Cardiac Surgery Made Ridiculously Sim

by Art Wallace, M.D., Ph.D.

Cardiac surgery is a dangerous and complex field of medicine with significant morb
anesthetic care with specific attention to detail can greatly enhance patient safety an
can lead to disaster. This document will attempt to describe the bare bones sequence
CABG and VALVE procedures with specific recommendations. It is not all inclusiv
critical requirements.
If you keep your head screwed on very tightly and pay 100% attention at all times, t
the time.
A good reference is: Cardiac Surgery in the Adult by L. Henry Edmunds, Jr., MD w
http://www.ctsnet.org/book/
An online reference text “Cardiothoracic Surgery Notes” for residents is available a
http://www.ctsnet.org/residents/ctsn/
An online Johns Hopkins Cardiac Intern Survival Guide is available at http://www.c
Attendings:
Mark Ratcliffe, M.D. Elaine Tseng, M.D. Fellow: Ted Wright, M.D.
Rounds: M, T, W, Th, Fri, Sat, Sun
[if !supportEmptyParas] [endif]
Conference: Thursday 12:30 QI Meeting 203-3B-66
Friday 6:00 Rounds
Friday 7:00 Case Discussion 1C-Teak Room
Tuesday 4:30 Cath Conference: 1A-62
Thursday 1:30 Chest Conference MRI Conference Room Basement by MRI.
Clinic: Thursday 9-12:30

General Rules:
1. Call fellow whenever in doubt.
2. If you don’t know, ask.
3. Never start or stop an inotrope infusion, without asking the fellow.
4. Do not transfuse blood products, without asking the fellow.
5. If a patient arrests start ACLS, and call the fellow.
6. Do not let a cardiac patient die with their chest closed.
7. Don't forget your ABC's.
8. In a code ELECTRICITY is your friend.
9. V-tach unstable or V-fib SHOCK-SHOCK-SHOCK epinephrine 1 mg, amiodaro
repeat.
10. A-fib is common, rarely requires shock.
11. If the Fellow does not call you back, call the attending on-call.
12. When things get tough, or you can not get the SCUT done, ask for help,
13. I was too busy- is not the right answer.
14. All patients going to the operating room must have a CARDIOTHORACIC PRE
filled out the night before surgery. If you don't fill out the note, the patient can't go t
15. All patients going to the operating room must have either a fellows or an attendi
note, no operation.
16. All patients must have a mark on their operative site. No mark, no operation.
17. All patients must have a consent that lists their operation, No consent, no operat

[if !supportEmptyParas] [endif]

ASSUME nothing: Assuming things makes an ASS out U and ME. There are two
things down, and those who forget.
Intern on call must:
1. Call consults early 2. Discharge patients early 3. Transfer patients from ICU 4.
Check all new cultures Take appropriate action on abnormal labs. 5. Keep the Co
calls. If you are called, go see the patient. 8. See the consults write a note and make
note 9. Keep the 3X5 cards up to date. 10. Make a good scut list and get everything
post-call intern go home until you are certain you can do all the work on the scut-lis
If there is a systematic problem with the service, ie order sets are wrong, this docum
out of date, notify the fellow and/or service chief to correct the mistake. 13. At the
chief will ask for a summary of the problems with the service. If there is a problem,
can be corrected. Thanks. 14. All patients going to the operating room must have a
PREOPERATIVE CHECKLIST note filled out the night before surgery. If you don
to the OR. No checklist, no operation. 15. All patients going to the operating room
attending note prior to going to the OR. No note, no operation.
16. All patients must have a mark on their operative site. No mark, no operation.
17. All patients must have a consent that lists their operation, No consent, no operat
Preoperative Evaluation:
Patient Examination:
Pre-surgical evaluation must include attention to cardiac history. The cath report, th
information includes: Left main disease or equivalent, poor distal targets, ejection fr
aneurysm, pulmonary hypertension, valvular lesions, congenital lesions. Past surgic
they had surgery on a leg which may compromise the availability of vein graft harv
in the groin that will make balloon pump placement difficult? Each of these points r
technique and specific information is required. How is their angina manifest? You n
verbal reports. If a patient's angina is experienced as shortness of breath, or nausea,
to be able to link that symptom to possible myocardial ischemia.
Past medical history including history of COPD, TIA, stroke, cerebral vascular dise
independent risk factor), hepatic insufficiency will change anesthetic management.
Past surgical history: Every operation they have had. If they have had surgery on a l
mapping.
Allergies:
Medications : Look specifically for anti-anginal regimen - synergism between calciu
COPD being treated? It is very important for patients to stay on their anti-anginal th
a patient is on a beta blocker, calcium channel blocker, nitrate, and/or ACE inhibito
throughout the perioperative period. The patient should get all anti-anginal medicati
following surgery. The day of surgery is the wrong time to go through a withdrawal
Withdrawing a single anti anginal drug during the perioperative period is associated
MI, Stroke, renal failure, and/or death.
Physical exam: What was that scar from? Do they have leg veins for grafts? Are the
Chest: Is the patient in failure? Pneumonia? COPD
Cardiac: Do they have a murmur? Are they in failure?
Abd: Ascities, Obesity
LABS: Minimal CBC, Plt, Lytes, BUN, CR, Glu, PT,PTT
CXR: Cardiomegaly? Tumors? Pleural effusions?
ECG: LBBB: Critical information if a pulmonary artery catheter is planned. Occasio
develop third degree block with
PA catheter placement.
Have they had a recent MI? Do they have resting ischemia? Where are their ST-T c
PFT and ABG: Are they going to become a respiratory cripple? All patients for card
FVC) for risk stratification. All patients for thoracic surgery need PFT's to decide if
Information: Tell them about the A-line, the PA catheter, and post op ventilation.
Consent: Patients having cardiac surgery have serious and frequent complications i
Neuropsychiatric Effects 90%, Death 1-3-10% (Depends on risk), Transfusion (40-9
discuss these risks. Copy the consent and have it scanned into the computer. Loss of
at least 30 minutes.
