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Cardiac Anesthesiology Made

Ridiculously Simple
by Art Wallace, M.D., Ph.D.
Cardiacsurgeryisadangerousandcomplexfieldofmedicinewithsignificantmorbidityand
mortality.Qualityanestheticcarewithspecificattentiontodetailcangreatlyenhancepatient
safetyandoutcome.Detailsthatareignoredcanleadtodisaster.Thisdocumentwillattempt
todescribethebarebonessequenceforcardiacanesthesiaforadultCABGandVALVE
procedureswithspecificrecommendations.Itisnotallinclusiveordefinitivebutitisthe
minimalcriticalrequirements.
Ifyoukeepyourheadscrewedonverytightlyandpay100%attentionatalltimes,things
willonlygopoorlysomeofthetime.
Agoodreferenceis:"ThePracticeofCardiacAnesthesia"byFrederickHensleyand
DonaldMartin,LittleBrownHandbook.
PatientExamination:
Anestheticevaluationmustincludeattentiontocardiachistory.Thecathreport,thallium,
echo,andECG.Criticalinformationincludes:Leftmaindiseaseorequivalent,poordistal
targets,ejectionfraction,LVEDP,presenceofaneurysm,pulmonaryhypertension,valvular
lesions,congenitallesions.Eachofthesepointsrequiresamodificationofanesthetic
techniqueandspecificinformationisrequired.Howistheiranginamanifest?Youneedto
beabletounderstandtheirverbalreports.Ifapatientsanginaisexperiencedasshortnessof
breath,ornausea,orheartburn,orwhatever,youneedtobeabletolinkthatsymptomto
possiblemyocardialischemia.
PastmedicalhistoryincludinghistoryofCOPD,TIA,stroke,cerebralvasculardisease,
renaldisease(CRIisanindependentriskfactor),hepaticinsufficiencywillchangeanesthetic
management.
Allergies
Medications:Lookspecificallyforantianginalregimensynergismbetweencalcium
channelandbetablockers,istheirCOPDbeingtreated?Itisveryimportantforpatientsto
stayontheirantianginaltherapythroughoutthehospitalstay.Ifapatientisonabeta
blocker,calciumchannelblocker,nitrate,and/orACEinhibitortheyshouldremainonthat
drugthroughouttheperioperativeperiod.Thepatientshouldgetallantianginalmedications
onthedayofsurgeryandfollowingsurgery.Thedayofsurgeryisthewrongtimetogo
throughawithdrawalprocessonanyantianginaldrug.
Physicalexam:Airway
Chest:Isthepatientinfailure?Pneumonia?COPD
Cardiac:Dotheyhaveamurmur?Aretheyinfailure?
Abd:Ascities,Obesity

LABS:MinimalCBC,Plt,Lytes,BUN,CR,Glu,PT,PTT
CXR:Cardiomegaly?Tumors?Pleuraleffusions?
ECG:LBBB:Criticalinformationifapulmonaryarterycatheterisplanned.Occasionally
patientswithLBBBcandevelopthirddegreeblockwithPAcatheterplacement.
HavetheyhadarecentMI?Dotheyhaverestingischemia?WherearetheirSTTchanges?
PFTandABG:Aretheygoingtobecomearespiratorycripple?
Information:TellthemabouttheAline,thePAcatheter,andpostopventilation.
Consent:Patientshavingcardiacsurgeryhaveseriousandfrequentcomplications
including:MI6%,CVA5%,NeuropsychiatricEffects90%,Death1310%(Dependson
risk),Transfusion(4090%),Pneumonia10%.Youmustdiscusstheserisks.
Note:Writeaclearnotewithallthestandarddetailsandconsent.TheywillgetanAline,
PAcatheter,TEE.Withthecomputerizedrecordsitiseasytogetallthepatients
information.Makesureyousignyournotesothatitisvisibletoothercomputerusers.
Premedication:Thesepatientsarescared.Theyunderstandthereisrealrisk.Theyalsowill
becomeischemicwithstress.Atleast40%getischemiapreopwithgoodpremedication.
Mostwillwithout.Givethemoxygenbynasalcannulawithsomepremed:Valium,
Morphine,something.Diazepam10mgPOoncalltoORisagoodchoice.
MedicationsPreop:Allpatientsmustgettheirantianginals.Ifthenursesputpatienton9P
9ABIDdrugsthenstateinthechartthatpatientistogetDrugX,Y,andZwithasipof
waterat6AM.Otherwiseat9AMtheywillbeintheOR,needingtheirantianginals.Be
incrediblyclearinyourpreopordersortheywon'tgettheirpremeds.Withdrawalofanti
anginalmedicationsduringcardiacsurgeryincreasesriskofdeath,MI,CVA,andrenal
failure.DONOTDOIT.
PACatheters:Atthepresenttimeallbypasscasesgetthestandardmonitorsplusanaline,
andapacatheter.ThereisanarticleinJAMAthatsuggestsPAcathetersofferlittle
additionalinformationandhaveinherentriskinICUpatients.Asyet,thishasnotchanged
ourpractice.ItisclearhoweverthatplacementofPAcathetersmustbeincrediblyskillful
withoutinjurytootherstructures.Withnoprovenbenefitallriskmustbereduced.One
methodtoachievethisisultrasonicmappingpriortocatheterplacement.Removethetowels
frombehindtheirhead,placethepatientinthepositionyouwouldlike,thentapetheheadin
place.Placethepatientintredellenburg.Takeapermanentmarkeranddrawoutthe
anatomy,sternocleidomastoid,clavicle,carotid,etc.Themorelinesthebetterasitishardto
drawoncetheultrasonicgoopisinplace.Placethebluelineinthecenteroftheechoscreen.
Placethebluedotontheprobetothepatient'sright.Makesuretheprobeisabsolutely
perpendiculartothebed.Ifyoupointitatanangletothebedyouwillhavetotaketheangle
intoaccountandfewcandotrigonometryinyourhead.Iwillbegladtotestyouonthis
point.Thentakethe5mHzprobeandmapoutthepathofthecarotidandtheIJ.TheIJis
biggerandcollapsesunderpressure,thecarotidisroundanddoesn'tcollapseunder
reasonablepressure.Ifyoudon'thavealineinanappropriateplace,wipeoffthegoop,
redraw,andthenmapagain.Thistechniquerequiresthepatienttonotmovebetween
mappingandplacement.Ithinkthissystemisfasterthannotusingtheecho,asyouwaste2
minutesmapping,andsave10minutesofsearchingwithaneedle.
Anesthesia:Despiteourbesteffortswehavenotbeenabletodemonstratethatoneformof

