RMH Cardiac Anaesthesia

An Introduction to Cardiac Anaesthesia at RMH

March 2012
Reny Segal
Gerard Stainsby
Garry Donnan
Dept. of Anaesthesia & Pain Management
Royal Melbourne Hospital

RMH Cardiac Anaesthesia

Contents
WELCOME TO CARDIAC ANAESTHESIA ............................................................................................................... 3
GENERAL PLAN OF THE OPERATION.................................................................................................................... 3
PREOPERATIVE ASSESSMENT .............................................................................................................................. 4
THEATRE PREPARATION ...................................................................................................................................... 7
ANAESTHETIC ROOM........................................................................................................................................... 7
THE SWAN-GANZ DEBATE .................................................................................................................................. 8
PRE-INDUCTION ................................................................................................................................................... 9
INDUCTION ........................................................................................................................................................ 10
MAINTENANCE .................................................................................................................................................. 11
TRANSOESOPHAGEAL ECHO .............................................................................................................................. 11
PRE-BYPASS ...................................................................................................................................................... 12
RUNNING ON BYPASS ........................................................................................................................................ 13
PACING .............................................................................................................................................................. 14
COMING OFF BYPASS ........................................................................................................................................ 15
POST-BYPASS .................................................................................................................................................... 17
BLEEDING.......................................................................................................................................................... 19
ICU ................................................................................................................................................................... 20
MODIFIED BYPASS: OPCAB AND PADCAB .................................................................................................... 21
REDO CARDIAC SURGERY ................................................................................................................................. 23
REMOVAL OF PERMANENT PACING LEAD SYSTEMS ......................................................................................... 24
INTERVENTIONAL CARDIOLOGY ....................................................................................................................... 25
APPENDIX A: INDUCTION IN SELECTED PATHOPHYSIOLOGICAL STATES....................................................... 27
APPENDIX B: ANTICIPATING THE SURGICAL STEPS ...................................................................................... 28
APPENDIX C: CARDIO-PULMONARY BYPASS ................................................................................................. 30
APPENDIX D: CARDIOPLEGIA ........................................................................................................................ 32
APPENDIX E: DRUGS ..................................................................................................................................... 34
APPENDIX F: IABP........................................................................................................................................ 35
APPENDIX G: SEPARATION FROM CPB FLOWCHART .................................................................................... 38
APPENDIX H: EPONYMS ................................................................................................................................ 39

About this document

This document has been based on Dr Reny Segals Guide to Cardiac Anaesthesia at Wellington, written in 2002
2003. It is intended to provide an introduction to the RMH Way of Cardiac Anaesthesia, with occasional
pointers/tips/suggestions & (hopefully) helpful guidelines. We hope that if you are new to cardiac anaesthesia it
will give you an idea of what to expect, and what is expected of you. If you have had experience elsewhere, it
will help you to adapt to local institutional habits. This is by no means a definitive text; techniques continue to
evolve, and practice is not necessarily uniform among anaesthetists.
The chapters are intended to follow the course of a typical operation; appendices deal with issues that would
otherwise interfere with the exciting narrative momentum (such as it is).
While our intentions are good, this document probably represents Class V evidence: what a bunch of us reckon
we do (and in some cases what we think other people do). Although we consider the risk slight, it is possibly
worth explicitly stating that readers should not perform cardiac anaesthesia without a thorough grounding in the
relevant intellectual disciplines and a suitable period of supervised practice.
The document is under constant revision, attempting to improve clarity and readability, but also reflecting
changes in techniques and the results of feedback from readers. Some errors are identified and corrected with
each revision, and of course new errors are quietly introduced.
Feedback and suggestions are solicited and, of course, always welcome.
- GS/GD/RS March 2010

Welcome to Cardiac Anaesthesia

Cardiac surgery presents the anaesthetist with many challenges. Every organ system is
directly or indirectly involved, either in the disease process or the surgery . Invasive
monitoring, issues such as neuro- and renal protection, active temperature management, and
cardiovascular and respiratory pathophysiology are routine; serious coronary and/or structural
heart disease is of course universal; and major co-morbidities are often present.
Transoesophageal echocardiography is a fundamental skill and takes the role of the
anaesthetist into the diagnostic realm. The interaction between the surgical and anaesthetic
teams is far closer than in any other specialty.
Preamble (Aims, Words of Wisdom & General Ramble):
We know its not for everyone. Unless you want it, we dont expect to make you a
cardiac anaesthetist.
Familiarise yourself with the College aims for the cardiothoracic modules. If there are
specific things you need from any one session/list, let your consultant know.
Do not panic or feel out of your depth. You will be well supported at all times. You will
gain skills that will be of use to you in all (well, most) areas of anaesthesia practice. You
will see fantastic physiology and pharmacology in action. You will get your module
signed off!
If you are an advanced trainee, use the opportunity to develop a feel for cardiac
anaesthesia and to hone your skills with sick patients, lines, infusion management,
inotropes, advanced monitoring, TOE, the theatre/ICU interface etc. Once you have
demonstrated reasonable ability, many consultants will permit you to take control of
cases.
Fellows should expect to take control of cases once they have seen enough of the routine
to be comfortable doing so.
Remember that cardiac anaesthesia is still anaesthesia. The fundamentals apply, and
oxygen remains a good thing etc.
It can be challenging (!) to cope with the variations in the techniques and philosophies of
the various consultants although this is by no means unique to cardiac anaesthesia.
Discuss the cases, see them together if possible, let them show you their individual tricks
and so on. Many are enthusiastic teachers and have particular areas of strength to take
advantage of.
Avoid passive spectator mode. You will do, learn and enjoy more if you take an active
role.
Have a great time or else!1

General Plan of the Operation

Usually, something like this:
Pre-induction
establish non-invasive & invasive monitoring
Pre-Bypass
prep & drape
conduit harvest & sternotomy
heparinisation & cannulation for bypass

or else you wont have a great time.

3

Cardiopulmonary Bypass
pre-clamp
cross-clamp
post-clamp
Post-Bypass
decannulation
closure
transfer & ICU handover
As always, the whole things starts with an adequate assessment & preoperative planning

Preoperative Assessment
For elective patients, this is generally done in Pre-Admission Clinic in 2E, days or weeks
preoperatively. Some patients bypass this process and may require assessment in the ward.
The 2E patients are generally easier because of the support systems that have been set up.
While particular attention is paid to cardiac issues, a holistic approach remains important for
what is essentially major whole-body surgery.

