Department of Anesthesiology

Cardiothoracic Anesthesia Rotation Manual

TABLE OF CONTENTS
Introduction
Goals of the Rotations
Objectives of the Rotations
Environment
Physical Setting
Personnel
Set-up
Communication
Procedure for Cardiac Anesthesia
Pre-operative Evaluation
Pre-medication
SPECIAL NOTE ON SERUM GLUCOSE
Time Sequence of Patient Preparation
Monitoring
Ischemia
Transesophageal Echocardiography
Care of Arterial Lines
Induction of Anesthesia
Pre-bypass
Hemodynamic Perturbations
Cardiopulmonary Bypass
After Bypass
Transport to CTICU
Management of Off-pump CABG (OPCAB)
Re-do sternotomy cases
Anticoagulation and Coagulation
Fluids
Pharmacy Support
Didactic Program
Additional References
Evaluation Procedures

Revised 12/15/09

1
Introduction

Welcome to your Cardiothoracic Anesthesia Rotation. Cardiac surgery is a complex field

of medicine, with the potential for significant patient morbidity and mortality. Quality
anesthetic care, with appropriate attention to detail, can enhance patient safety and
outcome. A team approach to patient management is ideal.

When you first begin on the CT Anesthesia service, you will work with both a CT
anesthesiologist and a senior resident. Once you gain confidence in managing cardiac
patients on your own, the senior resident may have other cardiothoracic assignments.
Although senior residents on the rotation can expect much more independence, the
faculty CT anesthesiologist will always be present in the OR at all critical points during
surgery, and for transport of patients to the intensive care unit.

Goals of the Rotations

The Junior Resident will acquire knowledge, skills, and experience sufficient to
administer anesthesia with confidence to patients undergoing elective coronary
revascularization, valve repair, lung resection, video-assisted thoracoscopic surgery
(VATS), and mediastinoscopy with supervision.

The Senior Resident will acquire additional knowledge, skills, and experience sufficient
to administer anesthesia with confidence to patients undergoing urgent or emergency
cardiac and thoracic procedures, including some of the following: exploration for post-
operative bleeding, sternal repair, heart transplantation, and insertion of ventricular assist
devices.

Objectives of the Rotations

Junior Resident
1. Develop a level of competence in the comprehensive evaluation of patients
scheduled for cardiothoracic surgery (*PC)
2. Acquire an understanding of
a. cardiac physiology (*MK)
b. pathophysiology of ischemic and valvular heart disease (*MK)
c. pharmacology and hemodynamic effects of inotropic and vasoactive drugs
(*MK)
d. mechanics of cardio-pulmonary bypass and pathophysiology of extracorporeal
circulation (*MK)
2. Improve skills in placement of radial and pulmonary artery catheters using sterile
technique (*PBL, PC)
3. Improve skills in placing thoracic epidural catheter and endobronchial tubes
(*PBL, PC)
4. Design a safe plan for the anesthetic management of a patient for coronary artery
surgery with and without cardiopulmonary bypass (*PC)

2
 5. Recognize and react appropriately in emergency situations and demonstrate sound
judgment (*SBP, PC, MK)
6. Demonstrate compassion, sensitivity and ethically sound practice (*PR)
7. Demonstrate effective communication with patients, their families, CT surgeons
and nurses, physician assistants and perfusionists (*ICS, SBP)
8. Use textbooks, handbooks, and online material, and continue to develop an ability
to read the literature critically (*PBL)

(* Denotes core competency area: PC-patient care, MK- medical knowledge, ICS-interpersonal and
communication skills, PR-professionalism, SBP-system based practice, PBL-practice based learning and
improvement)

Senior Resident
1. Provide anesthesia
and hemodynamic management for coronary revascularization procedures with
minimal supervision (*PC)
2. Acquire an advanced
understanding of the sequence and implications of different CT surgical interventions,
cardiopulmonary bypass and circulatory arrest (*MK, PBL, PC)
3. Organize, direct, and
teach junior residents in the care of an elective patient for coronary revascularization
(*PBL, ICS, SBP)
4. Demonstrate
proficiency in providing anesthesia care for exploration for post-operative bleeding
(*PC)
5. Place a
transesophageal echocardiogram probe and successfully perform an abbreviated TEE
examination (*PC, PBL)
6. Know the
pathophysiology and management of adult patients with congenital heart disease and
thoracic aortic dissection / aneurysm (*MK, PBL)
7. Demonstrate
proficiency in vessel cannulation and catheterization (PC)
8. Participate in teaching
medical students and student nurses (*PC, ICS)
9. Demonstrate
competence in using pacemakers and the intra-aortic balloon pump (*MK, PC)
10. Choose anesthetic plans that minimize the cost/benefit ratio (*SBP)
11. Critically evaluate the literature in cardiothoracic anesthesia (*PBL, MK)

Environment

Physical Setting
At Hahnemann University Hospital (HUH), CT surgery usually occurs in operating
rooms 7, 8, or 10 on the 8th floor OR suite. After operation, we transport patients to the
CTICU, located on 8th floor South Tower. Because access to the CTICU requires a

3
hospital ID badge, be sure to have yours with you at all times, in case you need CTICU
access in an emergency. The CT operating room anesthesia set-up differs slightly from
that of general surgical rooms. Learn to set-up the heart room for CPB and off pump
cases. Familiarize yourself with the supplementary red carts and red controlled substance
bags – they contain special drugs and equipment commonly used in the heart rooms.

Intraoperative Safety: Cardiac surgery can be bloody. Spattering and splashing of blood
demand that you wear barrier gloves and eye protection at all times in the operating
room. Keep the anesthesia record clean; change gloves when contaminated, and before
touching the anesthesia machine, TEE machine, or drug cart. Use the alcohol-based hand
cleanser when entering and when leaving the room.

Personnel
When you first start your rotation, please introduce yourself to the nurses, cardiothoracic
housestaff, surgeons, and perfusionists. They value your participation in the care of CT
surgery patients. Their trust and respect is earned, not expected. The CT residents and
fellows have completed five or more years of surgery training and are very
knowledgeable about cardiac physiology and pharmacology. If you have disagreements
about patient management, consult your anesthesia attending. Our anesthesia technicians
constitute a valuable resource regarding the equipment and the supplies in the heart room.
Develop a cordial working relationship with them.

Set Up
• Start with a standard room set up including suction, machine check, and airway
equipment. However, a standard drug cassette is not needed.
• Red cart: Every cardiothoracic case utilizes a red cart to supplement the
equipment in the standard anesthesia carts in every operating room. Know the
contents of every drawer of this cart before your first case.
• Drugs include opioid (fentanyl 40 mL or sufentanil 5 mL, but not both),
etomidate, pancuronium, phenylephrine, epinephrine, norepinephrine, antibiotics, and
heparin (300 U/kg). Patients may decompensate necessitating a rapid conversion of
an off-pump to an on-pump case. Protamine should not be drawn up until preparing to
wean the patient from bypass (or until the off pump grafting is nearly complete) to
minimize risk of a potentially fatal syringe-swap.
• Physiologic monitor: Rooms 7, 8, and 10 employ a Marquette monitor. This
differs from the Hewlett-Packard monitors in other 8th floor operating rooms. Be sure
to familiarize yourself with the operation of the selector knob and the menu options
before your first cardiothoracic case.

