CARDIAC

ANESTHESIOLOGY
Cardiac surgery is a dangerous and complex
field of medicine with significant morbidity and
mortality. Quality anesthetic care with specific
attention to detail can greatly enhance patient
safety and outcome.

This presentation will attempt to describe the

bare bones sequence for cardiac anesthesia for
adult CABG and VALVE procedures with
specific recommendations
 Patient Anesthetic evaluation must include attention to cardiac
history. The cath report, thallium, echo, and ECG.

Examination Critical information includes:

- Left main disease or equivalent
- Poor distal targets
- Ejection fraction
- LVEDP
- Presence of aneurysm
- Pulmonary hypertension
- Valvular lesions
- Congenital lesions
Each of these points requires a modification of anesthetic
technique and specific information is required.
 Patient Past medical history including history of:
- COPD

Examination - TIA
- Stroke
- Cerebral vascular disease
- Renal disease (CRI is an independent risk factor)
- Hepatic insufficiency
will change anesthetic management.
Medications • Look specifically for anti-anginal regimen - synergism
between calcium channel and beta blockers
• It is very important for patients to stay on their anti-
anginal therapy throughout the hospital stay.
• If a patient is on a beta blocker, calcium channel
blocker, nitrate, and/or ACE inhibitor they should
remain on that drug throughout the perioperative
period.

The patient should get all anti-anginal medications on the

day of surgery and following surgery. The day of surgery is
the wrong time to go through a withdrawal process on
any anti-anginal drug
Consent Patients having cardiac surgery have serious and frequent
complications including:
- MI 6%, CVA 5%
- Neuropsychiatric Effects 90%
- Death 1-3-10% (Depends on risk)
- Transfusion (40-90%)
- Pneumonia 10%
You must discuss these risks.

Write a clear note with all the standard details and

consent. They will get an Aline, PA catheter, TEE. With the
computerized records it is easy to get all the patient’s
information. Make sure you sign your note so that it is
visible to other computer users.
Premedication Give them oxygen by nasal cannula with some premed: - -
- Valium
- Morphine
- Diazepam 10 mg PO on call to OR is a good choice.

Medications Preop: All patients must get their anti-

anginals. (Withdrawal of anti-anginal medications during
cardiac surgery increases risk of death, MI, CVA, and renal
failure )
Anesthesia Halothane, Enflurane, Isoflurane, high and low dose
narcotics, and propofol based anesthetics are equivalent
as long as hemodynamics are controlled.

Desflurane is the only anesthetic not recommended for

patients with known coronary disease (Desflurane
inductions have been demonstrated to cause pulmonary
hypertension and myocardial ischemia )
 Dose • Fentanyl (High) 100-200 mcg/kg (Medium) 20-40
mcg/kg (Low)1-5 mcg/kg

Ranges • Sufentanyl (High) 20-40 mcg/kg (Medium) 10-20

mcg/kg (Low) 1-2 mcg/kg
• Remifentanyl 0.2 to 1.0 mcg/kg/min
• Midazolam (High) 3-5 mg/kg (Medium) 2 mg/kg (Low)
0.5 mg/kg
Remifentanyl Remifentanyl has a very short half life (5 - 10 minutes)
because of its metabolism by non specific cholinesterase

It can be used for cardiac anesthesia but the cost is high

and some narcotic must be given prior to wake up in the
ICU. Reduction in the dose may be possible by giving a
longer acting cheap narcotic (fentanyl) to occupy a
fraction of the mu receptors and then use the
remifentanyl to occupy a smaller fraction
 Early Early extubation should be planned for in all patients
because it requires planning right from the start of the

Extubation
case
• Limiting the total narcotic and benzodiazepine dose.
• Rely on volatile agents or propofol during the case.
• Provide sedation post op that is easy to get rid of
(propofol).
• Careful control of blood pressure with emergence.
• Remember some vasodilators (nitroprusside) inhibit
hypoxic pulmonary vasocontriction, increase shunt,
and make weaning of FIO2 more difficult.
• Rapid weaning of FIO2 post op is critical.
Extubation time is controlled by nursing shift changes and
protocols
Set Up Standard room set up including:
• Suction
• Machine checkout
• Airway equipment
• Drugs (Succinyl choline, thiopental, non-depolarizing
muscle relaxant, atropine, glycopyrolate, ephedrine,
neosynephrine (syringe and infusion ready), dopamine
(infusion ready), calcium chloride, heparin (30,000 units
drawn up), lidocaine and epi in drawer.
 Patient 1. At least one large IV ( < 16g), two are better, a-line on
right (left side is occluded by retractor for IMA)

