Mod2: PERIOPERATIVE MANAGEMENT FOR THE PATIENT UNDERGOING CARDIOPULMONARY BYPASS SURGERY Flashcards
PREOPERATIVE EVALUATION
Anesthesia for cardiovascular surgery that will utilize CPB requires an undestanding of
Pt’s history and disease processes, and
Impact of history and disease processeson on the anesthetic plan and the surgical plan
PREOPERATIVE EVALUATION
T/F: The provider must always recognize that the anesthetic plan must be individually tailored to each pt, and it must remain fluid throughout the whole perioperative process
True
PREOPERATIVE EVALUATION
Prior to the day of surgery, the pt should have had an adequate cardiovascular evaluation which will include:
Lab testing
Imaging
PREOPERATIVE EVALUATION
Prior to the day of surgery, the pt should have had an adequate cardiovascular evaluation which will include lab testing and imaging
However, a full anesthetic assessment and chart evaluation must still be completed. Why?
To cover all the basis
PREOPERATIVE EVALUATION
Cardiovascular surgery also requires constant communication between which providers?
Anesthesia team
Surgeon/Surgical team
Perfusionist
PREOPERATIVE EVALUATION
What are the goals of preoperative evaluation?
Quantify & reduce perioperative cardiovascular risk factors influencing perioperative morbidity & mortality
Determine ventricular function
Prompt identification & treatment of ischemia
Identify & evaluate comorbid diseases effecting cardiopulmonary bypass
Patient/family education
PREOPERATIVE EVALUATION
Integration of preoperative data/information leads to appropriate selection of:
Monitors and
Anesthetic techniques
CARDIAC EVALUATION
By the time the anesthesia provider is consulted, a definitive cardiac diagnosis has already been established
However, things that support the diagnosis and require that the anesthesia provider pays close attention to in the chart have to do with:
Cardiac history
Physical signs & symptoms
Invasive & noninvasive diagnostic test
Pulmonary history
Renal
Diabetes Evaluation
CARDIAC EVALUATION
Cardiac history, including: Previous MI, active chest pain/pressure, Exercise tolerance/ Stress test, CHF symptoms are important to evaluate, why?
You don’t want to exacerbate their symptoms during the preoperative preparatory phase and cause further myocardial damage
CARDIAC EVALUATION
Physical signs & symptoms that are relevant to cardiovascular surgery include?
Vital signs
JVD
Apical pulses (displaced?!)
CARDIAC EVALUATION - Invasive & noninvasive diagnostic test
Make sure to pay close attention to the diagnostic tests that have already been performed. Why?
Could give a clue into which technique to use for induction
CARDIAC EVALUATION
Results from which test will be available for a diagnosis of Multi-vessel disease?
Cardiac catheterization
CARDIAC EVALUATION
Results from which test will provide information regarding Ventricular Function or Valvular Function?
TTE or Prior TEE
CARDIAC EVALUATION
If the pt has Carotid artery disease or a hx of Stroke, which operation may they require prior to their cardiac procedure?
Carotid endarterectomy
CARDIAC EVALUATION
And at minimum, if their carotid artery stenosis is more than 50% on either side, what additional monitor would you want to consider?
Cerebral oximetry
CARDIAC EVALUATION - T&S/T&C, CMP, PT, PTT/INR
Some surgeons may only require a T&S if the surgical repair isn’t expected to be extensive. However, if it’s a complex case, make sure there is a
T&C on the chart, and
Make sure there are NO antibodies
CARDIAC EVALUATION - T&S/T&C, CMP, PT, PTT/INR
What if there are antibodies?
Make sure the surgical team is aware of how long it will take to have the blood available for the pt
CARDIAC EVALUATION - Pulmonary history
If Smoker of history of COPD, what’s the minimum period of time before surgery they should go without smoking?
2 weeks before/day of surgery
CARDIAC EVALUATION - Pulmonary history
If Smoking history or COPD, and unable or unwilling to stop smoking at least 2 weeks before/day of surgery, when should education regarding smoking cessation should occur?
Within the 24hr prior to surgery
(This is a national quality measurement)
CARDIAC EVALUATION - Pulmonary history
Other pulmonary assessment prior to cardiac surgery include:
Dyspnea/SOB
Pulmonary function test/ Chest X-ray
Recent URI
CARDIAC EVALUATION - Pulmonary history
What do you do if Recent URI (within 2 weeks)?
Postpone elective surgery
CARDIAC EVALUATION - Renal
If the pt has a history of renal insufficiency, this may be something to have a discussion with the surgeon and the perfusionist about; Why?
This may necessitate a change in treatment plan
CARDIAC EVALUATION - Renal
How could treatment plan change If the pt has a history of renal insufficiency?
Pt may require hemofiltration after bypass, or
Dosing of medication may need to be altered
In addition, pts with renal disease often have lower HCT and Hgb, and may require blood transfusion while on bypass
Other considerations may include Volume overload from priming, or Hyperkalemic cardioplegia solution
CARDIAC EVALUATION - Diabetes Evaluation
During bypass, Insulin requirements are higher for both diabetics and non-diabetics; why?