Note: Write a clear note with all the standard details and consent. With the compute
patient's information. If you copy someone else's note, check all the details with the
past information, check it for accuracy, and describe what you are going to do. If yo
Make sure you sign your note so that it is visible to other computer users.
Night Before Surgery:
1. All elective patients must have a note on the night prior to surgery by the attendin
preoperative condition of the patient and the surgical plan. If the note is written by t
operation must be specified, the plan must have been discussed and approved by tha
agree with the plan. The attending doing the case must review the cath films prior to
2. The house staff must fill out the CARDIOTHORACIC PREOPERATIVE CHEC
problems must be resolved prior to the morning of surgery. If you don't fill out the n
No checklist, no operation.
3. All work up on patients scheduled for the following day should be completed, if p
all completed by noon. If there is a problem, another case can be placed in the slot.
slot is lost.
Preoperative Testing:
1. Work Up: What tests are needed in each patient.
PFT: All patients for cardiac or thoracic surgery need PFT's. These tests are for requ
stratification. If the patient is scheduled for CABG, you need FEV1 and FVC. If the
(FEV1 < 1.5 or 50% of expected, on MDI steroids, morbid obesity, sleep apnea, or
gas. If they are for thoracic surgery they need a blood gas. Patients should get pulm
pulmonary function lab if possible. Bed side PFT's should not be obtained unless th
infusions. If the patient can not sit up or they are intubated, do not request the test. S
pulmonary function test on a drop in basis by calling 2415.
V/Q Scan: Any patient for lobectomy with FEV1 < 1.5 liters, any patient for pneum
PT/PTT If the patient has a coagulopathy preoperatively consider hematology consu
embolus, unexplained embolism, bleeding diathesis, hemophilia, get a consult. If a p
should be treated with iron and erythropoietin until their hematocrit is 48. Jehovah's
(any dose), NSAIDS, or platelet inhibitors (plavix) for 10 days prior to surgery. The
aprotinin.
Urine: If the patient has a positive leucocyte esterase or WBC in urine greater than 5
and culture it. If they have symptoms of a urinary tract infection (fever, tenderness t
should not have elective surgery. If they do not have an elevated WBC count or a fe
antibiotics, and may undergo elective CABG. If they have a UTI, no surgery with im
grafts, artificial conduits, ACID's, pacemakers). For surgery with an implant, contac
and reschedule.
Coronary Angiograms: Required for all coronary and valve cases. Study must be wi
operating surgeon. If study is in adequate, it will need to be repeated. For scheduled
attending doing the case on the day prior to the case. If attending is at Moffit-Long,
for their review. We hope to have Web accessible angiograms within a year. For em
available for review in the OR.
Vein Mapping: Any patient with a history of prior surgery on the leg, prior CABG,
scars on the leg, gross leg edema, thrombophybitis, varicosities, leg deformities, am
must have vein mapping prior to CABG surgery. If mapping demonstrates inadequa
the non dominant arm should be obtained.
Radial Artery Ultrasound: Any patient under the age of 60 will be considered for ra
dominant hand if possible. Use of the radial artery should be included in the consen
marked with a felt tip pen on the arm.
Carotid Ultrasound: Any patient over the age of 60, anyone with a carotid bruit, prio
surgery must have carotid ultrasound. If there is a velocity greater than 200 cm/sec,
greater lesion, call vascular surgery. If the carotid is 100% occluded they will not co
Contact your attending for any of these findings.
Cardiac CT or MRI: Patients with ascending aortic calcifications at an elevated risk
ascending aortic calcifications on angiogram, calcifications seen in the aortic arch o
ventricular wall should have a cardiac CT. If the patient will have a contrast dye loa
consider cardiac MRI. Any patient with severe ventricular dysfunction and a thin ou
dilated heart, or EF < 20% should be considered for Cardiac CT or MRI. Contact yo
ECHO: Nice to have in all patients but not always easy to obtain. There needs to be
patients prior to elective cardiac surgery. This assessment can be from ECHO, MUG
should go for elective cardiac surgery without some assessment of LV function. An
valvular disease, a murmer, history of valvular disease should have a cardiac echo p
ECHO's are good for 6 month unless there is a change in medical condition such as
Myocardial Viability Studies: These consist of PET (positron emission tomography
should be considered in any patient with an EF < 20%, or any re-operation with a lo
with questionable targets or a recent MI. Discuss with the attending prior to orderin
Dental Consult: We are trying to avoid operating on patients with dental abscesses t
broken or loose teeth that can be dislodged by laryngoscopy. Obtain in all patients g
(tube grafts, aortic root replacement), AICD or pacemaker, any implant.
Colonoscopy: We are trying to avoid severe GI bleeding after anti-coagulation. Any
rectal exam, unexplained anemia, dropping hematocrit. For dropping hematocrit con
hematuria.
Repeat all Work UP: Any patient with a recent MI needs a repeat CXR, ECHO, Car
surgery.