Preparation 2.
3.
Take into room
Place on O2 for rest of setup, 5 lead for machine, 3
lead for echo, cover V5 with tegaderm
4. Right IJ PA catheter
5. Preox while getting baseline values.
Intraoperative Cardiac surgery has large quantities of blood at arterial
and higher pressures

Safety You must wear eye protection at all times in the

operating room. Put them on at all times in the OR.
Hypotension The surgeons can cause profound hypotension with
cardiac manipulation. If the pressure suddenly drops or
PVC's develop look at what they are doing. Before you
give a drug to treat episodic hypotension look to see what
they are doing. If you give a drug because of hypotension
caused by the surgeons and then they let go of the heart,
the pressure will sky rocket.

State clearly "Pressure is 70/30” they will get the

message and stop lifting up the heart. They may ask you
to hand ventilate during some dissection. Watch what
they are doing to make sure you are helping not
hindering.
Hemodynamics Prior to Valve
recommendations:
Repairs there are specific

- AS: Preload: Keep it up Afterload: Maintain SVR:

Maintain HR: 50-80 Rhythm: NSR
- AI: Preload: Keep it up Afterload: Down SVR: Drop
HR: 60-80 Rhythm: NSR
- MS: Preload: Keep it up Afterload: Maintain SVR:
Maintain HR: 50-80 Rhythm: NSR
- MR: Preload:Keep it up Afterload: Down SVR: Down
HR: 50-80 Rhythm: NSR
Hemodynamics - Prebypass Hemodynamics: You should try to keep the
blood pressure within ± 20% of baseline ward pressure.
Heart rates between 40 and 80 are generally fine
depending on the clinical situation prior to bypass.

- Bypass Hemodynamics: You should keep the MAP

between 40-80 during the cold period of bypass (cross
clamp on) and between 60-80 during warm bypass (cross
clamp off). There will be exceptions such as patients with
carotid vascular disease or chronic renal insufficientcy
that may need higher pressures (60-80 mmHg) for the
entire pump run.
Hemodynamics - Post Bypass Hemodynamics: Systolic blood pressure
greater than 80 mmHg is fine. If it is between 100 and
120 mmHg everyone will be happy. If it is greater than
120 mmHg the patient is hypertensive and there will be
more bleeding. Cardiac index greater than 2.0 is fine.
Pa Diastolic less than 20 mmHg, CVP less than 15
mmHg. If CVP is ever greater than PAD there is a
problem: poor calibration or right ventricular failure.
Always consider surgical manipulation of the heart if
the chest is open, or tamponade when it is closed, for
hypotension.
 Preinduction • Measure and record SAP, HR, CVP, PAP, PAO, and CO
prior to anesthetic induction. If there is a problem you

Hemodynamics should correct it prior to induction.

• You can preoxygenate the patient during this time and

Measurements free up one hand by using the mask strap to hold the
mask in place.
Fluids • Post operative extubation is frequently delayed by
intraoperative fluid administration. Please attempt to
limit fluid administration intraoperatively.
• If you have two large bore IV's hep lock one of them.
Try to give less than 500 cc of LR prior to bypass.
• Do not administer any fluids during bypass except for
fluid required for vasoactive drugs. Use hespan post
bypass up to 20 cc/kg, then shift to albumin.
• If you use hextend, the 20 cc/kg limit may or may not
apply.
• Use a mechanical metering device on any carrier lines
to prevent accidental high flows.
• Use neosynephrine to support pressure before giving
large amounts of fluid prebypass.
TEE • Roll the latex prophylatic over the plactic filler device.
• Then fill the reservoir tip with ultrasonic jelly. There are two
types of plastic fillers: large and small. If you have a small one,
remove it as the probe can't fit through it. If you have a large
one, the probe can fit through it.
• Place the probe in the sheath and roll it all the way down.
• Next, empty the stomach of air with an NG tube, make sure
the probe is unlocked, use a laryngoscope to place it in the
esophagus
• Always use a bite block if the patient has teeth.
TEE TEE can be detrimental to patient care if one ignores the patient
while using it. It is an adjunct to patient care not a substitute or a
requirement.
It is useful for detecting air, ASD, VSD, AS, AR, MR, MS, volume
status, aortic plaque, myocardial ischemia, regional and global
ventricular function, valvular function, anatomy, etc.
The TEE exam frequently causes a modification in the surgical
plan. Unrecognized aortic plaque shifts to patient to off pump
CABG, or alters the cannulation site, or cancels the case. The
sooner it is done, the sooner the surgeons can decide on what to
do next.