Communication
Cardiac anesthesia involves a series of repetitive tasks that must be performed correctly.
The operation requires a team approach and you are a member of the team. Communicate
with the other personnel in the OR:
1. Ask questions. Tell others what you are doing and thinking. Don’t let your
activities or concerns be a mystery to the surgeons. When you sample from the
arterial line, announce over the drapes, “…on the A-line.”

4
 2. If you are having trouble, call your attending. Cardiac surgeons thrive on stress.
This may manifest as criticism when you show your inexperience or ignorance. Do
Not let this upset you -better to ask and risk criticism than harm the patient.
3. Confirm receipt of requests whether or not you can or intend to fulfill them at the
time the request occurs. If the surgeons asks you to raise the table height and you are
busy filling a syringe, simply reply, “…table coming up in a moment” rather than
have him/her wonder whether or not you heard the request.
4. Make sure the perfusionist knows when you begin, change, or discontinue
vasoactive medications, so that he/she can manage and anticipate changes in the
reservoir volume. Likewise, you determine the setting of the vaporizer connected to
the pump; request changes for it politely from the perfusionist and expect to know
whenever it is changed.

Procedure for Cardiac Anesthesia

Pre-op Evaluation
Make every effort to see your patients the day before surgery. Do a thorough pre-op evaluation
and obtain informed consent for anesthesia. Evaluate the patient for IV and arterial line access.
Evaluate the airway and landmarks for right internal jugular catheterization. Esophageal surgery
or esophageal stricture is a contraindication for TEE. Communicate with the CT resident or
fellow if there are any patient issues that have to be resolved. Do not assume that it will be
addressed. Call your anesthesia attending to discuss the patient and anesthetic management. A
full pre-anesthetic history and examination should be performed with particular reference to the
following points which may affect anesthetic management or indicate patient’s risk:
• Present illness: Angina (stable or unstable), dyspnea (systolic or diastolic dysfunction),
recent myocardial infraction (has it occurred since decision to operate), episodes of cardiac
failure, flash pulmonary edema.
• Co-existing disease: H/O asthma, diabetes, hypertension, or cerebro-vascular disease?
Has this patient had: convulsions, episodes of fainting, visual disturbances, peripheral
vascular disease (claudication), renal insufficiency, coagulation disorder, dental check up
performed for valve replacement? Does he/she understand the co-operation required for line
placement?
• Allergies: Especially to Heparin, Protamine, organic Iodine or antibiotics?
• Medications: Is the patient on anti-hypertensives, anti-anginals, anti-arrhythmics,
specific regimens for diabetes and asthma? Were aspirin, plavix and/or NSAIDS stopped?
OPCAB patient may sometimes remain on aspirin. Clopidogrel ( Plavix) should be stopped
5-7 days preop.
• History of Reflux/Dysphagia: Rapid sequence induction in these patients may pose
particular challenges. The placement of TEE probes is contraindicated in patients with
esophageal disease (strictures) or history of esophageal surgery.
• Physical Examination: Generally do they look unwell? Are they short of breath at rest?
Do they look grey or ashen as if they have peripheral vascular shut down? Have the signs of
left ventricular dysfunction been masked by diuretic use? Airway, dentition – anticipated
difficult intubation? Chest: CHF? Murmurs? Head & Neck: neck movement, carotid bruits:
JVP, previous carotid surgery scars, beards- will trimming be required for line placement?
Periphery: pulses; is radial artery from the non-dominant hand being considered as a bypass
conduit? Is there arterial insufficiency in either leg. Does the BP reading differ in different
limbs? Venous access?

5
 • Investigations
o CXR – cardiomegaly, effusions, aortic calcification, lung lesions?
o ECG – rate, rhythm, conduction abnormalities, pacemaker dependent, ischemia,
recent infarction, territory of infarcts? If patient has an AICD, EPS has to be consulted
and the device interrogated and anti-tachycardia function disabled in the holding area on
the day of surgery.
o CBC – Hb, Platelet count – especially in patients on heparin therapy (HIT?)
o Chemistry: K+, serum creatinine, glucose. Recent peaks of CK, CKMB, and
Troponin. ABGs and LFTs.
o Coags: Prolonged PTT in the absence of heparin (lupus antibody?). INR, if
patient was taking vitamine K antagonist (warfarin/Coumadin®).
o Xmatch – Does blood bank have suitable blood for antibody positive patient?
• Cardiac Catheterization & Echo Report – note the order:
o Pressures (R →L)
o Valves (R →L)
 Mitral Valve: Normal 4-6 cm2. <2=moderate MS. <1=severe mitral
stenosis. Mean gradient >15 = severe stenosis
 Aortic Valve Area: Normal= 2-4 cm2. <1=moderate AS; <0.75=severe
aortic stenosis. Mean gradient >50mmHg = severe stenosis
o Coronaries (LMain, LAD, LCx, R and any known carotid artery stenosis):
number, site, and severity of stenoses, including LMCA disease equivalent.
o LV Function – LV Ejection Fraction, LVEDP, pulmonary artery pressures.

Inform patients about fasting, medications, A-line, CVP, PA catheter, TEE, possible intra-
operative awareness, and post-operative ventilation. Patients for cardiac surgery have serious and
frequent complications including infarction, stroke, and death. The risk of stroke increases with
age, hypertension, diabetes and previous stroke. Mortality is 1-10% (depends on risk
stratification). You should discuss these risks. Warn diabetics that insulin requirements may
change markedly, and that non-insulin dependent diabetics may require insulin. Tell patients with
renal failure they may require temporary dialysis after operation.

Risk Stratification:
• Greatly increased risk: age>80 years, uncompensated cardiac failure, cardiogenic shock,
acute renal failure.
• Moderately increased risk: Age>70, re-operation, emergency surgery, pulmonary
hypertension, chronic renal failure.
• Other factors increasing risk: Diabetes, hypertension, obesity, Ejection fraction<40%,
valve surgery, LV aneurysm and female gender.

Pre-medication
These patients are apprehensive. They understand there is real risk. They also may become
ischemic with stress. Do Not let these patients suffer from anxiety (and ischemia) during line
insertion. Fast all adult patients from midnight as the order of the schedule may change
unpredictably.

All patients should receive by mouth their usual antianginals, antiarrhythmics and
antihypertensives. Specify by name in the chart the medications the patient should receive with a
sip of water at 6 AM. Discontinue aspirin and NSAIDs. Heparin may be discontinued in the
holding area if critically needed up to that time.

6
Special note regarding management of blood glucose: Current guidelines dictate that no measured
serum glucose peri-operatively exceeds 200 mg/dL, and that patients arrive for operation with
serum glucose < 140 mg/dL. We target a maximum of 140 mg/dL at all times peri-operatively.

Diabetics receiving insulin should be first on the schedule if possible. Although we rarely
administer insulin to patients before they arrive in the holding area, we do frequently administer
infusions of regular insulin intra-operatively; do not hesitate to commence an insulin infusion in
the holding area as needed.