anesthesiaisobviouslybetterthananyotherwithoneexception.Halothane,Enflurane,
Isoflurane,highandlowdosenarcotics,andpropofolbasedanestheticsareequivalentas
longashemodynamicsarecontrolled.Desfluraneinductionshavebeendemonstratedto
causepulmonaryhypertensionandmyocardialischemia.Desfluraneistheonlyanesthetic
notrecommendedforpatientswithknowncoronarydisease.Thereisalsohighdosespinal
narcotic(MS1mgsubarachnoid)butsafetydataforthistechniqueislimited.Duringthe
monthyouwilldotwokindsofcasesnonresearchcasesduringwhichyoushouldtryeach
ofthedifferenttechniquestogetafeelforthem,andresearchcaseswithananesthetic
controlledbyprotocol.Withskill,alltechniqueswork,withluck,wemaysomedayknow
whicharetrulysuperior.
DoseRanges
Fentanyl(High)100200mcg/kg(Medium)2040mcg/kg(Low)15mcg/kg
Sufentanyl(High)2040mcg/kg(Medium)1020mcg/kg(Low)12mcg/kg
Remifentanyl0.2to1.0mcg/kg/min
Midazolam(High)35mg/kg(Medium)2mg/kg(Low)0.5mg/kg
Remifentanyl:Toquoteoneofthegreatmastersofcardiacanesthesia,therearealotof
thingsthatonecandowhilestandingupinacanoe,butwhybother?Remifentanylhasa
veryshorthalflife(510minutes)becauseofitsmetabolismbynonspecificcholinesterase.
Itallowsveryrapidemergence.Itcanbeusedforcardiacanesthesiabutthecostishighand
somenarcoticmustbegivenpriortowakeupintheICU.Reductioninthedosemaybe
possiblebygivingalongeractingcheapnarcotic(fentanyl)tooccupyafractionofthemu
receptorsandthenusetheremifentanyltooccupyasmallerfraction.Thismethodofmixing
ashorthalflifewithalongerhalflifenarcoticmayalsosmoothemergenceandprevent
accidentalemergenceshouldtheinfusionterminateprematurely.Youshouldtryacasewith
remifentanylbutclearlyrecognizethedangersandcostofthisnewdrug.
Propofol:Youshouldtryacasewithpropofolusedcontinuouslyfromthestartofthecase,
andonewhereitisaddedafterbypass.Itisexpensivebutallowsasimpletechniquefor
earlyextubation.Ifearlyextubationanddischargefromtheunitisplannedtheexpenseof
drugsthatmakeitpossibleiseasytojustify.
Dexmedetomidineisanalpha2agonistwitha1500:1alpha2toalpha1ratio.Forexample,
clonidinehasa30:1alpha2toalpha1ratio.Itmaybeusedasanadjuncttoanesthetics
withreductionsinMACorasapostoperativesedativebyinfusion.Itsroleincardiac
anesthesiaisjustbeingfiguredout.
PlanningforEarlyExtubation:Withthehealthcarerevolutionthisisthenewthing.The
keyismultiplelittlechangesinanesthetictechniquethatmakeitpossibleandagood
candidatewhoisproblemfreetomakeitwork.Theproblemissimplythatmany
patientsappeartobegoodcandidatesandthenarentwhentheygettotheICU,
otherslooklikeproblemsanddowell.Thesimplestsolutionistotreatallpatientsas
candidatesforearlyextubationandthenseewhoqualifies.Earlyextubationshould
beplannedforinallpatientsbecauseitrequiresplanningrightfromthestartofthe
case.Themostsuccessfulcandidateshavereasonablecardiacandpulmonary
functionbutitiscertainlynotarequirement.Thechangeswehavemadeinclude
limitingfluidgiventothepatient.Limitingthetotalnarcoticandbenzodiazepine
dose.Relyonvolatileagentsorpropofolduringthecase.Providesedationpostop
thatiseasytogetridof(propofol).Carefulcontrolofbloodpressurewith

emergence.Remembersomevasodilators(nitroprusside)inhibithypoxicpulmonary
vasocontriction,increaseshunt,andmakeweaningofFIO2moredifficult.Rapid
weaningofFIO2postopiscritical.Thenextubatethepatient.Extubationtimeis
controlledbynursingshiftchangesandprotocols.Ifyouwanttoextubateearly,
weantheFIO2rapidly,wakethepatientup,andwhenthepatientmeetswritten
extubationcriteriadoit.Itrequiresaculturalshifttoaccomplish.Themostcommon
reasonfordelayedextubationissimplyV/Qmismatch(shunt)causedbyheparin
protaminecomplexesinthelung.Thesecondmostcommonreasonisexcessive
sedation.Finally,hemodynamics,coagulopathy,etc.getonthelist.
SetUp:StandardroomsetupincludingSuction,Machinecheckout,Airwayequipment,
Drugs(Succinylcholine,thiopental,nondepolarizingmusclerelaxant,atropine,
glycopyrolate,ephedrine,neosynephrine(syringeandinfusionready),dopamine(infusion
ready),calciumchloride,heparin(30,000unitsdrawnup),lidocaineandepiindrawer.
PatientPreparation:AtleastonelargeIV(<16g),twoarebetter,alineonright(leftside
isoccludedbyretractorforIMA),takeintoroomandplaceonO2forrestofsetup,5lead
formachine,3leadforecho,coverV5withtegaderm.RightIJPAcatheter.Preoxwhile
gettingbaselinevalues.
IntraoperativeSafety:Cardiacsurgeryhaslargequantitiesofbloodatarterialandhigher
pressures.Thereisfrequentsplash.Youmustweareyeprotectionatalltimesinthe
operatingroom.Expensivegogglesaroundtheneckarenotacceptable.Putthemonatall
timesintheOR.YoushouldconsidertheoperatingroomasawoodshopwithHIVonall
thewoodchips.Youwouldnotoperatepowertoolsinawoodshopwithouteyeprotection,
donotdoitintheOR.
Communication:Thisoperationisalongseriesofrepetitiveproceduresthatabsolutely,
positively,havetobedonecorrectly.Ifanyaredoneincorrectlythepatientwillsuffer.
Communicatewiththesurgeon.Askquestions.Tellhimwhatyouaredoing.Ifyouare
havingtrouble,tellhim/her.Theoperationrequiresateamapproachandyouareamember
oftheteam.Don'tletyouractivitiesorproblemsbeamysterytothesurgeons.
Hypotension:Thesurgeonscancauseprofoundhypotensionwithcardiacmanipulation.If
thepressuresuddenlydropsorPVC'sdeveloplookatwhattheyaredoing.Beforeyougive
adrugtotreatepisodichypotensionlooktoseewhattheyaredoing.Ifyougiveadrug
becauseofhypotensioncausedbythesurgeonsandthentheyletgooftheheart,the
pressurewillskyrocket.Stateclearly"Pressureis70/30)theywillgetthemessageandstop
liftinguptheheart.Theymayaskyoutohandventilateduringsomedissection.Watchwhat
theyaredoingtomakesureyouarehelpingnothindering.
Hemodynamics:
PriortoValveRepairstherearespecificrecommendations:
AS:Preload:KeepitupAfterload:MaintainSVR:MaintainHR:5080Rhythm:NSR
AI:Preload:KeepitupAfterload:DownSVR:DropHR:6080Rhythm:NSR
MS:Preload:KeepitupAfterload:MaintainSVR:MaintainHR:5080Rhythm:NSR
MR:Preload:KeepitupAfterload:DownSVR:DownHR:5080Rhythm:NSR
PrebypassHemodynamics:Youshouldtrytokeepthebloodpressurewithin20%of

