1. show valve function 2. EF 3. chamber size 4. contractility 5. RWMA 6. PAP 7. estimate CO

12. On/Off Pump Management Flashcards by Kira Harms

cardiac induction drug options

higher versed/fentanyl
etomidate
smaller propofol dose w/bag mask induction

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versed cardiac induction dose

5mg

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fentanyl cardiac induction dose

250mcg

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why would etomidate be considered for cardiac induction?

produces less hypotension

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when is intubation indicated during cardiac induction

once induction drugs have lowered BP to level that will prevent excessive HTN (under 100 systolic)

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BOBCAT

Baseline labs/ACT
OG insertion/removal
BIS monitor
Central line
Amicar
TEE

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Amicar bolus for cardiac surgery

liberty: 5g
lukes: 10g

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Amicar infusion

1g/hr

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why is amicar used for cardiac surgery

antifibrinolytic used to counteract bypass blood damage
decrease post op bleeding

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amicar alternative

TXA

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most sensitive detection of interoperative ischemia

RMWA is 4x more sensitive than ECG ST segment

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TEE functions (7)

show valve function
EF
chamber size
contractility
RWMA
PAP
estimate CO

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what procedure is the saphenous vein harvested in

CABG

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anesthesia tasks during sternal incision and sternotomy

turn off ventilator
remove breathing bag
avoid HTN
- give fentanyl
- NTG

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what drugs help avoid HTN during sternotomy

fentanyl
NTG

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what happens to intrathoracic pressure during sternal retraction

incr ITP
==decr venous return
==decr CO
==decr BP

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what procedure is the LIMA harvested in

CABG

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anesthesia tasks during LIMA harvesting

decr tidal volume to keep lungs out of surgeon’s view
incr RR to preserve MV

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is there significant stimulation during LIMA harvesting

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what might happen when the pericardium is opened?

vagal response

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pericardium nerves are derived from

vagus
phrenic

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is the pericardium closed at the end of surgery

no - closing the pericardium causes incr risk of tamponade

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when do you give heparin

prior to aortic cannulation

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what lab do you check after giving heparin? how long after?

ACT is checked 3 mins after giving heparin

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how much blood is needed for ACT

1mL

what ACT is pt ready for bypass

>450s

aortic cannulation an lead to

possible aortic dissection

what is cannulated first, arterial or venous?

arterial

anesthesia tasks during aortic cannulation

lower SBP to 90-100mmHg (decr risk of dissection)

where is venous cannulation done?

right atrial appendage

when is the pt considered "on pump"

once venous cannulation occurs and the venous reservoir is open

anesthesia tasks when pt starts bypass

1. vent off 2. vaporizer off 3. empty foley (pre-bypass urine) 4. monitor in "bypass" mode 5. put vasoactive infusions in stanby

what infusions do we keep on during bypass

amicar insulin

optimal MAP for pts on bypass

78mmHg

antegrade CP catheter placement

aortic root

when is strain on the heart minimized

when heart is empty

CP is given after

the cross clamp is placed

when is CP re-dosed

every 20-30 mins

what indicates that the surgeon is almost done repairing the heart

when the perfusionist begins to rewarm the pt

what risk increases during rewarming

risk for awareness increases during rewarming

hypothermia ______ MAC

hypothermia decreases MAC (provides anesthetic effects)

drugs given during rewarming

1. versed 2. antiarrhythmics - magnesium - amiodarone - lidocaine

magnesium rewarming dose

amidarone rewarming dose

150 mg over 10 mins

why are antiarrhythmics given during rewarming?

decr chance of fibrillation incr conversion rate if heart goes into fibrillation

first step to start coming off bypass

perfusionist refills heart with blood by partially closing venous reservoir

before the cross clamp is removed, what does the surgeon do?

looks for and removes any air bubbles in heart

how does the heart start beating again?

the cross clamp is removed blood from arterial cannula washes CP out of the heart

what rhythms does the heart typically go into after CP washout?