Always unlock it before removal. Hold onto the ET tube when

removing the probe as one can extubate the patient accidentally.
Discard the latex condom and then clean the probe.
ACT There are three techniques. Hemochron and HemoTech.

The Hemochron system has two techniques Celite and Kaelin.

1. Celite is diatomaceous earth (dirt) in a tube. You need 2 cc in
the tube. Push the button to start the clock. Shake 6 times
(with cap on). Place in machine. Rotate the tube to get the
green light to turn on. Fully heparinized ready to go on
bypass is greater than 450 seconds. If used with Aprotinin, it
needs to be above 800 seconds.
2. Kaelin is a white liquid in a dual tube cassette with little
plastic flags. Fully heparinized, ready to go on bypass is
greater than 450 seconds.. It is unaffected by Aprotinin.
ACT The Hemotechn system has little plastic cartridges with two
little plastic flags. It looks like a two hole miniature golf set. The
cartridge should be warmed in the machine prior to use.
Carefully, using a blunt needle, place blood up to the little black
line in each of the two wells. Do not get drops of blood between
the flag and the tube, as it will not work. Place the cartridge in
the machine and click the mechanism onto the cartridge. Same
times apply for on pump.
Sternotomy Painful process that occurs rapidly after induction, make
sure the patient is adequately anesthetized. They will ask
you to let the lungs down during opening.

You must disconnect the patient from the ventilator

and reconnect after they open the sternum. Develop a
system to prevent yourself from forgetting to place
patient back on ventilator. Do not rely on the alarm as the
only reminder.
Redo Heart In a redo heart the adhesions may bring the ventricle
close to the sternum. The sternal saw may cut through

Sternotomy the right ventricle with resulting (profound) hemorrhage.

You should have blood available and 2 large IV's. You may
also cut through the IMA or a saphenous graft.

You should have an idea of what this will do from the

catherization report and a plan. Instant severe myocardial
ischemia with rapid deterioration may result.
IMA Dissection • They may want the table tilted to the left and elevated.
• They may want the tidal volumes reduced and the rate
increased to help with dissection.
• It may be very hard to get an echo image during IMA
dissection
Heparinization
• Do not allow the surgeons to go on bypass without
heparinization.
• If the patient is not heparinized when the clamp is opened
on the bypass pump, the pump and oxygenator will clot
and the patient will most likely die.
• If the surgeons are placing a cannula in some artery ask if
they want the heparin given. When they ask for heparin,
respond with a verbal statement - the heparin has been
given.
• Always use the central line for heparin.
• Aspirate blood from the line before and after the heparin
dose to check to make sure the line is in a vein.

The dose of heparin is 300 U/kg which is about 21 cc of 1000

u/cc heparin in a 70 kg man. Check the ACT a minute or two
after the dose.
Amikar Epsilon amino caproic acid used as a antifibrinolytic.
Some evidence that it reduces post bypass bleeding.
Some clinical reports of problems (left ventricular
thrombus, arterial thrombi, etc.)

• Commonly given as 5 g IV prior to bypass and 5 g IV

after bypass. Can be given in higher doses 10 g prior and
10 g after in large patients.
• No FDA indication for this use. No convincing safety
data.
• Give 5 g IV slowly after you give the Heparin prior to
bypass. Give 5 G IV slowly after the protamine is in. You
do not want to give it prior to heparin. There are
adverse events associated with protamine
administration and it is easier if only one drug can be
blamed for each event.
Aprotinin Antifibrinolytic and platelet preserver that reduces
bleeding and transfusion associated with CABG surgery
in redos and people on aspirin.