2E patients are generally seen by the anaesthetist rostered to CPB; fellows/senior

registrars may be asked to help out.
In general, cardiac investigations should be relatively complete; however it is dangerous
to assume this is always the case.

Note: the following concentrates on the things that are different or especially important to
cardiac anaesthesia. Routine questions medications/allergies, etc still need to be covered.
History:
Basics
what is the planned operation?
age, weight & height (important for CPB, haemodynamic indices, TCI pumps).
medications including herbal and complementary products
Cardiac
functional status / failure?
risk factors and associated conditions
IHD
angina stable/unstable? Recent MI?
incidental valvular disease?
Valve surgery
valve lesion(s) and severity
incidental coronary disease?
Vascular
atherosclerosis is a systemic disease
may have implications for conduit and peripheral arterial cannulation
cerebrovascular disease? AAA? renal artery stenosis?
Respiratory
significant lung disease pre-op optimization (consider physio, bronchodilators,
steroids), intra-op and ICU management
smoking - the College has a policy document. Reinforce the need to stop, bearing in
mind that everyone else will have told them already. Why should they listen to you?
Renal
impaired? discuss with surgeon, perfusionist, renal medicine and ICU pre-op.
4

avoid nephrotoxins such as gentamicin

Endocrine
DM very common may not have been formally diagnosed
control (diet, OHG, insulin). HbA1c?
end organ damage?
Neurology
baseline cognitive impairment?
beware the older patient who is attended by their capable spouse and who is
unsure of their personal medical history, medications, etc.
pre-existent neurological deficits?
document baseline function
unfortunately at present it is next-to-impossible to get formal cognitive function
testing for surgical patients at RMH.
Musculoskeletal/Connective tissue/Genetic anomalies
Marfans?
fixed joint deformities can make positioning very difficult

Physical examination:
like any other, including airway
peripheral arteries
carotid bruits?
baseline heart rate, rhythm and BP are useful but easy to forget in the environment of
echo, angiography, nuclear medical scans and cardiac CT.
Investigations:
bloods
UEC, FBE, glucose, coag
Extended Group & Save for routine cases
crossmatch for small or anaemic patients, aortic and redo surgery
general
12 lead ECG
CXR
lung function if indicated
vascular
carotid duplex scan (there is a protocol to identify patients requiring this)
cardiac
There should be a coronary angiogram and/or an echocardiogram in the preadmission bundle or (for inpatients) progress notes. They clarify the anatomy, the
lesions and the cardiac function. The angiogram:
shows you the coronary anatomy, and may indicate potential targets. Beware
significant Left Main Stem disease!
Outlines ventricular ejection and systolic function
may give the LVEDP
wont tell you much about the valves
The echocardiogram will:
outline systolic and diastolic cardiac function and ejection fraction (note: EF
misleadingly high with valvular incompetence)
indicate valve function / gradients
show chamber dilatation, hypertrophy, and thrombi.
not tell you anything about the coronaries.
A myocardial perfusion scan (if available) can identify myocardium at risk.
At present cardiac CT seems to be used for screening rather than definitive anatomical
delineation of coronary lesions

Things to actually do
Document your assessment
Consent (or: Informed Decision Making)
ask the patient whether they have seen the video
provide information without overwhelming the patient
address the patients specific concerns
provide a balanced view of the risks
the surgery is generally far more dangerous than the anaesthesia
the patients untreated surgical condition is more dangerous still
the total anaesthetic risk is a small fraction of the overall risk
involve the patients family in the process
document the discussion, and have the patient sign the anaesthetic consent
Investigations
Ask the 2E staff to chase up anything that has been done but is not at hand
Routine bloods, CXR etc should have been ordered by the HMO
The 2E staff can help arrange other investigations if required.
Medications
In general, dont change prescription medications
do stop herbals
aspirin strategy depends on patient and surgeon
stop clopidogrel 7 10 days2 preop if possible
continue -blockers
specify preop management of diabetes for patient while fasting
provide clear written instructions
Dental
Patients with obvious oral hygiene problems and all patients for valve / aortic surgery
need to see a dentist at their own expense. The 2E nurses can coordinate this.
Inpatients:
Inpatients tend to be somewhat more difficult than patients admitted through 2E, because
they are often acutely unwell, and also because the system is generally set up for PAC /
DOSA.

If they have not been to the PAC, it is likely that you are the first anaesthetist to see them
for this operation. If you are around the day before, it is ideal to see them then.
Before you see the patient, go over the notes. This will provide context to focus your
clinical assessment.
Dont rush. Youll miss stuff and your patient generally will need all the reassurance they
can get. Allow 30 mins or more to see one patient.
Assessment: see the previous topic.
Check what antiplatelet agents / thrombolytics have been administered.
The patients will probably not have had the benefit of the video. They may not be
aware of invasive monitoring and postoperative ventilation in ICU. Calm reassurance and
decent explanations are called for if you have not yet developed this skill, use your
cardiothoracic cases to do so.
Chart sedation if appropriate. Bear in mind the patient might be subject to last-minute list
changes or cancellation, and that the patients active involvement in further medical
consultations may be required heavy duty premeds are potentially counter-productive.
Temazepam 20 30mg on-call is generally satisfactory.
Sort out your notes & inform the nursing staff of premed and other requirements. Discuss
the patient with your supervising consultant.

Send for inpatients early getting patients to theatre is not a high priority for busy wards.
2

The clopidogrel hysteria continues. Realistically 5 7 days would be plenty, but try telling a surgeon
6

Theatre Preparation

Arrive at 0710 07153

ICU beds are guaranteed for morning cases there is no need to check4.
Put correct TOE probe into OPA (observe protective precautions)
Perform machine check. Check monitoring. Position echo machine & IV poles.

Check
At least 2 or 3 TCI pumps available, depending on whether TIVA is planned.
Alaris PC pump with GTN 2 channel pump if possible.
Ensure mains power ON to all pumps it is axiomatic that batteries will fail at a
critical moment
Defibrillator with pacing is mounted on anaesthetic machine; check relevant cables
and defib pads are available
Blood in PACU fridge for redo & high-risk cases
Bair Hugger at foot of table.

