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Cardiac Anesthesiology Made Ridiculously Simple - page 11 / 13





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cable into channel 4 and change the label on channel 4 to CVP. To switch to slave mode the easiest thing to do it get a new pressure transducer. Hook the new arterial transducer to the balloon pump and plug the cable into channel 3. Change the label on channel three to ABP. This will make the trace red and the scale 0-200. Then plug the slave cable into channel three and send it to the balloon pump. There is a switch on the balloon pump that tells it to lok at external ECG and arterial pressure from the slave cable. Both settings must be switched. Do not hesitate to suggest if there is difficulty weaning from bypass.

LV Assist Device: Transportable centrifugal pump that can be used as a bridge to transplant or to allow recovery of severely stunned myocardium.

Closing the chest: May cause hypotension if inadequate volume status. Check a cardiac output after closure. If the lungs seem too large or the heart is lifting out of the chest, consider broncospasm with air trapping. Bronchodilators, ventilator and ETT adjustment can help.

Removing the TEE: Unlock it before removal! Call somebody to clean it.

Transport: Have the patient monitored at all times. Never remove the ECG until another is working. Place the transport leads, get it to work, then remove the OR leads. Do not change the A-line if hemodynamically unstable. Quickly re-zero. If you elevate the transducer 13.6 cm you will reduce the arterial pressure 10 mmHg. Keep the transducers at the right level. Be paranoid. If there is a problem. Stop and fix it.

Sudden hypotension on moving the patient: It is very common for the blood pressure to sag when the patient is moved from the operating table to the bed. This phenomena is not well understood but may be from reperfusion dependent tissues with the shift to the bed. The patient can have profound hypotension. Most patients drop their filling pressures noticibly. Have volume available. Do not make the shift if the patient is unstable or volume deplete. Fix the problem prior to the shift. Have volume, some drug to raise the pressure, some drug to lower the pressure, oxygen, mask, and any other drugs you have been using with you on transport.

ICU: Shift the monitors in the same way. The cartridge for the transport monitor simply plugs into the ICU monitor. If you don’t have this system get the ICU ECG working before removing the transport ECG/ Do not shift the A-line until the patient is hemodynamically stable. Listen to the chest immediately after hooking to the ventilator. If there is sudden hypotension suspect a problem the ventilator (infinite peep) and remove the patient from the ventilator and hand ventilate. Then get a new ventilator. Do not allow the nurses to change to their inotropes until you leave. Do not allow them to remove your iv's until you leave. Do not leave until the patient is truly stable.

When to Extubate: The checklist for extubation should include: No evidence of myocardial ischemia, infarction or failure, Hemodynamic stability on limited inotropic support, (no balloon pump or multiple inotropes with sweat dripping from the cardiac fellow’s brow), limited bleeding without a coagulopathy (chest tube drainage below 50 cc/hr for 2 hours), good gas on FIO2 is 0.40, SIMV 8, PEEP 5, TV = 10 cc/kg, the patient is awake and breathing, good gas on CPAP 5 cm H2O FIO2 =0.50 then extubate. Talk to the surgeons about your plans, they may have a very good reason why this patient is a lousy candidate (The grafts were poor, there is bleeding, there is tamponade.)

Anesthesia for Minimally Invasive Cardiac Surgery: MID-CABG or Off Pump CABG

I guess the first question should be what to call this new operation. It is minimally invasive CABG or minimal access CABG. Maximally difficult CABG. I don't know. A little cabbage is commonly known as a brussel sprout. This operation is changing rapidly. These is now a history to how it was done. That implies that we have maybe improved it.

Initially, there was the Heart Port operation. The marketing plan of the Heart Port System was to avoid that nasty sternotomy scar. Most people coming for a CABG are past the age when the scar will prevent them from being in the case of Bay Watch. The operation was simple, no that’s not right. An arterial inflow cannula was placed in a femoral artery and the venous outflow was placed through a femoral vein. A catheter with a balloon was advanced up the aorta and the balloon inflated in the ascending aortic arch. Aortic atherosclerotic disease was a definite contraindication for this operation. Picture sliding the catheter up a severely diseased aorta followed by retrograde perfusion from the groin. Cardioplegia was then delivered antegrade to the coronary arteries which have been separated from the systemic circulation by the ascending aortic arch balloon. A catheter was advanced from the internal jugular vein into the pulmonary artery for venting the left ventricle. The patient was placed on fem- fem bypass and cardioplegia established. A single vessel CABG was then performed either through a mini thoracotomy or thoracoscopically. The problem with this operation is obvious. The risk from with a CABG is the extracorporeal circulation not the sternotomy. One of the major morbidities of CABG surgery is the neuropsychiatric changes and strokes. The Heart Port

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