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Methods of Anesthesia I > On Pump vs. Off Pump Management for Open Heart Surgery > Flashcards

On Pump vs. Off Pump Management for Open Heart Surgery Flashcards

1
Q

what are the 4 types of surgical techniques for cardiac operations?

A

on pump with arrested heart (could be required or preferred)
on pump with beating heart (“pump assisted beating heart surgery”)
off pump (no bypass machine)
endovascular (new for valve repair or replacement)

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2
Q

List the Pump steps

A

1- cardiac induction, 2- BOBCAT, 3- leg incision to harvest saphenous, 4- sternal incision and sternotomy, 5- sternal retraction, 6- harvest LIMA, 7/8- open pericardium and administer heparin, 9- aortic cannulation, 10- venous cannula and open reservoir, 11- CP catheter inserted, 12- aortic cross clamp placed, 13- heart arrested with CP, 14- CABG or valve repair performed, 15- rewarming phase
16- perfusionist partially closes venous reservoir, 17- surgeon removes air from heart, 18- cross clamp removed, 19- heart resumes electrical activity, 20- defibrillation (maybe), 21- NSR established, 22- turn of volatile agent and ventilator, 23- venous reservoir completely closed, 24- venous and aortic cannula removed, 25- reversal of anticoagulant, 26/27- cell saver given and prepare sedation drip for transport, 28- chest closed and chest tube placed, 29- transport ICU with monitors

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3
Q

what are the steps prior to incision

A

1 cardiac induction

2- BOBCAT

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4
Q

cardiac induction 3 options

A

1- higher versed (5mg) and fent 250mcg
2- etomidate (debatable bc adrenal suppression)
3- smaller prop dose and followed by inhalational induction
give drugs more slowly and use aline to guide when to intubate

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5
Q

BOBCAT

A 
baseline labs/ACT
OG insertion and removal
BIS monitor placement
Central line placement
Amicar bolus followed by 1g/hr infusion
TEE regional wall motion abnormalities for ischemia
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6
Q

Amicar bolus at liberty vs lukes

A

liberty 5g

lukes 10g

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7
Q

amicar

A

antifibrinolytic to counteract damage done by bypass machine

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8
Q

what is the alternative to amicar

A

tranexamic acid

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9
Q

sternal incision and sternotomy considerations

A

avoid hypertension bc of intense stimulation, fent or NTG

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10
Q

What should the anesthetist do during sternal incision and sternotomy

A

turn off vent and remove breathing bag from circuit bc we want the lungs down

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11
Q

what happens to intrathoracic pressure during sternal retraction? what should we be concerned about?

A

intrathoracic pressure increases

venous return and cardiac output can decrease

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12
Q

what should we be concerned about for the retractor on the sternum?

A

could compress subclavian artery and cause right radial artery false low readings

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13
Q

harvesting LIMA considerations 3

A

less stimulation
lung expansion may get in the way
left sided radial arterial lines may not function due to compression

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14
Q

tasks during harvesting of the LIMA

A

decrease tidal volume (may need to increase RR for min vent)

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15
Q

when might the patient have a vagal response? why?

A

opening of the pericardium, pericardium is innervated by vagus and phrenic

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16
Q

do surgeons close the pericardium at end of surgery?

A

no, risk of cardiac tamponade

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17
Q

after the pericardium is opened what does the surgeon do?

A

sews it to the chest wall to get it out of the way

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18
Q

when do you give heparin

A

after pericardium opening and before aortic cannulation

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19
Q

what happens after you give heparin

A

1mL blood sample is drawn 3 min later
ACT >450 then ready
ACT <450 may need more heparin

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20
Q

aortic cannulation considerations

A

lead to possible aortic dissection

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21
Q

why is aortic cannulation before venous cannulation

A

incase you need rapid blood resuscitation

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22
Q

task during aortic cannulation

A

lower systolic pressure to 90-100 mmHg

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23
Q

where do you normally place the venous cannula

A

right atrial appendage (RAE)

