Cardiac Surgery Made Ridiculously Simple

by Art Wallace, M.D., Ph.D.

Cardiac surgery is a dangerous and complex field of medicine with significant morbidity and mortality. Quality anesthetic care with specific attention to detail can greatly enhance patient safety and outcome. Details that are ignored can lead to disaster. This document will attempt to describe the bare bones sequence for cardiac anesthesia for adult CABG and VALVE procedures with specific recommendations. It is not all inclusive or definitive but it is the minimal critical requirements.

If you keep your head screwed on very tightly and pay 100% attention at all times, things will only go poorly some of the time.

A good reference is: Cardiac Surgery in the Adult by L. Henry Edmunds, Jr., MD which is available online http://www.ctsnet.org/book/

An online reference text “Cardiothoracic Surgery Notes” for residents is available at http://www.ctsnet.org/residents/ctsn/

An online Johns Hopkins Cardiac Intern Survival Guide is available at http://www.ctsnet.org/doc/2695

Attendings:

Mark Ratcliffe, M.D. Elaine Tseng, M.D. Fellow: Ted Wright, M.D.

Rounds: M, T, W, Th, Fri, Sat, Sun

Conference: Thursday 12:30 QI Meeting 203-3B-66

Friday 6:00 Rounds

Friday 7:00 Case Discussion 1C-Teak Room

Tuesday 4:30 Cath Conference: 1A-62

Thursday 1:30 Chest Conference MRI Conference Room Basement by MRI.

Clinic: Thursday 9-12:30

General Rules:

1. Call fellow whenever in doubt.

2. If you don’t know, ask.

3. Never start or stop an inotrope infusion, without asking the fellow.

4. Do not transfuse blood products, without asking the fellow.

5. If a patient arrests start ACLS, and call the fellow.

6. Do not let a cardiac patient die with their chest closed.

7. Don't forget your ABC's.

8. In a code ELECTRICITY is your friend.

9. V-tach unstable or V-fib SHOCK-SHOCK-SHOCK epinephrine 1 mg, amiodarone 150 mg, lidocaine 100 mg, CPR repeat.

10. A-fib is common, rarely requires shock.

11. If the Fellow does not call you back, call the attending on-call.

12. When things get tough, or you can not get the SCUT done, ask for help,

13. I was too busy- is not the right answer.
14. All patients going to the operating room must have a CARDIOTHORACIC PREOPERATIVE CHECKLIST note filled out the night before surgery. If you don't fill out the note, the patient can't go to the OR. No checklist, no operation.
15. All patients going to the operating room must have either a fellows or an attending note prior to going to the OR. No note, no operation.
16. All patients must have a mark on their operative site. No mark, no operation.
17. All patients must have a consent that lists their operation, No consent, no operation.

ASSUME nothing: Assuming things makes an ASS out U and ME.
There are two kinds of interns, those who write things down, and those who forget.

Intern on call must:

1. Call consults early
2. Discharge patients early
3. Transfer patients from ICU
4. Check all labs
Check Pathology
Check all new cultures
Take appropriate action on abnormal labs.
5. Keep the Coumadin sheet up to date.
7. Take all calls. If you are called, go see the patient.
8. See the consults write a note and make a copy so that Staff can dictate a note
9. Keep the 3X5 cards up to date.
10. Make a good scut list and get everything done on that list.
11. Do not let the post-call intern go home until you are certain you can do all the work on the scut-list, call fellow if this is past noon.
12. If there is a systematic problem with the service, ie order sets are wrong, this document is out of date, clinical pathway is out of date,
notify the fellow and/or service chief to correct the mistake.
13. At the end of your rotation, the service chief will ask for a summary of the problems with the service. If there is a problem, notify the
service chief so that it can be corrected. Thanks.
14. All patients going to the operating room must have a CARDIOTHORACIC PREOPERATIVE CHECKLIST note filled out the night before surgery. If you don't fill out the note, the patient can't go to the OR. No checklist, no operation.
15. All patients going to the operating room must have either a fellows or an attending note prior to going to the OR. No note, no operation.
16. All patients must have a mark on their operative site. No mark, no operation.
17. All patients must have a consent that lists their operation, No consent, no operation.

Preoperative Evaluation:

Patient Examination:

Pre-surgical evaluation must include attention to cardiac history. The cath report, thallium, echo, and ECG. Critical information includes: Left main disease or equivalent, poor distal targets, ejection fraction, LVEDP, presence of aneurysm, pulmonary hypertension, valvular lesions, congenital lesions. Past surgical history is critical as well. Have they had surgery on a leg which may compromise the availability of vein graft harvest. Have they had vascular surgery in the groin that will make balloon pump placement difficult? Each of these points requires a modification of surgical technique and specific information is required. How is their angina manifest? You need to be able to understand their verbal reports. If a patient's angina is experienced as shortness of breath, or nausea, or heart burn, or whatever, you need to be able to link that symptom to possible myocardial ischemia.

Past medical history including history of COPD, TIA, stroke, cerebral vascular disease, renal disease (CRI is an independent risk factor), hepatic insufficiency will change anesthetic management.

Past surgical history: Every operation they have had. If they have had surgery on a leg they need ultrasonic vein mapping.