Time sequence of Preparing Patients on the Day of Surgery

1. Make sure the OR is set up completely. Be sure to arrive early enough to accomplish this
task. If someone else has set-up the room, confirm all is to your and your faculty’s
expectations. Proper set-up is YOUR responsibility alone.
2. Greet the patient by name; introduce yourself by name.
3. Check the patient’s chart for anesthesia evaluation and consent.
4. Place the intravenous and radial arterial catheters with the patient in the holding area. Use
a #16G or #14G IV catheter and a #20G arterial catheter. Use sterile technique at all times.
Remember that barrier gloves are not sterile; you should NOT touch the insertion site with a
gloved finger. Should you be unsuccessful initially in cannulating either vessel, seek
assistance early. Never delay entry to the operating room to place the IV or arterial catheter.
5. If a radial artery graft is planned, the specified upper extremity must remain free of
catheters and devices; place the IV and arterial catheter in the opposite arm. (Ask pharmacy
to prepare a diltiazem infusion; take it with you when bringing the patient into the operating
room.)
6. Check for allergies. Timing antibiotic administration is tricky for these cases: rapid
infusions (e.g., cefazolin) must complete less than 60 minutes prior to surgical incision;
slowly infused drugs (e.g., vancomycin) must commence well before incision. DOCUMENT
the start and end times of each antibiotic in the designated area of the anesthesia record.
Always infuse vancomycin over 30-40 minutes using a small drop administration set.
7. Antibiotic Administration
PREOPERTIVE
All patients receive mupirocin (Bactroban) 1 g divided between nostrils daily, at least one day
prior to operation.
PERIOPERATIVE
Patients without penicillin allergy
1) Ancef (1 gram for patients < 60 kg, 2 g for patients > 60 kg) is given preoperatively,
within 1 hour of incision.
2) Ancef 1 g is given every 3 an 4 hours if the procedure is on-going (with normal renal
function)
3) Vancomycin 1 g is given in patients getting a surgical implant (valve or graft), or at
higher risk for MRSA infection:
a. Preoperative hospitalization > 3 days
b. Transfer from another inpatient facility
c. Already on antibiotics for infection
d. Known colonized with MRSA

7
 e. Diabetics
This dose should be completed within 1 hour of skin incision, and is not repeated
intraoperatively.
Patients with Non-IgE-mediated penicillin allergy (rash): proceed with regimen for patients
without penicillin allergy
Patients with IgE-mediated penicillin allergy (anaphylaxis, hives, angioedema):
1) Vancomycin 1 g is given, and should be completed within 1 hour of skin incision. This
dose is not repeated intraoperatively.
2) Gentamycin 4 mg/kg can be used as a single dose for gram negative coverage
POSTOPERATIVE
All patients continue mupirocin (Bactroban) 1 g divided between nostrils daily, for 2 days.
Patients without penicillin allergy
1) Ancef 1 g IV q8 hours, for a maximum duration of 48 hours
2) Vancomycin 1 g IV 12 hours after operation, as a single dose (may need to adjust for
renal function)
Patients with IgE-mediated penicillin allergy
1) Vancomycin 1 g IV q 12 hours, for a maximum duration of 48 hours (adjust for renal
function
2) Consider Gentamycin 4 mg/kg to provide gram negative coverage (adjust for renal
function).
8. Sedation. All patients undergoing coronary revascularization must have a heart rate less
than 80/min prior to induction of anesthesia. Sedate all patients as necessary to achieve this
goal; provide supplemental oxygen and monitor with pulse oximetry. A second IV may be
started in the OR for re-do sternotomy cases. Patients should be in the OR no later than 7AM
on usual days and 8:15 AM on conference days.

Monitoring
Currently, all cardiac cases require, in addition to standard ASA monitors, arterial and PA
catheters, the former usually via radial artery and the latter usually via the right internal jugular
vein. Float the PA catheter with the balloon inflated until you achieve an occlusion pressure. Note
that pressure (it is the ONLY occlusion pressure you will obtain in the operating room), deflate
the balloon, and then pull back 3 to 5 cm of catheter to ensure an unoccluded vessel with the
balloon deflated. When using pressure monitors, always look at the tracing before looking at the
numbers: strange tracings usually reveal an artifact as the cause of strange numbers.

The TEE machine and probe should be in the OR if TEE is planned or requested. Should the
dedicated O.R. machine be claimed for another room, ask our anesthesia technicians to secure
another machine from cardiology.

Preinduction Hemodynamic Measurements: In high risk cases consider inserting a PA catheter

prior to induction. If you do so, measure CO and record SBP, HR, CVP, PAP and CO as it may
be necessary to initiate or continue inotropes prior to induction. Otherwise the PA catheter is best
inserted post induction.

Monitoring for Ischemia: EKG. Patients undergoing CABG surgery have intra-operative
episodes of myocardial ischemia. Leads II and V5 pick up the majority of ischemic episodes
detectable by EKG. Place the chest lead in the 5th intercostal space along the anterior axillary line.
PA Catheter. Insufficient blood flow to the myocardium causes wall motion abnormalities
within 5 to 10 seconds. Increases in the PA occlusion pressure eventually result, including new
V-waves from new mitral regurgitation. Increased PAD pressure reflects this. We do not “wedge”
the catheter during surgery; instead, we follow the PAD. Transesophageal Echo. TEE

8
monitoring will detect ischemia earlier than elevations of either ST-T waves or pulmonary arterial
pressures. Abnormal wall motion due to ischemia may occur without EKG changes. The
transgastric, short-axis mid-papillary TEE view best monitors for ischemia. However, it will not
detect ischemia in the basal or apical segments of the heart; use mid esophageal views for this
purpose.

Transesophageal Echocardiograhy: Following intubation, suction the stomach with an orogastric

tube, remove the OG tube, and insert the TEE probe. Probes are expensive and easily damaged –
handle them with extreme care. Always use a bite block and plenty of lubricant. The 3 EKG
wires of the TEE machine also must be applied to your patient. TEE can detect air, ASD, VSD,
AS, AR, MR, MS, volume status, aortic plaque, myocardial ischemia, regional and global
ventricular function and valvular function. It takes time and effort to gain facility with TEE, and
is well worth the effort. TEE can detract from patient care if one ignores the patient and other
monitors while using TEE. Use it to supplement patient care – not as a substitute for fundamental
monitors. At the end of the case, protect the TEE probe when removing it from the patient.
Return it to the anesthesia work room for cleaning. Insert an OG tube to suction the stomach.
Ascertain that the echo study has been uploaded to the main computer via Ethernet port in room 8
or 10.

Care of Arterial Lines: The sampling port is close to the transducer, not the patient, because the
patients arms are tucked in at his/her side. Follow these rules in use:
1. Ensure no air bubbles in the line before flushing to the patient.
2. Large, forceful flushes can force emboli retrograde to the central circulation and cause stroke.
Avoid flushing with a syringe; use the pigtail whenever possible.
3. When sampling, withdraw a full 10 mL of fluid from the line first, to avoid a sample diluted
with flush solution; return this fluid to the patient via a venous port.
4. ALWAYS flush the line after sampling, lest it clot and become useless!
5. Use sterile technique at all times. Keep the open stopcock port covered with a sterile syringe,
or a blue, occlusive sterile cap provided in each triple transducer kit. Do not use the non-
occlusive caps.
6. Flush stopcocks free of bloody fluid.
7. Remember, your barrier gloves are not sterile: watch what you touch!

Anesthesia Induction
No form of anesthesia is better than another with two exceptions: desflurane or ketamine
induction may cause tachycardia and myocardial ischemia, making them the only anesthetics not
recommended for induction in patients with known coronary disease.

