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Cardiac Anesthesiology Made Ridiculously Simple - page 5 / 13

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types of plastic fillers: large and small. If you have a small one, remove it as the probe can't fit through it. If you have a large one, the probe can fit through it. Then place the probe in the sheath and roll it all the way down. Get your mind out of the sewer! Next, empty the stomach of air with an NG tube, make sure the probe is unlocked, use a laryngoscope to place it in the esophagus, and treat it like it cost $50,000, as it did. Always use a bite block if the patient has teeth. TEE can be detrimental to patient care if one ignores the patient while using it. It is an adjunct to patient care not a substitute or a requirement. It is useful for detecting air, ASD, VSD, AS, AR, MR, MS, volume status, aortic plaque, myocardial ischemia, regional and global ventricular function, valvular function, anatomy, etc. It will take some time to get good at it but is well worth the effort. The TEE exam frequently causes a modification in the surgical plan. Unrecognized aortic plaque shifts to patient to off pump CABG, or alters the cannulation site, or cancels the case. The sooner it is done, the sooner the surgeons can decide on what to do next.

Always unlock it before removal. Hold onto the ET tube when removing the probe as one can extubate the patient accidentally. Discard the latex condom and then clean the probe.

Baseline ACT and ABG: Obtain after induction

ACT: There are three techniques. Hemochron and HemoTech.

The Hemochron system has two techniques Celite and Kaelin. Celite is diatomaceous earth (dirt) in a tube. You need 2 cc in the tube. Push the button to start the clock. Shake 6 times (with cap on). Place in machine. Rotate the tube to get the green light to turn on. Fully heparinized ready to go on bypass is greater than 450 seconds. If used with Aprotinin, it needs to be above 800 seconds. Kaelin is a white liquid in a dual tube cassette with little plastic flags. Fully heparinized, ready to go on bypass is greater than 450 seconds.. It is unaffected by Aprotinin.

The Hemotechn system has little plastic cartridges with two little plastic flags. It looks like a two hole miniature golf set. The cartridge should be warmed in the machine prior to use. Carefully, using a blunt needle, place blood up to the little black line in each of the two wells. Do not get drops of blood between the flag and the tube, as it will not work. Place the cartridge in the machine and click the mechanism onto the cartridge. Same times apply for on pump.

Sternotomy: Painful process that occurs rapidly after induction, make sure the patient is adequately anesthetized. They will ask you to let the lungs down during opening. You must disconnect the patient from the ventilator and reconnect after they open the sternum. Develop a system to prevent yourself from forgetting to place patient back on ventilator. Do not rely on the alarm as the only reminder.

Redo Heart Sternotomy: In a redo heart the adhesions may bring the ventricle close to the sternum. The sternal saw may cut through the right ventricle with resulting (profound) hemorrhage. You should have blood available and 2 large IV's. You may also cut through the IMA or a saphenous graft. You should have an idea of what this will do from the catherization report and a plan. Instant severe myocardial ischemia with rapid deterioration may result. The case is easier if the IMA and grafts are not functional. Functional grafts that the patient is dependent on is the most dangerous situation.

IMA Dissection: They may want the table tilted to the left and elevated. They may want the tidal volumes reduced and the rate increased to help with dissection. It may be very hard to get an echo image during IMA dissection

Heparinization: Do not allow the surgeons to go on bypass without heparinization. If the patient is not heparinized when the clamp is opened on the bypass pump, the pump and oxygenator will clot and the patient will most likely die. If the surgeons are placing a cannula in some artery ask if they want the heparin given. When they ask for heparin, respond with a verbal statement - the heparin has been given. Always use the central line for heparin. Aspirate blood from the line before and after the heparin dose to check to make sure the line is in a vein. The dose of heparin is 300 U/kg which is about 21 cc of 1000 u/cc heparin in a 70 kg man. Check the ACT a minute or two after the dose. Do not use the same IV to draw the blood that you infused the heparin in. (i.e. draw an arterial blood sample). You want to check the ACT quickly because it needs to be above 450 seconds to go on bypass and that is 7.5 minutes of waiting if you forget and have not drawn the blood sample. If the patient is on heparin preop, give the same dose (Heparin 300 U/kg). Do not stop the preop heparin just be careful putting in lines. Do not give anti- fibrinolytics until fully heparinized (amikar). If the ACT is not greater than 450 seconds after the dose, give more, until the ACT is above 450 seconds. If you are using aprotinin the celite ACT must be above 800 seconds. If a kaolin ACT is used the normal 450 second range is used.

Add heparin to your ACLS protocol for cardiac surgery patients. If the patient arrests give the heparin so that patient can be put on bypass for resuscitation.

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