Allergies:

Medications : Look specifically for anti-anginal regimen - synergism between calcium channel and beta blockers, is their COPD being treated? It is very important for patients to stay on their anti-anginal therapy throughout the hospital stay. If a patient is on a beta blocker, calcium channel blocker, nitrate, and/or ACE inhibitor they should remain on that drug throughout the perioperative period. The patient should get all anti-anginal medications on the day of surgery and following surgery. The day of surgery is the wrong time to go through a withdrawal process on any anti-anginal drug. Withdrawing a single anti anginal drug during the perioperative period is associated with a 3 to 5 times increased risk of MI, Stroke, renal failure, and/or death.

Physical exam: What was that scar from? Do they have leg veins for grafts? Are they going to have a GI bleed?

Chest: Is the patient in failure? Pneumonia? COPD

Cardiac: Do they have a murmur? Are they in failure?

Abd: Ascities, Obesity

LABS: Minimal CBC, Plt, Lytes, BUN, CR, Glu, PT,PTT

CXR: Cardiomegaly? Tumors? Pleural effusions?

ECG: LBBB: Critical information if a pulmonary artery catheter is planned. Occasionally patients with LBBB can develop third degree block with

PA catheter placement.

Have they had a recent MI? Do they have resting ischemia? Where are their ST-T changes?

PFT and ABG: Are they going to become a respiratory cripple? All patients for cardiac surgery need PFT's (FEV1 and FVC) for risk stratification. All patients for thoracic surgery need PFT's to decide if and what can be resected.

Information: Tell them about the A-line, the PA catheter, and post op ventilation.

Consent: Patients having cardiac surgery have serious and frequent complications including: MI 6%, CVA 5%, Neuropsychiatric Effects 90%, Death 1-3-10% (Depends on risk), Transfusion (40-90%), Pneumonia 10%. You must discuss these risks. Copy the consent and have it scanned into the computer. Loss of the consent form delays surgery by at least 30 minutes.

Note: Write a clear note with all the standard details and consent. With the computerized records it is easy to get all the patient's information. If you copy someone else's note, check all the details with the patient. Notes should accumulate all past information, check it for accuracy, and describe what you are going to do. If you don't check it, it will be wrong. Make sure you sign your note so that it is visible to other computer users.

Night Before Surgery:

1. All elective patients must have a note on the night prior to surgery by the attending or fellow specifying the preoperative condition of the patient and the surgical plan. If the note is written by the fellow, the attending doing the operation must be specified, the plan must have been discussed and approved by that attending, and the attending must agree with the plan. The attending doing the case must review the cath films prior to this note being written.

2. The house staff must fill out the CARDIOTHORACIC PREOPERATIVE CHECKLIST the night before surgery. All problems must be resolved prior to the morning of surgery. If you don't fill out the note, the patient can't go to the OR. No checklist, no operation.

3. All work up on patients scheduled for the following day should be completed, if possible, by 5 pm. It is best to have it all completed by noon. If there is a problem, another case can be placed in the slot. If the work up is delayed, then the slot is lost.

Preoperative Testing:

1. Work Up: What tests are needed in each patient.

PFT: All patients for cardiac or thoracic surgery need PFT's. These tests are for required by the VAMC for risk stratification. If the patient is scheduled for CABG, you need FEV1 and FVC. If they have a history of severe COPD (FEV1 < 1.5 or 50% of expected, on MDI steroids, morbid obesity, sleep apnea, or CO2 retainer) they also need a blood gas. If they are for thoracic surgery they need a blood gas. Patients should get pulmonary function testing in the pulmonary function lab if possible. Bed side PFT's should not be obtained unless the patient is in the ICU on multiple infusions. If the patient can not sit up or they are intubated, do not request the test. Spirometry can be obtained from the pulmonary function test on a drop in basis by calling 2415.

V/Q Scan: Any patient for lobectomy with FEV1 < 1.5 liters, any patient for pneumonectomy with FEV1 < 2.0 liters.

PT/PTT If the patient has a coagulopathy preoperatively consider hematology consult. Patients with prior pulmonary embolus, unexplained embolism, bleeding diathesis, hemophilia, get a consult. If a patient is a Jehovah's Witness, the should be treated with iron and erythropoietin until their hematocrit is 48. Jehovah's Witnesses may not receive asprin (any dose), NSAIDS, or platelet inhibitors (plavix) for 10 days prior to surgery. They should all receive intraoperative aprotinin.

Urine: If the patient has a positive leucocyte esterase or WBC in urine greater than 5 repeat the U/A with good technique and culture it. If they have symptoms of a urinary tract infection (fever, tenderness to percussion, elevated WBC) they should not have elective surgery. If they do not have an elevated WBC count or a fever, they should be treated with antibiotics, and may undergo elective CABG. If they have a UTI, no surgery with implants is recommended (valves, grafts, artificial conduits, ACID's, pacemakers). For surgery with an implant, contact attending, cancel case, treat the UTI and reschedule.

Coronary Angiograms: Required for all coronary and valve cases. Study must be within 6 months, unless approved by operating surgeon. If study is in adequate, it will need to be repeated. For scheduled surgery, films must be reviewed by attending doing the case on the day prior to the case. If attending is at Moffit-Long, copy the disk and put it on the shuttle for their review. We hope to have Web accessible angiograms within a year. For emergency surgery, film must be available for review in the OR.

Vein Mapping: Any patient with a history of prior surgery on the leg, prior CABG, prior vascular surgery, vein stripping, scars on the leg, gross leg edema, thrombophybitis, varicosities, leg deformities, amputations, or deep vein thrombosis must have vein mapping prior to CABG surgery. If mapping demonstrates inadequate conduit, then radial ultrasound of the non dominant arm should be obtained.

