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title: Post Cardiac Surgery tags: notebook: 🌑-FFICM

Anaesthesia for Cardiac Surgery

  • Premedication
  • Diazepam Plus Morphine
  • Lorazepam Plus Fentanyl
  • GTN, Nitrate, Clonidine
  • Monitor
  • SpO2
  • ECG
  • Art Line
  • PA Catheter/CVC
  • temperature
  • IV cannulae
  • Maybe
    • Oesophageal Manometry
    • PA Catheter
    • TOE
    • Cerebral Function
  • Bedside
    • ABG including electrolytes
    • TEG
  • Induction
    • Fentanyl 10-30 micro/kg
    • Pancuronium 0.1mg/kg
    • Propofol as little as possible
    • Additionally
    • Antibiotics
    • Magnesium
    • Heparin
    • Pressors/Vasodilators
    • Fast Track
      • Propofol
      • Isofluorane
      • Fentanyl
      • Normothermia 1

Valve Disease and Cardiac Surgery

Mitral Stenosis

  • Diagnosed by valve area
  • Normal 4-6cm2
  • Mild 1.5-2.5cm2
  • Mod 1-1.5cm2
  • Severe 1cm2
  • Manage by maximising left atrium pressure 1

Mitral Regurgitation

  • Diagnosed by regurgitation fraction
  • Severe >0.6
  • Manage by reducing SVR 1

Aortic Regurgitation

  • Diagnosed by regurgitation volume
  • Mild 1-3L/min
  • Mod 3-5L/min
  • Severe >6L/min
  • Manage by reducing SVR 1

Aortic Stenosis

  • Diagnosed by valve area
  • Severe <1cm2
  • Also diagnosed by pressure gradient 1

HOCM

  • Manage by reducing pressure gradient
  • Vasoconstrict
  • Beta blockers
  • Myocardial depressants
  • Maintain preload 1

Pericardial Tamponade Post Bypass Surgery

Tamponade post surgery needs emergency simultaneous diagnosis and managment (with surgeons) 1

Clinical Features

  • Decreased Cardiac Output
  • Hypotension, Narrow Pulse Pressure
  • High Filling Pressures (PAOP, CVP)
  • Failed Mediastinal Drainage
  • Looks like large initial drainage followed by clots 1

Management

Surgical Intervention - Remove Clot from Pericardium (in theatre if there's time) 1

  • Prepare for reanaesthetising
  • Check anaesthetic machine
  • Pressor/dilator drugs
  • Heparin for Bypass
  • Blood Bank
  • Haemodynamic support with inotropes, fluids, pacing
  • Monitor
  • Invasive monitoring
  • TOE
  • Induction
  • Fentanyl (10-20micro/kg)
  • Pancuronium, Sux, Rocuronium
  • Small dose thiopentone or ketamine
  • Maintenance
  • Watch for complications (arrhythmias)
  • May need Bypass
  • Don't extubate for ICU 1

Going on/off cardiopulmonary Bypass

  • Before
  • Anticoagulation
    • Heparin (300-400 units/kg)
    • Target ACT > 300
  • Haemodynamics
    • Systolic < 100
    • Monitor ECG
  • Ventilation
    • Monitor compliance
    • Monitor ABG
  • Confirm anaesthesia/paralysis
  • Confirm circuit connected, no bubbles, clamps off
  • Stop IV fluids
  • At Beginning
  • Check flows/Pressures
  • Check oxygen of aortic Blood
  • Stop ventilation when arrested
  • Continue monitoring
  • During Rest
  • Continue anticoag (ACT >400s)
  • Monitor circuit for fibrin
  • Monitor ABGs
  • Monitor MAP 40-90, PAP < 15, CVP <0
  • Monitor temperature
  • Monitor EEG/Facial Oedema
  • Urine output >1ml/kg/hr
  • Make sure pump is working
  • Coming off
  • Rewarm
    • Make sure neuro unresponsive
    • Adaquate coag, normal ABG/pH/electrolytes
    • Vasodilate
    • Defib available
  • Make sure suitable rhythm and MAP before coming off
  • Fill, vasodilate, check CVP and PAOP
  • Reinflate lungs
  • Vent any arterial air
  • After off
    • Protamine for coag
    • Fix any coagulopathy
    • Manage Haemodynamics
    • Maintain anaesthesia
    • Prepare for ICU 1

Post Bypass Bleeding

Post bypass patients have multiple possible causes of impaired haemostasis, bleeding can be severe and emergency 1

Management

  • ABCDE
  • Exclude tamponade and acute bleeding
  • Target haemodynamic stability 1

Assessment 1

  • History
  • inc drugs
  • operation details
  • Examination
  • Find source of bleeding
  • Find magnitude of bleeding
  • Tests
  • coag
  • DIC screen
  • TEG/Rotem 1

  1. Cardiac Surgery / Anaesthesia - anaesthesiauk.com ↩↩↩↩↩↩↩↩↩↩↩↩↩↩↩