Mod2: CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT Flashcards
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
When CPB is initiated, why is ventilation is stopped?
Pulmonary blood flow ceases
This is a critical time to talk with the perfusionist
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
prior to discontinuing ventilation, It’s imperative to ensure that
full pump flow has been established
Until left ventricular volume reaches a critically low level, ventricular ejection continues
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Prematurely stopping ventilation can cause
Right to left Shunting of
the remaining pulmonary blood flow,
causing hypoxemia
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Upon initiation of bypass, there may be some initial hypotension that occur, why?
Reduced blood viscosity,
secondary to the hemodilution, and also
Dilution of circulating catecholamines
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
BP should be controlled by vasopressors that can be given by either
the anesthesia provider, or
by the perfusionist
It’s best a this point to have an open dialogue with the perfusionist regarding BP support
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
You should also know your institution policy regarding administration of drugs while on pump; why?
Some institutions will have the drugs only given by the perfusionist
While others will have drugs given by both anesthesia and perfusion
On bypass, MAP will be determined by
pump flow rate and
systemic vascular resistance
So at a constant SVR, the MAP is proportional to pump flow
MAP = Pump flow x SVR
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
The ideal flow is
2-2.5 L/min/m2
(50-60 ml/kg/min)
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
The ideal Map is
50-80mmHg
With higher perfusions being for pts with renal disease or carotid artery disease
Higher (70-90 mmHg) if patient had carotid artery stenosis or renal insufficiency
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Hypertension is considered to be pressures above
100 mmHg
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Pressures above 150 are associated with
Aortic dissection, and
Cerebral hemorrhage
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
If pt is hypertensive while on pump, the perfusionist can
Increase the volatile anesthetic
Decrease pump flow (short-term fix), or
Give a vasodilator (e.g., NTG)
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Arterial Hypotension or Decreases peripheral perfusion (systemic pressures) can be caused by?
Inadequate venous return, d/t
- cannula too small, kinked, bleeding*
- Low pump flow*
- Poor occlusion*
- Kinked arterial cannula*
- Reduced vascular tone*
- Having the table too low*
(remember the venous reservoir if filled by gravity, so if the bed is too low, this could cause in decrease in venous return)
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Treatment for Arterial Hypotension or Decreases peripheral perfusion (systemic pressures) includes?
Increase volume
Increase pump flows
Vasopressors
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Arterial Hypertension can be caused by
Light anesthesia
Response to hypothermia
But also
- High pump flows*
- Arterial cannula misdirection*
- Vasoconstrictors*
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Treatment for Arterial Hypertension is to:
Decrease pump flow
Increase anesthetic depth
Make sure there are no background vasopressor running
Vasodilators
Narcotics
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
T/F: With the initiation of bypass, you must also assess the field, patient, and communicate with perfusion to ensure adequate pump pressures
True
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass Assess patient/field for how long?
30-60 seconds after CPB initiated
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass Assess pupils for correct cannula placement by looking for
unilateral dilation/conjunctival chemosis
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass Asses face for correct cannula placement by looking for or at:
Symmetry
Temperature
Edema
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass, palpation of carotid pulses will reveal thrills only; why?
Non-pulsatile flow
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Upon initiation of bypass, when will you check ACT, ABG, and other lab values?
Immediately, then
every 20-30 minutes
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
With the initiation of bypass, Excessive decreases in MAP or persistent pump alarms can be indicative of:
Malpositionned cannula
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
Upon initiation of bypass and because of pt’s positioning, it may be difficult to do a physical assessment. What could indicate a malpositionned cannula?
Unilateral dilation,
Face color or symmetry
Increases in CVP
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
After bypass is initiated, what happens to coronary and systemic circulation after the Aortic Cross-clamping is placed in the ascending aorta?
Aortic Cross-clamping separates coronary perfusion from systemic circulation
This causes cessation of coronary perfusion
Prevents blood regurgitation through aortic valve
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
After bypass initiation & Aortic Cross-clamping, what happens next?
Cardioplegia administered
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
After bypass initiation & Aortic Cross-clamping, Cardioplegia administered. What’s an important consideration in pts with aortic insufficiency?
The cardiac protection provided by antegrade cardioplegia may not provide sufficient protection to the heart
Retrograde cardioplegia would also likely be used
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
How is Cardioplegia administered?
Given every 15-20 minutes
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
T/F: When Cardioplegia is administered, Aortic insufficiency may reduce cardiac protection
True
Antegrade cardioplegia must be combined with Retrogade cardioplegia in Aortic insufficiency
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
T/F: During bypass and depending on the institution, the anesthesia provider doesn’t have much responsibility in regards to maintaining hemodynamics
True
The perfusionist will be the primary monitor of pump flow and MAP and treating them accordingly
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, while it isn’t our responsibility per se to manage hemodynamics, we should stay vigilant to:
MAPs,
especially if they are consistently low or high
Because the perfusionist may need support in managing them in the form of either a vasopressor infusion, or narcotics, benzos and muscle relaxants
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, we will also collaborate with the perfusionist to make sure that arterial blood gas values are within normal ranges. Why is this important?
CO2 can be reduced by increasing the fresh gas flow on the bypass machine
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, we will also monitoring urine output, ensuring that it stays at a minimun of?
0.5 ml/kg/hr
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
In general, bypass time is the time used to prepare for:
Weaning and coming off pump
So ensuring that all iV push drugs are refilled,
Infusions are primed and ready to go,
Charting is kept up to date,and
Any other preparatory work that’s needed
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, assess for adequate depth of anesthesia by monitoring for:
Shivering
Breathing
CARDIOPULMONARY BYPASS PERIOD MONITORING AND MANAGEMENT
During bypass time, Assess temperature for adequate systemic hypothermia by monitoring for:
Core vs Shell temperature
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, patient must be rewarmed. Deciding the appropriate time to rewarm is important. Why is that?
Adequate time must be given to the process
Rewarming too fast can have a negative effect, including neurologic complications
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, Air must be evacuated from the heart and any bypass grafts. Why is that important?
To reduce the chance of entry into systemic circulation
Especially during valvular repair surgeries, where the heart is actually openned