Prepare the drugs you expect to need for the patient (see Appendix E: Drugs )
Infusions made up, labelled, loaded into pumps, primed, pump parameters set and ready
to go. Check that the volumetric pump giving sets have been de-aired.
Monitoring default Cardiac profile should be satisfactory. While you can make changes
to suit special situations, reconfiguring the monitor defaults can result in abrupt
termination of your life functions. You have been warned.

Anaesthetic Room

Before you start, double check:

Planned operation. Youd be surprised how often the plan can change, or a radial
artery suddenly becomes required. Perhaps have another chat with the surgeons.
Laboratory results & blood availability
Morning case lines inserted on table in theatre. For afternoon case generally done in
anaesthetic room to reduce turnaround time. Most important stuff is set up by RNs but
you need to check and let them know if anything special is needed.
Find your patient in the admission bay.
Check that you have the right patient! Complete the Passport to Safe Surgery. Most
patients will have been to PAC and already had appropriate information and consent, but
inpatients have often bypassed this step. Does your patient have any last-minute questions
or concerns?
Use whatever techniques you have developed to establish rapport and gain the patients
confidence.
Review the medication chart. Was a premed given? Was a drug given that should not
have been?
If the lines are to be done in theatre, transfer the patient onto the table. Take steps to
minimize discomfort, including active warming.

Get ready to insert lines

Give O2 via Hudson mask. Help establish routine non-invasive monitoring (ECG,
oximetry).

Yes we know youre not paid until 0730. Nor are we.
So they say. Sometimes morning cases are put on hold for an inconvenient interval, but actually cancelling one
is almost unheard of.
4

Midazolam or low-dose propofol TCI +/- fentanyl can be titrated to effect to facilitate
line placement.
The requirement for one or both radial arteries to be harvested can sometimes be
anticipated but it is often better to speak directly with the surgeon. If in doubt, assume
both radials are needed.
Even if no radial artery harvest is needed, it is preferable to cannulate the right radial
artery because of the way the pressure transducers have been set up and because the
left may be required on short notice by the surgeons.
Perform ultrasound mapping if desired.
Peripheral lines:
16 14G x 1. If there is no suitable peripheral vein (e.g. both arms are needed for
surgery), just put something small in and use the neck line for giving volume. Several
anaesthetists are no longer using large peripheral IVs for routine cases.
Arterial line:
Aseptic procedure. Some operators like to use an arm board and chair.
Right radial or femoral artery unless required by the surgeon. Brachial or left axillary
artery can be used.
When it just wont happen, try ultrasound. Dont hesitate to get a colleague!
Central Venous lines:
check that last-minute cancellation isnt on the cards.
Generally awake5 at RMH, but some anaesthetists will consider asleep insertion in
suitable cases for patient comfort. (Note: this may increase turnaround time for pm
case).
Sterile procedure, gloves, gown, mask +/- ultrasound.
Usually via right internal jugular vein. Use ultrasound to check for a suitable vein
before you start.
Single or dual lumen Arrow sheaths. (ICU prefers dual lumen.)
PA Catheter:
used for most cases at RMH see The Swan Ganz Debate.
Epidural:
practice varies from nearly always to occasional to never. Heparinisation related
to CPB is not a contra-indication. If an epidural is to be placed, it is best done after
placement of the peripheral IV. Consider glycopyrrolate 200 mcg IV to reduce the
risk of vasovagal response. High thoracic; not for the beginner.
If you start an IV infusion at this stage, ensure the rate is controlled do not permit
administration of excessive crystalloid. Fluid warmer is routine ensure turned ON for
Off-Pump case.
Maintain reassuring verbal contact with your patient.
If the opportunity arises, consider giving the antibiotic at this stage.

The Swan-Ganz Debate

Cardiac surgery at RMH has included the routine use of Pulmonary Artery Catheters (PACs)
since the unit was established.
There is little evidence-based support for this continued practice, and over recent years the
risk benefit ratio of routine placement of the PAC has come into question, as there have
been several serious adverse outcomes (including deaths), with a cluster of cases in the early
00s6.

5
6

the patient, not the anaesthetist. The anaesthetist should endeavour to remain awake regardless.
my, how time flies!
8

Nevertheless it remains the stated policy of the Cardiac Surgical Unit itself that PAC
catheters be used.
Several anaesthetists have challenged this directive and are using a variety of criteria to
implement selective PAC placement. Patients in whom the perceived potential benefit is low
(in general, patients with good LV performance, normal RV pressures, absence of serious
valvular disease, and primary rather than redo surgery), or where the potential risk is high
(elderly, frail females, pulmonary hypertension) would instead have a short triple-lumen
CVC placed via a R IJV sheath. Some anaesthetists also prefer this CVC where off-pump
surgery is planned.
Some of the cardiac surgeons have complained that intraoperative management is only a
relatively small part of the patients care and that early postoperative care of the patient is
difficult without the PAC. They have requested that the unit policy be followed.
Registrars and fellows should expect to place a PAC unless a specific contra-indication exists
or the anaesthetist in charge has directed that it not be used. If there is a difference in the
views of the surgeon and the anaesthetist in this regard, we suggest that you do the arterial
line and leave the neck line to the boss.
Where a PAC is placed, it has now become standard practice not to wedge the catheter it is
advanced just a few centimetres past where the PA trace is obtained. This ensures that the tip
of the catheter does not retract into the RVOT when the balloon is deflated, as dysrhythmias
including VF can be induced otherwise.
The final position of the tip of the catheter should be confirmed intraoperatively using TOE,
and documented. Ideally the tip of the catheter should be in the proximal right pulmonary
artery during diastole.

Pre-induction
The morning patient will generally have had their lines inserted in theatre. Subsequent cases
will be on a trolley with more or less complete invasive monitoring set up. Bring them into
theatre and help the RN set up the monitoring.

Encourage a bit of quiet until your patient is asleep.

Ensure correct monitoring is available, attached and working. Check transducers have
been zeroed and heights correct, BIS working, etc.
Attach infusions to appropriate sites. Ensure fluids are running correctly.
Do not induce patients with critical aortic stenosis, left main stem disease, cardiac
tamponade or ongoing ischaemia, without presence of a senior surgeon, nursing team
scrubbed and set up, and clinical perfusionist immediately available. Other conditions
requiring heightened vigilance and modified induction include pulmonary hypertension
and acute valvular lesions (e.g. endocarditis).
Have all your induction and haemodynamic support drugs ready to go.
Proceed to induction in a calm, unhurried manner.
Patient will be anaesthetized slowly. Reassure them that this is normal.