Notify attending and fellow of all significant abnormal results. Place all results i
Notify Attending for 1) altered or abnormal LFT or albumin < 2.5. 2) Cr > 2.0. (Di
WBC > 15K 4) Glucose > 300. 5) Positive U/A (leucocyte esterase positive with Ur
focal infection. If patient has a previous TURP or difficult foley placement discuss w
urology place foley after induction of anesthesia
Presurgical: These patients are scared. They understand there is real risk. They also
At least 40% get ischemia preop with good premedication. Make sure they have a s
prior to surgery. Anesthesia will write for morning of surgery sedation. They need t
with a sip on night before surgery. They need to get all their medications except ora
surgery. They need a preoperative note that reviews the case, describes the surgical
consent, etc. All patients must have their surgical site marked with pen prior to surg
Medications Preop: All patients must get their anti-anginals. If the nurses put patie
the chart that patient is to get Drug X, Y, and Z with a sip of water at 6 AM. Otherw
needing their anti-anginals. Be incredibly clear in your preop orders or they won't g
anginal medications during cardiac surgery increases risk of death, MI, CVA, and re
TEST/Therapy Who Abnormal Wha
Labs: lytes, BUN, CR, All Cr > 2.0 Call
Glu, WBC, Plt, hgb, WBC > 15K
HCT, albumin, LFT, Glucose > 300
PT/PTT U/A +
LFT abnormal
Albumin < 2.5
PFT: All patients FEV1 < 2.0 Call
V/Q FEV1 < 1.5 for lobectomy or [if Call
< 2.0 for pneumonectomy !supportEmptyParas] [e
 ndif]
Erythropoetin + Iron Jehovah’s Witness [if Call
!supportEmptyParas] [e
ndif]
U/A All patients Leucocyte esterase + In v
and/or WBC > 5 RX
CAB
Coronary angiogram Everyone for CABG and [if [if
valve !supportEmptyParas] [e !sup
ndif] dif]
Vein Mapping Previous leg surgery, previous [if Call
CABG, abnormal leg. !supportEmptyParas] [e
ndif]
Radial Artery Age < 60, or no leg vein [if [if
Ultrasound !supportEmptyParas] [e !sup
ndif] dif]
Carotid Ultrasound Age > 60, TIA, CVA, prior velocity > 200 cm/sec, Call
vascular surgery severe carotid stenosis,
or a 75% or greater
lesion,
Cardiac CT/MRI Aortic calcifications, [if Call
!supportEmptyParas] [e befo
ndif]
ECHO Everyone unless other [if [if
assessment of LV function !supportEmptyParas] [e !sup
done already. ndif] dif]
Myocardial Viability EF<20% or [if Call
Study EF<35% with redo !supportEmptyParas] [e befo
ndif]
Dental Consult All Valves or serious dental [if Call
disease !supportEmptyParas] [e
ndif]
Colonoscopy Guiac +, anemia [if Call
!supportEmptyParas] [e befo
 ndif]
Intraoperative Care:
PA Catheters: At the present time all bypass cases get the standard monitors plus a
an article in JAMA that suggests PA catheters offer little additional information and
As yet, this has not changed our practice. It is clear however that placement of PA c
without injury to other structures. With no proven benefit all risk must be reduced. O
ultrasonic mapping prior to catheter placement. Remove the towels from behind the
position you would like, then tape the head in place. Place the patient in tredellenbu
draw out the anatomy, sternocleidomastoid, clavicle, carotid, etc. The more lines the
ultrasonic goop is in place. Place the blue line in the center of the echo screen. Place
patient's right. Make sure the probe is absolutely perpendicular to the bed. If you po
have to take the angle into account and few can do trigonometry in your head. I will
Then take the 5 mHz probe and map out the path of the carotid and the IJ. The IJ is
the carotid is round and doesn't collapse under reasonable pressure. If you don't hav
off the goop, redraw, and then map again. This technique requires the patient to not
placement. I think this system is faster than not using the echo, as you waste 2 minu
searching with a needle.
Planning for Early Extubation: With the health care revolution this is the new thin
in anesthetic technique that make it possible and a good candidate who is problem f
simply that many patients appear to be good candidates and then aren't when they g
problems and do well. The simplest solution is to treat all patients as candidates for
qualifies. Early extubation should be planned for in all patients because it requires p
case. The most successful candidates have reasonable cardiac and pulmonary functi
requirement. The changes we have made include limiting fluid given to the patient.
benzodiazepine dose. Rely on volatile agents or propofol during the case. Provide se
of (propofol). Careful control of blood pressure with emergence. Remember some v
hypoxic pulmonary vasocontriction, increase shunt, and make weaning of FIO2 mo
post op is critical. Then extubate the patient. Extubation time is controlled by nursin
want to extubate early, wean the FIO2 rapidly, wake the patient up, and when the pa
criteria do it. It requires a cultural shift to accomplish. The most common reason for
mismatch (shunt) caused by heparin-protamine complexes in the lung. The second m
sedation. Finally, hemodynamics, coagulopathy, etc. get on the list.
Communication: All information must be communicated to the surgical fellow or a
can't reach the fellow call the attending.
Hypotension: Hypotension with tachycardia is hypovolemia until proven otherwise
the chest. If the patient had good cardiac function coming off bypass and now is hyp
hypovolemic. If you have given volume, check the cardiac output, calculate the SVR
high, the CI is low (less than 2.0), and you are giving some inotrope, consider tamp
Tamponade: If the blood pressure is zero-open the chest. This is not like medical ta
on the atrium, the heart won't fill, and the blood pressure will collapse. If the blood
bleeding stops and the blood pressure drops- consider tamponade. Give volume, sta
echo and a chest xray. A widening of the heart, fluid around the heart, low chest tub
pressure - you should already be in the OR opening the chest.
Tension Pneumothorax: If the blood pressure is zero-open the chest. If the blood pre
tension pneumothorax. The chest tube can be blocked with blood, or crimped. Chec
place bilateral 14 guage angiocaths in the anterior-lateral chest at the T2-4 level, pla
Hemodynamics:
Prior to Valve Repairs there are specific recommendations:
AS: Preload: Keep it up Afterload: Maintain SVR: Maintain HR: 50-80 Rhythm:
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
MR: Preload:Keep it up Afterload: Down SVR: Down HR: 50-80 Rhythm: NSR
Prebypass Hemodynamics: You should try to keep the blood pressure within ± 20
rates between 40 and 80 are generally fine depending on the clinical situation prior
Bypass Hemodynamics: You should keep the MAP between 40-80 during the cold
and between 60-80 during warm bypass (cross clamp off). There will be exceptions
disease or chronic renal insufficientcy that may need higher pressures (60-80 mmHg
Post Bypass Hemodynamics: Systolic blood pressure greater than 80 mmHg is fin
everyone will be happy. If it is greater than 120 mmHg the patient is hypertensive a
Cardiac index greater than 2.0 is fine. Pa Diastolic less than 20 mmHg, CVP less th
than PAD there is a problem: poor calibration or right ventricular failure. Always co
heart if the chest is open, or tamponade when it is closed, for hypotension.
