Cardiac Anesthesia CVOR Guide

Resources

Great book resource Hensley’s Practical Approach to Cardiothoracic Anesthesia

Expectations and Keys to Success

No one is expecting you to become a cardiac nurse anesthetist. But, you will encounter many of these cardiac conditions in the main OR. There is no doubt you will have patients with aortic stenosis or coronary disease, and you should know how to manage them. You may find yourself reading a transesophageal echocardiogram report and see phrases like ‘severe global hypokinesis’ , and you should know what that looks like and how to manage these patients under anesthesia. This is meant to be a rough guide to get you started in cardiac OR here at St. Joes. Everyone does things differently, but I hope this rough guide will give you the tools you need to succeed.

A big key to success here is COMMUNICATION. If someone says ‘lungs down’, repeat the words ‘lungs down’ as you put the lungs down. Sometimes, the surgeon will just buzz the saw before cutting the sternum and not say anything. Communicate to them that you heard the saw by saying ‘lungs down’ even if they didn’t verbally tell you what they were doing. Closed loop communication with the entire team is important. The team in the heart room is very nice and they are really good at what they do, learn their names and they will be very appreciative.

One last key to success is to save the charting for when you are on pump. Pay attention to what is going on in the case, how the heart looks on echo and to your eye, what step in the procedure they are at and anticipate the next move. Cardiac anesthesia seems scary, but the steps are almost always identical and you can easily predict what comes next.

Morning Setup

• Normal machine check, size 8 ett for women and 8.5 for men especially if bronchial blocker is used
• OGT, pacemaker box on top of the pyxis and check for calcium, magnesium, potassium, milrinone, and at least two albumin available in the bottom drawer.
• Arterial line set up on rolling table llido in insulin/TB syringe for pre-induction line and whatever flavor of arterial catheter you like. Do not forget ultrasound jelly.
  • The anesthesia techs should have this mostly set up for you. They will set up the swan, cables, eye tegaderms, transcranial oximetry if needed, bronchoscope, etc.
• Make sure you tell the tech your glove and gown size for the central line.
  • They will prepare your tray and have your equipment on top.
• If using a bronchial blocker open the box and lubricate it and also open up the ETT adapter.

Cardiac Tower (all drips programmed but on standby)

• Amicar 1g/hr (except off pump CABG)
• Norepinephrine @ 0.04 mcg/kg/min
• Propofol 100mg vial dosing is age and situation dependent around 30mcg/kg/min
• Precdex dosing see propofol around 0.3 mcg/kg/min

Syringes

• Midazolam, 5mg
• Fentanyl, 500mcg
• Propofol, 200mg
• Rocuronium 100mg
• Cefazolin 2-3g
• Epinephrine, 10mcg/mL in 10cc (mix 1mg in 100cc bag)
• Norepinephrine, 16mcg/mL in 10cc (draw 5cc out of norepi bag and add 5cc saline to syringe)
• Nitroglycerin draw up vial without dilution for Dr. Velez. Others draw up 1 or 2 cc and add 9 or 8cc of saline to make 40-80mcg/cc
• Ketamine case dependent. Not for bicuspid AV, MS, dissection
• 2-4g of magnesium bags ready for infusion after induction

Case Flow

Pre-Induction/Induction/Lines

• If the case calls for a heartport (minimally invasive thoracotomy) You may be placing a ESP block immediately upon entering the room.
• We always do a pre-induction arterial line and we start on the right side. The right side because this is the same side as the swan, the same side of the monitoring equipment in the OR and the ICU, and there is less pulling on the lines when you transfer.
• Next will be induction and intubation.
• Then the neck will be prepped usually on the right side but sometimes both sides and the patient will be placed in a slight T-berg. You will use the avoguard hand wash in the room to “scrub”. Then you will get your gown and gloves on for the central line.
  • If you are new at central lines, talk through what you are doing and this will instill confidence in others you do know what you are doing. ‘I see IJ lateral to the carotid, the IJ is collapsible when I press down with the probe, I am going down with my needle at a steep angle towards the ipsilateral nipple as I aspirate’ etc etc. Once the attendings get to know you, they won’t hover as much, they just want to be confident you know what you are doing… and you do! At the beginning, silence and performing incorrect actions is more scary than narrating exactly what you are doing. Make sure you can see your needle tip as you are entering the IJ.
  • A major key to success in any central line placement is to never, ever lose sight of your wire. You don’t need to bury or hub your wire or needle, and you’ll likely see ectopy if you do. Once you thread the introducer over the central line, make sure you see the wire popping out the back before you begin to push in the dilator.
  • It would be highly suggested to practice suturing at home before you come into the CVOR. No one is expecting you to be perfect, but others may be tempted to take over the line procedure if you are fumbling with suturing. Use an orange, watch youtube videos, and practice with a needle driver on how to suture. This skill should not be overlooked.
  • You will take the swan from your anesthesia tech still sterile, and place the swan cover ~80cm and lock the distal end in place. (Little hole to the little swan) When inserting the swan, there is no reason to look down at the swan after you hit 20cm (and say ‘balloon up’), this is the time where you look at the monitor and watch the waveform change.
  • Remember when putting on your swan cover proximal to the patient there are two locks, one to lock the cover to the introducer and one lock to lock the swan in place so it doesn’t move inside the cover.
• Next will be TEE insertion.

