CABG Flashcards
(23 cards)
Draping
Groin towel/tegaderm
Utility drape for under each leg
Bottom drape
Towels and stockinettes for feet
Up to the chest - utility drapes X3
Belly towel
Ioban
Bar drape
Side drapes X2
Light handles
Throw off cords
-Use Ioban to secure another folded -wet blue towel across belly
-place instrument pouches
-Bovie
-Misty blower
-Waste suction
-Cell saver suction (extra curved yankeur tip and secure with hemostat)
-pacing wire runs behind the FA’s instrument pouch and passed to anesthesia
-rultract clamp needs to be tightened onto the bed frame at the patients midsternal level dr kwon does not like when the rultract isn’t centered change gloves after placing this clamp since it is technically below level of sterility
Tubing organizer:
Cardioplegia (tuck under bovie towel)
Pump sucker (w/metal suction tip)
Root vent
Bypass tubing (set up w/Jess)
Open
Lap pad on field
Wheatie on field
10 blade
Bogie
Sternal saw (» on high speed)
Cell saver suction to retract
Gel foam/bone wax
*follow Dr with army navy retractors and suction.. pull up sternum and protect lungs from bovie
Take down IMA
Blue towel & 2 hemostats to Kwon
Set up rultract
Stack of rays on pts head (unfold the top one as he uses them)
Long bovie tip (35)
Fine debakey (short/fine pickup)
Moist lap on field
Small clips w/tips pointed up
keep the bovie and clip applier clean as you go
*place the cell saver suction so that the tip is over the field for bovie plume)
Dr Kwon will tell anesth to heparinize and holster the bovie
Two large(orange) clips w/tips down
Tenotomy tips down
Bovie
Bulldog on applier
Papaverine syringe and fine/short forceps
Medium clip
Lay out the moist raytec from papaverine cup to wrap IMA
call out “raytec in” for the nurse
-Remove rultract top portion
(Make room for circulator to remove bottom portion)
-Replace long bovie tip worth short tip
-Take off outer gloves and pass kwon new gown and reglove him *he does not want bloody gloves to touch his new gown/gloves**
-put on new outer gloves
-pass up the Thompson Morse sternal retractor and a folded up blue towel to pad
Exposing heart
Thompson Morse retractor is placed
Short bovie tip(35)
Short debakey
0 silk pop offs (typically will use 4 forehand then 3 backhand)
if he asks for a clip at this point it is typically medium clip he wants
Cannulating “prep”
Aortic cannulation stitch:
3-0 RB1 single loaded
Hemostat on the belly
Rumel (red) to FA
Cut off needles/take driver w/needles
3-0RB1 double loaded
he may ask for the venous stitch to be pledgeted sometimes…if so, it will be double loaded and the FA will get a free pledget
Rumel (clear) to FA
Hemostat on belly
Cut off needles and take needles/driver back
Venous cannulation stitch:
3-0 SH single loaded
Hemostat on the belly
Blue rumel to FA
Cut off needles and take back the needles/driver
Cannulating
** make sure the aortic and venous lines are laid correctly so they are easy to connect to cannulas***
Aortic:
Metz
Cannula
11 blade
0 silk on a passer X1
Tubing clamp
Pitcher to catch blood
Heavy scissors to FA to trim the aortic line..will pass back the excess tubing and scissors to you
0 silk pop off X2
Venous:
Metz tip down
Venous cannula
0 silk tie on a passer X2
Stylet back from Dr Kwon
Unclamp venous line and pass to Dr to connect
Root vent placement
-3-0 RB1 double loaded X1
-Hemostat on belly
-Rumel to FA
-Cut off needles and take back the needles/driver
-Root vent to Dr Kwon (place in his hand like a pencil)
-Kwon will remove the needle and place on pt
-Hemostat
-heavy scissor to FA to cut the root vent line to proper length …excess tubing and scissors right back to you
Kwon will say “Let’s go on”
Curved mayo (to cut white clamp thing off of the pledge line?)