Fluids: There are lots of theories on fluids and little data to support the strongly hel
suck up large amounts of fluid intraoperatively with little obvious benefit. All of tha
postoperatively frequently by administering large amounts of lasix with subsequent
operative extubation is frequently delayed by intraoperative fluid administration. Pl
administration intraoperatively. A few suggestions. If you have two large bore IV's
than 500 cc of LR prior to bypass. Do not administer any fluids during bypass excep
drugs. Use hespan post bypass up to 20 cc/kg, then shift to albumin. If you use hext
not apply. If the patient has previously had 20 cc/kg of starch (hextend or hespan) u
metering device on any carrier lines to prevent accidental high flows. Use neosynep
giving large amounts of fluid prebypass.
Fluid Tallies: Tally the estimated blood lost, and fluids administered including crys
pump blood, bypass prime volume, and total fluid given by perfusionist on your rec
efforts where we ignored everything but the crystalloid, colloid, given by anesthesia
and perfusionists. The perfusionists can give large amounts of crystalloid and we ne
if they give hespan or hextend in the pump prime we should know about it.
Ischemia: Patients have CABG surgery because of myocardial ischemia. 40% of pa
have intraoperative episodes of myocardial ischemia. You should record a 5 lead EC
comparison. Ask the patient if they are having chest pain at this time. You should lo
at least every 60 seconds and ask - What is the rhythm? Is there ischemia? Only by
you detect a substantial fraction of the ischemia.
When the blood flow to myocardium is insufficient, it immediately stops contractin
At 60 to 90 seconds the ECG ST-T wave starts to change. This focal reduction in ca
watching the ECHO image. The best level is a short axis mid papillary view. You sh
axis mid papillary view for comparison. The ECHO is an adjunct to care not a requi
when looking at the echo.
Clotting: Cardiac surgical patients receive a lot of heparin (300 to 400 U/kg = 20,00
protamine. The protamine and heparin make a weak salt which is cleared in the lung
protamine, the patient can become reheparinized post operatively. Check the PT and
elevated give more protamine (25-50 mg). The anesthesiologists gave protamine in
so you are adding to the dose. Protamine is an evil, wicked, dangerous drug made fr
respect. It can cause profound vasodilation from histamine release. It can cause anap
hypertension. Treat it as the most lethal drug you will administer and you will not b
ready to treat hypotension from profound vasodilation (neosynephrine or epinephrin
Sternotomy: Painful process that occurs rapidly after induction, make sure the patie
anesthesia to let the lungs down during opening. Develop a system to prevent yours
back on ventilator. Do not rely on the alarm as the only reminder.
Redo Heart Sternotomy: In a redo heart the adhesions may bring the ventricle clos
may cut through the right ventricle with resulting (profound) hemorrhage. Blood mu
may also cut through the IMA or a saphenous graft. You should have an idea of wh
report and a plan. Instant severe myocardial ischemia with rapid deterioration may r
and grafts are not functional. Functional grafts that the patient is dependent on is the
Knowledge of the chest xray (pa and lateral), prior operative report with details of t
are essential to decide on how to handle these situations.
IMA Dissection: They may want the table tilted to the left and elevated. They may
the rate increased to help with dissection. It may be very hard to get an echo image
Heparinization: Do not go on bypass without heparinization. If the patient is not he
on the bypass pump, the pump and oxygenator will clot and the patient will most lik
in some artery give the heparin. When you ask for heparin, require a verbal reply - "
dose of heparin is 300 U/kg which is about 21 cc of 1000 u/cc heparin in a 70 kg ma
after the dose. If the patient is on heparin preop, give the same dose (Heparin 300 U
just be careful putting in lines. Do not give anti-fibrinolytics until fully heparinized
than 450 seconds after the dose, give more, until the ACT is above 450 seconds. If y
ACT must be above 800 seconds. If a kaolin ACT is used the normal 450 second ra
Add heparin to your ACLS protocol for cardiac surgery patients. If the patient arres
be put on bypass for resuscitation.
All patients getting cardiac surgery using extracorporeal circulatory support should
are several choices. It may be that all should get aprotinin, unless given in previous
been universally adopted. At the present time we use a two tier approach.
All patients going on extracorporeal circulatory support should have an anti-fibrinol
without risk factors they get amikar. If they are a redo case, a case with renal failure
or a Jehovah's Witness where bleeding would be lethal, they get aprotinin.
Amikar: Epsilon amino caproic acid used as a antifibrinolytic. Some evidence that
Some clinical reports of problems (left ventricular thrombus, arterial thrombi, etc.) C
bypass and 5 g IV after bypass. Can be given in higher doses 10 g prior and 10 g aft
expensive ($12/bottle) than aprotinin ($900/bottle) although the efficacy is not prov
No convincing safety data. We are using it on all cases. Give 5 g IV slowly after yo
Give 5 G IV slowly after the protamine is in. You do not want to give it prior to hep
associated with protamine administration and it is easier if only one drug can be bla
Aprotinin: Antifibrinolytic and platelet preserver that reduces bleeding and transfu
in redos and people on aspirin. Costs $900/case. The transfusions for a case average
If one considers the risk of disease transmission from transfusions amprotinin is a b
graft closure from clotting. If one looks at the morbidity and mortality associated w
reduces risk of death. It is allergenic so patients should probably only have one use
probably be for a redo CABG.
Our present use is for REDO CABG, patients with renal failure, patients with risk o
bleeding would be lethal (Jehovah's Witness). Order 6 M units (3 200cc bottles at 1
dose, then 20 cc over 20 minutes starting prior to skin incision. Then continue at 0.5
with 2 M units so give one bottle to them. I have tried to avoid using a fourth bottle
to 0.3 to 0.4 M U/hr so that the infusion bottle will last until the end of bypass. Low
slower infusion is probably reasonable. Remember celite ACT 800 seconds, kaolin
What operation are we doing today?: Cardiac surgery used to be done using extra
did CABG without the pump but it was rare and usually done elsewhere. In the last
surgeries done using off pump techniques has risen dramatically. The invention of t
easier, safer, and practical for most CABG operations to be done off pump. At the p
patients to "on pump" versus "off pump" care. If the decision seems random, you ar
fundamentally different for these two approaches so we will separately discuss the "
the "OFF PUMP" approach. You need to be flexible because they can change their m
Placing the cannulas:
Do not go on bypass without heparinization. The arterial pressure at this point shoul
cannula in the aorta (has a red tape on it) should not have any bubbles in it. Check f
aortic cannula there is splash - have your glasses on.
