Cardiac surgery

 

Preparation:

Anaesthetic

Anaesthetic:

·     Midazolam

·     Fentanyl x 2

·     Propofol

·     Relaxant

Vasoactives:

·     Metaraminol

·     GTN (50mcg/mL)

Coagulation:

·     Heparin x 8

·     TXA x 2

(do NOT draw up protamine until later)

Antibiotics:

·     CABG: cefazolin 2g if CA, vancomycin 1.5g if hospitalized >2 days

·     Valve: ceftriaxone 1g + vancomycin 1.5g

Airway

·     BMV with guedel (avoid air)

·     ETT

Access

·     Big PIVC right arm

·     A-line right arm

·     PA catheter right neck (MAC line if can’t insert big PIVC)

Probes

·     Standard (incl 5 lead ECG)

·     ABP

·     IDC

·     BIS

·     NMT

Pain

·     Opioid-heavy

People

·     Surgeon in the room

·     Perfusionist in the room

 

Anaesthesia:

Induction

·     Aim: stable HR and mAP

·     Drugs: opioid-heavy

·     Airway: BMV with guedel (avoid air), ETT

Pre-CPB

·     Baseline blood tests: ABG, ACT

·     Baseline heart assessment: thermodilution, TOE

·     Prepare for sternotomy: sympatholysis, lungs off

·     Open chest: surgeon-friendly ventilation (no PEEP, low VT)

·     Prepare for cannulation: ACT >480 and SBP 90-110

CPB

·     Regular ABG

·     Regular ACT

·     Ensure coronary perfusion

·     Ensure LV empty

Post-CPB

·     Prepare for decannulation: SBP 90-110

·     After decannulation: reverse anticoagulation (BE CAREFUL)

·     Check the pacemaker box

·     Repeat blood tests: ABG, ACT, formal blood tests

·     Repeat heart assessment: thermodilution, TOE

 

Temporary pacing:

 

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Mode

·     AAI: back-up atrial pacing (co-ordinated contraction but beware AV block)

·     VVI: back-up ventricular pacing (less co-ordinated contraction)

·     DDD: back-up A&V-pacing (semi-co-ordinated but beware R-on T)

Rate

·     For back-up: 50bpm

·     For output: 88bpm

Output

Question: how loudly must the pacemaker talk? (high = very loud)

·     Checking: set HR 100; dial up until the heart responds

·     Setting: 2x threshold

·     Normal: 5-10mA (?)

Sensitivity

Question: how attentively must the pacemaker listen? (low = very attentive)

·     N.B. can only perform if adequate underlying rhythm present

·     Checking: set output low; dial up until the ‘sense’ light flashes

·     Setting: 0.5x threshold

·     Normal: 2-5mV

A-V interval

·     Corresponds to PR interval

·     Ideal delay dependent on heart rate

·     ~150ms

 

ICU handover:

Summary

·      What operation

·      Why the operation

·      How did it go

Patient

·      HOPC: presentation, treatment, echo, angio

·      PMHx

Pre-CPB

·     Access

·     Airway

·     Cardiac function

CPB

·     Operation

·     Cross-clamp time

·     Total bypass time

Post-CPB

·     CVS: function, supports, rhythm

·     Resp: oxygenation, ventilation

·     Renal: urine output

·     Haem: clotting and products

·     Drugs: anaesthetic, pressor, relaxant, analgesic, antibiotic

·     Blood tests: Hb, lactate, ACT

 

Post-op hypotension DDx:

Fluid

Look at the drains

·      Bleeding: drains

Pump

Look at thermodilution and TOE

·      Ischaemia: global (supply/demand) vs local (graft)

·      Tamponade

Pipes

After excluding the others

·      Post-CPB vasoplegia

·      Sepsis

 

Post-op DO2 Ax:

Examination

·      Warmth

·      CRT

·      Urine output

Investigations

·      Thermodilution: CO/CI

·      Blood test: Hb, PaO2, lactate, SvO2

 

 

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