WEANING FROM BYPASS
Air going down into the coronary arteries can also cause:
Dysrhythmias

WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, Air must be evacuated from the heart and any bypass grafts. Which imaging technique can assist with this?
TEE
Heart allowed to beat after air removed
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, the aortic cross-clamp must be removed from the aorta. Why?
So that blood has a clear path from the left side of the heart into systemic circulation
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, lung ventilation must be resumed. When?
When pulmonary blood flow commences
Ventilation will also aid in air evacuation
WEANING FROM BYPASS
Prior to cardiopulmonary bypass being discontinued, and while lung ventilation is resumed, what would be the benefit of using Valsalva maneuver?
Removes air from lungs
Aids in filling cardiac Chambers
Recruits atelectatic alveoli
WEANING FROM BYPASS - REWARMING
Rewarming must occur gradually. The gradient between arterial outlet and venous inflow should be no more than?
10° C
WEANING FROM BYPASS - REWARMING
During rewarming, the gradient between arterial outlet and venous inflow should be no more than 10° C. Why is that crucial?
Prevents cerebral overheating
Prevent gas bubble (gasious emboli) formation.
Gasious emboli start to form because the gas solubitlity will decrease with increase temeperatures
WEANING FROM BYPASS - REWARMING
During rewarming, why should surgical teams limit arterial outlet blood temperatures to less than 37 degrees C?
To avoid cerebral hyperthermia
Research has also notes that arterial outlet blood temperatures underestimate cerebral temperature
Limit arterial outlet blood temperatures to less than 37 C
WEANING FROM BYPASS - REWARMING
What happens if patient temperature not adequate prior to conduction?
Fibrillation can occur
WEANING FROM BYPASS - REWARMING
The rewarming phase is the most critical time for AWARENESS/RECALL. Why is that?
Potentiation of anesthetic effect due to hypothermia dissipates
WEANING FROM BYPASS - REWARMING
How should AWARENESS/RECALL be prevented?
Administer/increase anesthetic depth
Inhalational agents beneficial if fast tracking planned
Supplement muscle relaxation, narcotics, and benzodiazepines
PREPARATION OF SEPARATION FROM BYPASS
As temperature is corrected, the surgeon will:
Remove the aortic cross clamp and
Allow the heart to begin beating