• If one considers the risk of disease transmission from

transfusions amprotinin is a benefit.
• There is an increased risk of graft closure from clotting.
• If one looks at the morbidity and mortality associated
with take backs for bleeding, aprotinin reduces risk of
death.
• It is allergenic so patients should probably only have
one use in a lifetime. That use should probably be for a
redo CABG.
Placing the Either check a twitch or give more non depolarizing
neuromuscular blocker prior to cannula placement. If the

Cannulas patient takes a breath with the atrium open, they can have
gas embolization and have severe injury.

Do not allow the surgeons to go on bypass without

heparinization. The arterial pressure at this point should
be below 120 mmHg. The small cannula in the aorta (has a
red tape on it) should not have any bubbles in it. If you see
a bubble tell the surgeons immediately. When they put in
the aortic cannula there is splash - have your glasses on.
Placing the The larger cannula with blue tape is the venous cannula
and goes into the apex of the right atrium into the inferior

Cannulas vena cava. It is a drain line and may have bubbles. On

mitral valve and ASD/VSD cases there will be two smaller
drain lines into the superior and inferior vena cava.
Placing the The small cannula with a balloon at one end is placed into
the coronary sinus through a purse string in the right

Cannulas atrium. If this is used they will ask you to measure the
pressure in the cannula. Hook this to the CVP transducer.
When the flow in the coronary sinus cardioplegia line is
200 ml/min the pressure should be about 40 mmHg. If the
pressure is like CVP and does not go up with coronary
sinus flow (retrograde cardioplegia), the cannula is not in
the coronary sinus. If this happens during continuous
warm cardioplegia, there is a period of warm ischemia
which can result in severe ventricular dysfunction and
death. If the pressure is very high (greater than 100
mmHg) with a flow of 200 ml/min the cannula is against
the wall and you also may not be having good retrograde
cardioplegia.
Check List for HAD2SUE

Going on Heparin: Always give prior to bypass.

Bypass ACT: Always check before going on bypass (450

seconds)
Drugs: Do you need anything (Non depolarizing
neuromuscular blocker).
Drips: Turn off the inotropes etc.
Swan: Pull the PA catheter back 5 cm to avoid
pulmonary arterial occlusion/rupture.
Urine: Account for bypass urine
Emboli: Check the Arterial cannula for bubbles.
There are three easy ways for the perfusionist to kill the
patient.

1. No oxygen in the oxygenator.

2. No heparin.
3. Reservoir runs empty.

If the power goes out there is a crank for the

perfusionist - you may be asked to help crank. If a line
breaks, you may have to help replace it.
Check List for WRMVP: Wide receiver most valuable player.

Going Off Warm: What is the bladder and blood temp?

Bypass
Rhythm: Are they in NSR or do you need to pace? Is the
rate adequate?
Monitors On: Turn back on if you turned them off for
bypass. Turn back on the alarms.

Ventilation: Turn on the ventilator.

Perfusion: What is the pump flow.

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

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

*) MAP: Mean Arterial Pressure

CVP: Central Venous Pressure
CO: Cardiac Output (Can be obtained by asking the
perfusionist what the pump flow is)
Weaning from A reasonable approach to weaning from bypass is to:
a. Make an educated guess as to the inotropic state of

bypass the ventricle. If it was lousy prior to bypass, it will

most likely still be lousy and an inotrope will be
necessary. If the inotropic state of the ventricle was
ok prior to bypass and cross clamp times were
reasonable (60 minutes or less) then it is likely no
inotropes will be needed.
b. Calculate the resistance and correct it.
c. Check the requirements for coming off pump.
Warm, Rhythm, Monitors On, Ventilator On,
Perfusion (resistance reasonable).
d. Be ready to change your plan.
Inotropes & • If you are using a drug that requires an infusion and
where the effects of an incorrect or fluctuating dose

Vasoactive would be difficult to manage, use an infusion pump.