Trap for beginners7 if a PAC has only been inserted to the RA (e.g. tricuspid valve surgery,
Ross procedure) make sure nothing is attached to the white or blue (RA) lumens.

experience lets you recognise your mistakes when you make them again
9

Induction
The Basics:
Induction is in theatre.
Maintain reassuring verbal contact with the patient.
Cast your eyes around & double-check things are ready.
Pre-oxygenate.
The drug recipes are many and varied. The exact recipe is less important than the desired
outcome an asleep patient with haemodynamic stability.
Suggested generic formula:
Give antibiotic pre-induction if possible
Midazolam to 5 mg, depending on pt condition and age
Fentanyl 500 mcg given slowly.
Propofol TCI 2 mcg/ml or 20 - 40 mg
Some anaesthetists are not using propofol at present, instead using an inhalational
technique with sevoflurane and/or desflurane
Sleep will be associated with BP degree varies with the induction agent used &
the condition (especially age) of the patient. May need to support with a pressor
pending intubation.
Remember that there is a lag time for the BIS to respond to changes in anaesthetic
depth and a further lag for the BP to respond
Rocuronium 50 - 100 mg +/- pancuronium 4 - 8mg.
Ventilate, intubate. These cases are generally not good ones for the HMO to practice
on show off your smoothest, slickest, least stimulating intubation.
Secure the ETT.
Support blood pressure as indicated.
metaraminol 0.25 - 0.5 mg increments or infusion
ephedrine 3 mg increments
inotrope infusion with induction should be considered for sick patients.
Reduce maintenance anaesthetic during prep & drape
Eye tapes must be waterproof as iodine/alcohol used by surgeons will dissolve corneas.
Insert TOE dont forget the bite block.
Insert CVC (sheath) PA catheter if not yet done. (You can use TOE to image the wire in
the SVC)
Surgical HMO will catheterise the patient. Catheter bag to our end of the table.
If DHCA likely, insist on catheter with inbuilt temperature probe.
Insert nasopharyngeal temperature probe.
Positioning:
Supine with the head on a head ring.
Most surgeons request a shoulder roll. Avoid excessive neck extension.
Apply adhesive defib pads if required
redos
modified access cases
r/o PPM leads
patient with deactivated ICD
Arms by side (unless radial to be used), palms facing inwards, elbows padded, arms
secured by over & under folded sheet. Ensure ulnar nerves free from pressure.
Check at the end of this routine that all your lines are still running, arterial trace
present, and pressure points are protected.
Head frame positioned over head at level of upper lip. Check clearance height.
Patients legs will be lifted if prepped. This will transiently increase central blood volume
and BP. This situation will also reverse when the legs are lowered. Do not overreact.
Once CV line in situ, connect and start infusions (see Maintenance).

10

Vasodilators and inotropes are connected to dedicated ports on the CV line/Swan

the use of a carrier line is highly recommended if multiple infusions are to be used.
Move transducers to headframe. Support lines on head frame or Soeding support
ensure IV injection ports are conveniently accessible

Maintenance
Aims generally the same as most GAs:
Asleep (BIS 40-50) with IV or volatile maintenance with the mixture of your choice:
opioids already given for induction. Titrate more if indicated.
remifentanil is infrequently used in cardiac surgery at RMH
propofol infusion 10-30ml/hr or TCI 1-2 mcg / ml
volatile sevo or desflurane
N2O is contra-indicated in cardiac anaesthesia. Air can be used before the chest is
opened but 100% O2 is recommended during IMA harvest because long apnoeas can
be required.
Neuromuscular blockade: Hard to monitor, theres an ICU bed, and the surgeon will
decompensate with even small amounts of diaphragmatic movement better to overthan under-dose.
check the patient from time to time, independent of the monitor
skin perfusion, diaphoresis, urine output
Dont give too much fluid.
Temperature management will depend on the nature of the case
off-pump cases temperature maintenance more critical
most teams use mild hypothermia (34 35 C) for bypass
There may be time for some house-keeping and TOE but if you are busy leave the
paperwork for later.
On pump cases, prepare for going on to bypass (see the next section).

Transoesophageal Echo
TOE was introduced into RMH by a small number of pioneers in the early to mid 90s. It has
quickly become adopted into routine cardiac surgery at RMH such that now there are few
cases in which it is not used.
Indications:
Cardiac: pretty much any cardiac surgery.
Non-cardiac:
assessment of unexpected cardiovascular instability
diagnostic use in trauma, etc.
Contra-indications:
Absolute (all very rare)
oesophageal trauma, stricture, vascular rings
oesophagectomy
Relative
oesophageal varices
frailty
cervical spine instability.

11

In theatre:
Enter the patients details so that the examination can be archived
Obtain an ECG signal if possible, usually by turning ON the defibrillator (turn the QRS
beep volume down) and attach a slave cable from the defib ECG OUT to the echo ECG
IN.
Prepare the probe, including the relevant paperwork
Insert the probe gently, after intubation but before the head frame is positioned
Do not use the friction brake or use large control deflections for long periods
Prioritise your examination so that you make important findings early.
Do not be distracted or pre-occupied by the TOE examination.
The desire to perform a complete study must be considered in context.
When idle, leave a useful live image (4CH or LVSAX)
Do not leave the machine in a Doppler imaging mode
If you are uncertain, say so. It may feel unsatisfactory to appear uncertain; it is worse to
be wrong in an important aspect of diagnostic work.
Ensure you are treating the live image, and not a loop.
Document your findings
The TOE probe:
Is expensive and delicate
Check for mechanical function before sterilising
Check electronics (calibration) before insertion
Remove after chest closure; clean and/or sterilise according to protocol
The handle is not waterproof! Only the insertion piece is to be immersed during cleaning!
The book:
Royse, Donnan & Royse: Pocket Guide to Perioperative and Critical Care
Echocardiography includes a fantastic CD!