1. bradycardia 2. Vtach/Vfib

are we worried about Vtach/Vfib post-cross clamp removal?

not really - the heart is still on bypass so it is still perfused

treatment for heart in Vfib/Vtach after bypass

10-20J defibrillation by surgeon

2 ways to help kick start the heart?

give inotropes epicardial pacing wires

what inotropes?

calcium (1g) epi milrinone

pacing rate

80-100 bpm

pacing capture

20mA

what should you titrate pacing current to?

10% higher than where capture is regained

anesthesia tasks once the heart is beating in sinus

vent ON Iso ON

when is the venous reservoir closed

when the pt is back on the ventilator

when is the venous cannula removed

after the venous reservoir is closed

when is the aortic cannula removed

after heparin is reversed with protamine

why do the surgeons wait to remove the aortic cannula?

precautionary action in case of protamine adverse reaction

primary agent to reverse heparin

protamine

what drug can be given if pt is bleeding more than expected after protamine?

DDAVP (desmopressin)

DDAVP mechanism

triggers clotting factor release promotes coagulation

DDAVP side effect

profound hypotension

DDAVP should be administered

SLOWLY

when is cell saver blood given?

after protamine

are pts extubated in OR after cardiac surgery?

sedation during transport options

1. propofol - 20-50mcg/kg/min 2. precedex

when do you start transport sedation

prior to chest closure

items to take during transfer to ICU

1. vasoactive meds for BP control 2. laryngoscope 3. ambu mask

redo sternotomy risk

uncontrollable hemorrhage

redo sternotomy prep

1. blood in room w/blood tubing 2. place defib pads before induction 3. gentle hand ventilation

is a redo sternotomy faster or slower than primary sternotomy

slower

post-op bleeding in chest tube: normal

0.5-1 mL/kg/hr

post-op bleeding in chest tube that requires immediate surgical intervention

8-10 mL/kg/hr

ischemic heart causes:

coronary artery blockage less perfusion during bypass

reperfusion refers to

1. occluded coronary artery opening OR 2. re-establishment of perfusion after bypass

causes of reperfusion injury

1. hypercalcemia 2. prolonged ischemia period

when should Ca be administered during bypass

15 mins after cross clamp release

what protects against reperfusion injury?

volatile agents

which is more protective against reperfusion: TIVA or VA?

VA is more protective than a TIVA with propofol

can you use nitrous during bypass

nitrous effects during bypass

1. air bubble expansion 2. incr PVR 3. incr PAP 4. worse RH output

off pump advantages (4)

1. faster recovery/shorter hospitalization 2. decr post-op neuro deficits 3. incr renal/pulm/cardiac protection 4. mx physiologic perfusion

off pump disadvantages

1. higher HD instability 2. poor distal anastamosis - incr risk of reocclusion/thrombosis 3. undervascularization 4. difficult for surgeon/steep learning curve

long term off pump CABG impacts

decr graft patency incr need for revascularization decr long term survival

prevent hypotension during off pump CABG

give fluid bolus prior to lifting heart 2 L crystalloid 500mL 5% albumin

arrythmia prevention during off pump CABG

prior to lifting heart give: amidarone (150mg) Mg (1-2g)

inotropic support during off pump CABG

prior to lifting heart give: Ca (1g)

optimal BP for distal anastamosis during off pump CABG

MAP 90-100 mmHg

optimal BP for proximal anastamosis during off pump CABG

SBP < 100mmHg

do you give amicar during off pump CABG

yes - same dose

which is sewn first: distal or proximal

Distal first

do you give heparin during off pump CABG

yes - dose may differ

more stenotic vessels

better collateral circulation less hypotension

less stenotic vessedl

poor collateral circulation more hypotension

options if off pump fails

1. full bypass and arrest heart 2. partial bypass

benefits to partial bypass

1. hypotension is less likely 2. better myocardial protection - less O2 demand

12. On/Off Pump Management Flashcards

(100 cards)