Mod2: PERIOPERATIVE MANAGEMENT FOR THE PATIENT UNDERGOING CARDIOPULMONARY BYPASS SURGERY

Question 1

_{PREOPERATIVE EVALUATION}

Anesthesia for cardiovascular surgery that will utilize CPB requires an undestanding of

Answer 1

Pt’s history and disease processes, and

Impact of history and disease processeson on the anesthetic plan and the surgical plan

Question 2

_{PREOPERATIVE EVALUATION}

T/F: The provider must always recognize that the anesthetic plan must be individually tailored to each pt, and it must remain fluid throughout the whole perioperative process

Answer 2

True

Question 3

_{PREOPERATIVE EVALUATION}

Prior to the day of surgery, the pt should have had an adequate cardiovascular evaluation which will include:

Answer 3

Lab testing

Imaging

Question 4

_{PREOPERATIVE EVALUATION}

Prior to the day of surgery, the pt should have had an adequate cardiovascular evaluation which will include lab testing and imaging

However, a full anesthetic assessment and chart evaluation must still be completed. Why?

Answer 4

To cover all the basis

Question 5

_{PREOPERATIVE EVALUATION}

Cardiovascular surgery also requires constant communication between which providers?

Answer 5

Anesthesia team

Surgeon/Surgical team

Perfusionist

Question 6

_{PREOPERATIVE EVALUATION}

What are the goals of preoperative evaluation?

Answer 6

Quantify & reduce perioperative cardiovascular risk factors influencing perioperative morbidity & mortality

Determine ventricular function

Prompt identification & treatment of ischemia

Identify & evaluate comorbid diseases effecting cardiopulmonary bypass

Patient/family education

Question 7

_{PREOPERATIVE EVALUATION}

Integration of preoperative data/information leads to appropriate selection of:

Answer 7

Monitors and

Anesthetic techniques

Question 8

_{CARDIAC EVALUATION}

By the time the anesthesia provider is consulted, a definitive cardiac diagnosis has already been established

However, things that support the diagnosis and require that the anesthesia provider pays close attention to in the chart have to do with:

Answer 8

Cardiac history

Physical signs & symptoms

Invasive & noninvasive diagnostic test

Pulmonary history

Renal

Diabetes Evaluation

Question 9

_{CARDIAC EVALUATION}

Cardiac history, including: Previous MI, active chest pain/pressure, Exercise tolerance/ Stress test, CHF symptoms are important to evaluate, why?

Answer 9

You don’t want to exacerbate their symptoms during the preoperative preparatory phase and cause further myocardial damage

Question 10

_{CARDIAC EVALUATION}

Physical signs & symptoms that are relevant to cardiovascular surgery include?

Answer 10

Vital signs

JVD

Apical pulses (displaced?!)

Question 11

_{CARDIAC EVALUATION - Invasive & noninvasive diagnostic test}

Make sure to pay close attention to the diagnostic tests that have already been performed. Why?

Answer 11

Could give a clue into which technique to use for induction

Question 12

_{CARDIAC EVALUATION}

Results from which test will be available for a diagnosis of Multi-vessel disease?

Answer 12

Cardiac catheterization

Question 13

_{CARDIAC EVALUATION}

Results from which test will provide information regarding Ventricular Function or Valvular Function?

Answer 13

TTE or Prior TEE

Question 14

_{CARDIAC EVALUATION}

If the pt has Carotid artery disease or a hx of Stroke, which operation may they require prior to their cardiac procedure?

Answer 14

Carotid endarterectomy

Question 15

_{CARDIAC EVALUATION}

And at minimum, if their carotid artery stenosis is more than 50% on either side, what additional monitor would you want to consider?

Answer 15

Cerebral oximetry

Question 16

_{CARDIAC EVALUATION - T&S/T&C, CMP, PT, PTT/INR}

Some surgeons may only require a T&S if the surgical repair isn’t expected to be extensive. However, if it’s a complex case, make sure there is a

Answer 16

T&C on the chart, and

Make sure there are NO antibodies

Question 17

_{CARDIAC EVALUATION - T&S/T&C, CMP, PT, PTT/INR}

What if there are antibodies?