Pre-bypass
The pre-bypass period extends from induction through to establishment of full CPB. This
section deals with the end of the pre-bypass period, during which preparations are made for
running onto bypass. Generally the surgical steps are: heparinisation is requested, the heart
and great vessels are exposed and pericardial stay sutures placed. The sterile heart-lung
machine tubing (lines) are taken onto the surgical field, and a pressure monitoring line is
passed to you to attach to the CVP transducer. Purse-string sutures are placed in the aorta and
right atrium. The aortic cannula is placed first, generally causing little haemodynamic
disturbance and permitting subsequent administration of volume from the heart-lung
machine. The venous line is placed via an incision into the right atrial appendage. The
surgeon will then place the retrograde cardioplegia catheter you will need to flush the
pressure monitoring line and then watch the coronary sinus on TOE. The antegrade
cardioplegia needle is then placed (either before or just after running on bypass) but does not
typically require intervention on our part. If an LV vent is used it is usually placed via the
right upper pulmonary vein. TOE is used to confirm correct placement of the catheter within
the left ventricular cavity.

Heparin 0.4 kIU/kg (usually 20 30 000 units) given into central line when requested
generally at the end of LIMA harvest (CABG) or after pericardiotomy (valve)
Confirm for surgeon that heparin given
Expect BP with large bolus heparin
Patients who have had recent or ongoing exposure to heparin (including LMWHs) can
exhibit significant heparin resistance.
12

ACT checked after ~ 3 minutes and 480 secs.

Pericardial stay sutures may impede atrial filling, exacerbating BP
Manipulation and placement of purse-string sutures in the right atrium can cause AF. If
poorly tolerated consider
temporary support with pressors & volume from CPB machine
synchronised DCR (unpopular with surgeon as clutters the field with paddles/cables)
run on bypass
Cannulation of the great vessels requires coordination between the surgeon and
anaesthetist
BP for aortic cannulation. Check before giving aramine that the surgeon isnt about
to cannulate. With luck, it is possible to make a low BP look deliberate.
lungs off for retrograde purse-string
TOE for retrograde cannulation & placement of LV vent (if reqd)
After the aortic cannula has been placed, volume can be given from the CPB machine.
Check the arterial line for bubbles the surgeon has a limited field of view through their
loupes.
Discuss anaesthetic issues with the perfusionist. They will usually have a good handle on
the patient anyway but Communication Is A Good Thing.

Running on Bypass
The venous line clamp is removed, diverting the venous return from the right heart to the
venous reservoir and pump/oxygenator. The lungs are isolated from the circulation and
should be deflated to optimise surgical access.

Double-check the ACT, should be 480 secs

Turn the lungs off
ventilator lever to bag mode, exhaust valve fully open
ventilator to CPB mode
do NOT turn O2 fully off (this is to avoid subatmospheric pressures in the breathing
system due to continued uptake by the lungs.) I usually leave 1 2 lpm running, as
this is safe if I forget to turn up the O2 flows post-bypass.
vaporiser off
inform the perfusionist if you need them to give a volatile agent
some anaesthetists prefer to open or disconnect the breathing system
IV off
GTN off
Draw the PA catheter back a few cm
unless youve positioned it in the proximal pulmonary vascular tree under TOE
avoid pulling the catheter tip back into the RVOT.
Anaesthesia
if youre giving propofol, ensure the route is appropriate (i.e. has not been excluded
from the circulation by the mechanics of CPB). This is sometimes a problem with bicaval cannulation e.g. for mitral valve surgery.
if youre relying on a volatile, make sure the perfusionist knows to continue it on
bypass.
make sure the perfusionist can see the BIS
consider giving another dose of your favourite NMB
Pass the metaraminol to the perfusionist
standard concentration used by perfusion is 0.5 mg/ml
really
regardless of what the anaesthetic consultant says
If not already done, have a chat with the perfusionist about particular goals for the case.
13

Repeat the ACT about 3 minutes after running on, and a blood gas about 3 mins after
cardioplegia has been given.

DO NOT TOUCH THE HEART-LUNG MACHINE WITHOUT THE PERMISSION OF

THE CLINICAL PERFUSIONIST.
really
this includes such apparently trivial interventions as blood sampling or drug
administration.

Pacing

Epicardial pacing wires are generally placed during payback (i.e. after removal of the
cross-clamp, prior to the wean from bypass)
Sinus bradycardia is common post-bypass.
Bradycardia is relative: target heart rate usually 84 86 bpm.
Atrial wires generally adequate
Ventricular wires if the AV node is at risk (e.g. aortic valve surgery) or if the atria
cannot be counted on to drive the ventricles (e.g. AF). Some surgeons routinely
place ventricular wires.
At RMH, pairs of unipolar leads are used (as opposed to bipolar leads)
Atrial wires to RA near appendage
Ventricular wires to ant wall of RV
Lead will be passed to you, usually colour-coded
Blue for A, White for V
but of course, which lead does what depends on what theyre attached to!
Plug the lead into the pacing box.
Familiarise yourself with the controls. The important ones are:
Rate
Atrial current
Ventricular current (Set to 0 for atrial-only modes)
Mode (access via the Menu button
Remember the 3-letter classification of pacing modes:

CHAMBER PACED
V = Ventricle
A = Atrium
O = None
D = Dual

CHAMBER SENSED
V = Ventricle
A = Atrium
O = None
D = Dual

RESPONSE TO SENSING
I = Inhibited
T = Triggered
O = None
D = Dual (I & T)

Commonly used modes at RMH are:

AAI: good for sinus brady, even if V as well as A wires placed. Just turn the V
output to zero.
AOO: good for sinus brady; ignores diathermy (and everything else).
VVI: brady if AV node non-functioning.
DDD: AV sequential pacing. May be preferable to use AAI or increase AV interval
to permit normal depolarisation pattern better contractility.

All of the synchronous modes are potentially susceptible to diathermy interference.

Defibrillation must be immediately available (i.e. external pads applied) if the
ventricle is to be asynchronously paced!
Resume synchronous pacing ASAP.
14