Although opioids form the basis for cardiac anesthetics, they alone cannot provide all of the
needed elements, viz., analgesia, amnesia, muscle relaxation, and inhibition of noxious reflexes.
We use propofol or etomidate, in hypnotic doses, only at induction, and supplemental isoflurane
or sevoflurane throughout most of the procedure; an isoflurane vaporizer mounted on the CPB
pump provides inhalational agent during bypass.

Never induce a patient without a surgeon and perfusionist in the vicinity, in the event institution
of bypass becomes necessary. Be sure all appropriate monitors are in place, including a backup
arm cuff should the arterial catheter fail.

The anesthetic goal during induction and intubation is stable heart rate and blood pressure. We
avoid nitrous oxide until after chest closure because of potential expansion of any gaseous emboli

9
or intraluminal air when the heart is opened. Inhalation agents may provide ischemic
(anesthetic?) preconditioning and ameliorate the effects of reperfusion injury.

Specific Drugs
• Fentanyl dose ranges in mcg/kg (total): High>100; Medium 20-60; Low 5-10. We tend to
use low-medium fentanyl doses for most cases (usually 1-2 mg total for off-pump cases and 2
mg for on-pump cases) to facilitate early extubation.
• Sufentanil: Use 1/10th the dose of fentanyl.
• Inhalational Agents: isoflurane, sevoflurane supplement the opioid.
• Benzodiazepines also provide supplementation.
• Propofol infusion provides on-going sedation for transport to the CTICU, while allowing
early extubation. Avoid the “no-man’s land” upon arrival to the CTICU of hypertension,
tachycardia, and bucking with minimal monitoring and tangled IV access: use propofol or
other techniques during the transport of intubated patients.
• We use pancuronium for muscle relaxation. The slight vagolysis from pancuronium
antagonizes the vagotonia from fentanyl or sufentanil to leave heart rate unchanged.

Planning for Early Extubation: Early extubation (“Fast-Tracking,” i.e., within 6 hours of
operation) may reduce ICU length of stay and lower costs without increasing patient morbidity.
High-risk cases are not suitable for early extubation. On-table extubation (“very early extubation”
= VEE) may be possible in OPCAB patients or following short bypass runs (ASD repair).
Discuss plans for fast tracking or VEE with your attending before induction, because each
requires planning from the start. Limit intravenous fluids, as well as the total narcotic and
benzodiazepine doses. Keep the patient warm: use a forced hot-air warming device as much as
possible. Consider VEE only when the patient’s temperature exceeds 35.5C, and when adequate
opioid analgesia can provide stability of blood pressure.

Completion of induction. (1) Soon after induction and intubation, draw arterial samples and give
them to the perfusionist for baseline ACT and ABG values. See the section on Care of Arterial
Lines regarding technique. (2) Determine baseline cardiac output, cardiac index, and SVR.
Remember SVR is calculated, not measured, and often reflects flow, rather than determining it.
(3) Remember to place the OG tube to gravity drainage using a glove; do not use continuous
suction. Remove the OG tube instead, if inserting a TEE probe. (4) Use an oral esophageal, not a
nasal pharyngeal temperature probe. Place NOTHING in the unprepared naris of a patient about
to receive generous doses of heparin. (5) Double check that antibiotic administration is timely. (6)
Get your anesthesia record up to date as soon as possible.

Pre-bypass Events
Incision and Sternotomy. Following induction, little stimulation occurs for a long time. Then two
graded stimuli follow: incision, followed shortly by a painful sternotomy and (even more
stimulating) sternal retraction. Your patient must be adequately anaesthetized prior to incision.
Disconnect the patient from the ventilator during sternotomy to avoid tearing the pericardium.
Will you remember to recommence ventilation? Develop a plan, such as holding the tubing in
your hand while the patient is apneic. During redo sternotomy with an oscillating saw, it may not
be necessary to hold ventilation.
IMA Dissection. The surgeons usually want the table tilted to the left and elevated. Because lung
inflation makes dissection more difficult, surgeons frequently request reduced tidal volumes;
increases the rate to maintain minute ventilation. They may also request hand ventilation (“lungs
down”): stand at the head of the table, with eyes on the wound and hand on the bag. Squeeze the
bag when the surgeon withdraws the electrocautery wand. Watch what they are doing to make

10
sure you are helping, not hindering. If you hold ventilation completely, do not disable alarms,
remind the surgeon every 30 seconds that the patient is apneic, and remember to turn the
ventilator on again (easily forgotten: have a plan!).
Cannulation. Use a small bolus dose of NTG (1-2 µ g/kg) or SNP (0.5-1µ g/kg) if needed, to
obtain a SBP of 100-120 mmHg to prevent aortic dissection during cannulation. Demonstrate that
you are paying attention to the procedure by anticipating this need and achieving the target SBP
in a timely manner, rather than have the surgeons wait impatiently while the drugs circulate. If
you have not yet administered heparin, ask the surgeons if they would like it given (they do, and
will wait, this time patiently, until it has circulated, before cannulating). They will place either a
single, large venous cannula into the right atrium via its auricle, or 2 moderately large cannulae
through the right atrium – one into the inferior and the other into the superior vena cava. Another,
small cannula with a balloon at one end is placed into the coronary sinus for retrograde
cardioplegia administration. The majority of emboli occur upon placement or removal of the
aortic cannula and upon placement and removal of the aortic cross clamp. At these times, high
glucose concentrations or warm brain temperatures (37 C) are not desirable. Many patients suffer
subtle neuro-psychiatric changes consistent with multiple small emboli.

Hemodynamic Perturbations.
The surgeons can cause profound hypotension with cardiac manipulation. If the pressure
suddenly drops or PVCs develop, look at what they are doing. Before you give a drug to treat
hypotension, rule out a transient surgical manipulation. State clearly “Pressure is 60/30.” They
will get the message and complete or abort their trespass. Be alert for ventricular fibrillation to
occur at any time. Always use the EKG and the arterial tracing (not numbers!) in tandem to
diagnose critical events. If you detect it first, calmly AND CLEARLY announce the fact to the
surgeons. They will provide an electrical cure. Give anti-dysrhythmic only following discussion.

Prebypass Hemodynamic Management: In general you should try to keep the systolic blood
pressure (SBP) around 120 mmHg and the heart rate 60-80 /min depending on the clinical
situation prior to bypass. During insertion of the aortic purse-string suture, bring SBP down to
100-120 mmHg to prevent aortic dissection during cannulation. Papaverine injection by the
surgeon during mammary artery harvest may drop the pressure transiently. Resist the temptation
to give phenylephine, lest SBP be 160 mmHg just as the surgeon is ready to cannulate. Treat
tachycardia and hypertension first by deepening anesthesia (remember to increase your fresh gas
flow transiently to deliver inhalation agent to the lungs), then consider esmolol, labetalol, or
metoprolol. Add nitroglycerine or nitroprusside as needed to control hypertension. Gain
experience and perspective in using these drugs for this purpose by discussion with your
attending.

Specific recommendations for valvular procedures. In general, maintain preload in the normal
range. Reduce afterload for regurgitant lesions; maintain it for stenotic lesions. Keep heart rate in
the high normal range (80-100/min) in patients with regurgitant valves; low normal (60-80/min)
for those with stenotic valves. In severe mitral stenosis, tachycardia can be life threatening.