PREPARATION OF SEPARATION FROM BYPASS
Once the aortic cross clamp is removed and the heart begins beating this is the time to oberve the heart directly by looking at the operating field, assessing its:
Contractility, rate and volume as the heart begins to beat
PREPARATION OF SEPARATION FROM BYPASS
Once the aortic cross clamp is removed and the heart begins beating, the surgeon will then request that the perfusionist allows the heart to:
Begin to fill
Perfusionist starts to give/take 50 – 100 ml increments of perfusate
The anesthesiologist assess the heart on the TEE
PREPARATION OF SEPARATION FROM BYPASS
What should be monitored while the heart is filling?
Filling pressures
Ventricular distention
Blood pressure
PREPARATION OF SEPARATION FROM BYPASS
What should be done if heart appears to not be able to handle the volume?
Inotropic support, with
Epinephrine, Dobutamine
PREPARATION OF SEPARATION FROM BYPASS
Which arrythmia is commonly seen after removal of the aortic cross clamp?
Ventricula Fibrillation
PREPARATION OF SEPARATION FROM BYPASS
What’s the pharmacologic treat for VF noted rafter removal of the aortic cross clamp?
Lidocaine 100 mg,
Magnesium 2-4 mg
PREPARATION OF SEPARATION FROM BYPASS
What’s the treatment for persistent VF noted rafter removal of the aortic cross clamp despite pharmacologic treatment?
Defibrillation with internal pads at 10-30 J
PREPARATION OF SEPARATION FROM BYPASS
Now we are almost prepared to fully disconnect from the CPB machine. There are a few mnemonics for weaning from bypass machine, but they pretty much all have the same preparatory steps.
Describe the Romanoff & Royster “CVP” mnemonic for weaning from CPB:
Romanoff & Royster “CVP” mnemonic for weaning from CPB
Note that it includes every step that can possibly occur from the time that the pt is weaned from bypass to transport to the ICU

PREPARATION OF SEPARATION FROM BYPASS
What are the key components to cover prior to coming off bypass?
Temperature
Must be normothermic (36-37 C)
Rate/Rhythm
Normal (70-90) - Slow rate treated with pacemaker
Cardioversion for SVT
Defibrillation for arrhythmias
Inhalation
Ventilation and inhalational agents and gas flows on
Filling pressures
Acceptable - Inotropic agents on if needed
Laboratory results
ACT, ABG, HCT, Glucose, Potassium
All WNL, especially K+
PREPARATION OF SEPARATION FROM BYPASS
What’s a benefit of knowing potential pt’s profiles you may see while attempting to wean off bypass?
Can help you determine appropriate treatment depending on the clinical picture
(See table attached)

PREPARATION OF SEPARATION FROM BYPASS
Both systemic BP and PA pressures shoud increase or decrease at the same time. If PA pressures increase and systemic BP decreases, that’s representative of?
LV failure