Basic operation:
Turn pacemaker box ON
The box will wake up in DDD with reasonable defaults
Check for the presence of a Low Battery indicator & change the battery if needed
The pacemaker can pace for a few seconds during a battery change, but its less
stressful to do it beforehand!
Set the target heart rate. 86 is quite a good number for weaning, but sometimes lower
rates are used during payback.
Set the desired pacing mode. AOO often useful post-bypass because it is not inhibited by
diathermy.
Plug the leads into the pacing box.
Test the pacing threshold of the leads. Pace at a rate comfortably higher than the patients
intrinsic rate. Reduce the output current until pacing fails. Increase it until it is recaptured.
Lower = Better.
Regardless of the threshold, its usual to pace at 10mA
changing the polarity of the electrodes (done by the surgeon) can sometimes reduce
(improve) the threshold
Common settings
Most settings can be left at the default values (except while checking thresholds)
Rate: 86 /min
increase the A-V interval if youre trying to encourage intrinsic conduction
Recheck for successful pacing, especially with closure of the pericardium and chest.
Take a bit of time and familiarise yourself with the pacing box (settings, controls, etc)
before the case. Its far less painful than trying to work it out on the spot.
Permanent Pacemakers:
liaise with cardiology dept
approach will depend on whether pt is pacemaker dependent
generally, ignore or set to slow DDD
the surgeon will apply atrial leads, enabling rate control
ignore pacemaker and pacing spikes during induced arrest.
AICDs:
will diagnose diathermy as a malignant arrhythmia and may deliver anti-tachyarrhythmia
therapy (i.e. programmed shock)
disable shock delivery during surgery:
inhibit with a magnet placed over the device, or
ask cardiology pacemaker tech to reprogram to disable defibrillation
apply external defib paddles
ensure device re-enabled at early opportunity postop.

Coming off Bypass

This is the moment of truth they are about to take away the nice CPB machine and make
the circulation your problem again!
Communication with the surgeon and perfusionist is critical. The job is especially
challenging because the heart is recovering from ischaemia, cardioplegia, handling, and
reperfusion.
You should have an idea of the degree of support the heart is likely to need by its pre-bypass
function and the nature of the surgery. Beware that the heart can sometimes look artificially
15

good pre-bypass (e.g. mitral incompetence); the full degree of LV dysfunction is revealed
after the valve has been repaired.
Checklist:
Ventilator on, lungs inflated
If a LIMA graft has been performed, initial lung inflation is performed manually,
while the surgeon visualises the LIMA and the left lung. If done without due care,
lung inflation can avulse the LIMA graft (usually to the LAD).
Cardiac rhythm stable, adequate rate (pace if necessary)
Cardiac chambers closed, de-aired.
Major bleeding controlled
Physiology OK:
ABG, Hb, K+
Hb 7-ish
Temperature > 36 C
LV capable of ejection
adequate payback
inotropes running and in patient (beware deadspace, 3-way tappisms)
Partial Bypass & Wean:
the perfusionist will partially clamp the venous line and blood will be diverted through
the right heart and lungs. This blood should then be ejected from the LV.
the lungs must be ventilated during periods of partial bypass otherwise the pulmonary
blood-flow through the deflated lungs serves as a shunt, and can cause desaturation.
as always, apnoeas might be required for surgical access. Keep them brief, or go back
on full flows
the partial bypass period can help give an idea of LV performance. Look for snappy
contraction and a brisk upstroke on the systemic arterial waveform. Beware a poopylooking ventricle, one that doesnt eject, or one with dyskinetic segments, especially
since, in general,
All hearts look good on bypass
(Goldblatts Second Law8)
If the heart looks crappy at this stage, consider more payback or start some inotropes and
wait until they hit the circulation. If the situation is really poor, IABP may be required.
Beware LV distension. If the heart cannot eject and fills, discuss with the surgeon either
re-applying the cross-clamp with retrograde perfusion, or inserting an LV vent.
Air in the right coronary artery is a common occurrence and results in impressive STsegment elevation and inferior SWMAs. Treat with
time
raised perfusion pressure
pulsatile perfusion
GTN
To wean from bypass, the perfusionist further clamps the venous line and displaces blood
volume from the venous reservoir to the patient
systemic pressure becomes more pulsatile
PAP & ETCO2 rise as pulmonary capillary flow returns
drugs administered into the venous reservoir might not get to the patient
IV drugs go via our vascular access
remember to turn on the vaporiser!
re-route drugs being given into the heart-lung machine

Goldblatts First Law: the person who answers the phone wont know whats going on. The people who do
know whats going on are too busy working to answer the phone. Also, see the section on Eponyms.
16

Difficult or failed wean (see Appendix: Separation Flowchart)

maintain two-way communication with the surgeons
do not merely prop up the BP with metaraminol
maintain perfusion pressure
check the basics:
blood oxygen content OK?
check O2 from wall outlets to patient
check ventilation (MV, lungs inflated)
rhythm / heart rate / pacing mode & capture
conduits unclamped?
CO / wedge
TOE examination
volume
adequate? esp. for non-compliant ventricles (diastolic dysfunction)
excessive? (ventricle distended)
global LV function
SWMA
acute valvular dysfunction
if dire, consider a further period of full or partial support on bypass
volume- or pressure-loaded RV needs plenty of perfusion pressure
dont forget anaphylaxis (or similar) as a cause of circulatory failure
protamine & blood products
Inotropes
decision to use inotropes (rather than temporising with calcium and pressors) and
selection of a particular agent or combination is sometimes more of an art than a science
and depends on
LV performance
pulmonary vascular resistance / PAP
measured parameters such as BP & CO
surgeons and anaesthetists innate preferences and experience

combinations include
dopamine
like low dose adrenaline
adrenaline
when youre not mucking around
noradrenaline
where CO is maintained or high but hypotension is the problem
dobutamine
milrinone / noradrenaline combination
we usually use about of the low dose regimen
milrinone 25 mcg / kg load, then 0.25 mcg / kg / min infusion
(usually 2 mg load then 10 ml/hr of standard (120 mcg / ml) brew)

Post-bypass
The bypass cannulae are removed and the cannulation sites secured. Heparin is reversed with
protamine and definitive surgical haemostasis is achieved. The pericardium is closed, then the
sternum wired. The circulating blood volume is adjusted in response to clinical and TOE
assessment. Anaesthesia including neuromuscular blockade is maintained. Preparations for
transfer to the ICU bed are made.
17