Bypass Hemodynamics: Keep the MAP 60-70 mmHg during bypass. Exception: patients with
significant carotid occlusive disease or chronic renal insufficiency may need higher pressures
(70-80 mmHg) for the entire pump run. Control MAP with inhalation agent, vasodilators (NTG /
SNP), and vasoconstrictors (phenylephrine or norepinephrine). Do not treat low perfusion
pressure with vasoconstrictor when the pump flow is deliberately reduced. Listen to the dialog
between surgeon and perfusionist to know what they are doing at all times.

Cardiopulmonary Bypass

11
On initiating bypass, the surgeon removes the clamp from the venous line and a siphon effect
drains central venous blood into the venous reservoir. Without this siphon effect, venous return to
the CPB machine would cease. With little blood giong into the right ventricle, cardiac output
plummets. The perfusionist then turns on the roller head nearest you, pushing blood through the
oxygenator and filters back to the patient’s aorta. The perfusionist will announce “full flow”
when pump flow has reached around 2.2L/min/m2 . You should then discontinue mechanical
ventilation. Pulmonary artery pressures should be low while the patient is on CPB.

Check List for Going on Bypass. Do all of these items:

1. Heparin: Always give prior to cannulation for bypass.
2. ACT: Always check before going on bypass (>480 seconds).
3. Drugs: Do you need anything (neuromuscular blocker, opioid)?
4. Drips: Turn off the inotropes and IV fluids. Maintain antifibrinolytics and carrier.
5. Pull the PA catheter back 2 cm to avoid pulmonary arterial occlusion/rupture.
6. Alarms: Disable alarms tones (ECG, BP, CO2, Pulse Ox etc).
7. Ventilator: Turned off once patient is safely on bypass (full Flow).
8. Urine: Empty the urimeter and note volume on the anesthesia record.

The three serious perfusion errors are no oxygen flow to the oxygenator, failure to give heparin,
and no fluid in the reservoir with massive air embolism. Other things can happen on bypass. If
electrical power fails, we turn the roller head with a hand crank – you may be asked to help crank.
If a fluid line breaks, you may have to help replace it. An air lock in the venous drainage (loss of
siphon) can eliminate blood return to the pump. If you or the perfusionist note bubbles in the
venous return line, check the integrity of the central line sheath. Are all stopcocks closed to air? Is
air entering the venous system via any infusion line? The surgeon should check the right atrial
purse strings. A temporary reduction in pump flow will increase venous pressure, and decrease
any air entry. The venous lines to the pump can be refilled with saline if complete airlock occurs.

Cardioplegia: There are different approaches in both termperature (cold; warm; warm induction +
cold maintenance + warm reperfusion) and composition (crystalloid; blood). It is given antegrade
via a catheter in the aorta proximal to the cross clamp, or retrograde via the coronary sinus. The
only essential ingredient in cardioplegia is a high potassium concentration to induce diastolic
arrest. The cold variety (4 C) reduces myocardial oxygen demand.

De-airing Maneuvers: In open ventricle or aortic procedures the surgeon will have you place the
patient head-down. You may also be asked to deliver a Valsalva breath (to de-air the pulmonary
circulation). At this time, the TEE displays a storm of little bubbles in the ventricle.

Check list for Weaning from Bypass: Call the faculty cardiac anesthesiologist before the urinary
catheter temperature reaches 36 C. Check these items. Note than you can form a mnemonic
device by imagining that each begins with the letter “P”:
1. Positive pressure ventilation. If you forget this, you’ll feel quite stupid.
2. Protamine drawn up, ready to administer, but out of sight and reach.
3. “Pee” – empty the urimeter and note volume on the anesthesia record.
4. Potassium is less than 5.5 mEq/L
5. pH, PCO2, and PO2 all acceptable
6. Pulse: heart rate and rhythm are optimal (NSR or paced, rate 70-90/min)
7. Pressure: a MAP<60 mmHg suggests need for vasoconstrictor

12
Weaning from bypass: Do you have a plan? Was ventricular function good prior to bypass? Was
the cross clamp applied a long time? What does the heart look like now? Communicate your plan
with the attending anesthesiologist. The surgeon probably has a plan that should be considered.
Remember that heart rate and stroke volume determine cardiac output. (Note the “P” motif
continues: pulse, preload, pressure [afterload], and power [contractility].)
1. Always have ready epinephrine, or less commonly, a different inotrope. Most (80-90%) first
time CABG patients can wean from bypass without inotropes.
2. The perfusionist partially occludes the venous drainage line, reducing the amount of blood
draining into the venous reservoir. Right atrial pressure increases and blood enters the beating
right ventricle. The perfusionist, on orders from us or the surgeon, increases the occlusion of
the venous return line to the pump, filling the right ventricle more blood. S/he also decreases
the pump flow in tandem. For example, when the surgeon or anesthesiologist says “3 and 2,”
the perfusionist sets pump flow to 3 L/min and occludes the venous line so that the venous
reservoir holds 200 mL.
3. The pulmonary artery and systemic pressures become pulsatile. Careful attention is paid to
both the right and left ventricles to make sure they are not distending. When the perfusionist
says, “off”, s/he has clamped the venous line. The request “give a hundred” asks the
perfusionist to transfuse 100 mL of blood from the reservoir to the patient via the aortic
cannula. Once both venous and arterial lines have zero flow, the patient is off bypass. Note
the clock time.
4. Once off the pump, determine cardiac index and SVR. Adequate cardiac output despite low
systemic pressure denotes a problem not cardiac in nature, but rather low SVR. Hence
employ a rather than an inotrope.
5. Make an educated guess as to the inotropic state of the ventricle. With time you will develop
the ability to roughly assess cardiac contractility simply by observing the heart. However,
you are viewing only the right ventricle. Look at the LV on TEE, if available. If LV
contractility was poor prior to bypass, it will most likely still be poor and an inotrope will be
necessary. Once hemodynamics are stable, the surgeon will remove the venous cannula. The
arterial line is still in place so the perfusionist can continue to transfuse blood if necessary.
6. Intra Aortic Balloon Pump. The IABP may improve ventricular function in a failing heart via
afterload reduction and increased coronary perfusion pressure. The pump is synchronized
with the EKG or arterial pressure. Failure to improve after IABP placement may necessitate
placement of an LV Assist Device.

After Bypass. The goals in this period include maintenance of adequate cardiac output and other
hemodynamics, restoration of coagulation and control of surgical bleeding, and achieving a
physiologic metabolic state. Remember these items:
1. Inotropes and Vasoactive Compounds: Use standard concentrations only. Check the label and
expiration date. Do not choose phosphodiesterase inhibitors (milrinone) as first line
inotropes. They produce profound vasodilation and will most likely require a concomitant
vasoconstrictor. Remember to turn the stopcock on the multiple infusion manifold so that the
fluid enters the patient.
2. Potassium: Low potassium, < 4.0 mEq/L, associates with arrhythmias. Administer 20 mEq
KCl by infusion if [K+] < 4.0. ALWAYS use an infusion pump when giving KCl
intravenously. [K+] > 5.0 occurs commonly on bypass from the cardioplegia, and will correct
with time.
3. Post Bypass Hemodynamics: Systolic blood pressure between 100 and 120mmHg would be
ideal. If it is greater than 120 -140mmHg there will be more bleeding. Cardiac index greater
than 2.0 is fine. If CVP is ever greater than PAD there is a problem: poor calibration or right
ventricular failure.