Radial Artery Ultrasound: Any patient under the age of 60 will be considered for radial arterial graft use. Use the non-dominant hand if possible. Use of the radial artery should be included in the consent, included on the OR schedule, and marked with a felt tip pen on the arm.

Carotid Ultrasound: Any patient over the age of 60, anyone with a carotid bruit, prior TIA or CVA, or any prior vascular surgery must have carotid ultrasound. If there is a velocity greater than 200 cm/sec, severe carotid stenosis, or a 75% or greater lesion, call vascular surgery. If the carotid is 100% occluded they will not consider carotid revascularization. Contact your attending for any of these findings.

Cardiac CT or MRI: Patients with ascending aortic calcifications at an elevated risk of stroke. Any patient with ascending aortic calcifications on angiogram, calcifications seen in the aortic arch on chest xray, or calcifications in the ventricular wall should have a cardiac CT. If the patient will have a contrast dye load (cath + CT) greater than 3 ml/kg consider cardiac MRI. Any patient with severe ventricular dysfunction and a thin out section of myocardial wall, a large dilated heart, or EF < 20% should be considered for Cardiac CT or MRI. Contact your attending prior to ordering.

ECHO: Nice to have in all patients but not always easy to obtain. There needs to be an assessment of LV function in all patients prior to elective cardiac surgery. This assessment can be from ECHO, MUGA, or the LV gram. No patient should go for elective cardiac surgery without some assessment of LV function. Any patient with hypertrophy on ECG, valvular disease, a murmer, history of valvular disease should have a cardiac echo prior to elective cardiac surgery. ECHO's are good for 6 month unless there is a change in medical condition such as MI.

Myocardial Viability Studies: These consist of PET (positron emission tomography) or Thallium scintigraphy. They should be considered in any patient with an EF < 20%, or any re-operation with a low EF (EF < 35%), or any patient with questionable targets or a recent MI. Discuss with the attending prior to ordering myocardial viability studies.

Dental Consult: We are trying to avoid operating on patients with dental abscesses that will seed the surgical site or broken or loose teeth that can be dislodged by laryngoscopy. Obtain in all patients getting a valve, all prosthetic grafts (tube grafts, aortic root replacement), AICD or pacemaker, any implant.

Colonoscopy: We are trying to avoid severe GI bleeding after anti-coagulation. Any patient with a positive guiac on rectal exam, unexplained anemia, dropping hematocrit. For dropping hematocrit consider other sources such as hematuria.

Repeat all Work UP: Any patient with a recent MI needs a repeat CXR, ECHO, Cardiac Cath prior to elective cardiac surgery.

Notify attending and fellow of all significant abnormal results. Place all results in preop note. Additionally you must
Notify Attending for 1) altered or abnormal LFT or albumin < 2.5. 2) Cr > 2.0. (Discuss with fellow if Cr > 1.4) 3) WBC > 15K 4) Glucose > 300. 5) Positive U/A (leucocyte esterase positive with Urine WBC > 5. 6) Any cellulitis or focal infection. If patient has a previous TURP or difficult foley placement discuss with fellow and consider having urology place foley after induction of anesthesia

Presurgical: These patients are scared. They understand there is real risk. They also will become ischemic with stress. At least 40% get ischemia preop with good premedication. Make sure they have a sleeping pill available on the night prior to surgery. Anesthesia will write for morning of surgery sedation. They need to be NPO except for medications with a sip on night before surgery. They need to get all their medications except oral hypoglycemics on the morning of surgery. They need a preoperative note that reviews the case, describes the surgical plan, and checks for labs, tests, consent, etc. All patients must have their surgical site marked with pen prior to surgery.

Medications Preop: All patients must get their anti-anginals. If the nurses put patient on 9P - 9A BID drugs then state in the chart that patient is to get Drug X, Y, and Z with a sip of water at 6 AM. Otherwise at 9AM they will be in the OR, needing their anti-anginals. Be incredibly clear in your preop orders or they won't get their premeds. Withdrawal of anti-anginal medications during cardiac surgery increases risk of death, MI, CVA, and renal failure. DO NOT DO IT.

TEST/Therapy	Who	Abnormal	What do
Labs: lytes, BUN, CR, Glu, WBC, Plt, hgb, HCT, albumin, LFT, PT/PTT	All	Cr > 2.0 WBC > 15K Glucose > 300 U/A + LFT abnormal Albumin < 2.5	Call fellow/attending
PFT:	All patients	FEV1 < 2.0	Call fellow/attending
V/Q	FEV1 < 1.5 for lobectomy or < 2.0 for pneumonectomy		Call fellow/attending
Erythropoetin + Iron	Jehovah’s Witness		Call fellow/attending
U/A	All patients	Leucocyte esterase + and/or WBC > 5	In valves, implants, AICD RX and cancel CABG - RX
Coronary angiogram	Everyone for CABG and valve
Vein Mapping	Previous leg surgery, previous CABG, abnormal leg.		Call fellow/attending
Radial Artery Ultrasound	Age < 60, or no leg vein
Carotid Ultrasound	Age > 60, TIA, CVA, prior vascular surgery	velocity > 200 cm/sec, severe carotid stenosis, or a 75% or greater lesion,	Call vascular surgery
Cardiac CT/MRI	Aortic calcifications,		Call fellow/attending before ordering
ECHO	Everyone unless other assessment of LV function done already.
Myocardial Viability Study	EF<20% or EF<35% with redo		Call fellow/attending before ordering
Dental Consult	All Valves or serious dental disease		Call oral surgery
Colonoscopy	Guiac +, anemia		Call fellow/attending before ordering

