Adult Cardiac Surgery : Colligative - Practical Wisdom in Anesthesia, Surgery, and Medicine.

Sep 03, 2013

If redo sternotomy in patient with previous CABG, there is risk of rupturing grafts and developing myocardial ischaemia, especially with previous LIMA grafts

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Jul 09, 2011

If redo sternotomy, place defibrillation pads on prior to induction. Patient is at risk of arrhythmia from diathermy around heart.

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Aug 22, 2011

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Assessment, Workup

Document the weight, height and BMI for use in echo, cardiac output, drug dose and bypass flow calculations

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Dec 03, 2012

If there is clinical evidence of carotid stenosis, perform a carotid doppler ultrasound. If this reveals carotid stenosis, higher perfusion pressures will need to be maintained during cardiopulmonary bypass

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Oct 07, 2011

Standard blood workup (FBE/FBC, electrolytes, urea, creatinine) clotting (INR, APTT), thyroid function (TFTs) & hepatitis status

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May 18, 2011

Preoperative Optimisation

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Consent, Discussion

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Coordinating

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Medication management, Premed

Cease long acting antiplatelet therapy (clopidogrel) 7-10 days before surgery, where possible, to reduce perioperative blood loss.

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Jul 08, 2011

Cease warfarin/coumadin 5-7 days before surgery to reduce perioperative blood loss. Place on heparin/clexane/LMWH protocol if high risk for thromboembolism

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Jul 08, 2011

Prescribe premedication

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May 18, 2011

10-20mg Oxycodone +
10-20mg Temazepam +
Oxygen via hudson mask, to be given "On call". IV antibiotics as premed if inpatient for >7days prior to procedure #MMC

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Equipment, Preparation

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Duration

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Anatomy

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IV access

Ensure that the central line isn't pulled out when adhesive surgical drapes are removed at the end of case

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Dec 03, 2012

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Monitoring

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Special drugs

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If administering vancomycin, ensure slow infusion to minimise risk of severe reduction in SVR and profound hypotension. Ensure rate is not quicker than 10mg/min. refl.in/dn

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Aug 22, 2011

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When sampling for ACT after administering protamine, pause any pump blood return. This ensures you aren't sampling any pump blood (still heparinised) running into arm & returning a falsely elevated ACT

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Oct 07, 2011

Activated coagulation time (ACT) may be prolonged by heparin contamination from preceding blood gas sampling if taken from same port.

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Jul 08, 2011

Take ACT sample before blood gas sample, or ensure adequate aspiration of line before taking ACT

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Antibiotics as per surgeons prior to skin incision

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Dec 03, 2012

Consider treating refractory VF with Magnesium 10-20mmol, Lignocaine 1mg/kg, and Calcium Gluconate 10mmol.

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Sep 23, 2011

Draw up GTN bolus solution to manage hypertensive episodes

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May 18, 2011

Take 0.5ml of 600mcg/ml soln
Dilute to 20ml giving 15mcg/ml. Give 0.5-1ml PRN (AR MMC)

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Pancuronium's peak effect is at approximately 5 minutes. Giving suxamethonium with this will shorten the time to intubation, reducing the time for things to go wrong (especially if you're a sole anesthesiologist)

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Sep 23, 2011

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Airway, Ventilation

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At sternotomy, deflate lungs to reduce risk of lung injury

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Aug 22, 2011

Nasal ETT for children below puberty. This is more secure than an oral tube in this age group.

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Feb 21, 2012

When "turning off the lungs" at the surgeons request, disconnect the circuit at the ETT as well as turning off ventilation at the anesthetic machine to eliminate the risk of an error at the anesthetic machine (eg not opening APL valve)

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Sep 21, 2011

Positioning, Surgical access

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Procedure technique

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Anesthesia, Analgesia, Antiemesis

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Cardiovascular, Renal, Fluids

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Maintain low normal systolic blood pressure (~100mmHg) at the time of insertion of the aortic cannula to minimise risk of aortic dissection

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Sep 17, 2011

Aim systolic ~100mmHg. Modify with GTN infusion. Caution not to overshoot to high with vasopressors if it dips too low

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Test epicardial pacemaker capture and function with overdrive pacing prior to transfer to ICU even if the native rate is adequate. This avoids the potential scenario of finding yourself unable to pace if the patient develops a bradycardia following transfer to ICU

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Dec 15, 2011

Blood pressure often falls at the time the chest is closed due to reduced venous return to the heart. #ref

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Sep 23, 2011

Coronary air embolus occurs more frequently in the right coronary artery as it's origin is superior (in the supine position) in relation to left coronary in the aortic root. This usually manifests as right ventricular dysfunction, and treatment is inotropy (eg adrenaline infusion) to perfuse the air through the coronary circulation.

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Sep 23, 2011

For internal defibrillation commence at 10J. Increase by increments of 10J to max 50J. #ref #improve

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Sep 23, 2011

If performing cardiac output measurements, do one reading before administering the heparin bolus, as this may reduce the cardiac output in some patients.

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Sep 22, 2011

If refractory arrhythmia (eg VF, VT) following cardioplegia, confirm temperature, electrolytes, acid-base are all within normal limits.

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Sep 23, 2011

If requiring a large energy for internal defibrillation (eg 50J) myocardium may be stunned and more likely to require an adrenaline infusion coming off pump #ref

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Sep 23, 2011

Native ventricular depolarisation is preferred to ventricular pacing where possible when pacing is commenced.

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Aug 29, 2011

AOO after leads placed and whilst diathermy continues, then DDD #improve #ref

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Blood loss, blood products

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Crossmatch blood (PRBC)

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Sep 24, 2011

Minimum 6 units #mmc

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Temperature

If nasal temperature probe required (usually by perfusionist), insert before heparinisation to minimise risk of airway bleeding

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Jun 07, 2011

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Endocrine, Nutrition

Intensive insulin therapy during cardiac surgery (BSL target 4.4 - 5.8mmol/L) does not reduce perioperative death or morbidity. The increased incidence of death and stroke in the intensive treatment group raises concern about routine implementation of this intervention. refl.in/iq Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery A Randomized Trial Gunjan Y. Gandhi, MD

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Sep 19, 2011