Decannulation:
clinical perfusionist announces venous is clamped
the venous cannula is usually removed immediately
volume given via aortic cannula as required
commence protamine (see below)
systolic BP 90 100 for removal of aortic cannula
transient aggressive hypotension (~ 60 mmHg) is sometimes required if haemostasis of
aortic cannula site is a problem
Do NOT give or continue protamine in this situation because it precludes the use of
cardiotomy suction
Protamine:
After full wean from bypass
subject to surgical clearance
pt looking reasonable & separation likely to be successful
valve repair or prosthesis satisfactory
primary surgical haemostasis reasonable
dose based on heparin dose
usually described as equal to the heparin dose (see Appendix D)
anaesthetists vary in their approach to protamine dosing if additional heparin given
test dose (10 20mg), then slowly to rd of the planned total dose (approx 20 30
mg/min)
at rd, make announcement and stop
arterial line removed (ensure systolic BP 90 100)
surgeons will have last suck with cardiotomy suction
continue protamine after aortic haemostasis confirmed, surgical clearance, &
cardiotomy off
announce full protamine dosage given
ACT 3 mins later. Target ~ 105 140 secs, lower is better.
Protamine reaction:
any combination of:
hypotension, hypoxia, pulmonary hypertension, pulmonary oedema, circulatory
collapse
often a diagnosis of presumption after attempts to exclude other causes
potentially lethal
can require re-establishment of CPB
give more heparin!
so, how to reverse heparin in this situation? Usually protamine, on the basis that
there are few other options (polybrene has been used, but is very difficult to get
hold of), and that the second attempt with protamine is usually surprisingly well
tolerated.
Closure:
Closing the pericardium reduces cardiac chamber compliance
may need volume and / or pressor
Closing the sternum reduces chest wall compliance
use volume (not pressure) target for ventilation
ensure adequate paralysis
Surgical stimulation is relatively slight during the post-bypass period and the maintenance
anaesthetic can often be reduced.
monitor the BIS
maintain systolic BP 100 110 (but some surgeons prefer higher BP)
GTN / fentanyl or hypnotic to treat hypertension
18

Bleeding
Few things strike fear into the heart of the cardiac anaesthetist so much as the prospect of
bleeding9. Broadly speaking, troublesome bleeding can be classified as audible haemorrhage
(torrential, exsanguinating haemorrhage, for example, arising from a surgical misadventure),
surgical, and coagulopathic haemorrhage.
Although cardiopulmonary bypass results in platelet injury and factor consumption, in most
patients reasonable haemostasis can be obtained with adequate reversal of heparin
(protamine) and meticulous surgical technique (prolene).
Some fundamentals:
bleeding causes bleeding; take prompt action to control haemorrhage
avoid physiological states that favour bleeding such as hypertension and hypothermia
anticipate difficulties in haemostasis and consider pre-emptive management strategies
redo surgery
complex surgery such as Ross, Bentall, or compound operations
deep hypothermia
prolonged bypass
perioperative antiplatelet or thrombolytic treatment
massive transfusion
most cases of surgical haemostatic unhappiness respond to adequate doses of protamine
and early administration of platelets
use a heparinase ACT (cuvettes in the refrigerator in the perfusion room) to rule out
residual heparin effect
the Blood Bank (ext 27275 / 27276) understands CPB-related platelet dysfunction and
will issue platelets without a platelet count for these patients.
If bleeding continues despite these simple measures:
establish liaison with the Blood Bank and a transfusion haematologist.
platelets, FFP, cryo. More platelets, more FFP, more cryo. More prolene.
Send coag studies (make it clear whether the patient is heparinised or not)
keep control of the BP
if clot lysis seems to be the problem, consider adding an antithrombolytic. (For most of
the cases above, the patient will have been on aprotinin or tranexamic acid anyway.)
facilitate / encourage the surgical teams efforts at primary haemostasis
Novo 7 (eptacog alpha, or recombinant Factor VIIa) can make a remarkable difference.
Its a little hard to get because of the cost involved suggest it early. Make sure there is
enough substrate around for it to make a difference (platelets, cryoprecipitate). May not
help that much if bleeding is associated with a synthetic graft.
Surgical haemorrhage:
While we are dependent on the efforts of the surgeon to gain control10, meticulous
attention to BP control, provision / replacement of platelets and clotting factors is
necessary. It is sometimes necessary to over-treat presumptive coagulopathy to
demonstrate that the haemostatic defect is, indeed, surgical.
Many of the surgical efforts effectively plug holes from the outside. Hypertension can
sabotage these efforts.
Novo 7 can have a role here: whatever size hole will stop bleeding without Novo 7, a
bigger hole will stop with it.

inter alia, it has the potential to make the case go late

its axiomatic that difficult surgical bleeding is from somewhere impossible to get to, around the back of the
heart.
10

19

Audible haemorrhage:
Help the surgeons with their efforts to gain control.
Consider heparinising & using cardiotomy suction to collect blood into the pump
reservoir. If the arterial anatomy is sufficiently intact the situation can sometimes be
salvaged by using sucker bypass until definitive control is achieved.
if selective perfusion is necessary, remember that retrograde cerebral and myocardial
perfusion can buy time.
At the end of a difficult (in the haemostatic sense) case, send off repeat coag studies & FBE
prior to heading off to ICU. Itll take an hour off the time for ICU to get a result.

ICU
Postoperative ventilation in ICU remains a notable feature of the routine care of patients after
cardiac surgery. The rationale for this is largely pragmatic: patients seem to do better11. A
combination of potentially large fluid shifts and altered capillary permeability may
predispose to circulatory instability, cerebral & pulmonary oedema.
Having the ICU bed also means that the anaesthetist can use techniques, such as high-dose
opioid-based anaesthesia, that would otherwise not be available.
Most patients are extubated after 4 6 hours.
There is no need to check for a bed for the morning case (but therell occasionally be a
delay for its availability). For subsequent cases the patients are not released by 2E unless
a bed is available.12
if there is uncertainty, speak directly with the ICU Bed Manager (ext 24105)
ICU require a call hr before the patient arrives13. The anaesthetic nurse will usually do
this, you but can sometimes save embarrassment by checking that it has been done.
Transfer:
Move patient onto ICU bed; transfer monitoring
ECG, SpO2, Art, PA, ETCO2
ICU appreciate transducers on pole to patients left hand side
Patient ventilated on 100% O2 on transport ventilator, usually an Oxylog.
Check primary & backup O2 cylinders
Sedation / hypnosis / analgesia & NMB as appropriate
Routine extra equipment includes:
transport kit - self-inflating bag, laryngoscope, etc
defibrillator at foot of bed but not usually attached to pt
Drugs to bring:
hypnotic of choice
pressor
Infusion safety: ensure infusions that are not in pumps are turned off (3-way tap), to
prevent uncontrolled administration
Outside tech will help move bed. The surg reg/fellow will accompany you to ICU
ICU handover:
Identify the RN who will look after the patient; wait for the intensivists
11

and many people have tried.