(This includes dopamine, dobutamine, epinephrine,

Compounds norepinephrine, nitroprusside,

neosynephrine, and propofol).
nitroglycerin,

• The fluctuations caused by relying on gravity drips

are unacceptable. Gravity is reliable, back pressure is
not.
• All drugs must be mixed in concentrations approved
by the pharmacy.
Prophylactic • Some surgeons believe that prophylactic high dose
steroids are thought to reduce the immune reaction

Drugs to bypass or reduce neural injury. Scientific evidence

for these theories is limited. Downside to steroids are
infections and poor wound healing.
• Some surgeons believe in prophylactic inotropes or
vasodilators.
• Post bypass prophylatic nitroglycerin infusions have
been suggested as a preventative measure for IMA
spasm and myocardial ischemia, downside is
hypotension, supply limited ischemia, and more fluid
requirements to keep preload adequate.
• Magnesium is thought to be an anti-arrythmic, anti
ischemic agent.
Phosphodiesterase • Do not start a phosphodiesterase
inhibitor (Amrinone, Milrinone) without

Inhibitors talking to the cardiac surgeons.

• Do not choose it as first line inotrope.
• A phosphodiesterase inhibitor will
vasodilate profoundly and will most
likely require a second drug with
vasoconstrictor properties.
Potassium • Low potassium is defined as less than 4.0 meq. It is
associate with arrhythmia's. Replace if less than 4.0.
• High potassium depends on timing. Greater than 5.0
is common on bypass from the cardioplegia.

You would like it to be below 5.0 but greater than 4.0

when you come off pump. The perfusionist can dialyze
the patient if needed.
Hematocrit Drops with the hemodilution of the bypass pump. If it is
below 20 you need to correct. Between 20-25 you need
to use clinical judgment. Talk to the surgeons, they may
have an absolute rule and if you don't follow it, they will
simply follow it in the unit and be irritated with you in
the OR.
Protamine • There are allergic, anaphylactic, and histamine
responses.
• Protamine 10 mg will equalize Heparin 1000 units.
• Protamine comes as 10 mg per cc so if you used 30 cc
of heparin, 30 cc of protamine will neutralize it.
• You need to give the dose and then check the
response by measuring the ACT. Some of the V/Q
mismatch and shunt post op is caused by clearance
of heparin-protamine complexes by the reticulo-
endothelial system in the lung.

Give 10 mg = 1 cc peripherally and check for allergic

response manifested as hypotension, broncospasm,
rash, or pulmonary hypertension. Stop administration
for problems.
Post Bypass • If there is bleeding post bypass, check the ACT.
• If elevated, correct it.

Bleeding • If there was aspirin given in the last 4 days you may
need platelets.
• If there is medical bleeding, you may need platelets.
• If there is surgical bleeding, they should fix it with a
stitch or the bovie not infusions of platelets. Recently
a new factor was discovered in the clotting cascade it
is a 6-0 proline.
Transport • Have the patient monitored at all times.
• Never remove the ECG until another is working.
• Place the transport leads, get it to work, then remove
the OR leads.
• Do not change the A-line if hemodynamically
unstable.
• Quickly re-zero.
• If you elevate the transducer 13.6 cm you will reduce
the arterial pressure 10 mmHg.
• Keep the transducers at the right level.
• If there is a problem. Stop and fix it.
Transport Sudden hypotension on moving the patient: It is very
common for the blood pressure to sag when the patient
is moved from the operating table to the bed. This
phenomena is not well understood but may be from
reperfusion dependent tissues with the shift to the bed.
The patient can have profound hypotension. Most
patients drop their filling pressures noticibly. Have
volume available. Do not make the shift if the patient is
unstable or volume deplete. Fix the problem prior to the
shift. Have volume, some drug to raise the pressure,
some drug to lower the pressure, oxygen, mask, and
any other drugs you have been using with you on
transport.
 When to The checklist for extubation should include:
- No evidence of myocardial ischemia, infarction or

Extubate failure,
- Hemodynamic stability on limited inotropic support,
(no balloon pump or multiple inotropes with sweat
dripping from the cardiac fellow’s brow), limited
bleeding without a coagulopathy (chest tube
drainage below 50 cc/hr for 2 hours), good gas on
FIO2 is 0.40, SIMV 8, PEEP 5, TV = 10 cc/kg, the
patient is awake and breathing, good gas on CPAP 5
cm H2O FIO2 =0.50 then extubate.
Talk to the surgeons about your plans, they may have a
very good reason why this patient is a lousy candidate
(The grafts were poor, there is bleeding, there is
tamponade.)