13
4. Protamine: Prepare and administer according to guidelines in this manual.
5. Post Bypass Bleeding: First, check the ACT. If elevated, administer additional protamine.
Most non-surgical bleeding arises from platelet dysfunction; platelet transfusions may be
necessary.
6. Returning to Bypass: Severe hypotension, bleeding, low cardiac output or other problems
may prompt a return to bypass. If you have already given protamine, give another dose of
heparin, 400 units/kg, and check an ACT.
7. Sternal closure may cause hypotension if volume status is low. If the lungs appear
hyperinflated, or if the heart lifts out of the chest, consider bronchospasm with air trapping.
Bronchodilators, ventilator and endotracheal tube adjustment may help.

Transport to CTICU is a critical process frought with hazard. Call your attending to the room
when the surgeons are closing skin. Expect your attending to accompany you with the patient to
the CTICU. Consider these items:
1. Get organized to move the patient from the OR table to the ICU bed. Disconnect infusion
pumps from electrical outlets. Assemble emergency drugs to take with you (opioid,
vasoconstrictor, vasodilator, inotrope, atropine).
2. Ready the transducers and pacemaker for movement with the patient. Disconnect the CVP
and PA transducers from the grey monitor cables, and transfer the ARTERIAL transducer to
the grey cable attached to the transport monitor. Do so with as few missed beats as possible.
3. Make sure the bed’s oxygen tank is sufficiently full (calculate from tank pressure and flow
setting). Ensure oxygen flows into the Ambu bag, and that the bag holds pressure before
transferring the patient to the ICU bed. Bed transfer often leads to hypotension; be prepared
to intervene.
4. Monitor the patient at all times. Do not leave the OR with unstable hemodynamics.
5. You cannot push the IV pole with infusion pumps, squeeze the breathing bag, monitor the
patient’s hemodynamics, and watch where you’re walking all at once. Divide these tasks
amongst those accompanying the patient.
6. Avoid catastrophic dynamic pulmonary hyperinflation, a situation in which stacked breaths
increase thoracic pressure to obliterate venous return. Opening the endotracheal tube to
atmosphere will cure this condition.
7. Descend the ramp to South Tower slowly enough to prevent crashing the bed into the wall,
but quickly enough to prevent massive lower extremity pooling of venous blood.
8. Watch out for carts, machinery, and other obstacles in your path. You will likely pass
visitors, possible your patient’s relatives, on the way. Act with dignity, politeness, and
professionalism at all times, and encourage colleagues to do the same by your example.

OFF PUMP CABG (OPCAB)

We accomplish coronary bypass surgery on a beating heart without cardiopulmonary

bypass by stabilizing the heart using two arms of the device which has rows of suckers
like octopus legs. A different retractor shaped like a small footplate also works. A CO2
gas blower keeps the field dry while the surgeon operates. This technique requires
technical expertise from both surgeon and anesthesiologist: the heart moves and must
generate flow despite being ischemic during the coronary anastomosis. Hemodynamic
instability and arrhythmias occur often as a result of unphysiologic positioning of the
heart to gain access to the circumflex and posterior descending coronary arteries.
1. A perfusionist should be immediately available if required.

14
 2. Positioning of the heart and placement of stay sutures/ may require preload
adjustments. Fluids and vasoconstrictors are frequently necessary. Beta-agonists may
produce pro-arrhythmic effects. Trendelenberg’s position aids right ventricular filling.
3. Anticoagulate with 100 units/kg heparin, rather than the usual 300 units/kg.
Check the ACT every 20-30 minutes and add heparin to maintain an ACT >300
seconds. Remember that if you need to institute bypass urgently, you must give
additional heparin!
4. We currently give all patients antifibrinolytic therapy during OPCAB.
5. Keep SBP around 120–140 mmHg during distal anastomoses and <100 mmHg
during proximal anastomoses. Use norepinephrine, epinephrine, NTG, and SNP as
needed. Check cardiac output frequently. Be prepared for sudden, unexpected
ventricular fibrillation.
6. Be prepared to treat reperfusion arrhythmias.
7. Reverse the heparin with protamine. Remember you don’t have a bypass circuit
ready to bail you out. Usually 100-150 mg of protamine is adequate.

Re-do Heart – Sternotomy

In a redo case, adhesions may bring the ventricle close to the sternum. The surgeons use a
different, rotating sternal saw; nevertheless, it may cut through the right ventricle or
innominate vein, causing massive hemorrhage. Have 2 large bore peripheral intravenous
lines. Make sure you have checked 2 units of blood and replaced them in the OR
refrigerator. The surgeon may cut through the IMA or a saphenous graft inadvertently.
You should have an idea of what this will do from the catheterization 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. A functional graft that the patient is dependent
on is potentially the most hazardous situation.

Anticoagulation and Coagulation

Heparin.
In cardiac anesthesia, the only “syringe-swap” guaranteed to kill the patient is that of
heparin with anything else. If the patient is not heparinized when the clamp is opened on
the bypass machine, the pump and oxygenator will clot. When they ask for heparin,
respond with a verbal statement- “the heparin is in”. Always use the CVP line to inject
heparin. Aspirate from the CVP line before the heparin dose to check to make sure the
line is in a vein. If you can’t aspirate blood choose a different lumen. If you choose the
lumen that SNP or NTG has been going through, avoid giving a bolus of vasodilator. If
there is another line piggy-backed to the one you are using for heparin, make sure the
heparin doesn’t run up the side line.

If an IMA is being harvested, the surgeons will ask for the heparin prior to detaching the
distal end, otherwise they will ask during purse string insertion into the aorta or right
atrium. Give heparin over 10-15 seconds. Often, a slight decrease in systemic pressure
follows.

15
The dose of heparin is 300 U/kg for on-pump cases. Its onset is immediate, but check the
ACT 3 minutes after the dose to avoid a transient peak. You can use an arterial or venous
blood sample as long as you aspirate an adequate volume of dead space. You want to
check the ACT quickly because it needs to be 480 seconds to go on bypass – that’s 8.5
minutes of waiting if you’ve forgetten to draw the sample. For patients receiving heparin
infusions before operation, give 400 units/Kg. If the ACT is less than 400 seconds after
the dose, tell the surgeon and perfusionist, and give more heparin until the ACT is above
480 seconds.

Antifibrinolytic.
We use epsilon aminocaproic acid (Amicar®), an inexpensive (<$5/dose), synthetic drug
to provide antifibrinolytic effects. No surgeon currently uses aprotinin for cardiac
surgery at our institution. Both agents work by inhibiting clot breakdown (fibrinolysis)
and by protecting platelets from partial activation during CPB by blocking their plasmin
receptors.

The reduction in post bypass bleeding differs slightly for these 2 agents: 30% less
bleeding with aminocaproic acid, and 40% less with aprotinin. Prepare aminocaproic acid
according to the instruction sheet in the red cart. The total dose is 10g per case.

Aprotinin has received some notoriety recently based on safety issues, particularly with
respect to its use in total circulatory arrest, and a potential role in postoperative
myocardial infarction. Aprotinin prolongs the celite ACT, but not kaolin ACT, the reason
why all ACTs at HUH employ kaolin as the activator. A bovine protein, anaphylaxis
from aprotinin can occur: always give a 1 mL test dose 10 minutes before starting an
aprotinin infusion.

Protamine.
NEVER GIVE PROTAMINE WHILE YOU ARE STILL ON BYPASS! (Sounds
obvious but it is surprisingly easy to do and may kill the patient).