baselinewardpressure.Heartratesbetween40and80aregenerallyfinedependingonthe
clinicalsituationpriortobypass.
BypassHemodynamics:YoushouldkeeptheMAPbetween4080duringthecoldperiod
ofbypass(crossclampon)andbetween6080duringwarmbypass(crossclampoff).There
willbeexceptionssuchaspatientswithcarotidvasculardiseaseorchronicrenal
insufficientcythatmayneedhigherpressures(6080mmHg)fortheentirepumprun.
PostBypassHemodynamics:Systolicbloodpressuregreaterthan80mmHgisfine.Ifitis
between100and120mmHgeveryonewillbehappy.Ifitisgreaterthan120mmHgthe
patientishypertensiveandtherewillbemorebleeding.Cardiacindexgreaterthan2.0is
fine.PaDiastoliclessthan20mmHg,CVPlessthan15mmHg.IfCVPisevergreaterthan
PADthereisaproblem:poorcalibrationorrightventricularfailure.Alwaysconsider
surgicalmanipulationoftheheartifthechestisopen,ortamponadewhenitisclosed,for
hypotension.
PreinductionHemodynamicMeasurements:IfyouputaPAcatheterinpriortoinduction
youhaveindicatedthatyouneeditforpatientmanagement.Youshouldthereforemeasure
andrecordSAP,HR,CVP,PAP,PAO,andCOpriortoanestheticinduction.Ifthereisa
problemyoushouldcorrectitpriortoinduction.Youcanpreoxygenatethepatientduring
thistimeandfreeuponehandbyusingthemaskstraptoholdthemaskinplace.
Fluids:Therearelotsoftheoriesonfluidsandlittledatatosupportthestronglyheldbeliefs.
Cardiaccasescaneasilysuckuplargeamountsoffluidintraoperativelywithlittleobvious
benefit.Allofthatfluidthenhastobediuresedpostoperativelyfrequentlybyadministering
largeamountsoflasixwithsubsequentelectrolytedisturbances.Postoperativeextubationis
frequentlydelayedbyintraoperativefluidadministration.Pleaseattempttolimitfluid
administrationintraoperatively.Afewsuggestions.IfyouhavetwolargeboreIV'sheplock
oneofthem.Trytogivelessthan500ccofLRpriortobypass.Donotadministeranyfluids
duringbypassexceptforfluidrequiredforvasoactivedrugs.Usehespanpostbypassupto
20cc/kg,thenshifttoalbumin.Ifyouusehextend,the20cc/kglimitmayormaynotapply.
Useamechanicalmeteringdeviceonanycarrierlinestopreventaccidentalhighflows.Use
neosynephrinetosupportpressurebeforegivinglargeamountsoffluidprebypass.
FluidTally's:Tallytheestimatedbloodlost,andfluidsadministeredincludingcrystalloid,
colloid,Blood,cellsaver,pumpblood,bypassprimevolume,andtotalfluidgivenby
perfusionistonyourrecord.Thisisachangefrompreviouseffortswhereweignored
everythingbutthecrystalloid,colloid,givenbyanesthesia,andthebloodgivenby
anesthesiaandperfusionists.Theperfusionistscangivelargeamountsofcrystalloidandwe
needtonoteitontheanesthesiarecord.iftheygivehespanorhextendinthepumpprime
weshouldknowaboutit.
Ischemia:PatientshaveCABGsurgerybecauseofmyocardialischemia.40%ofpatients
undergoingCABGsurgeryhaveintraoperativeepisodesofmyocardialischemia.You
shouldrecorda5leadECGpriortoinductionforabaselinecomparison.Askthepatientif
theyarehavingchestpainatthistime.YoushouldlookattheECGeithercontinuouslyorat
leastevery60secondsandaskWhatistherhythm?Isthereischemia?Onlybyabsolute
attentiontotheECGwillyoudetectasubstantialfractionoftheischemia.
Whenthebloodflowtomyocardiumisinsufficient,itimmediatelystopscontracting.This
processtakes5to10seconds.At60to90secondstheECGSTTwavestartstochange.
ThisfocalreductionincardiacfunctioncanbedetectedbywatchingtheECHOimage.The
bestlevelisashortaxismidpapillaryview.Youshouldrecordafixedpreincisionshort
axismidpapillaryviewforcomparison.TheECHOisanadjuncttocarenotarequirement.

Donotignorethepatientwhenlookingattheecho.
InductionandIntubation:Neverinducethepatientwithoutasurgeonwhocanputthe
patientonbypassintheroom.Neverinducewithoutaperfusionistandapump.Theyshould
beabletoplacethepatientonbypassinlessthan5minutesifthepatientarrestson
induction.Theycan'tdothat,iftheyaren'tthereandyouwillbeliable.Takecaretoavoid
hypotensionandhypoxia(really?Yes!).TrytolimittheLRforthecasetolessthanaliter.
Thatmeanslessthan500ccpriortobypass.Use500ccbagstoavoidrunawayinfusions.
Mostpeopleyouputtosleepdroptheirbloodpressure.Incardiaccasesweattempttolimit
thedropbygivingvasoactivesubstances.Therearetwoapproachestogivingthesedrugs.
Youcaninducethepatientandthenrespondtothehypotensioninthe95%ofpatientsthat
youinduce.Thealternativeistostartaneoinfusioninallpatientspriortoinductionandthen
turnitoffwhennotneeded.Thesecondapproachisvastlysmootherandeasieron
everyonebecauseyoudonthavetoscramblearoundgettingsomethinggoing.
TEE:WearenotsupposedtouseCidexanymoretocleantheprobes.Thereforeyouwill
beissuedsomethingthatlookslikeDr.RuthWestheimerwasconsultingatMarineWorld.
Pleasetrytomaintainprofessionaldemeanorwhenperformingthisprocedure.Rollthelatex
prophylaticovertheplacticfillerdevice.Thenfillthereservoirtipwithultrasonicjelly.
Therearetwotypesofplasticfillers:largeandsmall.Ifyouhaveasmallone,removeitas
theprobecan'tfitthroughit.Ifyouhavealargeone,theprobecanfitthroughit.Thenplace
theprobeinthesheathandrollitallthewaydown.Getyourmindoutofthesewer!Next,
emptythestomachofairwithanNGtube,makesuretheprobeisunlocked,usea
laryngoscopetoplaceitintheesophagus,andtreatitlikeitcost$50,000,asitdid.Always
useabiteblockifthepatienthasteeth.TEEcanbedetrimentaltopatientcareifoneignores
thepatientwhileusingit.Itisanadjuncttopatientcarenotasubstituteorarequirement.Itis
usefulfordetectingair,ASD,VSD,AS,AR,MR,MS,volumestatus,aorticplaque,
myocardialischemia,regionalandglobalventricularfunction,valvularfunction,anatomy,
etc.Itwilltakesometimetogetgoodatitbutiswellworththeeffort.TheTEEexam
frequentlycausesamodificationinthesurgicalplan.Unrecognizedaorticplaqueshiftsto
patienttooffpumpCABG,oraltersthecannulationsite,orcancelsthecase.Thesooneritis
done,thesoonerthesurgeonscandecideonwhattodonext.
Alwaysunlockitbeforeremoval.HoldontotheETtubewhenremovingtheprobeasone
canextubatethepatientaccidentally.Discardthelatexcondomandthencleantheprobe.
BaselineACTandABG:Obtainafterinduction
ACT:Therearethreetechniques.HemochronandHemoTech.
TheHemochronsystemhastwotechniquesCeliteandKaelin.Celiteisdiatomaceousearth
(dirt)inatube.Youneed2ccinthetube.Pushthebuttontostarttheclock.Shake6times
(withcapon).Placeinmachine.Rotatethetubetogetthegreenlighttoturnon.Fully
heparinizedreadytogoonbypassisgreaterthan450seconds.IfusedwithAprotinin,it
needstobeabove800seconds.Kaelinisawhiteliquidinadualtubecassettewithlittle
plasticflags.Fullyheparinized,readytogoonbypassisgreaterthan450seconds..Itis
unaffectedbyAprotinin.
TheHemotechnsystemhaslittleplasticcartridgeswithtwolittleplasticflags.Itlookslikea
twoholeminiaturegolfset.Thecartridgeshouldbewarmedinthemachinepriortouse.
Carefully,usingabluntneedle,placeblooduptothelittleblacklineineachofthetwo
wells.Donotgetdropsofbloodbetweentheflagandthetube,asitwillnotwork.Place
thecartridgeinthemachineandclickthemechanismontothecartridge.Sametimesapply
foronpump.