Answer 17

Make sure the surgical team is aware of how long it will take to have the blood available for the pt

Question 18

_{CARDIAC EVALUATION - Pulmonary history}

If Smoker of history of COPD, what’s the minimum period of time before surgery they should go without smoking?

Answer 18

2 weeks before/day of surgery

Question 19

_{CARDIAC EVALUATION - Pulmonary history}

If Smoking history or COPD, and unable or unwilling to stop smoking at least 2 weeks before/day of surgery, when should education regarding smoking cessation should occur?

Answer 19

Within the 24hr prior to surgery

(This is a national quality measurement)

Question 20

_{CARDIAC EVALUATION - Pulmonary history}

Other pulmonary assessment prior to cardiac surgery include:

Answer 20

Dyspnea/SOB

Pulmonary function test/ Chest X-ray

Recent URI

Question 21

_{CARDIAC EVALUATION - Pulmonary history}

What do you do if Recent URI (within 2 weeks)?

Answer 21

Postpone elective surgery

Question 22

_{CARDIAC EVALUATION - Renal}

If the pt has a history of renal insufficiency, this may be something to have a discussion with the surgeon and the perfusionist about; Why?

Answer 22

This may necessitate a change in treatment plan

Question 23

_{CARDIAC EVALUATION - Renal}

How could treatment plan change If the pt has a history of renal insufficiency?

Answer 23

Pt may require hemofiltration after bypass, or

Dosing of medication may need to be altered

In addition, pts with renal disease often have lower HCT and Hgb, and may require blood transfusion while on bypass

Other considerations may include Volume overload from priming, or Hyperkalemic cardioplegia solution

Question 24

_{CARDIAC EVALUATION - Diabetes Evaluation}

During bypass, Insulin requirements are higher for both diabetics and non-diabetics; why?

Answer 24

Surgical stressandnon-physiological state of bypass cause and increase in glucose levels

Question 25

_{CARDIAC EVALUATION - Diabetes Evaluation} Pts taking NPH insulin may produce antibodies to which drug? Why is that?

Answer 25

**Protamine** Because NPH insulin contains protamine moiety This could cause an increased risk for ***allergic reaction*** with the administration of protamine when it's time to *reverse the heparin*

Question 26

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} For preparation, how long ahead of time will the anesthesia provider typically arrive?

Answer 26

*At least* **one hour** before the pt comes in the room ## Footnote *This time can varry depending on the complexity of the case*

Question 27

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} T/F: A Routine anesthesia machine check is completed

Answer 27

True

Question 28

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Airway should be gathered depending on?

Answer 28

what's available at the institution

Question 29

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Why should you consider and ETT designed for possible extended intubation?

Answer 29

Because a lot of cardiac surgery pts may require prolonged ventilatory support

Question 30

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} What's the best ET tube for extended intubation and Why?

Answer 30

**SealGuard ETT**, or Any ETT designed for prolonged intubation SealGuard have an ET **cuff** with *better seal at lower intracuff pressures* Also has a **suction port** that sits above the balloon for subglotic suctioning This suction port has been associated with a *reduction in ventilator acquired pneumonia*

Question 31

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Other Airway equipments include:

Answer 31

Nasal cannula for supplemental O2 End-tidal CO2 monitor

Question 32

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Intravenous Access:

Answer 32

Usually two large-bore IV’s (14-18g-gauge) Central line PA catheter

Question 33

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} What features must a central line used during cardiac surgery have?