Intraoperative Care:

PA Catheters: At the present time all bypass cases get the standard monitors plus an a-line, and a pa-catheter. There is an article in JAMA that suggests PA catheters offer little additional information and have inherent risk in ICU patients. As yet, this has not changed our practice. It is clear however that placement of PA catheters must be incredibly skillful without injury to other structures. With no proven benefit all risk must be reduced. One method to achieve this is ultrasonic mapping prior to catheter placement. Remove the towels from behind their head, place the patient in the position you would like, then tape the head in place. Place the patient in tredellenburg. Take a permanent marker and draw out the anatomy, sternocleidomastoid, clavicle, carotid, etc. The more lines the better as it is hard to draw once the ultrasonic goop is in place. Place the blue line in the center of the echo screen. Place the blue dot on the probe to the patient's right. Make sure the probe is absolutely perpendicular to the bed. If you point it at an angle to the bed you will have to take the angle into account and few can do trigonometry in your head. I will be glad to test you on this point. Then take the 5 mHz probe and map out the path of the carotid and the IJ. The IJ is bigger and collapses under pressure, the carotid is round and doesn't collapse under reasonable pressure. If you don't have a line in an appropriate place, wipe off the goop, redraw, and then map again. This technique requires the patient to not move between mapping and placement. I think this system is faster than not using the echo, as you waste 2 minutes mapping, and save 10 minutes of searching with a needle.

Planning for Early Extubation: With the health care revolution this is the new thing. The key is multiple little changes in anesthetic technique that make it possible and a good candidate who is problem free to make it work. The problem is simply that many patients appear to be good candidates and then aren't when they get to the ICU, others look like problems and do well. The simplest solution is to treat all patients as candidates for early extubation and then see who qualifies. Early extubation should be planned for in all patients because it requires planning right from the start of the case. The most successful candidates have reasonable cardiac and pulmonary function but it is certainly not a requirement. The changes we have made include limiting fluid given to the patient. Limiting the total narcotic and benzodiazepine dose. Rely on volatile agents or propofol during the case. Provide sedation post op that is easy to get rid of (propofol). Careful control of blood pressure with emergence. Remember some vasodilators (nitroprusside) inhibit hypoxic pulmonary vasocontriction, increase shunt, and make weaning of FIO2 more difficult. Rapid weaning of FIO2 post op is critical. Then extubate the patient. Extubation time is controlled by nursing shift changes and protocols. If you want to extubate early, wean the FIO2 rapidly, wake the patient up, and when the patient meets written extubation criteria do it. It requires a cultural shift to accomplish. The most common reason for delayed extubation is simply V/Q mismatch (shunt) caused by heparin-protamine complexes in the lung. The second most common reason is excessive sedation. Finally, hemodynamics, coagulopathy, etc. get on the list.

Communication: All information must be communicated to the surgical fellow or attending. Call early and often. If you can't reach the fellow call the attending.

Hypotension: Hypotension with tachycardia is hypovolemia until proven otherwise. If the blood pressure is zero-open the chest. If the patient had good cardiac function coming off bypass and now is hypotensive, they are probably hypovolemic. If you have given volume, check the cardiac output, calculate the SVR, look at the PAD. If they PAD is high, the CI is low (less than 2.0), and you are giving some inotrope, consider tamponade.

Tamponade: If the blood pressure is zero-open the chest. This is not like medical tamponade. If you have a clot pushing on the atrium, the heart won't fill, and the blood pressure will collapse. If the blood pressure is zero-open the chest. If the bleeding stops and the blood pressure drops- consider tamponade. Give volume, start and inotrope, call the fellow, get an echo and a chest xray. A widening of the heart, fluid around the heart, low chest tube drainage, low CI, low blood pressure - you should already be in the OR opening the chest.
Tension Pneumothorax: If the blood pressure is zero-open the chest. If the blood pressure suddenly drops, consider tension pneumothorax. The chest tube can be blocked with blood, or crimped. Check the chest tubes, unblock them, place bilateral 14 guage angiocaths in the anterior-lateral chest at the T2-4 level, place chest tube on side with hiss.

Hemodynamics:

Prior to Valve Repairs there are specific recommendations:

AS: Preload: Keep it up Afterload: Maintain SVR: Maintain HR: 50-80 Rhythm: NSR

AI: Preload: Keep it up Afterload: Down SVR: Drop HR: 60-80 Rhythm: NSR

MS: Preload: Keep it up Afterload: Maintain SVR: Maintain HR: 50-80 Rhythm: NSR

MR: Preload:Keep it up Afterload: Down SVR: Down HR: 50-80 Rhythm: NSR

Prebypass Hemodynamics: You should try to keep the blood pressure within ± 20% of baseline ward pressure. Heart rates between 40 and 80 are generally fine depending on the clinical situation prior to bypass.

Bypass Hemodynamics: You should keep the MAP between 40-80 during the cold period of bypass (cross clamp on) and between 60-80 during warm bypass (cross clamp off). There will be exceptions such as patients with carotid vascular disease or chronic renal insufficientcy that may need higher pressures (60-80 mmHg) for the entire pump run.