The larger cannula with blue tape is the venous cannula and goes into the apex of th
cava. It is a drain line and may have bubbles. On mitral valve and ASD/VSD cases
into the superior and inferior vena cava.
The small cannula with a balloon at one end is placed into the coronary sinus throug
When the flow in the coronary sinus cardioplegia line is 200 ml/min the pressure sh
pressure is like CVP and does not go up with coronary sinus flow (retrograde cardio
coronary sinus. If this happens during continuous warm cardioplegia, there is a peri
in severe ventricular dysfunction and death. If the pressure is very high (greater than
ml/min the cannula is against the wall and you also may not be having good retrogr
The left ventricular vent line is placed through the right superior pulmonary vein. It
Check List for Going on Bypass:
HAD2SUE Remember this mnemonic. Say it often. Avoid killing patient by using i
Heparin: Always give prior to 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.
Clean Kills and the Perfusionist: There are three easy ways for the perfusionist to
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
If a line breaks, you may have to help replace it.
Air Lock: The venous line drains by siphon. Nothing is quite as reliable as gravity b
system can cause the loss of the siphon. If the perfusionist notes bubbles on the ven
integrity of the cordis, closure of all stop cocks, the surgeons will check the atrial pu
temporarily the venous pressure will rise and the air leak will diminish. The lines ca
airlock occurs.
Cardioplegia: There are lots of types. Cold, Warm, Warm induction - Cold Mainte
Shot, Crystalloid, Blood, Antegrade, Retrograde. The best is a short cross clamp wi
record the on bypass time, the off bypass time, the on cross clamp, the off cross clam
1 hour ventricular function deteriorates, as it exceeds 2 hours it gets worse. Cardiop
are lots of things added to cardioplegia and the bypass prime and you should find ou
They will say something like "Nothing special" which translates into potassium, lid
manitol, bicarb, adenosine, free radical scavenger of the day, and snake oil. Ask and
in the cardioplegia bag, most of it only in the eye of the orderer. If something weird
to 30, potassium sky rockets, glucose is very high) consider what is in the cardiople
De-Airing Maneuvers: It is bad to pump air to the patient. It is difficult to get all o
the middle cerebral artery during bypass demonstrate 50-2000 emboli per case. It is
atherosclerotic plaque. The smaller the bubble the bigger the echo signal. On open v
surgeons will have you place the head down. Then they will bump the patient, roll f
ventricle, aspirate from the aorta, etc. in the hopes of getting out all of the bubbles. T
want. If you look at the echo at this time there will be a snow storm of little bubbles
one or more than usual say something.
The majority of emboli occur on aortic cannulation, cross clamp placement, cross cl
side bitter removal, weaning from bypass, and aortic cannula removal. It is best not
temperatures ( 37oC) during any of the embolic times. 95% of patients suffer subtle
with multiple small emboli.
Check List for Getting Off Bypass:
WRMVP: Wide receiver most valuable player.
Warm: What is the bladder and blood temp?
Rhythm: Are they in NSR or do you need to pace? Is the rate adequate?
Monitors On: Turn em back on if you turned them off for bypass. Turn back on the
Ventilation: Turn on the ventilator. Easy to forget and you look very stupid.
Perfusion: What is the pump flow.
Weaning from bypass: You need to have a plan. What was the ventricular function
cross clamp? What does the heart look like now? What is the resistance now? Once
the surgeon. If you plan to use a drug with prolonged side effects ask them what the
may have an opinion that should be considered. Have some inotrope ready. You sho
time CABG patient's from bypass with no inotropes. Calcium chloride is commonly
been associated with pancreatitis.
A standard weaning plan would be to calculate the systemic vascular resistance (SV
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
SVR should be in the 1000 to 1200 wood units. It routinely will be 600 to 800 and t
develop a reasonable pressure post bypass will be too high. Vasoconstrictors (pheny
some vasocontrictive effects (dopamine, epinephrine, norepinephrine) are commonl
reasonable levels. Here is an example. The MAP is 50 and the CVP is 10. You ask t
pump flow is 5 liters/min. That gives a SVR of (50-10)/5*80 which equals 640 woo
Let's take two approaches. The first is to come off pump and let the heart try to pum
pressure. Once off pump the SVR will be 640, the MAP will be 50 and the BP will
cardiac in nature. The problem is simply low resistance. An inotrope is not needed a
If the SVR had been raised to 1200 prior to coming off pump, the 5 liter/min cardia
with a CVP of 10. The BP would then be about 95/50 and all would be well.
A reasonable approach to weaning from bypass is to:
a. Make an educated guess as to the inotropic state of the ventricle. If it was lousy p
be lousy and an inotrope will be necessary. If the inotropic state of the ventricle was
times were reasonable (60 minutes or less) then it is likely no inotropes will be need
b. Calculate the resistance and correct it.
c. Check the requirements for coming off pump. Warm, Rhythm, Monitors On, Ven
reasonable).
d. Be ready to change your plan.
Why does the patient "go on bypass"? and How does the patient "come off byp
The bypass system is basically a large plastic pipe with lots of holes placed through
inferior vena cava. The large plastic pipe is full of fluid and hooked to the venous re
large clamp. Note: Before attempting any of this activity, (not recommended in the
sure you have fulfilled the criteria for going on bypass (HADDSUE) or coming off
NEVER LET THEM GO ON PUMP IF YOU HAVE NOT HEPARINIZED. H
very reassuring but not absolutely essential in dire and I mean dire emergencies. Oth
must be greater than 450.