Many formulae provide calculation of protamine dosage. Ideally, one wishes to provide 1
mg protamine for every REMAINING 100 Units of heparin activity. Check with your
faculty anesthesiologist regarding his/her preferred method before you commit to a
specific dose. It may involve giving less protamine than you think.

Dilute the neutralizing dose of protamine in a 50 mL bag of normal saline, attach a small
drop administration set, and store it on the back table during CPB. Inform surgeon before
starting protamine infusion. Adjust the drip rate initially at < 1 drop/second, advancing
the rate only after several minutes have passed without adverse sequelae: hypotension,
bronchospasm, rash, or pulmonary hypertension. Stop administration for any of the above
problems. The duration of infusion should always exceed 3 minutes, with a minimum of
10 minutes as your target.

Once 1/3 of the protamine has been infused inform the surgeon and perfusionist. They
will discontinue suction from the surgical field to the pump to avoid clotting the pump (if

16
it clots, you cannot return the patient to bypass). Two minutes after infusion completion,
check the ACT. If it hasn’t returned to baseline, give a small, additional dose of
protamine, about ½ mg/kg. You may bolus to 20 mg of protamine every 2 minutes. If you
give pump blood after chest closure, you will need to give additional protamine to
neutralize the heparin in the pump-blood, up to 0.1 mg/mL.

Fluids
Amount. Many theories but few data pertain to fluid management. Cardiac patients can
easily receive large amounts of fluid intraoperatively with little obvious benefit. That
fluid then must be excreted postoperatively - frequently by administering large doses of
furosemide with subsequent electrolyte disturbances. This approach frequently delays
post-operative extubation. Please try to limit fluid administration intraoperatively; for
on-pump cases, the hematocrit on CPB should always exceed 21%. In off-pump cases,
use phenylephrine and norepinephrine and the head-down position to maintain blood
pressure during mild hypovolemia; check cardiac index frequently to ensure adequate
flow. Vasodilation occurs commonly after bypass; expect to administer fluid at sternal
closure and thereafter.
Type. Discuss with your faculty attending the choices of clear fluid (Isolyte®), 5%
albumin, and hetastarch. We limit hetastarch to 500 mL based on its platelet effects.

Pharmacy Support

The 8th OR pharmacy provides all the infusions ordinarily used (epinephrine,
nitroprusside, nitroglycerine, phenylephrine) except for norepinephrine. It supplies
antibiotics, propofol, and insulin infusions. After pharmacy hours and on weekends, these
drugs are available from the refrigerator in the anesthesia workroom.

The induction pack used in CT is different from the one used in the general OR. All of
the drugs found in the general OR packs are found in the CT pack, but there are more
syringes of phenylephrine and epinephrine in the CT pack, and the pack also contains a
dobutamine syringe. All other drugs needed should be available in the CT cart in the
room. For all cases, dilute a 4 mg vial of norepinephrine from the CT cart into 250 mL
NSS solution to yield 16 mcg/mL. Prepare and label a 10 mL syringe of this mixture. For
transplant cases, ask the pharmacy for isoproterenol (1 mg/5 mL), to mix in 250 mL of
NSS to yield 4 mcg/mL. The pharmacy will prepare on request a diltiazem infusion for
use in CABG cases where a radial artery is harvested.

For thoracic cases where an epidural infusion is planned for postoperative pain, the
pharmacy will prepare one of several epidural infusions on request. Most commonly, we
use a mixture of bupivacaine 0.125% with fentanyl 4 mcg/mL.

17
Didactic Program

In the course of your eight week CT rotation, you will discuss the following specific
topics with the assigned CT faculty member. Set up a convenient time and date with the
assigned faculty member to discuss the following:

1. The CBP machine and pathophysiology of CPB – Dr Okum

2. Myocardial oxygen supply, demand and anesthetic management for myocardial
revascularization – Dr Okum
3. Anticoagulation (Heparin and Protamine) – Dr Horrow
4. Anesthetic management of valvular heart disease – Dr Neilsen
5. Pacemakers and Intra aortic balloon pump – Dr Cohen
6. Anesthetic management for cardiac transplantation – Dr Lingaraju
7. Thoracic aneurysms and aortic dissections – Dr Zonshayn
8. Intraoperative Transesophageal Echocardiography – Dr Lingaraju

Recommended Text Reading

Junior Residents:
Pace yourself to complete chapters 1-3, 5-9, 11, 12, 13, 18, and 25 in this outline text:
Hensley FA Jr, Martin DE, Gravlee GP (eds.): A practical approach to cardiac
anesthesia, 4th ed. Elsevier, Philadelphia, 2000.

Senior Residents:
Read chapters 4, 15, 17, and 19-24 in the above mentioned outline text.
Also, read the following in Kaplan JA, Reich DL, Lake CL, Konstadt SN (eds.).
Kaplan’s Cardiac Anesthesia, 5th ed., Elsevier Saunders, Philadelphia, 2006:
Chapter 5, pages 71- 89, Cardiac physiology
Chapter 9, pages 165-212, Pharmacology of Anesthetic Drugs
Chapter 10,pages 213-280, Cardiovascular Pharmacology
Chapter 14,pages 385-436, Monitoring of the Heart and Vascular System
Chapter 15,pages 437-488, Intraoperative Echocardiography
Chapter 19,pages 585-643, Anesthesia for myocardial revascularization
Chapter 20,pages 645-690, Valvular Heart Disease
Chapter 26,pages 845-865, Anesthesia for Heart, Lung, and Heart-Lung Transplantation
Chapter 28,pages 893-935, Cardiopulmonary bypass and the Anesthesiologist
Chapter 31,pages 1023-1040, Discontinuing Cardiopulmonary Bypass

These texts are available for loan from the department. See the departmental academic
coordinator for access to the texts. If you borrow a book, you must (1) read it; and (2)
return it.

Recommended Periodical Reading

1. Brodsky J, Lemmens HJ: Left double-lumen tubes: Clinical experience with 1,170
patients. J Cardiothoracic Vasc Anesth 2003; 17:289-98.

18
 2. Duggan M, Kavanagh BP: Pulmonary atelectasis. Anesthesiology 2005; 102:838-
54.
3. Maslow A, Aronson S, et al: Off-pump coronary artery bypass graft surgery. J
Crdiothoracic Vasc Anesth 1999; 13:764-781.
4. Shanewise JS, Cheung AT, Aronson S, et al: ASE/SCA guidelines for performing
a comprehensive intraoperative multiplane TEE examination: Recommendations of
the ASE council for Intraoperative Echocardiography and the SCA taskforce for
certification in perioperative TEE. Anesth Analg 1999; 89:870-84.
5. Levy JH. Hemostatic agents and their safety. J Cardiothoracic Vasc Anesth 1999;
13:6-11.
6. Cheng DCH, et al: Randomized assessment of resource use in fast-track cardiac
surgery, 1-year after hospital discharge. Anesthesiology 2003; 98:651-657.
7. Khan NE, De Souza, et al: A randomized comparison of off-pump and on-pump
coronary-artery bypass surgery. N Engl J Med 2004; 350:21-8.
8. Shann KF, Likosky DS, et al: An evidence-based review of the practice of
cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control,
hemodilution and the inflammatory response. J Thorac Cardiovasc Surg 2006;
132:283-290.
9. Mangano DT, Tudor IC, et al: Multicenter study of perioperative ischemia
research group; Ischemia research and and education foundation. The risk associated
with aprotinin in cardiac surgery. N Engl J Med 2006; 354: 353-65.
10. Concato J, Shah N, Horowitz R. Randomized, controlled trials, observational
studies, and the hierarchy of research designs. N Engl J Med 2000; 342:1887-92.