Sternotomy:Painfulprocessthatoccursrapidlyafterinduction,makesurethepatientis
adequatelyanesthetized.Theywillaskyoutoletthelungsdownduringopening.Youmust
disconnectthepatientfromtheventilatorandreconnectaftertheyopenthesternum.
Developasystemtopreventyourselffromforgettingtoplacepatientbackonventilator.Do
notrelyonthealarmastheonlyreminder.
RedoHeartSternotomy:Inaredohearttheadhesionsmaybringtheventricleclosetothe
sternum.Thesternalsawmaycutthroughtherightventriclewithresulting(profound)
hemorrhage.Youshouldhavebloodavailableand2largeIV's.Youmayalsocutthrough
theIMAorasaphenousgraft.Youshouldhaveanideaofwhatthiswilldofromthe
catherizationreportandaplan.Instantseveremyocardialischemiawithrapiddeterioration
mayresult.ThecaseiseasieriftheIMAandgraftsarenotfunctional.Functionalgraftsthat
thepatientisdependentonisthemostdangeroussituation.
IMADissection:Theymaywantthetabletiltedtotheleftandelevated.Theymaywantthe
tidalvolumesreducedandtherateincreasedtohelpwithdissection.Itmaybeveryhardto
getanechoimageduringIMAdissection
Heparinization:Donotallowthesurgeonstogoonbypasswithoutheparinization.Ifthe
patientisnotheparinizedwhentheclampisopenedonthebypasspump,thepumpand
oxygenatorwillclotandthepatientwillmostlikelydie.Ifthesurgeonsareplacinga
cannulainsomearteryaskiftheywanttheheparingiven.Whentheyaskforheparin,
respondwithaverbalstatementtheheparinhasbeengiven.Alwaysusethecentrallinefor
heparin.Aspiratebloodfromthelinebeforeandaftertheheparindosetochecktomakesure
thelineisinavein.Thedoseofheparinis300U/kgwhichisabout21ccof1000u/cc
heparinina70kgman.ChecktheACTaminuteortwoafterthedose.Donotusethesame
IVtodrawthebloodthatyouinfusedtheheparinin.(i.e.drawanarterialbloodsample).
YouwanttochecktheACTquicklybecauseitneedstobeabove450secondstogoon
bypassandthatis7.5minutesofwaitingifyouforgetandhavenotdrawnthebloodsample.
Ifthepatientisonheparinpreop,givethesamedose(Heparin300U/kg).Donotstopthe
preopheparinjustbecarefulputtinginlines.Donotgiveantifibrinolyticsuntilfully
heparinized(amikar).IftheACTisnotgreaterthan450secondsafterthedose,givemore,
untiltheACTisabove450seconds.IfyouareusingaprotinintheceliteACTmustbe
above800seconds.IfakaolinACTisusedthenormal450secondrangeisused.
AddheparintoyourACLSprotocolforcardiacsurgerypatients.Ifthepatientarrestsgive
theheparinsothatpatientcanbeputonbypassforresuscitation.
Allpatientsgettingcardiacsurgeryusingextracorporealcirculatorysupportshouldgetan
antifibrinolyticdrug.Thereareseveralchoices.Itmaybethatallshouldgetaprotinin,
unlessgiveninprevioussurgeries,butthischangehasnotbeenuniversallyadopted.Atthe
presenttimeweuseatwotierapproach.
Allpatientsgoingonextracorporealcirculatorysupportshouldhaveanantifibrinolytic.If
theyareafirsttimecasewithoutriskfactorstheygetamikar.Iftheyarearedocase,acase
withrenalfailure,acasewithahighriskofbleeding,oraJehovahsWitnesswhere
bleedingwouldbelethal,theygetaprotinin.
Amikar:Epsilonaminocaproicacidusedasaantifibrinolytic.Someevidencethatit
reducespostbypassbleeding.Someclinicalreportsofproblems(leftventricularthrombus,
arterialthrombi,etc.)Commonlygivenas5gIVpriortobypassand5gIVafterbypass.
Canbegiveninhigherdoses10gpriorand10gafterinlargepatients.Muchless
expensive($12/bottle)thanaprotinin($900/bottle)althoughtheefficacyisnotproven.No
FDAindicationforthisuse.Noconvincingsafetydata.Weareusingitonallcases.Give5

gIVslowlyafteryougivetheHeparinpriortobypass.Give5GIVslowlyafterthe
protamineisin.Youdonotwanttogiveitpriortoheparin.Thereareadverseevents
associatedwithprotamineadministrationanditiseasierifonlyonedrugcanbeblamedfor
eachevent.
Aprotinin:Antifibrinolyticandplateletpreserverthatreducesbleedingandtransfusion
associatedwithCABGsurgeryinredosandpeopleonaspirin.Costs$900/case.The
transfusionsforacaseaverage$1000sothecostisrevenueneutral.Ifoneconsiderstherisk
ofdiseasetransmissionfromtransfusionsamprotininisabenefit.Thereisanincreasedrisk
ofgraftclosurefromclotting.Ifonelooksatthemorbidityandmortalityassociatedwithtake
backsforbleeding,aprotininreducesriskofdeath.Itisallergenicsopatientsshould
probablyonlyhaveoneuseinalifetime.ThatuseshouldprobablybeforaredoCABG.
OurpresentuseisforREDOCABG,patientswithrenalfailure,patientswithriskof
bleeding,orpatientsinwhichbleedingwouldbelethal(JehovahsWitness).Order6M
units(3200ccbottlesat10,000unitspercc).Give1cctestdose,then20ccover20minutes
startingpriortoskinincision.Thencontinueat0.5MU/hr.Theperfusionistwillprimewith
2Munitssogiveonebottletothem.Ihavetriedtoavoidusingafourthbottleinlongcases
byslowingtheinfusionto0.3to0.4MU/hrsothattheinfusionbottlewilllastuntiltheend
ofbypass.Lowerdosesofaprotininwork,sothisslowerinfusionisprobablyreasonable.
RememberceliteACT800seconds,kaolinACT450withAprotinin.
Whatoperationarewedoingtoday?:Cardiacsurgeryusedtobedoneusing
extracorporealsupport.AfewsurgeonsdidCABGwithoutthepumpbutitwasrareand
usuallydoneelsewhere.InthelastfewyearsthepercentageofCABGsurgeriesdoneusing
offpumptechniqueshasrisendramatically.Theinventionoftheoctopusandstarfishhave
madeiteasier,safer,andpracticalformostCABGoperationstobedoneoffpump.Atthe
presenttimewearerandomizingpatientstoonpumpversusoffpumpcare.Ifthe
decisionseemsrandom,youarecorrect,itis.Theanestheticcareisfundamentallydifferent
forthesetwoapproachessowewillseparatelydiscusstheONPUMPanestheticcareand
thentheOFFPUMPapproach.Youneedtobeflexiblebecausetheycanchangetheir
mindatamomentsnotice.
Placingthecannulas:
Eithercheckatwitchorgivemorenondepolarizingneuromuscularblockerpriortocannula
placement.Ifthepatienttakesabreathwiththeatriumopen,theycanhavegasembolization
andhavesevereinjury.
Donotallowthesurgeonstogoonbypasswithoutheparinization.Thearterialpressureat
thispointshouldbebelow120mmHg.Thesmallcannulaintheaorta(hasaredtapeonit)
shouldnothaveanybubblesinit.Ifyouseeabubbletellthesurgeonsimmediately.When
theyputintheaorticcannulathereissplashhaveyourglasseson.
Thelargercannulawithbluetapeisthevenouscannulaandgoesintotheapexoftheright
atriumintotheinferiorvenacava.Itisadrainlineandmayhavebubbles.Onmitralvalve
andASD/VSDcasestherewillbetwosmallerdrainlinesintothesuperiorandinferiorvena
cava.
Thesmallcannulawithaballoonatoneendisplacedintothecoronarysinusthrougha
pursestringintherightatrium.Ifthisisusedtheywillaskyoutomeasurethepressureinthe
cannula.HookthistotheCVPtransducer.Whentheflowinthecoronarysinuscardioplegia
lineis200ml/minthepressureshouldbeabout40mmHg.IfthepressureislikeCVPand
doesnotgoupwithcoronarysinusflow(retrogradecardioplegia),thecannulaisnotinthe