• And finally a bronchial blocker if needed.

• If the case is a sternotomy then the last step is to help with the monster. THis is a large metal tray to help protect the patient’s head and allow for supplies storage during the case.

• At this point if sternotomy you may be performing a sternal block and possibly a bilateral rectus sheath block. More information on those below.

• Start the amicar drip at 1g/hr and then add a bolus of 5g over 30min.

Pre-CPB Time

• Be mindful of your IV fluids and limit these as much as possible. Perfusion does do retrograde autologous priming, but we need to preserve the Hct as much as possible. Before pump it would be ideal to have less than a liter in, so be mindful when you are pushing drugs and leaving drip lines open.

• Some of the surgeons will ask anesthesia ‘OK to start?’, so before this time you should be prepared for the high blood pressure that will come with incision. Some of the surgeons don’t say anything at all and just make an incision. The 3 most stimulating portions of the procedure: incision, sternotomy, and cutting through the pericardium. You want to get ahead of this response before they make incision- many of us give fentanyl prior to incision as we are finishing draping and turn up the gas. You also have propofol and nitroglycerin at your disposal. But do not let the pressure hit 190 as the case starts, be vigilant and prepared for the next steps of the case.

• With a CABG, you will have some ‘down time’ between sternotomy and going on pump as they harvest. When taking down the LIMA/RIMA watch your tidal volumes and peep and they’ll typically ask or make you keep bring the lungs down.

• Prior to cannulation the surgeon will ask for Heparin, which comes from perfusion, and you’ll draw an ACT 3 minutes after. Goal ACT 400-500. Watch your pressure after a huge slug of heparin due to its effect on viscosity.

• In order of cannulation: they will first cannulate the aorta, then insert their venous cannula(s), next is the antegrade cardioplegia cannula, retrograde cardioplegia cannula if they are using it, and then finally the LV vent.

• During aortic cannulation the pressure needs to be less than 100 systolic.

• If they are cannulating the groin the blood pressures do not matter as much but they should still be in the target range to avoid any arterial injuries. With groin cannulation we are responsible for guiding their wires across the IVC/SVC and descending aorta with the TEE.

On CPB

DO NOT STOP VENTILATION UNTIL PERFUSION HAS ANNOUNCED FULL FLOW.

• If there is pulsatility on the arterial line you are responsible for ventilation/oxygenation. Turn the ventilator off/standby, turn off vaporizer, turn FGF down to 0.1LPM
• Ensure perfusion has turned on their isoflurane vaporizer. Communicate with the patient’s anesthetic requirements.
• Paralytics: Redosing is preference but it is accepted practice to redose at the beginning of bypass and/or upon rewarming/or when the aortic clamp comes off.
• Electrolytes/Labs: Keep the glucose under 180. Insulin drips and boluses are your friend. Keep an eye on acid base status and potassium/calcium. Perfusion will be adjusting their setup for titration but we can offer assistance as needed.
• Monitor urine output. It is good practice to know the prebypass, bypass, and post bypass urine amounts. If output is low while on bypass, let perfusion know (goal ~1mL/kg/hr on pump).
• Pressers: Perfusion generally manages vasopressor requirements but we can turn on drips if needed such as norepinephrine etc. When transitioning to bypass ensure that perfusion is aware of current vasoactive drips. There will be a discussion about which ones to continue and how much. Titration may be required so keep the lines of communication open.
• Plan for separation of bypass: Use this time to plan the separation process in terms of drips. Consider LV and RV function preop and how the surgery is going. Any added procedures, prolonged cross clamp time etc. Have a plan for which drips, doses, and when to start them with your attending since they may not be in the room.
• Rewarming: Anesthetic requirements increase with temperature. This is the second most likely time for awareness after sternotomy. Ensure patients have adequate depth! Try not to give versed at this point due to post operative/ICU delerium especially in the elderly.