Bovie
Flush pledge into blood pitcher:
Say “flush pledge” to perfusion and then once the line runs pink and you have enough fluid say “off pledge”
make sure that perfusion turns off the pledge line before you clamp your end or else the pressure could blow the tube
Vein graft prep
Kwon will typically ask to see the vein around this time in the procedure
-Lay white towel down on field
-Pass vein from bowl of hep saline
-Hep saline distender/syringe
-Fine thing (clamps across the vein)
-11 blade (slices straight across)
-Fine thing (to hold the edge of the vein opening)
-Forward Potts (to prep the opening)
-Place back in bucket of hep saline do not remove the fine thing from the vein once the opening has been prepped, leave it on
Position heart
Dr Kwon will dig his hand under the heart
-go around clamp
-Heart net laid out on pt (for FA to grab)
-Peon (Kwon calls it a Kelly)
-Long debakey
-Go around again
Cross clamp
Cross clamp to his left hand
3 towel bump to FA
Small towel clip
Slush
we are now cold**
Around this time Dr Kwon will move the heart net around and clip w/towel clip (R) and hemostat (L)
Short debakey and curved mayo scissors to cut heart net for exposure to distal target
Distal anastomosis
-Mammary/Distal forcep in left hand
-15 blade in right hand
-Pig sticker
-Forward Potts
-Reverse Potts
look in the field to try to orient the Potts scissors correctly when passing
-Pass vein graft up(carefully/fine thing at top)
-7-0 BV1 on the short distal needle holder (short Castro), clamp other end w/tag set down so Dr Kwon can grab it
Dr kwon asked for distal coronary sutures to be loaded backhanded
Lay white towel down when doing anastomosis so that suture doesn’t get caught on tubes/sternal retractor
-Needles back to you on the driver
-Squirt hand when tying suture
-Vein squirt (bloody syringes) X2 to the FA to check anastomosis
checking for bleeding/may need repair suture
-Bulldog on applier
-Distender syringe
-Distal forceps
-Tenotomy tips down
-Tacking stitch 6-0 BV1 single loaded
-Tag to FA
-Forward Potts
-Bulldog remover
tacking suture needle back from FA (they are not very helpful at passing the needle back carefully)
Repeat for additional distals
Appendage LAAE
after Kwon completes his distals, he will move on to the LAAE
Kwon will cut out the heart net and needs long debakey to pull it out (trash)
Raytec
Bovie (long tip @ 25)
Hockey stick to measure
Atriclip opened to field (wash in Vanco)
Atriclip to Dr Kwon
Mammary
Distal forceps and long debakey to remove mammary raytec (be sure to call out “raytec out”
-Marker on hemostat
-slushy laps and long debakey (call out “lap in”)
-#15, pig, forward Potts, reverse Potts
-Bulldog
-Tenotomy
-Forward Potts
-7-0 BV1 w/tag on the other end
- Bulldog remover before he ties down this anastomosis
-squirt hands when tying
-squirt with a tip
-6-0BV1 tacking suture (Dr kwon will have the FA tie this suture, be sure to squirt his hands)
-6-0 BV1 tacking suture again to Dr Kwon (squirt FA hands again)
-Metz to Dr Kwon to cut the suture for FA
*be sure to get back both tacking needles from the FA
ask what size aortic punch to have opened to field
Proximal
-Switch to proximal forceps
-if the proximal end of the graft was not prepped earlier in the case then he will need to do that now: distender, bulldog, tenotomy, fine thing, and forward potts
(If he did prep the proximal end already then he may just ask for a fine thing to hold the vein graft while he sutures)
- # 11 blade
- aortic punch
-6-0RB2 w/tag on other end of the suture
(Check the punch to make sure tissue donut is there and wipe it out)
“O ring” marker on mosquito to FA
wet hands when tying prolene
repeat as needed for more proximals
Dr Kwon may splice a graft if he does not have a good proximal/aortic site to graft to, meaning he will do an end to side anastomosis of the vein graft to another vein graft rather than to the aorta. In this case he does not need a punch or the 15 blade; he can use the poker and Potts to prep the target site directly on a vein graft and then may need a 6-0RB2 or a 7-0BV1 for the anastomosis
Cross clamp coming off
*warm fluids**
Needle for deairing
Squirt w/tip
Pacing lead at this time?? Or after Decannulation? I don’t remember 🤔
Get ready to decannulate
Decannulation: Venous