coronarysinus.Ifthishappensduringcontinuouswarmcardioplegia,thereisaperiodof
warmischemiawhichcanresultinsevereventriculardysfunctionanddeath.Ifthepressure
isveryhigh(greaterthan100mmHg)withaflowof200ml/minthecannulaisagainstthe
wallandyoualsomaynotbehavinggoodretrogradecardioplegia.
Theleftventricularventlineisplacedthroughtherightsuperiorpulmonaryvein.It
decompressestheleftventricle.
CheckListforGoingonBypass:
HAD2SUERememberthismnemonic.Sayitoften.Avoidkillingpatientbyusingit.
Heparin:Alwaysgivepriortobypass.
ACT:Alwayscheckbeforegoingonbypass(450seconds)
Drugs:Doyouneedanything(Nondepolarizingneuromuscularblocker).
Drips:Turnofftheinotropesetc.
Swan:PullthePAcatheterback5cmtoavoidpulmonaryarterialocclusion/rupture.
Urine:Accountforbypassurine
Emboli:ChecktheArterialcannulaforbubbles.
CleanKillsandthePerfusionist:Therearethreeeasywaysfortheperfusionisttokillthe
patient.
1.Nooxygenintheoxygenator.
2.Noheparin.
3.Reservoirrunsempty.
Ifthepowergoesoutthereisacrankfortheperfusionistyoumaybeaskedtohelpcrank.
Ifalinebreaks,youmayhavetohelpreplaceit.
AirLock:Thevenouslinedrainsbysiphon.Nothingisquiteasreliableasgravitybutair
introducedintothevenoussystemcancausethelossofthesiphon.Iftheperfusionistnotes
bubblesonthevenousreturnline,oryoudo,checktheintegrityofthecordis,closureofall
stopcocks,thesurgeonswillchecktheatrialpursestring.Ifyoureducepumpflow
temporarilythevenouspressurewillriseandtheairleakwilldiminish.Thelinescanbe
refilledwithsalineifcompleteairlockoccurs.
Cardioplegia:Therearelotsoftypes.Cold,Warm,WarminductionColdMaintenance
WarmRepercussion,HotShot,Crystalloid,Blood,Antegrade,Retrograde.Thebestisa
shortcrossclampwithaskillfulsurgeon.Youshouldrecordtheonbypasstime,theoff
bypasstime,theoncrossclamp,theoffcrossclamp.Asthecrossclamptimeexceeds1hour
ventricularfunctiondeteriorates,asitexceeds2hoursitgetsworse.Cardioplegiaduring
crossclamphelps.Therearelotsofthingsaddedtocardioplegiaandthebypassprimeand
youshouldfindoutwhattheyarefromtheperfusionist.Theywillsaysomethinglike
"Nothingspecial"whichtranslatesintopotassium,lidocaine,aspartate,glutamate,D50,
manitol,bicarb,adenosine,freeradicalscavengeroftheday,andsnakeoil.Askandyou

willlearn.Thereismuchmagicinthecardioplegiabag,mostofitonlyintheeyeofthe
orderer.Ifsomethingweirdhappensonbypass(iepressuregoesto30,potassiumsky
rockets,glucoseisveryhigh)considerwhatisinthecardioplegiasolution.
DeAiringManeuvers:Itisbadtopumpairtothepatient.Itisdifficulttogetalloftheair
outanddopplerstudiesofthemiddlecerebralarteryduringbypassdemonstrate502000
embolipercase.Itishardtodecideifthisisairoratheroscleroticplaque.Thesmallerthe
bubblethebiggertheechosignal.Onopenventricleoraorticproceduresthesurgeonswill
haveyouplacetheheaddown.Thentheywillbumpthepatient,rollfromsidetoside,stick
aneedleintheventricle,aspiratefromtheaorta,etc.inthehopesofgettingoutallofthe
bubbles.Theywilldirectyouonwhattheywant.Ifyoulookattheechoatthistimethere
willbeasnowstormoflittlebubblesintheventricle.Ifyouseealargeoneormorethan
usualsaysomething.
Themajorityofembolioccuronaorticcannulation,crossclampplacement,crossclamp
removal,sidebitterplacement,sidebitterremoval,weaningfrombypass,andaorticcannula
removal.Itisbestnottohavehighglucoseoroverlywarmtemperatures(37o C)duringany
oftheembolictimes.95%ofpatientssuffersubtleneuropsychiatricchangesconsistentwith
multiplesmallemboli.
CheckListforGettingOffBypass:
WRMVP:Widereceivermostvaluableplayer.
Warm:Whatisthebladderandbloodtemp?
Rhythm:AretheyinNSRordoyouneedtopace?Istherateadequate?
MonitorsOn:Turnembackonifyouturnedthemoffforbypass.Turnbackonthealarms.
Ventilation:Turnontheventilator.Easytoforgetandyoulookverystupid.
Perfusion:Whatisthepumpflow.
Weaningfrombypass:Youneedtohaveaplan.Whatwastheventricularfunctionpriorto
bypass?Howlongwasthecrossclamp?Whatdoestheheartlooklikenow?Whatisthe
resistancenow?Onceyouhaveaplancommunicatewiththesurgeon.Ifyouplantousea
drugwithprolongedsideeffectsaskthemwhattheythink(amrinone,milrinone).Theymay
haveanopinionthatshouldbeconsidered.Havesomeinotropeready.Youshouldbeable
towean8090%offirsttimeCABGpatient'sfrombypasswithnoinotropes.Calcium
chlorideiscommonlyused.Excessivedoses(2g)havebeenassociatedwithpancreatitis.
Astandardweaningplanwouldbetocalculatethesystemicvascularresistance(SVR):
SVR=[(MAPCVP)/CO]*80
MAP:MeanArterialPressure
CVP:CentralVenousPressure
CO:CardiacOutput(Canbeobtainedbyaskingtheperfusionistwhatthepumpflowis)
SVRshouldbeinthe1000to1200woodunits.Itroutinelywillbe600to800andthe
cardiacoutputnecessarytodevelopareasonablepressurepostbypasswillbetoohigh.
Vasoconstrictors(phenylephrine)oracatecholaminewithsomevasocontrictiveeffects

(dopamine,epinephrine,norepinephrine)arecommonlynecessarytoraisetheresistanceto
reasonablelevels.Hereisanexample.TheMAPis50andtheCVPis10.Youaskthe
perfusionistandhetellsyouthepumpflowis5liters/min.ThatgivesaSVRof(50
10)/5*80whichequals640woodunits.
Let'staketwoapproaches.Thefirstistocomeoffpumpandletthehearttrytopump
sufficientlytodevelopareasonablepressure.OnceoffpumptheSVRwillbe640,theMAP
willbe50andtheBPwillbeabout70/40.Theproblemisnotcardiacinnature.The
problemissimplylowresistance.Aninotropeisnotneededavasocontrictoris.
IftheSVRhadbeenraisedto1200priortocomingoffpump,the5liter/mincardiacoutput
wouldyieldaMAPof65withaCVPof10.TheBPwouldthenbeabout95/50andall
wouldbewell.
Areasonableapproachtoweaningfrombypassisto:
a.Makeaneducatedguessastotheinotropicstateoftheventricle.Ifitwaslousypriorto
bypass,itwillmostlikelystillbelousyandaninotropewillbenecessary.Iftheinotropic
stateoftheventriclewasokpriortobypassandcrossclamptimeswerereasonable(60
minutesorless)thenitislikelynoinotropeswillbeneeded.
b.Calculatetheresistanceandcorrectit.
c.Checktherequirementsforcomingoffpump.Warm,Rhythm,MonitorsOn,Ventilator
On,Perfusion(resistancereasonable).
d.Bereadytochangeyourplan.
Whydoesthepatient"goonbypass"?andHowdoesthepatient"comeoffbypass"?:
Thebypasssystemisbasicallyalargeplasticpipewithlotsofholesplacedthroughtheright
atrialappendageintotheinferiorvenacava.Thelargeplasticpipeisfulloffluidandhooked
tothevenousreservoir.Thepipeisclampedwithalargeclamp.Note:Beforeattempting
anyofthisactivity,(notrecommendedintheprivacyofyourownhome)makesureyou
havefulfilledthecriteriaforgoingonbypass(HADDSUE)orcomingoffbypass
(WRMVP)asnotedabove.NEVERLETTHEMGOONPUMPIFYOUHAVENOT
HEPARINIZED.HavinganACTgreaterthan450isveryreassuringbutnotabsolutely
essentialindireandImeandireemergencies.Otherthanthedireemergency.ACTmustbe
greaterthan450.
Thesimpleexplanationforgoingonbypassistheperfusionistremovestheclampfromthe
venousdrainlineandasiphoneffectdrainsbloodfromtherightatriumandinferiorvena
cavaintothevenousreservoir.Itisimportanttomaintainthesiphoneffecttokeepthisflow
going.Since,thereisnoorlessbloodgoingintotherightventricle,thecardiacoutputdrops.
Theperfusionistthenturnsonthepumpandreturnsthebloodtothroughtheaorticcannula
intothepatient'saorta.Ifallisworkingwellthebloodwillbeheated/cooledandoxygenated
bytheheater/cooler/oxygenatorbeforebeingpumpedthroughthefilterandbackintothe
aorta.Unclampingthevenousdrainlinereducestherightatrialpressureanddivertsblood
intothepump.Theperfusionistwillsaysomethinglike"Fullflow"whichmeanstheyhave
4or5litersaminuteofvenousdrainageandareabletopump4to5liters/minintothe
patient.Atthispointyoucanturnofftheventilator.Pulmonaryarterypressuresshouldbe
nonpulsatile.
Comingoffpumpistheexactreversesituation.Youfulfillallthecriteriaforcomingoff
pump.(WRMVP),i.e.thepatientiswarm,theheartisbeating,themonitorsareturnedon,