Surgical stressandnon-physiological state of bypass cause and increase in glucose levels
CARDIAC EVALUATION - Diabetes Evaluation
Pts taking NPH insulin may produce antibodies to which drug? Why is that?
Protamine
Because NPH insulin contains protamine moiety
This could cause an increased risk for allergic reaction with the administration of protamine when it’s time to reverse the heparin
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
For preparation, how long ahead of time will the anesthesia provider typically arrive?
At least one hour before the pt comes in the room
This time can varry depending on the complexity of the case
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
T/F: A Routine anesthesia machine check is completed
True
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Airway should be gathered depending on?
what’s available at the institution
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Why should you consider and ETT designed for possible extended intubation?
Because a lot of cardiac surgery pts may require prolonged ventilatory support
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
What’s the best ET tube for extended intubation and Why?
SealGuard ETT, or
Any ETT designed for prolonged intubation
SealGuard have an ET cuff with better seal at lower intracuff pressures
Also has a suction port that sits above the balloon for subglotic suctioning
This suction port has been associated with a reduction in ventilator acquired pneumonia
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Other Airway equipments include:
Nasal cannula for supplemental O2
End-tidal CO2 monitor
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Intravenous Access:
Usually two large-bore IV’s (14-18g-gauge)
Central line
PA catheter
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
What features must a central line used during cardiac surgery have?
Hemostatic valve
Type of central line will varry depending on institution
Typivally a 9Fr introducer that has a hemostatic valve for PA catheter placement
Ultimately, you want a multilumen central catheter that would allow for mutiple drugs to be infused while simultaneously being able to measure hemodynamic parameters, and also with the ability to infuse large volumes of fluid in case of an emergency
One port should always only be dedicated to drug infusion and nothing else
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Standard ASA monitors used in cardiac surgery
5 lead EKG
Temperature
CVP, PA, Arterial BP
(Transduced, leveled and zeroed)
Cardiac Output
TEE
Multiple infusion pumps
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Pre-drawn Medications
Benefit of Pre-drawn Medications, and when to draw them?
Will save you in an emergency
Should be drawn up prior to bringing the pt to the OR
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Pre-drawn Medications
Heparin is one of the very important drugs to have pre-drawn up. Why? What’s its predraw dose?
The las thing you want to have to do draw up heparin to crash on bypass
Heparin predrawn dosed 400 units/kg
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Pre-drawn Medications
Other drugs to predraw include?
Induction medications
“Uppers”
Neo, Levo, Epi
“Downers”
NTG, Cardene
in 10cc syringe IVP, for immediate tx of hypo or HTN
Antibiotics
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion
How do you prepare infusion drips and pumps for cardiac surgery?
Infusion drips should be pre-spiked and
pumps should be pre programmed for the pt’s weight
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion
Which drips should be readied for cardiac surgery?
Phenylephrine, Norephrine, Epinephrine, Dopamine, Vasopressin, Dobutamine, Amiodarone***, Milrinone, Insulin, NTG, Cardene, etc.
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion
Amiodarone should be confirmed with the surgeon; why?
Because it is costly and not always required
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion
T/F:
Amiodarone must also have its own dedicated line with an in-line filter
True
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion
A pacemaker with extra batteries should always be available in the OR for cardiac surgery; why?
Intrinsic rhythm sometimes take a while to come back, or
They may even have complete heart block
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion
If the pt is asystole under the pacemaker, what must you consider having?
Backup pacemaker
ANESTHETIC PREPARATION FOR CARDIAC SURGERY - Drips for infusion
Blood products available/in room?
????
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Current Drug Therapy for cardiac surgery pts typically includes which classes of drugs?
Beta-blockers
Calcium channel blockers
ACE inhibitors
Digitalis preparations
Diuretics
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Pts are Usually instructed to continue Current Drug Therapy until time of surgery; with the exception of
Diuretics
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
For Pre induction, when and where are A-line, central line typically placed ?
Prior to induction
either in the pre-op area or the OR
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Sometimes, pts are unable to tolerate line placement prior to induction, so it will be important to do a thourough pre-op evaluation to assess their
Tolerance
This would include anxiety level, ability to lie flat while awake, chest pain/pressure they are currently experiencing, restless leg syndrome
Will need opioids and benzodiazepines for sedation for invasive line placement
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
T/F: Sedative tend to make restless leg syndrome more active
True
and they will not be able to lie still for line placement
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Pre-induction, why is O2 administration required for sedation?
You want to increase O2 content by increasing delivery
While reducing consumption
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Why is it important to evaluate their current drug therapy? Are they in-patient, and are already on heparin, NTG, Insulin?
NTG and insulin requirements may change prior to induction
This is something to take into consideration
ANESTHETIC PREPARATION FOR CARDIAC SURGERY
Why is it important to have a pressor and a “downer” readily available at induction?
They may require additional support
Sedation could cause hypotension requiring a vasopressor, or HTN requiring Nicardipine?