DISCONTINUATION OF BYPASS
If the heart is able to handle the volume that’s given, the perfusionist will
Begin to decrease the pumps flows and
Allow the heart to fully resume cardiac output
- Decrease venous return to pump by gradual/incremental occlusion of the venous cannula*
- CPB circuit starts directing more volume to heart and lungs*
DISCONTINUATION OF BYPASS
T/F: The bypass flows will gradually decrease until the pump is completely off
True
Bypass flow is initially decreased by 50%
DISCONTINUATION OF BYPASS
Ongoing evaluation cardiac function will occur by
Direct visualization of heart filling and contractility
TEE
Hemodynamics
DISCONTINUATION OF BYPASS
In adjusting blood pressure, what must be considered first?
Remember volume from CPB machine can be given back to patient
Optimizing preload is a goal
DISCONTINUATION OF BYPASS
After safely weaned off bypass and Once the surgeon and anesthesia provider are satisfied, what happens next
Venous Decannulation
Venous cannula will be clamped and removed
Venous line removed 1st
Blood in the venous system will be drained by gravity into the venous reservoir, and then transfused via the aortic cannula
DISCONTINUATION OF BYPASS
Commonly seen arrythmia during decannulation:
Atrial/junctional rhythm
Disappear when cannula is out
DISCONTINUATION OF BYPASS
After venous decannulation, why does the Arterial cannula remain?
For continued transfusion of pump contents
DISCONTINUATION OF BYPASS
After Venous Decannulation and Once all blood in the reservoir is transfused, Drop SBP less than 100 mmHg again or MAP less than 60mmHg. Why?
To allow for the Aortic/Arterial cannula to be removed
Aortic/Arterial Decannulation
DISCONTINUATION OF BYPASS
After Aortic/Arterial Decannulation, Heparin reversed by protamine; at which Dose?
1 mg of Protamine per 100 units of heparin
given SLOWLY through peripheral site
DISCONTINUATION OF BYPASS
After Aortic/Arterial Decannulation and Heparin reversal by protamine, when should a repeat ACT be obtained?
Repeat ACT 3-5 minutes after administration
Assess surgical field for bleeding
POST CARDIOPULMONARY BYPASS - PROTAMINE
Mechanism of action:
Positively-charged protein molecule derived from salmon sperm
Binds the negatively charged heparin AND inactivates anticoagulant effect

POST CARDIOPULMONARY BYPASS - PROTAMINE
Why should Protamine be administered slowly?
Because its administration causes
Histamine release by lungs
Which results in vasodilation & hypotension
POST CARDIOPULMONARY BYPASS - PROTAMINE
Anaphylactic/anaphylactoid reaction that follows its administration during bypass surgery is well known
Manifested as:
IGE mediated venodilation: ↓cardiac filling pressures,
↓ SVR = hypotension
↑Pulmonary vascular resistance (↑PIP)
POST CARDIOPULMONARY BYPASS - PROTAMINE
Population at greatest risk of allergic reaction from Protamine due to antibodies include?
Presensitization from prior administration
(Prior cardiac surgery/catheterization)
Previous hemodialysis
NPH insulin
Vasectomy
Fish allergy
POST CARDIOPULMONARY BYPASS
After bypass, the assessment of adequate control of bleeding should continual; Paying close attention to
Chest tube volumes & Hemodynamics
POST CARDIOPULMONARY BYPASS
Whys is Chest closure an important phase for vigilance for new ischemia for the anesthesia provider?
Increase in intra-mediastinal pressure could cause
↓systemic venous return leading to transient ↓BP
Potential kinking or occlusion of new graphs
POST CARDIOPULMONARY BYPASS
Why must anesthesia pay close attention to the EKG during Chest closure?
To make sure No new ischemia forms
POST CARDIOPULMONARY BYPASS
Why is a post closure TEE needed?
To make sure that there is no changes observed
POST CARDIOPULMONARY BYPASS
Transport to SICU when? Accompanied with what supplies?
When hemodynamically stable
Accompanied with Lifepak, Ambu bag with 100% O2, emergency drugs
FAILURE TO WEAN FROM BYPASS
Common causes for failing to wean from bypass include
Left ventricular dysfunction
Right ventricular dysfunction
(Nitric oxide, Hyperventilation)
Unrecognized ischemia
Valvular dysfunction
FAILURE TO WEAN FROM BYPASS
In cases of “failing to wean from bypass” where the pt is relatively hemodynamically stable, which can be started for support?
Inotropic agents
(Epi, Dopamine, Dobutamine)
FAILURE TO WEAN FROM BYPASS
In cases of “failing to wean from bypass” where the pt is relatively hemodynamically stable, and the pt is unresponsive to (Epi, Dopamine, Dobutamine), which drug could be added?
Milrinone
FAILURE TO WEAN FROM BYPASS
In cases of “failing to wean from bypass”, the surgeon may elect to resume full bypass while trouble shooting the problem occurs. Which drug should you remember to redose in this situation?
Heparin
Followed by rechecking ACT, and ABG for lab irregularities