theventilatoristurnedon,andyouhaveadjustedtheresistanceandinotropicstatetoan
appropriatelevel.Theperfusionistthenpartiallyoccludesthevenousdrainline.Thisreduces
theamountofblooddrainingintothevenousreservoir.Therightatrialpressureincreases
andbloodstartstogointotherightventricleandoutthepulmonaryartery.Atthispointyou
canhaveapumpflowthatisafractionofthetotalsystemicbloodflowwiththerest
producedbytheheart.Thesurgeonwillsaysomethinglike,Leavesomeinandcometo4
liter/min.Youwillnoticethatthepulmonaryarteryandsystemicpressuresbecomepulsatile.
Theywillthendroptosay2liter/minthen1liter/min.Theyarewatchingtherightandleft
ventriclestomakesuretheyarenotdistending.Theyalsowatchthepressuresandslowly
loadtheheart.Whentheysaysomethinglike"Giveahundred".Whattheyaretellingthe
perfusionististoleave100cclessbloodinthereservoir.Theperfusionistmaybedraining2
liters/minofbloodfromthepatientandpumping2liter/mintothepatient.Theyare
supposedtopump100moreccofbloodthantheywithdrew.Itisaninexactscience.But
yougettheidea.
Thesurgeonwillthenclampthevenousdrainlineandyoucantellthatyouaretrulyoff
pump.Theywillremovethevenouscannula.Ifyouhaveakindsurgeon,theywillplaceit
inabucketofsalineandthendrainthebloodbacktothereservoirkeepingthelinefullof
saline.Thisallowstheperfusionisttostarthemoconcentratingthebloodinthesystembut
keepsthevenouslinereadyincaseyouhavetoreturntobypass.Thearteriallineisstillin
placesotheperfusionistcangivefluid.Whenthepatient'sbloodvolumeislowyouwill
hear"giveahundred".Theperfusionistbasicallyunclampsthearteriallinewiththepump
onanddrains100ccoffluidfromthereservoir.
Whoweansthepatientfrombypassandwhogivesvolumeorders?Thisvariesbyinstitution
andsurgeon.Atsomeinstitutionstheanesthesiologistdoesatothersthesurgeondoes.Ifyou
arenotreadytoweanapatient,sayso.Ifyouthinkthepatientneedstogobackonbypass,
tellthesurgeontoputthecannulasbackin.Ifthepatientisdoingpoorly,tellthemnotto
takeoutthearterialcannula.Ifyouneedmorevolume,askforit.Youarepartoftheteam.
Thisisonesurgerywhereitisessentialthatyoubeabletotellthesurgeonwhattodo,and
whentodoit.Whenthingsaregoingbad,communicationiskey.Itisessentialthatitisa
teamprocess.Theyneedtoknowwhatyouneedandwhatisgoingon.Ifsomethingisnot
working,theyneedtoknowaboutit.Theycanandwillmostlikelytrytofixit.
InotropesandVasoactiveCompounds:Ifyouareusingadrugthatrequiresaninfusion
andwheretheeffectsofanincorrectorfluctuatingdosewouldbedifficulttomanage,usean
infusionpump.Thisincludes(dopamine,dobutamine,epinephrine,norepinephrine,
nitroprusside,nitroglycerin,neosynephrine,andpropofol).Thefluctuationscausedby
relyingongravitydripsareunacceptable.Gravityisreliable,backpressureisnot.Alldrugs
mustbemixedinconcentrationsapprovedbythepharmacy.Thelabelswiththeappropriate
concentrationareinablackboxintheanesthesiamachine.Ifyoumixitandlabelitwiththe
yellowlabelthentheICUnurseswillnotthrowitawaywhenyougettotheICU.Ifyou
mixsomeweirdconcentration,labelitpoorly,orthenputitonadialaflow,thenurseswill
throwawayyourdrugsandthepatientwillgetlessthanoptimalcare.
ProphylacticDrugs:Somesurgeonsbelievethatprophylactichighdosesteroidsare
thoughttoreducetheimmunereactiontobypassorreduceneuralinjury.Scientificevidence
forthesetheoriesislimited.Downsidetosteroidsareinfectionsandpoorwoundhealing.
Somesurgeonsbelieveinprophylacticinotropesorvasodilators.Postbypassprophylatic
nitroglycerininfusionshavebeensuggestedasapreventativemeasureforIMAspasmand
myocardialischemia,downsideishypotension,supplylimitedischemia,andmorefluid
requirementstokeeppreloadadequate.Magnesiumisthoughttobeanantiarrythmic,anti
ischemicagent.SomepeopleloadwithmagnesiumpriortoCABGsurgery(2gramsIV)

othersdonot.Thescientificevidenceformanyofthesetherapiesisequivocal.Onceagain
youhavetocommunicateandaskyoursurgeontheirpreference.Youwillhavetocometo
somesortofintelligent,professionalcompromiseonprophylacticdruguse.
PhosphodiesteraseInhibitors:Donotstartaphosphodiesteraseinhibitor(Amrinone,
Milrinone)withouttalkingtothecardiacsurgeons.Donotchooseitasfirstlineinotrope.A
phosphodiesteraseinhibitorwillvasodilateprofoundlyandwillmostlikelyrequireasecond
drugwithvasoconstrictorproperties.
Potassium:Lowpotassiumisdefinedaslessthan4.0meq.Itisassociatewitharrhythmia's.
Replaceiflessthan4.0.Highpotassiumdependsontiming.Greaterthan5.0iscommonon
bypassfromthecardioplegia.Youwouldlikeittobebelow5.0butgreaterthan4.0when
youcomeoffpump.Theperfusionistcandialyzethepatientifneeded.
Hematocrit:Dropswiththehemodilutionofthebypasspump.Ifitisbelow20youneedto
correct.Between2025youneedtouseclinicaljudgment.Talktothesurgeons,theymay
haveanabsoluteruleandifyoudon'tfollowit,theywillsimplyfollowitintheunitandbe
irritatedwithyouintheOR.
PostBypassHemodynamics:Systolicbloodpressuregreaterthan80mmHgisfine.Ifitis
between100and120mmHgeveryonewillbehappy.Ifitisgreaterthan120mmHgthe
patientishypertensiveandtherewillbemorebleeding.Cardiacindexgreaterthan2.0is
fine.PaDiastoliclessthan20mmHg,CVPlessthan15mmHg.IfCVPisevergreaterthan
PADthereisaproblem:poorcalibrationorrightventricularfailure.Alwaysconsider
surgicalmanipulationoftheheartifthechestisopenortamponadewhenitisclosed,asa
causeofhypotension.
Protamine:Fishsemeninabottle.Thereareallergic,anaphylactic,andhistamine
responses.DoseispersonalbutProtamine10mgwillequalizeHeparin1000units.
Protaminecomesas10mgperccsoifyouused30ccofheparin,30ccofprotaminewill
neutralizeit.Youareformingaweaksaltbetweenabaseandanacid.Youaretitratingthe
response.YouneedtogivethedoseandthenchecktheresponsebymeasuringtheACT.
SomeoftheV/Qmismatchandshuntpostopiscausedbyclearanceofheparinprotamine
complexesbythereticuloendothelialsysteminthelung.
ProtamineAdministration:Give10mg=1ccperipherallyandcheckforallergicresponse
manifestedashypotension,broncospasm,rash,orpulmonaryhypertension.Stop
administrationforproblems.Youcangetseverehypotensionfromprotamine,bereadywith
phenylephrine.Steroids,H1&H2blockers,vasoconstrictors,inotropes,andreturningto
bypasscanhelp.Allowingtheheparintospontaneouslybemetabolizedisanotheroptionfor
severereactions.
Thengivetherestofthedoseslowly.Whatisslowly?IfyoufollowthePDRitwouldbe
about2hours.Ifyouareatsomeinstitutionsitwouldbe1minute.Over20minutesisnot
unreasonable.Once1/3oftheprotamineisintelltheperfusionistsothattheycanstopthe
pumpsuckersandavoidclottingthepump.Ifyouclotthepumpandneedtoreturnto
bypassyouwillbevery,very,veryunhappy.
Oncealltheprotamineisin,tellthesurgeons,andthencheckanACT.Youshouldreturnto
baseline(120130).Ifyouhavenot,givemoreprotamine.Ifyougivepumpbloodafterthis
pointyoumayneedtogivemoreprotamine.Youcanonlyfindthisoutbymeasuringthe
ACT.ChecktheACTafteryougivebloodproductsfromthepumporcellsaver.
PostBypassBleeding:Ifthereisbleedingpostbypass,checktheACT.Ifelevated,correct

