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Cardiac Anesthesiology Made Ridiculously Simple - page 7 / 13





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The left ventricular vent line is placed through the right superior pulmonary vein. It decompresses the left ventricle.

Check List for Going on Bypass:

HAD2SUE Remember this mnemonic. Say it often. Avoid killing patient by using it.

Heparin: Always give prior to bypass.

ACT: Always check before going on bypass (450 seconds)

Drugs: Do you need anything (Non depolarizing neuromuscular blocker).

Drips: Turn off the inotropes etc.

Swan: Pull the PA catheter back 5 cm to avoid pulmonary arterial occlusion/rupture.

Urine: Account for bypass urine

Emboli: Check the Arterial cannula for bubbles.

Clean Kills and the Perfusionist: There are three easy ways for the perfusionist to kill the patient.

  • 1.

    No oxygen in the oxygenator.

  • 2.

    No heparin.

  • 3.

    Reservoir runs empty.

If the power goes out there is a crank for the perfusionist - you may be asked to help crank.

If a line breaks, you may have to help replace it.

Air Lock: The venous line drains by siphon. Nothing is quite as reliable as gravity but air introduced into the venous system can cause the loss of the siphon. If the perfusionist notes bubbles on the venous return line, or you do, check the integrity of the cordis, closure of all stop cocks, the surgeons will check the atrial purse string. If you reduce pump flow temporarily the venous pressure will rise and the air leak will diminish. The lines can be refilled with saline if complete airlock occurs.

Cardioplegia: There are lots of types. Cold, Warm, Warm induction - Cold Maintenance - Warm Repercussion, Hot Shot, Crystalloid, Blood, Antegrade, Retrograde. The best is a short cross clamp with a skillful surgeon. You should record the on bypass time, the off bypass time, the on cross clamp, the off cross clamp. As the cross clamp time exceeds 1 hour ventricular function deteriorates, as it exceeds 2 hours it gets worse. Cardioplegia during cross clamp helps. There are lots of things added to cardioplegia and the bypass prime and you should find out what they are from the perfusionist. They will say something like "Nothing special" which translates into potassium, lidocaine, aspartate, glutamate, D50, manitol, bicarb, adenosine, free radical scavenger of the day, and snake oil. Ask and you will learn. There is much magic in the cardioplegia bag, most of it only in the eye of the orderer. If something weird happens on bypass (ie pressure goes to 30, potassium sky rockets, glucose is very high) consider what is in the cardioplegia solution.

De-Airing Maneuvers: It is bad to pump air to the patient. It is difficult to get all of the air out and doppler studies of the middle cerebral artery during bypass demonstrate 50-2000 emboli per case. It is hard to decide if this is air or atherosclerotic plaque. The smaller the bubble the bigger the echo signal. On open ventricle or aortic procedures the surgeons will have you place the head down. Then they will bump the patient, roll from side to side, stick a needle in the ventricle, aspirate from the aorta, etc. in the hopes of getting out all of the bubbles. They will direct you on what they want. If you look at the echo at this time there will be a snow storm of little bubbles in the ventricle. If you see a large one or more than usual say something.

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