Cardiac Anesthesiology Made Ridiculously Simple
by Art Wallace, M.D., Ph.D.
Cardiac surgery is a dangerous and complex field of medicine with significant morbidity and mortality. Quality anesthetic care with specific attention to detail can greatly enhance patient safety and outcome. Details that are ignored can lead to disaster. This document will attempt to describe the bare bones sequence for cardiac anesthesia for adult CABG and VALVE procedures with specific recommendations. It is not all inclusive or definitive but it is the minimal critical requirements.
If you keep your head screwed on very tightly and pay 100% attention at all times, things will only go poorly some of the time.
A good reference is: "The Practice of Cardiac Anesthesia" by Frederick Hensley and Donald Martin, Little Brown Handbook.
Anesthetic evaluation must include attention to cardiac history. The cath report, thallium, echo, and ECG. Critical information includes: Left main disease or equivalent, poor distal targets, ejection fraction, LVEDP, presence of aneurysm, pulmonary hypertension, valvular lesions, congenital lesions. Each of these points requires a modification of anesthetic technique and specific information is required. How is their angina manifest? You need to be able to understand their verbal reports. If a patient’s angina is experienced as shortness of breath, or nausea, or heart burn, or whatever, you need to be able to link that symptom to possible myocardial ischemia.
Past medical history including history of COPD, TIA, stroke, cerebral vascular disease, renal disease (CRI is an independent risk factor), hepatic insufficiency will change anesthetic management.
Medications : Look specifically for anti-anginal regimen - synergism between calcium channel and beta blockers, is their COPD being treated? It is very important for patients to stay on their anti-anginal therapy throughout the hospital stay. If a patient is on a beta blocker, calcium channel blocker, nitrate, and/or ACE inhibitor they should remain on that drug throughout the perioperative period. The patient should get all anti-anginal medications on the day of surgery and following surgery. The day of surgery is the wrong time to go through a withdrawal process on any anti-anginal drug.
Physical exam: Airway
Chest: Is the patient in failure? Pneumonia? COPD
Cardiac: Do they have a murmur? Are they in failure?
Abd: Ascities, Obesity
LABS: Minimal CBC, Plt, Lytes, BUN, CR, Glu, PT,PTT
CXR: Cardiomegaly? Tumors? Pleural effusions?
ECG: LBBB: Critical information if a pulmonary artery catheter is planned. Occasionally patients with LBBB can develop third degree block with PA catheter placement.
Have they had a recent MI? Do they have resting ischemia? Where are their ST-T changes?
PFT and ABG: Are they going to become a respiratory cripple?
Information: Tell them about the A-line, the PA catheter, and post op ventilation.