it.Iftherewasaspiringiveninthelast4daysyoumayneedplatelets.Ifthereismedical
bleeding,youmayneedplatelets.Ifthereissurgicalbleeding,theyshouldfixitwithastitch
orthebovienotinfusionsofplatelets.Recentlyanewfactorwasdiscoveredintheclotting
cascadeitisa60proline.
ReturningtoBypass:Ifthereisseverehypotension,bleeding,lowcardiacoutput,other
problems,youmayneedtoreturntobypass.Ifyouhavegiventheprotamine,giveanother
doseofheparinat300U/kgandcheckanACT.Beforetheaorticcannulaisremoved,you
shouldmakeadecisionaboutwhetheryoumayneedtoreturntobypass.Ifyouarehaving
severeproblemsmaintainingthepressuredespiteinotropes,tellthesurgeons.Theywill
delayremovingtheaorticcannulaorimmediatelyreturntobypass.Itisverybadforthe
hearttobedilatedbyhighfillingpressureandthenhavelowcoronaryperfusionpressure.
Youmayhavetoreturntobypass.
BalloonPump:Verynicesystemforinadequateleftventricularfunction.Theballoon
pumpneedsanECGsignalandanarterialpressuresignal.OntheDatexmonitortheslave
cableplugsintochannel3.Channel3isusuallytheCVPchannel.PlugtheCVPcableinto
channel4andchangethelabelonchannel4toCVP.Toswitchtoslavemodetheeasiest
thingtodoitgetanewpressuretransducer.Hookthenewarterialtransducertotheballoon
pumpandplugthecableintochannel3.ChangethelabelonchannelthreetoABP.This
willmakethetraceredandthescale0200.Thenplugtheslavecableintochannelthreeand
sendittotheballoonpump.Thereisaswitchontheballoonpumpthattellsittolokat
externalECGandarterialpressurefromtheslavecable.Bothsettingsmustbeswitched.Do
nothesitatetosuggestifthereisdifficultyweaningfrombypass.
LVAssistDevice:Transportablecentrifugalpumpthatcanbeusedasabridgetotransplant
ortoallowrecoveryofseverelystunnedmyocardium.
Closingthechest:Maycausehypotensionifinadequatevolumestatus.Checkacardiac
outputafterclosure.Ifthelungsseemtoolargeortheheartisliftingoutofthechest,
considerbroncospasmwithairtrapping.Bronchodilators,ventilatorandETTadjustmentcan
help.
RemovingtheTEE:Unlockitbeforeremoval!Callsomebodytocleanit.
Transport:Havethepatientmonitoredatalltimes.NeverremovetheECGuntilanotheris
working.Placethetransportleads,getittowork,thenremovetheORleads.Donotchange
theAlineifhemodynamicallyunstable.Quicklyrezero.Ifyouelevatethetransducer13.6
cmyouwillreducethearterialpressure10mmHg.Keepthetransducersattherightlevel.
Beparanoid.Ifthereisaproblem.Stopandfixit.
Suddenhypotensiononmovingthepatient:Itisverycommonforthebloodpressureto
sagwhenthepatientismovedfromtheoperatingtabletothebed.Thisphenomenaisnot
wellunderstoodbutmaybefromreperfusiondependenttissueswiththeshifttothebed.
Thepatientcanhaveprofoundhypotension.Mostpatientsdroptheirfillingpressures
noticibly.Havevolumeavailable.Donotmaketheshiftifthepatientisunstableorvolume
deplete.Fixtheproblempriortotheshift.Havevolume,somedrugtoraisethepressure,
somedrugtolowerthepressure,oxygen,mask,andanyotherdrugsyouhavebeenusing
withyouontransport.
ICU:Shiftthemonitorsinthesameway.Thecartridgeforthetransportmonitorsimply
plugsintotheICUmonitor.IfyoudonthavethissystemgettheICUECGworkingbefore
removingthetransportECG/DonotshifttheAlineuntilthepatientishemodynamically
stable.Listentothechestimmediatelyafterhookingtotheventilator.Ifthereissudden