Post Bypass Hemodynamics: Systolic blood pressure greater than 80 mmHg is fine. If it is between 100 and 120 mmHg everyone will be happy. If it is greater than 120 mmHg the patient is hypertensive and there will be more bleeding. Cardiac index greater than 2.0 is fine. Pa Diastolic less than 20 mmHg, CVP less than 15 mmHg. If CVP is ever greater than PAD there is a problem: poor calibration or right ventricular failure. Always consider surgical manipulation of the heart if the chest is open, or tamponade when it is closed, for hypotension.

Fluids: There are lots of theories on fluids and little data to support the strongly held beliefs. Cardiac cases can easily suck up large amounts of fluid intraoperatively with little obvious benefit. All of that fluid then has to be diuresed postoperatively frequently by administering large amounts of lasix with subsequent electrolyte disturbances. Post operative extubation is frequently delayed by intraoperative fluid administration. Please attempt to limit fluid administration intraoperatively. A few suggestions. If you have two large bore IV's hep lock one of them. Try to give less than 500 cc of LR prior to bypass. Do not administer any fluids during bypass except for fluid required for vasoactive drugs. Use hespan post bypass up to 20 cc/kg, then shift to albumin. If you use hextend, the 20 cc/kg limit may or may not apply. If the patient has previously had 20 cc/kg of starch (hextend or hespan) use albumin. Use a mechanical metering device on any carrier lines to prevent accidental high flows. Use neosynephrine to support pressure before giving large amounts of fluid prebypass.

Fluid Tallies: Tally the estimated blood lost, and fluids administered including crystalloid, colloid, Blood, cell saver, pump blood, bypass prime volume, and total fluid given by perfusionist on your record. This is a change from previous efforts where we ignored everything but the crystalloid, colloid, given by anesthesia, and the blood given by anesthesia and perfusionists. The perfusionists can give large amounts of crystalloid and we need to note it on the anesthesia record. if they give hespan or hextend in the pump prime we should know about it.

Ischemia: Patients have CABG surgery because of myocardial ischemia. 40% of patients undergoing CABG surgery have intraoperative episodes of myocardial ischemia. You should record a 5 lead ECG prior to induction for a baseline comparison. Ask the patient if they are having chest pain at this time. You should look at the ECG either continuously or at least every 60 seconds and ask - What is the rhythm? Is there ischemia? Only by absolute attention to the ECG will you detect a substantial fraction of the ischemia.

When the blood flow to myocardium is insufficient, it immediately stops contracting. This process takes 5 to 10 seconds. At 60 to 90 seconds the ECG ST-T wave starts to change. This focal reduction in cardiac function can be detected by watching the ECHO image. The best level is a short axis mid papillary view. You should record a fixed pre incision short axis mid papillary view for comparison. The ECHO is an adjunct to care not a requirement. Do not ignore the patient when looking at the echo.

Clotting: Cardiac surgical patients receive a lot of heparin (300 to 400 U/kg = 20,000 - 40,000 Units). It is reversed with protamine. The protamine and heparin make a weak salt which is cleared in the lungs. If there isn't quite enough protamine, the patient can become reheparinized post operatively. Check the PT and PTT post surgery. If the PTT is elevated give more protamine (25-50 mg). The anesthesiologists gave protamine in the OR (3-4 mg/kg 200 to 400 mg) so you are adding to the dose. Protamine is an evil, wicked, dangerous drug made from salmon seamen. Treat it with respect. It can cause profound vasodilation from histamine release. It can cause anaphylaxis or massive pulmonary hypertension. Treat it as the most lethal drug you will administer and you will not be surprised. Give it slowly and be ready to treat hypotension from profound vasodilation (neosynephrine or epinephrine may be required).

Sternotomy: Painful process that occurs rapidly after induction, make sure the patient is adequately anesthetized. Ask anesthesia to let the lungs down during opening. Develop a system to prevent yourself from forgetting to place patient back on ventilator. Do not rely on the alarm as the only reminder.

Redo Heart Sternotomy: In a redo heart the adhesions may bring the ventricle close to the sternum. The sternal saw may cut through the right ventricle with resulting (profound) hemorrhage. Blood must be available and 2 large IV's. You may also cut through the IMA or a saphenous graft. You should have an idea of what this will do from the catherization report and a plan. Instant severe myocardial ischemia with rapid deterioration may result. The case is easier if the IMA and grafts are not functional. Functional grafts that the patient is dependent on is the most dangerous situation. Knowledge of the chest xray (pa and lateral), prior operative report with details of the LIMA graft, and the cath report are essential to decide on how to handle these situations.

IMA Dissection: They may want the table tilted to the left and elevated. They may want the tidal volumes reduced and the rate increased to help with dissection. It may be very hard to get an echo image during IMA dissection

Heparinization: Do not go on bypass without heparinization. If the patient is not heparinized when the clamp is opened on the bypass pump, the pump and oxygenator will clot and the patient will most likely die. If you are placing a cannula in some artery give the heparin. When you ask for heparin, require a verbal reply - "the heparin has been given". The dose of heparin is 300 U/kg which is about 21 cc of 1000 u/cc heparin in a 70 kg man. Check the ACT a minute or two after the dose. If the patient is on heparin preop, give the same dose (Heparin 300 U/kg). Do not stop the preop heparin just be careful putting in lines. Do not give anti-fibrinolytics until fully heparinized (amikar). If the ACT is not greater than 450 seconds after the dose, give more, until the ACT is above 450 seconds. If you are using aprotinin the celite ACT must be above 800 seconds. If a kaolin ACT is used the normal 450 second range is used.