Deep Hypothermic Cardiac Arrest Review

• This is done for aortic dissections or certain situations when the aorta cannot be clamped.
• Bilateral Aline especially left if right brachiocephalic artery getting worked on
• Consider Femoral Aline
• Prior to Ciric Arrest: 5 Versed, 100 Roc, 200 Prop or 10 Versed and 100 Roc
• Stop All infusions
• Cherney only one who does antegrade perfusion catheter
• Femoral Arterial cannulation
• Consider glide scope for intubation to be less stimulating
• 20C for temp then slowly rewarm
• Get products in the room

Discontinue Cardiac Bypass

WARM acronym

• Assess what was done during the surgery ie. look at the surgical valve or look at the ventricular function for an isolated CAABG.
• Warm 36
• Anesthesia
• Adjunct meds
• Air
• Rate
• Rhythm
• Respiratory
• Metabolic/Monitors
  • K
  • Ca
  • Glucose

It is common that there is VF/VT requiring defibrillation prior to separation. The zoll should be hooked up and ready. If using the internal paddles charge to 10j. If using the normal chest pads 200j is standard. Ensure everyone is clear of the patient before shocking.

Optimizing the patient before separation is good practice. Usually the first separation is the best separation.

Pacemaker Settings Review

Post Bypass

• Once separated, switch the monitor back to cardiac mode, and turn on CO monitoring.
• Low MAP and Low CVP give volume.
• Low MAP with high CVP give inotropes.
• High MAP and low CI start nicardipine.
• Volume is usually the toughest call to make. Look at the heart. Is it bulging and has no wrinkles? Volume is probably not needed. Does it look normal and snappy? Might need some inotropes.

It is not appropriate to just give bolus after bolus of neo/norepi until you drop off in the unit. Use drips, volume, and a plan to guide your thinking.

The goal blood pressure is usually 90-110 systolic.

Be prepared in some situations to give lots of products such as FFP, cryo, platelets, Kcentra, DDAVP, and of course PRBCs. It is important to recall the order and ratios of transfusion especially when giving large amounts.

Protamine

Large dose in a relatively short time frame. Consider using calcium and/or vaso to help with protamine hemodynamic shifts/protamine reaction. Once the protamine is in, wait five minutes and draw abg/act and coags.

Chest Closure and Transport

• After the chest closes CVP should rise so be mindful of additional volume if CVP is already 15.
• Lungs down so the sternum does not trap the lungs between it. Usually no PEEP during chest closure.
• Once the sternum is closed the level of stimulation drops off and so does the blood pressure.
• If the patient is stable, begin preparing for transport. Cleaning up your lines, disconnecting cables etc. Wait for vital signs cables until the final second before moving over. TEE probe can come out and an OGT can go in. When moving to the bed the patient can become unstable due to hemodynamic shifts and air bubble movement. Watch the monitor and know where your push line is. Have pressers ready.
• Make sure you have enough oxygen to get the unit. Be judicious in ventilation. Be mindful of all wires and cables. This will be the time the pacer wires are pulled out or you lose an arterial line. Get to the ICU safely and assist with hook up as needed. - Have a sign out report ready for the team. Do not leave until everyone is satisfied and the patient is stable.

Remeber to plug the bed in!

Structural Heart (EP/Hybrid)

• General Set up: Standard GETA set up with arterial line set up. Fluid warmer with blood tubing and stopcocks for bolusing drugs ready to go. Phenylephrine syringe, norepi syringe, norepi drip spiked but not hooked up to the patient, nitroglycerin syringe. - Heparin and protamine will be given to you.
• Consider having some 5% albumin available or blood in the room
• Pacer box and zoll available and turned on. TAVRs require two pacer boxes.
• Discuss plan for access and procedure with all providers involved. In some cases we can use their radial or femoral access for BP monitoring.
• Induction: Gentle and then get lines in quickly. TEE probe follows if necessary. Aline will be pre sedation for tavrs.
• Maintenance: Maintain the BP and monitor EBL and any ectopy. Be ready to give immediate emergency drugs and or zoll therapy. Sometimes the proceduralist needs to be reminded that there is significant ectopy and they can back off on what they are doing and things stabilize without additional treatment. Best practice is to keep communicating and give very small amounts of drugs due to the potential for proceduralist induced hypotension with rapid resolution.
• These are not overly stimulating procedures. It is generally accepted to keep the patient paralyzed and keep the anesthetics to a minimum. Any movement can prove deadly due to the intracardiac devices present in the heart.
• Emergence: Smooth with minimal coughing. Be mindful of the access points. Patients should not move their legs etc.