The simple explanation for going on bypass is the perfusionist removes the clamp fr
siphon effect drains blood from the right atrium and inferior vena cava into the veno
maintain the siphon effect to keep this flow going. Since, there is no or less blood g
cardiac output drops. The perfusionist then turns on the pump and returns the blood
patient's aorta. If all is working well the blood will be heated/cooled and oxygenated
before being pumped through the filter and back into the aorta. Unclamping the ven
pressure and diverts blood into the pump. The perfusionist will say something like "
or 5 liters a minute of venous drainage and are able to pump 4 to 5 liters/min into th
off the ventilator. Pulmonary artery pressures should be non-pulsatile.
Coming off pump is the exact reverse situation. You fulfill all the criteria for comin
patient is warm, the heart is beating, the monitors are turned on, the ventilator is tur
resistance and inotropic state to an appropriate level. The perfusionist then partially
reduces the amount of blood draining into the venous reservoir. The right atrial pres
into the right ventricle and out the pulmonary artery. At this point you can have a pu
systemic blood flow with the rest produced by the heart. The surgeon will say some
to 4 liter/min. You will notice that the pulmonary artery and systemic pressures bec
say 2 liter/min then 1 liter/min. They are watching the right and left ventricles to ma
also watch the pressures and slowly load the heart. When they say something like "G
telling the perfusionist is to leave 100 cc less blood in the reservoir. The perfusionis
blood from the patient and pumping 2 liter/min to the patient. They are supposed to
they withdrew. It is an inexact science. But you get the idea.
The surgeon will then clamp the venous drain line and you can tell that you are truly
venous cannula. If you have a kind surgeon, they will place it in a bucket of saline a
reservoir keeping the line full of saline. This allows the perfusionist to start hemo co
but keeps the venous line ready in case you have to return to bypass. The arterial lin
can give fluid. When the patient's blood volume is low you will hear - "give a hundr
unclamps the arterial line with the pump on and drains 100 cc of fluid from the rese
Who weans the patient from bypass and who gives volume orders? This varies by in
institutions the anesthesiologist does at others the surgeon does. If you are not ready
think the patient needs to go back on bypass, tell the surgeon to put the cannulas bac
tell them not to take out the arterial cannula. If you need more volume, ask for it. Yo
surgery where it is essential that you be able to tell the surgeon what to do, and whe
communication is key. It is essential that it is a team process. They need to know wh
something is not working, they need to know about it. They can and will most likely
Inotropes and Vasoactive Compounds: If you are using a drug that requires an in
incorrect or fluctuating dose would be difficult to manage, use an infusion pump. Th
epinephrine, norepinephrine, nitroprusside, nitroglycerin, neosynephrine, and propo
relying on gravity drips are unacceptable. Gravity is reliable, back pressure is not. A
concentrations approved by the pharmacy. The labels with the appropriate concentr
anesthesia machine. If you mix it and label it with the yellow label then the ICU nur
get to the ICU. If you mix some weird concentration, label it poorly, or then put it o
away your drugs and the patient will get less than optimal care.

Drug Alpha Beta Dopamine PDE-I NO MAP HR CO SVR D

Phenylephrine ++ + ± - + 1
0
Ephedrine + + 5
Norepinephrine +++ ++ +++ - ± +++ 0
Dopamine + + + + + +++ + 2
Dobutamine + ± + +++ - 2
Isoproterenol + - ++ +++ - 0
Amrinone ++ - + - 5
Milrinone 0
Nitroglycerine + - + - - 0
Nitroprusside + - + + - 0
Prophylactic Drugs: Some surgeons believe that prophylactic high dose steroids ar
reaction to bypass or reduce neural injury. Scientific evidence for these theories is li
infections and poor wound healing. Some surgeons believe in prophylactic inotrope
prophylatic nitroglycerin infusions have been suggested as a preventative measure f
ischemia, downside is hypotension, supply limited ischemia, and more fluid require
Magnesium is thought to be an anti-arrythmic, anti ischemic agent. Some people loa
surgery (2 grams IV) others do not. The scientific evidence for many of these therap
have to communicate and ask your surgeon their preference. You will have to come
professional compromise on prophylactic drug use.
Phosphodiesterase Inhibitors: Do not start a phosphodiesterase inhibitor (Amrinon
cardiac surgeons. Do not choose it as first line inotrope. A phosphodiesterase inhibi
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 arrhy
High potassium depends on timing. Greater than 5.0 is common on bypass from the
below 5.0 but greater than 4.0 when you come off pump. The perfusionist can ultraf
Hematocrit: Drops with the hemodilution of the bypass pump. If it is below 20 you
need to use clinical judgment. Talk to the surgeons, they may have an absolute rule
simply follow it in the unit and be irritated with you in the OR.
Post Bypass Hemodynamics: Systolic blood pressure greater than 80 mmHg is fin
everyone will be happy. If it is greater than 120 mmHg the patient is hypertensive a
Cardiac index greater than 2.0 is fine. Pa Diastolic less than 20 mmHg, CVP less th
than PAD there is a problem: poor calibration or right ventricular failure. Always co
heart if the chest is open or tamponade when it is closed, as a cause of hypotension.
Protamine: Fish semen in a bottle. There are allergic, anaphylactic, and histamine r
Protamine 10 mg will equalize Heparin 1000 units. Protamine comes as 10 mg per c
cc of protamine will neutralize it. You are forming a weak salt between a base and a
response. You need to give the dose and then check the response by measuring the A
shunt post op is caused by clearance of heparin-protamine complexes by the reticulo
Protamine Administration: Give 10 mg = 1 cc peripherally and check for allergic
broncospasm, rash, or pulmonary hypertension. Stop administration for problems. Y
protamine, be ready with phenylephrine. Steroids, H1& H2 blockers, vasoconstricto
can help. Allowing the heparin to spontaneously be metabolized is another option fo
Then give the rest of the dose slowly. What is slowly? If you follow the PDR it wou
some institutions it would be 1 minute. Over 20 minutes is not unreasonable. Once 1
perfusionist so that they can stop the pump suckers and avoid clotting the pump. If y
to bypass you will be very, very, very unhappy.
