing of Monitor black out, overdosing of meds, interruption of drips and meds, interruption of drips and hemodynamic instability en route are hemodynamic instability en route are just a few of the possible just a few of the possible complications that can occurcomplications that can occur


One of the most common errors is that One of the most common errors is that drips, once removed from pumps, are drips, once removed from pumps, are either left to drip wide open or are either left to drip wide open or are hooked up again either improperly or hooked up again either improperly or at improper flow rates due to time at improper flow rates due to time constraints and difficult position to be constraints and difficult position to be able to see the pump displays properlyable to see the pump displays properly

BE CAREFUL WITH YOUR DRIPS AND BE CAREFUL WITH YOUR DRIPS AND DOUBLE CHECK THEM AFTER DOUBLE CHECK THEM AFTER TRANSFERTRANSFER

TransportationTransportation Prior to transfer from the OR table to Prior to transfer from the OR table to

the bed, several things need to be the bed, several things need to be made ready:made ready:

1)1) O2 source with Ambu and FULL tankO2 source with Ambu and FULL tank2)2) Monitor for EKG, O2 Sat, A-line Monitor for EKG, O2 Sat, A-line

readingsreadings3)3) Infusion pumps (the correct number)Infusion pumps (the correct number)4)4) Emergency drugs (Neosynephrine, Emergency drugs (Neosynephrine,

Ephedrine, Fentanyl; some even carry Ephedrine, Fentanyl; some even carry 1-2cc of NTG in case the BP spikes in 1-2cc of NTG in case the BP spikes in transit)transit)


Once the patient is moved to the ICU Once the patient is moved to the ICU bed and you assume control of their bed and you assume control of their ventilations, go as quickly (BUT NOT ventilations, go as quickly (BUT NOT recklessly) to the ICU and watch ALL recklessly) to the ICU and watch ALL your tubings while in transityour tubings while in transit

Once in the ICU go slowly into the Once in the ICU go slowly into the room so nothing hangs up on room so nothing hangs up on monitors, vent arms, etc.monitors, vent arms, etc.

ICUICU

Your care of the patient continues Your care of the patient continues even in the ICU until you have given even in the ICU until you have given report AND the ICU nurse feels report AND the ICU nurse feels comfortable with the patientcomfortable with the patient

DO NOT leave your emergency drugs DO NOT leave your emergency drugs behind for the nurse to use if neededbehind for the nurse to use if needed

Let them use their own meds!!!!Let them use their own meds!!!! Especially remember to bring back Especially remember to bring back

your FENTANYL; don’t leave that your FENTANYL; don’t leave that behindbehind

ICUICU You are responsible to give an accurate report You are responsible to give an accurate report

to the ICU RN. It should include:to the ICU RN. It should include:1)1) Patient namePatient name2)2) AllergiesAllergies3)3) PM HistoryPM History4)4) ProcedureProcedure5)5) Any eventful activities that went onAny eventful activities that went on6)6) Bypass time and how easy they came offBypass time and how easy they came off7)7) Is heparin reversed?Is heparin reversed?8)8) Fluids in/Blood loss outFluids in/Blood loss out9)9) Any drips they are on and what doses/ratesAny drips they are on and what doses/rates10)10) Labs incl. K+, ABG readings and coags if Labs incl. K+, ABG readings and coags if

bleeding was a problembleeding was a problem

ICUICU Here is an example:Here is an example:“ “ This is Mr. Homer Simpson, allergic to PCN; This is Mr. Homer Simpson, allergic to PCN;

has a history of 3 vessel disease with good has a history of 3 vessel disease with good LVF, DM, Smoking, and elev. Cholesterol; just LVF, DM, Smoking, and elev. Cholesterol; just had a 4 vessel bypass, pump run was 38 min., had a 4 vessel bypass, pump run was 38 min., came off pump easily; Heparin reversed; on came off pump easily; Heparin reversed; on Neo/Epi at 15cc and NTG at 5cc; last Fentanyl Neo/Epi at 15cc and NTG at 5cc; last Fentanyl dose was 5cc about 10 min. ago and is dose was 5cc about 10 min. ago and is currently in stable condition; Fluids given currently in stable condition; Fluids given were Crystalloid 3500cc, 2U PRBC’s, Urine were Crystalloid 3500cc, 2U PRBC’s, Urine output 1200, Blood loss 3500cc labs were output 1200, Blood loss 3500cc labs were good w/ an ACT of 135, K+ at 4.4 and glucose good w/ an ACT of 135, K+ at 4.4 and glucose at 215” (ABG can be given as well)at 215” (ABG can be given as well)

ICUICU

While you are giving report, the While you are giving report, the nurse and assistants will be hooking nurse and assistants will be hooking up the patient up the patient

DON’T LEAVE A MASS OF TANGLED DON’T LEAVE A MASS OF TANGLED TUBING TO BE SORTED THROUGHTUBING TO BE SORTED THROUGH

Try to be neat and organized and Try to be neat and organized and they will love you for it (NOW you will they will love you for it (NOW you will see what it is like on the OTHER see what it is like on the OTHER side!!! NOT SO EASY IS IT!!!)side!!! NOT SO EASY IS IT!!!)

ICUICU Your stay in the ICU should last between 10-Your stay in the ICU should last between 10-

15 minutes until you get a set of vitals from 15 minutes until you get a set of vitals from the ICU nurse and are sure that your patient the ICU nurse and are sure that your patient is stable and the nurse is comfortableis stable and the nurse is comfortable

I would ALWAYS ask if it was OK for me to I would ALWAYS ask if it was OK for me to leave prior to departureleave prior to departure

Also, make sure your SG cath is wedging Also, make sure your SG cath is wedging before you leave; the caths have a tendency before you leave; the caths have a tendency to advance during surgery and you end up to advance during surgery and you end up with an OVER wedged reading; check and with an OVER wedged reading; check and adjust before you take offadjust before you take off

NG TubesNG Tubes

I left out the NG tube!!!!I left out the NG tube!!!! It doesn’t pay to put it in on induction It doesn’t pay to put it in on induction

because it will be coming out when because it will be coming out when the TEE goes inthe TEE goes in

Put it in Put it in AFTERAFTER heparin is reversed heparin is reversed and ACT is back to baselineand ACT is back to baseline

Grease it up real good since you may Grease it up real good since you may be dealing with faulty platelets and be dealing with faulty platelets and you don’t want a nasal hemorrhage on you don’t want a nasal hemorrhage on your handsyour hands

ConclusionConclusion

Doing Hearts is like Peds; you LOVE it Doing Hearts is like Peds; you LOVE it or you HATE itor you HATE it

Unfortunately the Heart surgeons tend Unfortunately the Heart surgeons tend to be a bunch of assholes in general so to be a bunch of assholes in general so that does not add to the pleasurethat does not add to the pleasure

Get used to being yelled at and blamed Get used to being yelled at and blamed for everything even if they did it for everything even if they did it themselvesthemselves

If you develop a tough skin, you can If you develop a tough skin, you can really enjoy doing the hearts and have really enjoy doing the hearts and have a very satisfying experiencea very satisfying experience

anesthesia for coronary artery bypass surgery

Documents

blood temp

rollers pumps blood

gravity drainage of

o2 flow

cpb circuitroller pumps

cpb machineoxygenatorco2

rate of flow

normal pulsatile flow