FAILURE TO WEAN FROM BYPASS
In cases of “failing to wean from bypass”, which mechanical circulatory device might the surgeon opt to place while the pt is rested on bypass?
Intra-aortic balloon pump counterpulsation (IABP)
FAILURE TO WEAN FROM BYPASS - IABP
Describe how the IABP works?
The IABP Assist a beating/ejecting heart
It’s a synchronized counter pulsation
Does not pump blood, but rather
Augments diastolic BP and coronary blood flow after closure of the aortic valve

FAILURE TO WEAN FROM BYPASS - IABP
How is Diastolic augmentation acheived?
Balloon infaltes during Diastole, just after the dicrotic notch
↑AoDP = ↑coronary perfusion pressure
Enhances forward flow distally

FAILURE TO WEAN FROM BYPASS - IABP
Balloon is deflated during
Systole, resulting in
Afterload reduction
LV ejects against a ↓ systemic diastolic pressure

FAILURE TO WEAN FROM BYPASS - IABP
T/F: IABP is the ONLY method that ↓MVO2 & ↑myocardial O2 supply
True
FAILURE TO WEAN FROM BYPASS - IABP
Where is the IABP inserted? Where are its proximal and distal tips positioned?
Inserted into femoral artery
Guided to the correct position using the TEE
Distal tip: Below L subclavian artery
Proximal tip: Rests above renal arteries
The anesthesiologist will tell the surgeon when the balloon is in the correct position

FAILURE TO WEAN FROM BYPASS - IABP
To acheive successful counter pulsation, the balloon triggering must be timed to the pt’s
Cardiac cycle
This can be done by using either the pt’s EKG, the arterial wave form, or the intrinsic pump rate
FAILURE TO WEAN FROM BYPASS - IABP
Usually triggering of the balloon occurs with which EKG wave?
R-wave

INTRAAORTIC BALLOON PUMP
Typically after surgery, the IABP is initiated with an Assist ratio of
1:1

INTRAAORTIC BALLOON PUMP
As the pt’s cardiac function improves, he will be weaned from the pump; decreasing the ratio to
1:2, 1:3 ….

INTRAAORTIC BALLOON PUMP
Complications:
Arterial obstruction
Aortic perforation/dissection
Balloon rupture
Displacement of the balloon pump, occluding the subclavian artery or renal arteries
Ischemia distal to site of balloon insertion
Thrombosis
Platelet destruction/thrombocytopenia
POST CARDIOPULMONARY BYPASS
Often post-bypass Complications include
Post bypass bleeding
Persistent oozing is not uncommon following heparin reversal
POST CARDIOPULMONARY BYPASS
Typical causes of oozing is following heparin reversal
Inadequate surgical hemostasis
Reduced platelet count function
Insufficient dose of protamine
Dilutional coagulopathies
Heparin rebound
POST CARDIOPULMONARY BYPASS
Bring backs (reexploration) within 24 hr d/t
Persistent bleeding
Excessive blood loss
Unexplained poor CO
Cardiac tamponade
POST CARDIOPULMONARY BYPASS
What percentage of of cardiac cases require postop reexploration, usually within 24 hr?
4-10%
CARDIAC TAMPONADE
When does it occur?
When is increase in fluid in the pericardial sac
Normally houses about 15-30mL of fluid