Once all the protamine is in, tell the surgeons, and then check an ACT. You should
have not, give more protamine. If you give pump blood after this point you may nee
only find this out by measuring the ACT. Check the ACT after you give blood prod
Post Bypass Bleeding: If there is bleeding post bypass, check the ACT. If elevated
in the last 4 days you may need platelets. If there is medical bleeding, you may need
bleeding, they should fix it with a stitch or the bovie not infusions of platelets. Rece
the clotting cascade it is a 6-0 proline.
Returning to Bypass: If there is severe hypotension, bleeding, low cardiac output,
return to bypass. If you have given the protamine, give another dose of heparin at 30
the aortic cannula is removed, you should make a decision about whether you may n
having severe problems maintaining the pressure despite inotropes, tell the surgeons
cannula or immediately return to bypass. It is very bad for the heart to be dilated by
low coronary perfusion pressure. You may have to return to bypass.
Balloon Pump: Very nice system for inadequate left ventricular function. The ballo
an arterial pressure signal. On the Datex monitor the slave cable plugs into channel
channel. Plug the CVP cable into channel 4 and change the label on channel 4 to CV
easiest thing to do it get a new pressure transducer. Hook the new arterial transduce
cable into channel 3. Change the label on channel three to ABP. This will make the
plug the slave cable into channel three and send it to the balloon pump. There is a sw
to lok at external ECG and arterial pressure from the slave cable. Both settings mus
suggest if there is difficulty weaning from bypass.
LV Assist Device: Transportable centrifugal pump that can be used as a bridge to tr
severely stunned myocardium.
Closing the chest: May cause hypotension if inadequate volume status. Check a car
seem too large or the heart is lifting out of the chest, consider broncospasm with air
and ETT adjustment can help.
Transport: Have the patient monitored at all times. Never remove the ECG until an
leads, get it to work, then remove the OR leads. Do not change the A-line if hemody
If you elevate the transducer 13.6 cm you will reduce the arterial pressure 10 mmHg
level. Be paranoid. If there is a problem. Stop and fix it.
Sudden hypotension on moving the patient: It is very common for the blood pres
from the operating table to the bed. This phenomena is not well understood but may
tissues with the shift to the bed. The patient can have profound hypotension. Most p
noticibly. Have volume available. Do not make the shift if the patient is unstable or
prior to the shift. Have volume, some drug to raise the pressure, some drug to lower
other drugs you have been using with you on transport.
ICU: Shift the monitors in the same way. The cartridge for the transport monitor sim
you don't have this system get the ICU ECG working before removing the transport
the patient is hemodynamically stable. Listen to the chest immediately after hooking
hypotension suspect a problem the ventilator (infinite peep) and remove the patient
ventilate. Then get a new ventilator. Do not allow the nurses to change to their inotr
them to remove your iv's until you leave. Do not leave until the patient is truly stabl
When to Extubate: The checklist for extubation should include: No evidence of my
failure, Hemodynamic stability on limited inotropic support, (no balloon pump or m
from the cardiac fellow's brow), limited bleeding without a coagulopathy (chest tub
hours), good gas on FIO2 is 0.40, SIMV 8, PEEP 5, TV = 10 cc/kg, the patient is aw
CPAP 5 cm H2O FIO2 =0.50 then extubate. Talk to the surgeons about your plans,
why this patient is a lousy candidate (The grafts were poor, there is bleeding, there i

Cardiac Surgery for Minimally Invasiv

Surgery:
Off Pump CABG
I guess the first question should be what to call this new operation. It is minimally i
CABG. Maximally difficult CABG. I don't know. A little cabbage is commonly kno
operation is changing rapidly. These is now a history to how it was done. That impl
Initially, there was the Heart Port operation. The marketing plan of the Heart Port S
sternotomy scar. Most people coming for a CABG are past the age when the scar w
case of Bay Watch. The operation was simple, no that's not right. An arterial inflow
artery and the venous outflow was placed through a femoral vein. A catheter with a
and the balloon inflated in the ascending aortic arch. Aortic atherosclerotic disease w
this operation. Picture sliding the catheter up a severely diseased aorta followed by
Cardioplegia was then delivered antegrade to the coronary arteries which have been
circulation by the ascending aortic arch balloon. A catheter was advanced from the
pulmonary artery for venting the left ventricle. The patient was placed on fem-fem b
A single vessel CABG was then performed either through a mini thoracotomy or th
this operation is obvious. The risk from with a CABG is the extracorporeal circulati
major morbidities of CABG surgery is the neuropsychiatric changes and strokes. Th
bypass run for a single vessel CABG. It maximizes the risk of stroke while eliminat
was doomed to failure from the start.
CTS (Chuck Taylor Surgical or Cardio Thoracic Surgical) and US Surgical worked
by Bennetti. It was in essence a mini-thoracotomy with no bypass. The standard wa
was stabilized by placing latex sutures under the LAD proximal and distal to the site
presses on the myocardium while the sutures pull the heart into the foot. Blood flow
the stabilizing sutures. The technique requires improved technical skill on the part o
moving (contraction as well as respiratory movement). It also requires increased tec
anesthesiologist because an area of myocardium is ischemic, and non -functional, an
The advantage of the operation is reduced cost (no extracorporeal circulation, reduc
risk of stroke (no extracorporeal circulation). If surgeons and anesthesiologists can s
(motion, bleeding, arrythmias, hemodynamics, exposure) it offered great promise. O
difficult and inferior wall vessels were hard to appoach.
Octopus and Starfish. These retractors use suction to stabilize the heart. Instead of s
CTS system, the Octopus system sucks up the myocardium with two little arms. Th
tighten the area and reduce motion. The Starfish is retractor for lifting and moving t
like a Y. With these retractors hemodynamics are much improved during stabilizatio
The equipment for MID-CABG is changing constantly. The fundamental problems
address is what is the plan when the patient has ventricular fibrillation. If the surgic
thoracotomy what is going to happen when the ischemia caused by the stabilizing su
caused by releasing the sutures progresses to ventricular fibrillation? The second pr
despite the efforts of the surgeon.
My favorite plan is this.