- Tubing clamp
- 15 blade (kwon will pass it right back to you)
(Venous line is clamped and removed) - take the line and submerge fully in hep saline bucket:
-Dr Kwon will say “give it back” = unclamp the venous line
-Jess will say “all good “ = reclamp the line and set under mayo stand
Venous cannulation site typically closed w/sutures that are already in place..if not, Kwon may ask for a pledgeted SH 3-0 prolene for the oversew
Pass #2 probe and put gel on the field for medistim
Pass #4 probe
Decannulation: root vent
-Hemostat used to remove root vent
-Squirt hands when tying
-3-0 RB1 pledgeted stitch (double loaded)
-Free pledget to FA on mosquito
when Jess says “pump sucker off” = remove the metal pump sucker tip
Decannulation: Aortic
Have lap pad on the field to cover spray
-tubing clamp
-15 blade to FA
- Cannula is clamped and removed > connect to pump sucker line quickly and unclamp it
-rumel tourniquets are removed and squirt hands when tying suture
- 3-0 RB1 pledgeted comeback stitch - free pledget on mosquito to FA
Pacing lead to Dr Kwon
Pop off to FA
When Kwon says “two fine” he wants two fine debakey forceps to look over the anastomoses
Chest tube prep/placement
*at any time during the case of Dr Kwon has to wait he may ask for the knife for the tubes **
- #15 blade
- bovie
- nurolon to Dr kwon and to FA (one per chest tube)
-after nurolons are tied, use a hemostat to secure the loose ends and tuck them under the bovie towel/lines
(During the distal anastomosis is the best time in the case to ask the circulator to open the chest tubes and trim them)
*Bevel the “non star” end of the tubes with straight mayo scissors
At the end of the case:
-Kwon asks for the chest tubes passer = adson tonsil
-pass beveled end of the tubes to FA
-Hold up tubes while Kwon and FA tie nurolon (be careful not to pull on them or they may slide out a bit)
-Trim both tubes to the same length and connect to atrium
(Make sure to trim them straight across and give them enough length so that Dr kwon can later strip the tubes with gel)
Closing
First count can begin
Thompson Morse comes out =bovie to 100
-dry lap on field
-army navy’s to FA
- bovie to Kwon
- measuring thing for Jace plates at this time make sure to write down the numbers for manubrium/upper/lower
-2-0 SH vicryl to close pericardium
-after connecting the chest tubes to the atrium, place a folded blue towel over the tubes and lines
-0 CT1 vicryl on heavy driver w/hemostat on the other end to close the subxyphoid X3 w/bonnie forceps
-lay another folded blue towel over these sutures
-sternal wires (X7 or X8 normally)
-have the wire cutter laying on the field for FA
-Make vanco paste with 5cc saline and stir with a knife handle..pass to Dr kwon after the last sternal wire)
-Dr Kwon and FA will pull wires and twist them to reapproximate the sternum
-Wire cutter to FA
-wheatie on the field
-take the cut wires and rubios from Dr kwon
-large wire twister
-Rubio (to lay the cut ends of the wires down flat against the sternum)
Sternum = glue and mesh
Jace plates
Kwon always uses the “boomerang” plate for the manubrium, so have this one loaded on the handle with the screws in it and the drill ready to go
-have plates and pickups on the mayo stand so kwon can pick out the plates he wants to use
-load the box/screws onto the sternal plates he wants to use
-if he uses the benders to shape a sternal plate, then use the gold bit and load the screws for him one at a time directly onto the driver and give the FA the “plate holder”
-ensure that the RN knows what plates and screws were used
Closing continued
-Lube on the field for kwon to strip chest tubes
-FA will tie the subxyphoid sutures at this time
- bring up the irrigation pitcher with 2 laps in it for FA to irrigate the sternum
-Dry lap on field again
-Bovie to 35
-1CTX vicryl on a heavy driver to close w/bonnie forceps
(if Chad is closing, he also uses a 2-0 on a CT1 to close ?)
- 4-0 monocryl and adson (adson brown for chad)
Skin count
-Have clean wet and dry laps available for FA
-organize instruments and take off booties/inserts/etc while FA is closing
-move mayo stands back and take off the bypass tubing/instruments from drapes/etc
-Drain sponge for each chest tube
-CHG neck dressing
-Exofin sternal mesh dressing