Add heparin to your ACLS protocol for cardiac surgery patients. If the patient arrests give the heparin so that patient can be put on bypass for resuscitation.

All patients getting cardiac surgery using extracorporeal circulatory support should get an anti-fibrinolytic drug. There are several choices. It may be that all should get aprotinin, unless given in previous surgeries, but this change has not been universally adopted. At the present time we use a two tier approach.

All patients going on extracorporeal circulatory support should have an anti-fibrinolytic. If they are a first time case without risk factors they get amikar. If they are a redo case, a case with renal failure, a case with a high risk of bleeding, or a Jehovah's Witness where bleeding would be lethal, they get aprotinin.

Amikar: Epsilon amino caproic acid used as a antifibrinolytic. Some evidence that it reduces post bypass bleeding. Some clinical reports of problems (left ventricular thrombus, arterial thrombi, etc.) Commonly given as 5 g IV prior to bypass and 5 g IV after bypass. Can be given in higher doses 10 g prior and 10 g after in large patients. Much less expensive ($12/bottle) than aprotinin ($900/bottle) although the efficacy is not proven. No FDA indication for this use. No convincing safety data. We are using it on all cases. Give 5 g IV slowly after you give the Heparin prior to bypass. Give 5 G IV slowly after the protamine is in. You do not want to give it prior to heparin. There are adverse events associated with protamine administration and it is easier if only one drug can be blamed for each event.

Aprotinin: Antifibrinolytic and platelet preserver that reduces bleeding and transfusion associated with CABG surgery in redos and people on aspirin. Costs $900/case. The transfusions for a case average $1000 so the cost is revenue neutral. If one considers the risk of disease transmission from transfusions amprotinin is a benefit. There is an increased risk of graft closure from clotting. If one looks at the morbidity and mortality associated with take backs for bleeding, aprotinin reduces risk of death. It is allergenic so patients should probably only have one use in a lifetime. That use should probably be for a redo CABG.

Our present use is for REDO CABG, patients with renal failure, patients with risk of bleeding, or patients in which bleeding would be lethal (Jehovah's Witness). Order 6 M units (3 200cc bottles at 10,000 units per cc). Give 1 cc test dose, then 20 cc over 20 minutes starting prior to skin incision. Then continue at 0.5 M U/hr. The perfusionist will prime with 2 M units so give one bottle to them. I have tried to avoid using a fourth bottle in long cases by slowing the infusion to 0.3 to 0.4 M U/hr so that the infusion bottle will last until the end of bypass. Lower doses of aprotinin work, so this slower infusion is probably reasonable. Remember celite ACT 800 seconds, kaolin ACT 450 with Aprotinin.

What operation are we doing today?: Cardiac surgery used to be done using extracorporeal support. A few surgeons did CABG without the pump but it was rare and usually done elsewhere. In the last few years the percentage of CABG surgeries done using off pump techniques has risen dramatically. The invention of the octopus and starfish have made it easier, safer, and practical for most CABG operations to be done off pump. At the present time we are randomizing patients to "on pump" versus "off pump" care. If the decision seems random, you are correct, it is. The anesthetic care is fundamentally different for these two approaches so we will separately discuss the "ON PUMP" anesthetic care and then the "OFF PUMP" approach. You need to be flexible because they can change their mind at a moments notice.

Placing the cannulas:

Do not go on bypass without heparinization. The arterial pressure at this point should be below 120 mmHg. The small cannula in the aorta (has a red tape on it) should not have any bubbles in it. Check for bubbles. When they put in the aortic cannula there is splash - have your glasses on.

The larger cannula with blue tape is the venous cannula and goes into the apex of the right atrium into the inferior vena cava. It is a drain line and may have bubbles. On mitral valve and ASD/VSD cases there will be two smaller drain lines into the superior and inferior vena cava.

The small cannula with a balloon at one end is placed into the coronary sinus through a purse string in the right atrium. When the flow in the coronary sinus cardioplegia line is 200 ml/min the pressure should be about 40 mmHg. If the pressure is like CVP and does not go up with coronary sinus flow (retrograde cardioplegia), the cannula is not in the coronary sinus. If this happens during continuous warm cardioplegia, there is a period of warm ischemia which can result in severe ventricular dysfunction and death. If the pressure is very high (greater than 100 mmHg) with a flow of 200 ml/min the cannula is against the wall and you also may not be having good retrograde cardioplegia.

The left ventricular vent line is placed through the right superior pulmonary vein. It decompresses the left ventricle.

Check List for Going on Bypass:

HAD2SUE Remember this mnemonic. Say it often. Avoid killing patient by using it.

Heparin: Always give prior to bypass.
ACT: Always check before going on bypass (450 seconds)
Drugs: Do you need anything (Non depolarizing neuromuscular blocker).
Drips: Turn off the inotropes etc.
Swan: Pull the PA catheter back 5 cm to avoid pulmonary arterial occlusion/rupture.
Urine: Account for bypass urine
Emboli: Check the Arterial cannula for bubbles.