CARDIAC TAMPONADE
The increase in fluid causes an impairment in
Diastolic filling of the ventricle
CARDIAC TAMPONADE
Why is CO decreased?
Due to decreased stroke volume
CARDIAC TAMPONADE
How is CVP affected by cardiac tamponade?
Increased CVP
CARDIAC TAMPONADE
In response to decreased Diastolic filling of the ventricle, the circulation will increase systemic pressures and pulmonary venous pressures to
Prevent collapse of the cardiac chamber
This result in an Equalization of diastolic pressures throughout the heart
RAP = RVEDP = LAP = LVEDP
CARDIAC TAMPONADE
Why is the y descent abolished on the CVP waveform during cardiac tamponade?
Because the y descent correlates with the opening od the tricupsid valve and filling of the ventricle
But since there is an impairement in atrial emptying and diastolic filling, the y wave disapears
CARDIAC TAMPONADE
Reflexive sympathetic activation accompany cardiac tamponade?
Increased HR and contractility to maintain CO
Increased SVR to support BP
CARDIAC TAMPONADE
Why do pts in cardiac tamponade have a fast HR? Why shouldn’t you slow it down?
SINCE SV IS FIXED, CARDIAC OUTPUT BECOMES DEPENDENT ON HR
SO THESE PATIENTS WILL HAVE A fast HR
DON’T SLOW IT DOWN! YOU WILL DRASTICALLY REDUCE their CO
CARDIAC TAMPONADE - Clinical Presentation
CARDIAC TAMPONADE can either be chronic or acute
When associated with cardiac surgery, it is Acute. What’s its clinical presentation?
Sudden decrease in BP
Tachycardia
Tachypnea
CARDIAC TAMPONADE - Clinical Presentation
Besides Hypotension, Tachycardia and Tachypnea, what are other clinical signs of cardiac tamponade?
Beck’s triad
Low BP, JVD, muffled heart sounds
Orthopnea
Narrowed pulse pressure
CARDIAC TAMPONADE - Clinical Presentation
Pulsus paradoxus is very similar to “Systolic pressure variation”. What causes it?
Occurs as a result of accumulation of fluid to the point where the pericardium can no longer distend
This is also known as “ventricular interdependence”
Ventricular interdependence during ventilation, when volume increases on one side of the heart, it also decreases on the other side
So what occurs during inhalation is that it causes a 10mmHg or more drop in systolic BP
Cyclic inspiratory decrease in SBP > 10mmHg with inspiration

CARDIAC TAMPONADE - Clinical Presentation
Electrical alternans can be seen with cardiac tamponade. What is it?
It’s the Cyclic alteration in magnitude of P wave, QRS, and T wave as a result of a fluid filled cavity

CARDIAC TAMPONADE - Clinical Presentation
In cardiac tamponade, TEE is invaluable in diagnosing?
Diastolic compression or collapse of RA and RV
Leftward displacement of ventricular septum
Left sided collapse rarely seen d/t thickness of LV and posterior position of LA unless effusion very large
CARDIAC TAMPONADE - Clinical Presentation
On TEE, interventricular septum flattening could be seen as:
RV compressing, LV filling

CARDIAC TAMPONADE - Clinical Presentation
T/F: Collapse of LA occurs with large effusions only
True
CARDIAC TAMPONADE - Anesthetic Considerations
How is pericardial effusion evacuated In pts with severe hemodynamic compromise?
Bedside => Pericardiocentesis/xiphoid drainage
OR =>Pericardial window or Re-exploration
Re-exploration is the primary option in the immediate post op phase
Reopen median sternotomy for post-bypass patients
CARDIAC TAMPONADE - Anesthetic Considerations
What’s the “rule of tumb” in the management of cardiac tamponade?
Fast, Forward, and Tight/Full
Maintain a high sympathetic tone until tamponade relieved
Optimize preload
CARDIAC TAMPONADE - Anesthetic Considerations
What should you avoid in the he management of cardiac tamponade?
Anything that will reduce venous return and ultimately CO
Avoid induction phase because it can precipitate severe hypotension/cardiac arrest
Avoid Bradycardia and vasodilators
Avoid Positive pressure ventilation if possible
Avoid Large tidal volumes, coughing, straining
Avoid Increased SVR
CARDIAC TAMPONADE - Anesthetic Considerations
T/F: Typically, as seen in the immediate post op phase, they may still be intubated, and the induction phase can precipitate severe hypotension/cardiac arrest
True
Use a slow inhalation induction technique in these pts, with added vasopressors
CARDIAC TAMPONADE - Anesthetic Considerations
Keep tidal volume to a minimum and compensate for the reduced tidal volume by:
Increasing the respiratory rate
CARDIAC TAMPONADE - Anesthetic Considerations
Which drug should you use as temporary inotrope and and for chronotropy?
Epinephrine (5-10ug)