1. Choose an anesthetic that lowers the heart rate (fentanyl, sufentanyl, alfentanyl, r
2. Use a median sternotomy approach. The morbidity is small compared to the risk
Have the perfusionist available. Don't prime the pump but have it completely set up
the lines just be ready. If you can't convince the surgeon to do the case as a sternoto
emergency sternotomy when the patient fibrillates. The other advantage of the stern
multivessel CABG without extracorporeal circulation is possible. With the mini-tho
thoracotomies are needed for the second and third distal anastamosis. If you end up
mini-thoracotomies, consider using a double lumen tube for better exposure. They a
3. Anti-coagulate the patient just as you would for a CABG with extracorporeal circ
is a problem it is easy to cannulate and go on pump.
4. Prophylax for arrhythmias with you favorite drugs. Magnesium 2 gram IV plus L
infusion at 2 mg/min. I am a strong proponent of amiodarone (IV). If you have arry
10 minutes, then 1 mg/min IV for 6 hours, then 0.5 mg/min for 18 hours.
5. After the surgeon has retracted the heart, placed the stay sutures and the stabilizer
(hespan / hextend) and maintain the pressure with vasoconstrictors. I try to avoid be
tachycardia and pro- arrythmic effects. Tachycardia makes the anastamosis more di
adjusting hemodynamics only to have all your work reversed when the heart is let o
trendellenburg is very useful for inferior wall distal anastamosis.
6. Adjust the ventilator to reduce motion (small tidal volumes with increased rate).
7. Have a plan to lower the heart rate even more if necessary (esmolol, adenosine). I
use atrial pacing. Do not use glycopyrolate or atropine when asked to increase the h
undo when the surgeon changes his mind.
8. Be ready for reperfusion arrhythmias with release of the stay sutures.
9. Reverse the heparin gently. Remember you don't have a bypass circuit ready to b
protamine may be reduced because of the lack of damage to the platelets. Check the
the protamine to avoid overdosing.
10. Consider anticoagulation post reversal of protamine. CABG surgery benefits fro
coagulation system. When was the last time you saw a post CABG pulmonary embo
anticoagulating after a valve? In a Off Pump-CABG where the coagulation system w
circulation circuit the coagulation system is normal. All of the problems with pulmo
clotting that the vascular surgeons have will now occur with cardiac surgery. If graf
night trip to the OR to remove the clot for vascular surgeons. Off Pump CABG graf
cold blue patient and a trip to the morgue. Be very, very, very careful about post op
anastamosis was done in less than optimal circumstances (movement, bleeding, lim
system is fully functional. We are trying dextran infusions to try to have some prolo
bleeding. The jury is still out though.
We have had thirty years to figure out all the tricks for normal CABG's. The Off Pu

Post Operative Care:

Most important things to watch for on a fresh post-op Heart patient.
1. Bleeding: What is significant bleeding?
Chest tube output >200 ml/hr x 4hrs, greater than 1000 mls, or sudden 400 mls.
2. Low Cardiac output CI <2.0: What should you consider?
• Tamponade: not like medical tamponade, can be pressure on atrium. If the chest
blood pressure drops despite volume, and the central venous pressure and pulm
elevated (greater than 20 mmHg), you must consider tamponade. Get a chest x
mediastinum. Get an echo. If you have started 2 inotropes, and given volume,
2.0), you must rule out tamponade.
• Hypovolemia: The diastolic function of the ventricle is stiffer than normal, the pa
vasodilating. Hypovolemia is very common. What did the anesthesiologists gi
hextend if they gave more than 20 cc/kg. Give albumin if the hematocrit is ok.
• Cardiogenic Shock: If the patient was stable coming off pump (IE no or minimal
consider why they are now in cardiogenic shock. It is more common to have v
systolic function in a patient that was ok coming off pump. Call your fellow, s
ECG, get a CXR, rule out other problems.
• MI: We just revascularized the heart but plaques can rupture, grafts can clot, air b
inotropes all can lead to MI. Troponin I levels less than 10X the upper limit of
surgery from the tissue damage associated with surgery. Troponin I levels gre
normal are probably myocardial infarctions. The higher the troponin I level th
3. Low urine output
• hypovolemia: anemia hct. <25% under resuscitated bleeding
• lasix defficency: pod#1-4 lasix unless prerenal {BUN>30, Cr>2.0}
4. Atrial Fibrillation is very common
cause; fluid, electrolyte, hypoxia, Pulmonary emboli, MI
Treatment:
digoxin load
diltiazem iv
any other drug tx call fellow
Pacemaker:
wires left in AVR for 72 hrs
Wires left in CABG or MV for 48 hrs
You must inform the RN and have patient on telemetry before you pull wire. WHY
Do not ever leave a patient in DOO or VOO mode.
Thoracic Surgery Patients
1. They are different than cardiac surgery patients
2. Chest tube management
Suction or Water Seal
when to pull tube?
Usually 24hrs on Water Seal no airleak and less than 150cc per 24hrs before consid
3. Keep most patients DRY
especially pneumonectomy
4. Pain control very important
5. Pulmonary Toilet
6. DVT Prophylaxis Heparin 5000u SQ bid.
7. DC f/u need CXR PA & LAT pt must bring the film to clinic
8. Bowel Care important, ileus can be severe.
Pre op of Lung Cancer patient
1. What is the type of Tumor? What treatment have they had?
2. CT of chest
3. PFT's
4. Old or h/o of Heart Disease
5. Stage of tumor
bronch results
medianstinscopy results
6. If FEV1 <1.5L get quantative V/Q scan
7. R/o metastatsis, consider PET scan
8. Bowel prep MgCitrate 1 bt.

3x5 cards
1. Stamp with Patient's card
2. referring MD's name, address or phone, hospital
3. operation or diagnosis
4. big events during hospitalization

Good Luck: You should enjoy your rotation at the VAMC. You will get a reasonab
surgery. If there are any comments, changes, additions, errors in this text, I, Art Wa
is very important for this document to be an accurate reflection of the service as it s
the mistakes, it will get out of date and be useless. Please, if you find an error or the
maintenance, notify me as soon as possible. Please e-mail me with suggestions.
by Art Wallace, M.D., Ph.D.