Clean Kills and the Perfusionist: There are three easy ways for the perfusionist to kill the patient.

1. No oxygen in the oxygenator.

2. No heparin.

3. Reservoir runs empty.

If the power goes out there is a crank for the perfusionist - you may be asked to help crank.

If a line breaks, you may have to help replace it.

Air Lock: The venous line drains by siphon. Nothing is quite as reliable as gravity but air introduced into the venous system can cause the loss of the siphon. If the perfusionist notes bubbles on the venous return line, or you do, check the integrity of the cordis, closure of all stop cocks, the surgeons will check the atrial purse string. If you reduce pump flow temporarily the venous pressure will rise and the air leak will diminish. The lines can be refilled with saline if complete airlock occurs.

Cardioplegia: There are lots of types. Cold, Warm, Warm induction - Cold Maintenance - Warm Repercussion, Hot Shot, Crystalloid, Blood, Antegrade, Retrograde. The best is a short cross clamp with a skillful surgeon. You should record the on bypass time, the off bypass time, the on cross clamp, the off cross clamp. As the cross clamp time exceeds 1 hour ventricular function deteriorates, as it exceeds 2 hours it gets worse. Cardioplegia during cross clamp helps. There are lots of things added to cardioplegia and the bypass prime and you should find out what they are from the perfusionist. They will say something like "Nothing special" which translates into potassium, lidocaine, aspartate, glutamate, D50, manitol, bicarb, adenosine, free radical scavenger of the day, and snake oil. Ask and you will learn. There is much magic in the cardioplegia bag, most of it only in the eye of the orderer. If something weird happens on bypass (ie pressure goes to 30, potassium sky rockets, glucose is very high) consider what is in the cardioplegia solution.

De-Airing Maneuvers: It is bad to pump air to the patient. It is difficult to get all of the air out and doppler studies of the middle cerebral artery during bypass demonstrate 50-2000 emboli per case. It is hard to decide if this is air or atherosclerotic plaque. The smaller the bubble the bigger the echo signal. On open ventricle or aortic procedures the surgeons will have you place the head down. Then they will bump the patient, roll from side to side, stick a needle in the ventricle, aspirate from the aorta, etc. in the hopes of getting out all of the bubbles. They will direct you on what they want. If you look at the echo at this time there will be a snow storm of little bubbles in the ventricle. If you see a large one or more than usual say something.

The majority of emboli occur on aortic cannulation, cross clamp placement, cross clamp removal, side bitter placement, side bitter removal, weaning from bypass, and aortic cannula removal. It is best not to have high glucose or overly warm temperatures ( 37oC) during any of the embolic times. 95% of patients suffer subtle neuro-psychiatric changes consistent with multiple small emboli.

Check List for Getting Off Bypass:

WRMVP: Wide receiver most valuable player.

Warm: What is the bladder and blood temp?

Rhythm: Are they in NSR or do you need to pace? Is the rate adequate?

Monitors On: Turn em back on if you turned them off for bypass. Turn back on the alarms.

Ventilation: Turn on the ventilator. Easy to forget and you look very stupid.

Perfusion: What is the pump flow.

Weaning from bypass: You need to have a plan. What was the ventricular function prior to bypass? How long was the cross clamp? What does the heart look like now? What is the resistance now? Once you have a plan communicate with the surgeon. If you plan to use a drug with prolonged side effects ask them what they think (amrinone, milrinone). They may have an opinion that should be considered. Have some inotrope ready. You should be able to wean 80-90% of first time CABG patient's from bypass with no inotropes. Calcium chloride is commonly used. Excessive doses ( 2g) have been associated with pancreatitis.

A standard weaning plan would be to calculate the systemic vascular resistance (SVR):

SVR = [(MAP - CVP)/CO]*80

MAP: Mean Arterial Pressure

CVP: Central Venous Pressure

CO: Cardiac Output (Can be obtained by asking the perfusionist what the pump flow is)

SVR should be in the 1000 to 1200 wood units. It routinely will be 600 to 800 and the cardiac output necessary to develop a reasonable pressure post bypass will be too high. Vasoconstrictors (phenylephrine) or a catecholamine with some vasocontrictive effects (dopamine, epinephrine, norepinephrine) are commonly necessary to raise the resistance to reasonable levels. Here is an example. The MAP is 50 and the CVP is 10. You ask the perfusionist and he tells you the pump flow is 5 liters/min. That gives a SVR of (50-10)/5*80 which equals 640 wood units.

Let's take two approaches. The first is to come off pump and let the heart try to pump sufficiently to develop a reasonable pressure. Once off pump the SVR will be 640, the MAP will be 50 and the BP will be about 70/40. The problem is not cardiac in nature. The problem is simply low resistance. An inotrope is not needed a vasocontrictor is.

If the SVR had been raised to 1200 prior to coming off pump, the 5 liter/min cardiac output would yield a MAP of 65 with a CVP of 10. The BP would then be about 95/50 and all would be well.

A reasonable approach to weaning from bypass is to:

a. Make an educated guess as to the inotropic state of the ventricle. If it was lousy prior to bypass, it will most likely still be lousy and an inotrope will be necessary. If the inotropic state of the ventricle was ok prior to bypass and cross clamp times were reasonable (60 minutes or less) then it is likely no inotropes will be needed.

b. Calculate the resistance and correct it.

c. Check the requirements for coming off pump. Warm, Rhythm, Monitors On, Ventilator On, Perfusion (resistance reasonable).

d. Be ready to change your plan.