TAVR

• Antibioitcs are usually ancef.
• Usually MAC (75%) Many different cocktails including propofol drip, midazolam/fentanyl, precedex bolus and drip, remifentanil drip, precedex/midazolam/fentanyl bolus etc etc. Be ready for potential conversion to open cardiac surgery. Be prepared and have heparin available for CPB.
• During the valve deployment there needs to be rapid ventricular pacing. Heart rates are typically 150-220bpm. If you are doing a mac the patient may and will feel dizzy, woozy, lightheaded, and have crushing chest pain. Try to warn them and console them if they feel this.
• Also be prepared for brief but extreme hypotension: MAP < 50. Do not treat as this will cause a large overshoot after the valve is deployed and the HR returns to normal.
• Once the valve is in, keep the BP <160. You may need to turn off or titrate up/down some vasoactives.
• Rapid pacing and valve deployment can cause rhythm disturbances after the valve is in. This is partly due to the proximity of the aortic valve annulus and the conduction system. Have two pacer boxes ready so that you can quickly pace at a rate of 60-80bpm if the patient is in heart block or asystole.

Watchmans

• These normally require arterial lines. Usually post induction. These can go fast so stay efficient.
• Standard GETA tailored to the patient

Mitral Clips/Triscupid Clips

• hese cases are for patients with severe regurgitation but are not surgical candidates. They will get groin access and have a transseptal puncture (Mitral). A clip is then guided with TEE in order to help the leaflets close better to hopefully reduce the regurgitant flow.
• These cases take time or they can be over very quickly.
• Anesthesia is general with an ETT, TEE, arterial line, sometimes extra lines for pacing as needed. Use the standard cath lab anesthesia set up adding drips as needed (some of these patients are very sick and already lined up, intubated etc in the unit).
• The best way to do these cases is keep them paralyzed and as close to their normals as possible.
• Usually very judicious fluid management, again think their normal.

Lead Extractions

• These cases are general with an ETT and arterial line. Sometimes temporary venous pacing wires are needed which necessitate an IJ introducer. Have all of these ready.
• These patients can be very sick from their infection so ensure you have all of the drips as stated above ready.
• These patients can lose lots of volume quickly from SVC damage, subclavian damage, and direct cardiac damage. There is always a CT surgeon and operative team on standby. You should have blood available and/or 5% albumin in the room.
  • In terms of volume, often these patients have a very poor EF so that will hamper significant resuscitative efforts.
  • Communicate with the surgical and procedural team if you are struggling.
• The proceduralist will place a balloon in the superior vena cava in the event the subclavian vein is severely damaged or ripped off. This will be the first step of the procedure.
• The next step will be to excise the pacemaker device and then isolate the leads. Extraction will then commence.
  • This happens with two devices: a tightrail and a laser. Your attending should be in the room when the laser comes on, or the tighrail is being used. Both devices need to have the leads be pulled tight to work, both devices can result in catastrophic damage. When the leads are pulled tightly there can be invagination of the heart tissues. This can cause a drastic decrease in RV output and therefore decrease in cardiac output and blood pressure. Watch the monitors during this time and alert the proceduralist to rapid loss in blood pressure. Be careful to treat this as the blood pressure can be quickly corrected by letting off the lead. Communicate with the proceduralist!!! If the blood pressure is starting to trend down be communicative as this can mean bleeding from the subclavian, vena cava, and/or the heart. Be vigilant and communicate!
• The final piece of this case is what will the patient have for a pacemaker after the device is removed? Ensure that there is a plan in place before the device is removed!!!

Other cases involving ECMO and Impella insertion/removal

• These patients often are intubated with drips and lines but you may need to add something. Drips will be different depending on if the device is being inserted or removed.
• Some impella removals are done with just local/light mac. It is good practice to have all lines, GETA things ready to go in case things do not proceed according to plan.

Cardiac Aneshesia Nerve Blocks

Parasternal Intercostal Fascial Plane Block (PIFB)

See the PDF regarding the blocks as it covers all of the blocks that we do!

View PDF