Evaluations and Feedback Mechanisms

Resident by faculty. The faculty members assigned to supervise you in CT will evaluate
your performance based on the current objectives. Click for CA1 or CA2 or CA3 to view
evaluation forms.

INTERIM EVALUATION: At the conclusion of your 2nd week in CT, the Director of CT
anesthesia or his/her designate will review available evaluations and recommend areas of
concentration for your efforts for the remainder of the rotation. Click here to see the
evaluation forms for residents.

FINAL EVALUATIONS: The program director will review all evaluations with you at
your next regularly scheduled quarterly meeting.

Resident by CT Personnel. CT operating room personnel will rate you on your patient
and interpersonal skills, your ability to function as a cohesive team member, your
communication skills, and your professionalism. They will use this evaluation form.

Rotation and Personnel by Resident. You will evaluate the CT rotation on the last day of
your rotation. Your evaluation will include an opportunity to provide feedback on

19
individual faculty members, CT personnel, as well as the structure, organization, and
topical material in the rotation. Click here to see the form you will use.

Common Mistakes/Tips
Please arrive early enough to check the room that you will be working in for the day. It is
imperative that YOU yourself check all the equipment which means the following:
-Check if all your IVAC pumps are working
-Make sure there is NO AIR in any of your lines that you have primed
-Make sure all your drips are NOT EXPIRED (common mistake)
-Enter all the height and weight into the computer to calculate cardiac output and index
-Make sure you have TEE probe and machine available if TEE is going to be used
-If no TEE probe is found on the machine ask one of the technicians to help you find one
or you may need to page cardiology (nurse can do it for you also) to bring a probe
-Always be aware where you Heparin is and where you Protamine is placed.
-Figure out a way to remind yourself when you have turned off the VENT and will have
to turn it back on when the patient is coming of CPB
-Make sure you have your size sterile gloves to place the lines

-ASK FOR HELP IF YOU HAVE NO IDEA

20
 Obtaining the 20 Standard
Transesophageal Echocardiography Views 0
Hypopharynx

0 UE + 90 UE
AA LAX AA SAX

90 ME Asc 0 ME Asc
Aor LAX Aor SAX

120 ME 60 ME 30 ME 0
AV RV OT AV ME 5C
LAX SAX

+ +
P r ob e D epth

90 ME 120 90 60 0 + 0 ME Desc 90 ME Desc

Bicaval ME LAX ME 2C ME MC ME 4C Aor SAX Aor LAX
R
A
+
0 TG -
Basal SAX

120 TG 120 90 0 TG
RV Inflow TG LAX TG 2C Mid SAX
R
Legend A
+
A Anteflex probe Rotate probe left 0
Deep TG
R Retroflex probe Rotate probe right

Decrease omniplane
-
depth (display depth)
Increase omniplane
+
depth (display depth)
Change omniplane
angle
Increase probe 2C - Two Chamber Asc Aor - Ascending Aortic ME - Mid Esophageal
depth
4C - Four Chamber Desc Aor - Descending Aortic RV - Right Ventricle
Decrease probe 5C - Five Chamber OT - Outflow Tract (Inflow-Outflow) SAX - Short Axis
depth 21
AA - Aortic Arch LAX - Long Axis TG - Transgastric
90 AV - Aortic Valve MC - Mitral Commissural UE - Upper Esophageal
Omniplane angle
©Toronto General Hospital Department of Anesthesia and Pain Management 2008. All rights reserved.
Name Going on PUMP (ACT>480 seconds)
Age: Start Time: End Time:
Height: inches Start Time: End Time:
Weight: lbs kgs
BSA: (calculated via comp) Fluids (Ins/Outs) prior to going on pump
Time: Time:
Baseline Values Returning from PUMP Sternal Closure Isolyte: Isolyte:
CO: Urine: Urine:
CI:
SVR: Fluids (Ins/Outs) coming off pump
CVP: Time: Time:
PAP/PAD: Isolyte: Isolyte:
ABG: Note on chart Urine: Urine:

Heparin Going on BYPASS: "HAD2SUE"

Heparin Dose #1 units @ ACT: @ Heparin: Always give PRIOR to cannulation for bypass
Heparin Dose #2 units @ ACT: @ Act: Greater then 480 seconds.
Heparin Dose #3 units @ ACT: @ Drugs: Do you need anything (neuromuscular blockage, opiods)?
Heparin Dose #4 units @ ACT: @ Drips: Turn OFF inotropes and IV fluids. Maintain antifibrinolytics and carrier
Heparin Dose #5 units @ ACT: @ Swan: Pull back 2cm to avoid pulmon arterial occlusion/rupture
Urine: Empty urimeter and note volume on chart
Protamine Efficieny: Disable all alrams and turn of vent once pt is on bypass (FULL FLOW!)
Protamine Dose #1 mg @ ACT: @
Protamine Dose #2 mg @ ACT: @ Weaning from BYPASS: "WRMVP6"
Protamine Dose #3 mg @ ACT: @ Wide Receiver Most Valuable Player
Warm-Pt should be warm-check urine temp, central temp is more influenced by CPB
Dosing Heparin: Rhythm-Aim for optimal rhythm NSR versus paced at 70-90b/min
Off PUMP CABG: 100u/kg of heparin. Aim for ACT >300seconds Monitors-Turn them back on
On PUMP CABG: 300u/kg of heparin. Aim for ACT>480seconds Ventilation-TURN IT BACK ON!
On heparin prior to surgery: 400u/kg of heparin, Check ACT P-Protamine draw up and ready but out of sight, Pee-check and record, Potassium-
Return to PUMP due to emergency and protamine given then give 400u/kg of heparin less then 5.5, pH, PCO2, PO2 all acceptable, Pressure-MAP<60 might need constrict
Heparin works by augmenting activity of Antithrombin III which complexes with and
inactivates circulating coag factors (except Factor VII). Formulas:
CO = HR x SV
Dosing Protamine: Many ways check with attending, here is "usual" way CI = CO / BSA (2.2-4.2 L/min/m2)
Usually 150mg of Protamine are diluted in a 50ml bag and start infusion at less then CPP = DBP - LVEDP (coronary perfusion pressure)
1 drop/second and advance rate only if no adverse reaction: Hypotension, broncho- SVR = 80 X (MAP-CVP / CO)
spasm, rash or pulmonary edema. Note protamin is fish sperm and can cause hypo-
tension b/c it can induce histamine release from mast cells. If protamine given to pt Valve Repairs-Guidelines
who has had NO heparin then it can bind to platelets and soluble coag factors cause- AS: Preload: Keep it up Afterload: Maintain SVR: Maintain HR: 50-80
ing an anticoagulant effect. Protamine is +charged bind negaive charged heparin AI: Preload: Keep it up Afterload: Down SVR: Drop HR : 60-80 22
forming protmaine-heparin complexes removed in LUNG! MS: Preload: Keep it up Afterload: Maintain SVR: Maintain HR: 50-80
To calculate: 1.3mg for each 100u of heparin given MR: Preload: Keep it up Afterload: Down SVR: Down HR :50-80
23