Why does the patient "go on bypass"? and How does the patient "come off bypass"?:
The bypass system is basically a large plastic pipe with lots of holes placed through the right atrial appendage into the inferior vena cava. The large plastic pipe is full of fluid and hooked to the venous reservoir. The pipe is clamped with a large clamp. Note: Before attempting any of this activity, (not recommended in the privacy of your own home) make sure you have fulfilled the criteria for going on bypass (HADDSUE) or coming off bypass (WRMVP) as noted above. NEVER LET THEM GO ON PUMP IF YOU HAVE NOT HEPARINIZED. Having an ACT greater than 450 is very reassuring but not absolutely essential in dire and I mean dire emergencies. Other than the dire emergency. ACT must be greater than 450.

The simple explanation for going on bypass is the perfusionist removes the clamp from the venous drain line and a siphon effect drains blood from the right atrium and inferior vena cava into the venous reservoir. It is important to maintain the siphon effect to keep this flow going. Since, there is no or less blood going into the right ventricle, the cardiac output drops. The perfusionist then turns on the pump and returns the blood to through the aortic cannula into the patient's aorta. If all is working well the blood will be heated/cooled and oxygenated by the heater/cooler/oxygenator before being pumped through the filter and back into the aorta. Unclamping the venous drain line reduces the right atrial pressure and diverts blood into the pump. The perfusionist will say something like "Full flow" which means they have 4 or 5 liters a minute of venous drainage and are able to pump 4 to 5 liters/min into the patient. At this point you can turn off the ventilator. Pulmonary artery pressures should be non-pulsatile.

Coming off pump is the exact reverse situation. You fulfill all the criteria for coming off pump. (WRMVP), i.e. the patient is warm, the heart is beating, the monitors are turned on, the ventilator is turned on, and you have adjusted the resistance and inotropic state to an appropriate level. The perfusionist then partially occludes the venous drain line. This reduces the amount of blood draining into the venous reservoir. The right atrial pressure increases and blood starts to go into the right ventricle and out the pulmonary artery. At this point you can have a pump flow that is a fraction of the total systemic blood flow with the rest produced by the heart. The surgeon will say something like, Leave some in and come to 4 liter/min. You will notice that the pulmonary artery and systemic pressures become pulsatile. They will then drop to say 2 liter/min then 1 liter/min. They are watching the right and left ventricles to make sure they are not distending. They also watch the pressures and slowly load the heart. When they say something like "Give a hundred". What they are telling the perfusionist is to leave 100 cc less blood in the reservoir. The perfusionist may be draining 2 liters/min of blood from the patient and pumping 2 liter/min to the patient. They are supposed to pump 100 more cc of blood than they withdrew. It is an inexact science. But you get the idea.

The surgeon will then clamp the venous drain line and you can tell that you are truly off pump. They will remove the venous cannula. If you have a kind surgeon, they will place it in a bucket of saline and then drain the blood back to the reservoir keeping the line full of saline. This allows the perfusionist to start hemo concentrating the blood in the system but keeps the venous line ready in case you have to return to bypass. The arterial line is still in place so the perfusionist can give fluid. When the patient's blood volume is low you will hear - "give a hundred". The perfusionist basically unclamps the arterial line with the pump on and drains 100 cc of fluid from the reservoir.

Who weans the patient from bypass and who gives volume orders? This varies by institution and surgeon. At some institutions the anesthesiologist does at others the surgeon does. If you are not ready to wean a patient, say so. If you think the patient needs to go back on bypass, tell the surgeon to put the cannulas back in. If the patient is doing poorly, tell them not to take out the arterial cannula. If you need more volume, ask for it. You are part of the team. This is one surgery where it is essential that you be able to tell the surgeon what to do, and when to do it. When things are going bad, communication is key. It is essential that it is a team process. They need to know what you need and what is going on. If something is not working, they need to know about it. They can and will most likely try to fix it.

Inotropes and Vasoactive Compounds: If you are using a drug that requires an infusion and where the effects of an incorrect or fluctuating dose would be difficult to manage, use an infusion pump. This includes (dopamine, dobutamine, epinephrine, norepinephrine, nitroprusside, nitroglycerin, neosynephrine, and propofol). The fluctuations caused by relying on gravity drips are unacceptable. Gravity is reliable, back pressure is not. All drugs must be mixed in concentrations approved by the pharmacy. The labels with the appropriate concentration are in a black box in the anesthesia machine. If you mix it and label it with the yellow label then the ICU nurses will not throw it away when you get to the ICU. If you mix some weird concentration, label it poorly, or then put it on a dial-a-flow, the nurses will throw away your drugs and the patient will get less than optimal care.

Drug	Alpha	Beta	Dopamine	PDE-I	NO	MAP	HR	CO	SVR	Dose
Phenylephrine	++					+	±	-	+	100 mcg 0.1-5mg/kg/min
Ephedrine	+	+								5 mg
Norepinephrine	+++	++				+++	-	±	+++	0.01-0.1mg/kg/min
Dopamine	+	+	+			+	+	+++	+	2-20mg/kg/min
Dobutamine		+				±	+	+++	-	2-20mg/kg/min
Isoproterenol		+				-	++	+++	-	0.03-0.15mg/kg/min
Amrinone Milrinone				++		-		+