Transfer to SICU Flashcards
Transport to SICU
take emergency drugs
call PMTs for assistance
fellow goes with you
hazards in transfer
air, clot dislodgement
pulling out line, chest tubes, foley
S/S of end-stage tamponade
hypotension
low voltage ECG
distant heart tones
widened mediastinum
early s/s pericardial tampanode
impaired diastolic filling
equalization of right and left heart pressures
pt compensates for significant amounts of fluid and then decompensates quickly
anesthetic of choice for pericaridal tampanode
ketamine?
circualty arrest indications
aortic aneurisms, aortic root repair, congenital heart defects
- involves removal of perfusion cannula and cessation of CPB
- myocardial and cerebral protection
- potential for large blood loss post-arrest
maximum duration of circulatory arrest
one hour
cerebral protection: cooling
done with CPB to 18 degrees c
wrap head in ice
monitor the temp
retrograde perfusion @ 40ml/min
-SVC to IJ through the brain bleed out to carotid and vertebral artiers
-provides 02 to the brain, fluses out air and potential thrombi
Pharmacologic cerebral protectants
thipoental
mannitol
methylprednisilone
Dose and goal of Thiopental in cerebral protection
aim is burst suppression on EEG
15-20 mg/kg
Dose and goal of Mannitol in cerebral protection
decreases edema, renal protectant
.25-.5 G/kg
Dose and goal of methylprednisilone in cerebral protection
30 mg/kg
membrane stabilization
Off pump CABG approach
Mini thoractomy approach
midline sternotomy
benefits of off pump CABG
avoid systemic inflammatory response seen post-bypass
avoid problems with hypothermia, cannulation, cardiac arrest and cardioplegia
avoid issues with organ perfusion with non-pulsatile flow
preperation for off pump CABG
standard monitors and induction same set up have lots of pressors available Heaprin for ACT 250-300 General +/- intercostal blocks
intraop off pump CABG considerations
-use of stabilizing devise reduces CO
-manipulation of heart and placement of distal grafts produces dramatic cardiac dysfunction and arrythmias
-reduces venous return to heart
reduces coronary blood flow with reflexive tachycardia
-ISCHEMIA
-be prepared for profound hypotension
ischemic preconditioning during off pump CABG
- brief repetivite occulsions of artery to be bypassed
- preconditioned hearts showed less decrease in LV dysfunction after ischemia and arrythmias
- inconsistnet
Proximal anastomosis
-partially occluding aortic clamps
SBP
proximal anstomosis interoperative goals
maintain CPP prevent ischemia maintain CO euvolemia rest the heart bw manipualtions large dose of pressors and/or vol
when to go on bypass? (off pump CABG)
- technical reason or sudden servere decompensation following occlusion of coronary artery
- deterioration from a previous steady state that doesn’t respond to aggressive tx