pt is on pump after venous reservoir is opened

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24
Q

anesthetist task at the onset of bypass

A 
1 turn off ventilator and vaporizer
2 put vasoactive infusions on standby (amicar and insulin continued)
3 measure pre bypass urine output
4 chart BIS, MAP, and temp
5 put monitor on bypass mode
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25
what is the target MAP while on pump? why?
50-80mmHG | aortic dissection and cerebral hemorrhage likely with high MAPs
26
what is the usual way of cardioplegia
antegrade cardioplegia is administered via aortic root
27
arresting the heart with CP
typically given every 20-30 min but can be given continuously
28
when is the patient usually cooled?
when the CABG or valve repair is performed
29
what does perfusionist starting rewarming indicate?
surgeon almost done with repairing heart | risk for awareness increases
30
what are the possible drugs to dose during the rewarming phase
versed (increased awareness counteract) antiarrhythmics (avoid vfib or vtach) calcium (kick start heart)
31
when is looking for bubbles especially indicated?
operations where the myocardium or aorta was opened
32
when will the heart start beating again
when the aortic cross clamp is removed and the CP solution is flushed out
33
what are the two rhythms that the heart will usually go into?
bradycardia | vtach/vfib
34
when and how to defibrillate
if in vtach or vfib | apply 10-20J shock to heart
35
how can the anesthetist kick start the heart?
``` give inotrop (calcium, epi, milrinone) have surgeon place temporary pacing wires ```
36
what do some people recommend to keep oxygen demand low during recovery?
let heart beat in empty state for 20-30 min prior to filling
37
pacing during heart surgery
external pacemaker settings energy 20mA rate 80-100bpm
38
what are the options for reversal of anticoagulation?
protamine | DDAVP (desmopressin)
39
when does heparin reversal occur
prior to chest closure bc surgeon wont close unless bleeding is under control
40
why do you give cell saver after protamine?
takes time for the blood to be centrifuged
41
what are the options for sedation during transport
propofol (20-50mcg/kg/min) (most common) | precedex
42
why is a sedation drip started prior to chest closure?
because it is a slow rate and could take up to 20 min for the drug to start getting to the pt
43
what should you have when transporting to the ICU
transport monitor laryngoscope vasoactive drugs
44
redo sternotomy
could be problematic bc heart structures adhere to the back of the sternum high risk of uncontrollable hemorrhage
45
management steps for a redo sternotomy
have blood and blood tubing available have defibrillator pads placed ventilation is necessary bc it will take longer (hand ventilate)
46
post op bleeding % of pts
2-4% of pts will have post op bleeding
47
most common blood output through chest tube post surgery
0.5-1mL/kg/hr
48
what blood output through chest tube post surgery requires immediate surgical intervention??
8-10mL/kg/hr
49
reperfusion injury
when the heart gets reperfused there is a chance that further injury can occur; contractile dysfunction, infarction, arrhythmias
50
ischemia causes during heart surgery
coronary arter blockage | less perfusion during bypass
51
what can reperfusion refer to?
occluded coronary artery opened up | reestablishment of perfusion after bypass
52
2 causes of reperfusion injury
accumulation of intracellular calcium (calcium should be administered 15 min after aortic cross clamp comes off) prolonged ischemia period
53
Why is nitrous oxide avoided during bypass surgery
potential to expand air bubbles increase pulmonary vascular resistance and elevate PA pressures patients require higher FiO2 during bypass
54
what does off pump mean
no bypass machine | heart stays beating
55
when is off pump NOT and option?
heart needs to be arrested | heart needs to be drained of blood
56
surgical technique for off pump CABG
must lift heart occasionally and could lead to: arrhythmias decreased CO or EF hypotension
57
problem of off pump cardiac procedures
more difficult for surgeon | more difficult for anesthetist
58
off pump advantages 3
faster recovery and shorter hosp stay post op neuologic deficiencies decreased (less aorta manipulation) better protection of renal, pulmonary and myocardial tissue
59
disadvantages to off pump CABG 4
1 higher degree of hemodynamic instability 2 distal anastomosis may not be as good as when on pump 3 total number of grafts being performed may be less resulting in under vascularization 4 steep learning curve which can result in worse outcomes
60
common procedures for off pump
CABG transmyocardial laser revascularization endovascular valve repair
61
collateral circulation
more distal or severely stenosed arteries are more likely to have collateral flow
62
preoperative cath report
we should look at this to locate and assess the severity of coronary lesions so we know which ones are being bypassed
63
more stenotic vessels
more collateral circ | less hypotension expected
64
less stenotic vessels
undeveloped collateral circ | more hypotension expected
65
when are proximal anastomosis sewn on and what should we do?
after the distals | keep systolic BP below 100mmHg
66
when are distal anastomosis sewn on and what should we do
before proximals | vasopressors and inotropes usually required to maintain normotension MAP of 90-100
67
off pump CABG management
1- prepare to prevent hypotension, arrhythmias, decreased CO 2- doses amicar even though the CPB machine isnt used 3- heparin also administered but the dose differs 4- anesthetist maintains BP in correct range for proximal or distals
68
how to prepare to prevent hypotension, arrhythmias, and decreased CO
administer fluid bolus after incision prior to lifting heart dosing antiarrhytmics prior to incision dose 1 g calcium prior to lifting heart for distals
69
two antiarrhythmics to give off pump management
magnesium 1-2 g | amiodarone 150mg
70
options for when off pump fails
place pt on full bypass and arrest heart | place pt on full or patial bypass and leave heart beating
71
main thing to remember for full vs partial bypass
full- no ventilation needed | partial- ventilation and volatile agent needed
72
what are the two benefits of pump assisted beating heart surgery over off pump
hypotension less likely | better myocardial protection
73
advantages to arresting the heart
lower oxygen demand | easier for surgeon
74
disadvantages to arresting the heart
aortic cross clamp is placed worse perfusion (reperfusion injury, hypothermia) heart must be restarted
75
advantages to beating heart cardiac surgery
perfusion better less neurologic risk (less reperfusion injury, ischemia reduced) heart doesnt need to be restarted
76
disadvantages to beating heart cardiac surgery
higher oxygen demand of heart higher risk of air and debris embolization bc no cross clamp more challenging for surgeon

Methods of Anesthesia I (10 decks)

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