Answer 33

**Hemostatic valve** Type of central line will varry depending on institution Typivally a _9Fr introducer_ that has a *hemostatic valve for PA catheter placement* Ultimately, you want a multilumen central catheter that would allow for *mutiple drugs to be infused* while simultaneously being able to measure hemodynamic parameters, and also with the ability to *infuse large volumes* of fluid in case of an emergency One port should always only be *dedicated* to *drug infusion* and nothing else

Question 34

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Standard ASA monitors used in cardiac surgery

Answer 34

5 lead EKG Temperature CVP, PA, Arterial BP ^{(Transduced, leveled and zeroed)} Cardiac Output TEE Multiple infusion pumps

Question 35

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Pre-drawn Medications} Benefit of Pre-drawn Medications, and when to draw them?

Answer 35

Will save you in an emergency Should be drawn up prior to bringing the pt to the OR

Question 36

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Pre-drawn Medications} Heparin is one of the very important drugs to have pre-drawn up. Why? What's its predraw dose?

Answer 36

The las thing you want to have to do draw up heparin to crash on bypass **Heparin** predrawn dosed **400 units/kg**

Question 37

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Pre-drawn Medications} Other drugs to predraw include?

Answer 37

**Induction medications** **“Uppers”** ^{Neo, Levo, Epi} **“Downers”** ^{NTG, Cardene} *^{in 10cc syringe IVP, for immediate tx of hypo or HTN}* **Antibiotics**

Question 38

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion} How do you prepare infusion drips and pumps for cardiac surgery?

Answer 38

Infusion drips should be **pre-spiked** and pumps should be **pre programmed** for the pt's weight

Question 39

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion} Which drips should be readied for cardiac surgery?

Answer 39

Phenylephrine, Norephrine, Epinephrine, Dopamine, Vasopressin, Dobutamine, Amiodarone\*\*\*, Milrinone, Insulin, NTG, Cardene, etc.

Question 40

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion} Amiodarone should be confirmed with the surgeon; why?

Answer 40

Because it is costly and not always required

Question 41

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion} T/F: Amiodarone must also have its own dedicated line with an in-line filter

Answer 41

True

Question 42

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion} A pacemaker with extra batteries should always be available in the OR for cardiac surgery; why?

Answer 42

**Intrinsic rhythm** sometimes take a while to come back, or They may even have **complete heart block**

Question 43

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion} If the pt is asystole under the pacemaker, what must you consider having?

Answer 43

**Backup pacemaker**

Question 44

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion} Blood products available/in room?

Answer 44

????

Question 45

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Current Drug Therapy for cardiac surgery pts typically includes which classes of drugs?

Answer 45

Beta-blockers Calcium channel blockers ACE inhibitors Digitalis preparations Diuretics

Question 46

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Pts are Usually instructed to continue Current Drug Therapy until time of surgery; with the exception of

Answer 46

Diuretics

Question 47

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} For Pre induction, when and where are A-line, central line typically placed ?

Answer 47

Prior to induction either in the pre-op area or the OR

Question 48

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Sometimes, pts are unable to tolerate line placement prior to induction, so it will be important to do a thourough pre-op evaluation to assess their

Answer 48

**Tolerance** This would include ***anxiety*** level, ability to ***lie flat*** while awake, ***chest pain/pressure*** they are currently experiencing, ***restless leg syndrome*** Will need opioids and benzodiazepines for sedation for invasive line placement

Question 49

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY}​ T/F: Sedative tend to make restless leg syndrome more active

Answer 49

**True** and they will not be able to lie still for line placement

Question 50

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Pre-induction, why is O2 administration required for sedation?

Answer 50

You want to increase O2 content by increasing delivery While reducing consumption

Question 51

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Why is it important to evaluate their current drug therapy? Are they in-patient, and are already on heparin, NTG, Insulin?

Answer 51

NTG and insulin requirements may change prior to induction This is something to take into consideration

Question 52

_{ANESTHETIC PREPARATION FOR CARDIAC SURGERY} Why is it important to have a pressor and a "downer" readily available at induction?

Answer 52

They may require additional support Sedation could cause hypotension requiring a vasopressor, or HTN requiring Nicardipine?