hypotensionsuspectaproblemtheventilator(infinitepeep)andremovethepatientfromthe
ventilatorandhandventilate.Thengetanewventilator.Donotallowthenursestochange
totheirinotropesuntilyouleave.Donotallowthemtoremoveyouriv'suntilyouleave.Do
notleaveuntilthepatientistrulystable.
WhentoExtubate:Thechecklistforextubationshouldinclude:Noevidenceof
myocardialischemia,infarctionorfailure,Hemodynamicstabilityonlimitedinotropic
support,(noballoonpumpormultipleinotropeswithsweatdrippingfromthecardiac
fellowsbrow),limitedbleedingwithoutacoagulopathy(chesttubedrainagebelow50cc/hr
for2hours),goodgasonFIO2 is0.40,SIMV8,PEEP5,TV=10cc/kg,thepatientis
awakeandbreathing,goodgasonCPAP5cmH2 OFIO2 =0.50thenextubate.Talktothe
surgeonsaboutyourplans,theymayhaveaverygoodreasonwhythispatientisalousy
candidate(Thegraftswerepoor,thereisbleeding,thereistamponade.)
AnesthesiaforMinimallyInvasiveCardiacSurgery:MIDCABGorOffPumpCABG
Iguessthefirstquestionshouldbewhattocallthisnewoperation.Itisminimallyinvasive
CABGorminimalaccessCABG.MaximallydifficultCABG.Idon'tknow.Alittle
cabbageiscommonlyknownasabrusselsprout.Thisoperationischangingrapidly.These
isnowahistorytohowitwasdone.Thatimpliesthatwehavemaybeimprovedit.
Initially,therewastheHeartPortoperation.ThemarketingplanoftheHeartPortSystem
wastoavoidthatnastysternotomyscar.MostpeoplecomingforaCABGarepasttheage
whenthescarwillpreventthemfrombeinginthecaseofBayWatch.Theoperationwas
simple,nothatsnotright.Anarterialinflowcannulawasplacedinafemoralarteryandthe
venousoutflowwasplacedthroughafemoralvein.Acatheterwithaballoonwasadvanced
uptheaortaandtheballooninflatedintheascendingaorticarch.Aorticatherosclerotic
diseasewasadefinitecontraindicationforthisoperation.Pictureslidingthecatheterupa
severelydiseasedaortafollowedbyretrogradeperfusionfromthegroin.Cardioplegiawas
thendeliveredantegradetothecoronaryarterieswhichhavebeenseparatedfromthe
systemiccirculationbytheascendingaorticarchballoon.Acatheterwasadvancedfromthe
internaljugularveinintothepulmonaryarteryforventingtheleftventricle.Thepatientwas
placedonfemfembypassandcardioplegiaestablished.AsinglevesselCABGwasthen
performedeitherthroughaminithoracotomyorthoracoscopically.Theproblemwiththis
operationisobvious.TheriskfromwithaCABGistheextracorporealcirculationnotthe
sternotomy.OneofthemajormorbiditiesofCABGsurgeryistheneuropsychiatricchanges
andstrokes.TheHeartPortoperationhasalongbypassrunforasinglevesselCABG.It
maximizestheriskofstrokewhileeliminatingthesternotomy.Thisoperationwasdoomed
tofailurefromthestart.
CTS(ChuckTaylorSurgicalorCardioThoracicSurgical)andUSSurgicalworkedto
improvethetechniquepopularizedbyBennetti.Itwasinessenceaminithoracotomywith
nobypass.ThestandardwasasingleIMAtotheLAD.Theheartwasstabilizedbyplacing
latexsuturesundertheLADproximalanddistaltothesiteoftheanastamosis.Asmallfoot
pressesonthemyocardiumwhilethesuturespulltheheartintothefoot.Bloodflowwas
stoppedinthetargetvesselbythestabilizingsutures.Thetechniquerequiresimproved
technicalskillonthepartofthesurgeonbecausetheheartismoving(contractionaswellas
respiratorymovement).Italsorequiresincreasedtechnicalskillonthepartofthe
anesthesiologistbecauseanareaofmyocardiumisischemic,andnonfunctional,andprone
toreperfusionarrythmias.Theadvantageoftheoperationisreducedcost(noextracorporeal
circulation,reducedhospitalizationtime)andreducedriskofstroke(noextracorporeal
circulation).Ifsurgeonsandanesthesiologistscansurmountthetechnicalchallenges
(motion,bleeding,arrythmias,hemodynamics,exposure)itofferedgreatpromise.Onthe

downside,theoperationwasdifficultandinferiorwallvesselswerehardtoappoach.
OctopusandStarfish.Theseretractorsusesuctiontostabilizetheheart.Insteadof
squashingtheheartwithafootliketheCTSsystem,theOctopussystemsucksupthe
myocardiumwithtwolittlearms.Thearmsthenseparateslightlytotightentheareaand
reducemotion.TheStarfishisretractorforliftingandmovingtheheartwithasuctioncup
shapedlikeaY.Withtheseretractorshemodynamicsaremuchimprovedduring
stabilization.
TheequipmentforMIDCABGischangingconstantly.Thefundamentalproblemshave
not.Oneofthefirstproblemstoaddressiswhatistheplanwhenthepatienthasventricular
fibrillation.Ifthesurgicalplanconsistsofasmallthoracotomywhatisgoingtohappen
whentheischemiacausedbythestabilizingsuturesorthereperfusionarrhythmiascausedby
releasingthesuturesprogressestoventricularfibrillation?Thesecondproblemis
maintainingvenousreturndespitetheeffortsofthesurgeon.
Myfavoriteplanisthis.
1.Chooseananestheticthatlowerstheheartrate(fentanyl,sufentanyl,alfentanyl,
remifentanyl).
2.Useamediansternotomyapproach.Themorbidityissmallcomparedtotheriskof
prolongedventricularfibrillation.Havetheperfusionistavailable.Dontprimethepumpbut
haveitcompletelysetupandreadytoprime.Don'thandoffthelinesjustbeready.Ifyou
can'tconvincethesurgeontodothecaseasasternotomyfromthestartbereadyforthe
emergencysternotomywhenthepatientfibrillates.Theotheradvantageofthesternotomy
fromthestartapproachismultivesselCABGwithoutextracorporealcirculationispossible.
Withtheminithoracotomymultipleminithoracotomiesareneededforthesecondandthird
distalanastamosis.IfyouendupdoingaMIDCABGwithmultipleminithoracotomies,
considerusingadoublelumentubeforbetterexposure.Theyarenotessentialbutfrequently
help.
3.AnticoagulatethepatientjustasyouwouldforaCABGwithextracorporealcirculation
(Heparin300U/kg).Ifthereisaproblemitiseasytocannulateandgoonpump.
4.Prophylaxforarrhythmiaswithyoufavoritedrugs.Magnesium2gramIVplusLidocaine
100mgfollowedbyaninfusionat2mg/min.Iamastrongproponentofamiodarone(IV).If
youhavearrythmiasstartamiodarone150MGover10minutes,then1mg/minIVfor6
hours,then0.5mg/minfor18hours.
5.Afterthesurgeonhasretractedtheheart,placedthestaysuturesandthestabilizer,load
thepatientwithvolume(hespan/hextend)andmaintainthepressurewithvasoconstrictors.I
trytoavoidbetaagonistsbecauseofthetachycardiaandproarrythmiceffects.Tachycardia
makestheanastamosismoredifficult.Youwillspendalotoftimeadjustinghemodynamics
onlytohaveallyourworkreversedwhentheheartisletoutofwhateverpositionitisin.
Steeptrendellenburgisveryusefulforinferiorwalldistalanastamosis.
6.Adjusttheventilatortoreducemotion(smalltidalvolumeswithincreasedrate).
7.Haveaplantolowertheheartrateevenmoreifnecessary(esmolol,adenosine).Ifthe
heartrateisirregularortoolowuseatrialpacing.Donotuseglycopyrolateoratropinewhen
askedtoincreasetheheartratebecausetheyarehardtoundowhenthesurgeonchangeshis
mind.

8.Bereadyforreperfusionarrythmiaswithreleaseofthestaysutures.
9.Reversetheheparingently.Rememberyoudon'thaveabypasscircuitreadytobailyou
out.Moreover,thedoseofprotaminemaybereducedbecauseofthelackofdamagetothe
platelets.ChecktheACT1/3and2/3ofthewaythroughtheprotaminetoavoidoverdosing.
10.Consideranticoagulationpostreversalofprotamine.CABGsurgerybenefitsfrom
prolongeddamagetothecoagulationsystem.WhenwasthelasttimeyousawapostCABG
pulmonaryembolus?Whendotheystartanticoagulatingafteravalve?InaOffPump
CABGwherethecoagulationsystemwasnotexposedtoanextracorporealcirculation
circuitthecoagulationsystemisnormal.Alloftheproblemswithpulmonaryembolus,graft
closure,graftclottingthatthevascularsurgeonshavewillnowoccurwithcardiacsurgery.If
graftclosurecausesacoldlegandamidnighttriptotheORtoremovetheclotforvascular
surgeons.OffPumpCABGgraftclosurecausesanMIandpossiblyacoldbluepatientand
atriptothemorgue.Bevery,very,verycarefulaboutpostoperativeMI's.Rememberthe
anastamosiswasdoneinlessthanoptimalcircumstances(movement,bleeding,limited
positioning).Thecoagulationsystemisfullyfunctional.Wearetryingdextraninfusionsto
trytohavesomeprolongedanticoagulanteffectwithoutbleeding.Thejuryisstillout
though.
WehavehadthirtyyearstofigureoutallthetricksfornormalCABG's.TheOffPump
CABGisstillinitschildhood.
GoodLuck:YoushouldenjoyyourmonthattheVA.Youwillgetareasonableexperience
withadultcardiacsurgery.Ifthereareanycomments,changes,additions,errorsinthistext,
I,ArtWallace,M.D,Ph.D.,amresponsible.Pleaseemailmewithsuggestions.
byArtWallace,M.D.,Ph.D.
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