Sadly, this is no longer true. To the contrary: sometimes ones bed is stolen and one can be left in limbo.
13
Exactly why this should be is unclear. One theory is that the phone call is a trigger to scatter obstacles along
the path through ICU
12

20

Handover should include relevant background, as well as important intraoperative events

patient identity, presenting history & relevant risk factors; significant co-morbidities
functional status
operation/s performed
notable intraoperative events
anaesthetic technique
intubation difficulties; ventilation issues
unexpected findings (e.g. on TOE)
complications
difficulty with wean from CPB
arrhythmias associated with r/o cross-clamp are usually inconsequential
haemodynamic issues; inotrope or pressor support
haemostasis issues
pacing
antibiotics given
make sure any infusions running are clearly labelled and pharmacologically sane.

Delay for ICU bed

maintain sedation / analgesia
switch to propofol infusion if maintenance has been with a volatile agent
continue IPPV. Add PEEP and reduce FiO2 now that apnoeas are no longer likely
continue full haemodynamic monitoring
continue suction on drains, etc.
manage circulatory volume with pump blood, colloids and/or crystalloid.
do the routine initial ICU bloods & manage the results
CXR if theres time
if the wait is long, ensure pressure care
if the patient is very well behaved, consider extubation
Morning case can sometimes be moved into PACU
check with DA nurse-in-charge first!
This allows the theatre to be used for the second case14, but will take an anaesthetist and a
nurse out of play
if the delay is likely to be short, the transport ventilator and monitoring can be used
dont forget to plug power & O2 into wall outlets!
otherwise use a spare anaesthetic machine to provide IPPV & full monitoring.

Modified Bypass: OPCAB and PADCAB

Background: In late 90s & early 00s, there was widespread surgical enthusiasm for OffPump Coronary Artery Bypass (OPCAB) and, to a lesser extent, Perfusion Assisted Direct
Coronary Artery Bypass (PADCAB). This was largely in an attempt to mitigate adverse
surgical outcomes believed to be due to CPB or to cross-clamping, e.g. neuropsychological
defects, coagulopathy, and myocardial ischaemia15.
A variety of techniques were developed to manipulate the heart so that the target sites could
be accessed, and immobilising devices with names like Octopus or Platypus were a
healthy source of income for company reps. Temporary shunts were sometimes used to allow
coronary perfusion during the anastomosis.
14
15

of course, therell now be a delay for the second bed, too. Better ring home, youre gonna be late .
Well, there may have been some me too-ism as well.
21

Unfortunately, the hoped-for neuropsychological and other outcome benefits were largely
unrealised. PTCA has taken most of the easy candidates for CABG, and some surgeons
consider that there is potential compromise in the selection of targets and in the anastomoses.
As a result, the techniques have fallen somewhat out of favour, although there are some cases
which remain suitable. In particular, be on the lookout for cases where few grafts are planned
(esp. CABG x 1 2 on LAD +/- PDA systems only)
OPCAB
Very poor correlation between booked OPCAB and actual OPCAB
Our setup (monitoring, patient positioning, etc) basically as for on-pump case. Some
anaesthetists prefer to avoid use of PA catheter for OPCAB.
Speak up if you dont think the patient will cope (e.g. poor cardiac output with marginal
BP requiring support).
While doing a case off pump is principally a surgical decision, factors such as the
coronary anatomy, the patients cardiac function, and the presence of calcification or
severe atheroma of the great vessels (esp. the ascending aorta) are important.
The heart-lung machine is prepared and available on standby.
Heparinisation is still required. Start with 200 250 U / kg. Aim for an ACT > 380.
Recheck ACT every 20-30 min. Heparin 2500 5000 U prn to maintain ACT.
Surgeon may request for reduced tidal volume. Compensate with higher resp rate, or
accept CO2
Have a pressor available administer in small doses (e.g. metaraminol 0.1 0.25 mg) or
by infusion. Judicious volume loading may also be needed to maintain systemic perfusion
pressure.
temporary pacing can be needed if the AV node misbehaves, e.g. during PDA grafts
If you need to reduce the blood pressure, do it gently. Take some GTN from the infusion
bag into a syringe and administer 0.25 0.5 ml ( = 150 300 mcg)
The surgeon will usually want the systolic pressure around 90-100 mmHg.
Access to the LAD and PDA territories is usually straightforward. Grafting the posterior
surface of the heart (grafts to the obtuse marginals) is more difficult and requires
substantial displacement of the heart.
With the heart dislocated, there is a degree of interference with both venous return and
forward flow
Keep the surgeon informed. If BP does not come up with volume loading & some
pressor, it may be necessary to reduce the displacement or abandon the off-pump
approach.
The VTI of descending aortic flow can be used to monitor stroke volume
The surgeon may apply a side-biting clamp to the aorta to sew top ends.
Tight control of the BP is important hypertension can cause the clamp to slip or
cause aortic injury.
There is the risk of plaque embolisation. This is largely out of our hands, but good
BP control can make initial placement of the clamp easier and therefore less likely to
need repositioning. Encourage the surgeon to do an epiaortic study.
Blood loss can be insidious but substantial. Encourage the surgeons to use the cell-saver
suction. Keep an eye on the patients volume status.
Keep the patient warm
Raise the room temperature
Forced air warmer on as much of the patient as you can.
Check gases regularly throughout the procedure.
Protamine is given in reduced dose. Usually only partial heparin reversal is desired.
Transfer to ICU intubated and ventilated

22

PADCAB
This is basically doing the case on-pump, but without applying the cross-clamp. As a result,
the heart continues to beat (a nuisance for the surgeon and therefore bad) but the myocardium
is not subject to ischaemia & cardioplegia, and systemic perfusion is maintained even with
aggressive cardiac displacement (good). Sometimes viewed by surgeons as combining the
worst features of all of the available techniques!
Sometimes suitable for patients who cannot be cross-clamped because of aortic disease
(porcelain aorta), severe atheroma, etc.
Obviously, set-up and heparinisation etc is as for standard on-pump case.
Lungs off, as for on-pump, unless the BP is pulsatile (i.e. partial bypass), in which case,
ventilate with MV. Dont forget to again when pump off!
Unlikely to have to worry about side-biting aortic clamp (were doing this because of
aortic disease, right?)
Hypothermia can be used (in contrast to OPCAB) but must be moderate (Tmin 32C or
so) to avoid hypothermia-related cardiac rhythm disturbances
Some R-sided open cardiac procedures can be done in a similar fashion (e.g. pulmonary
valve). For others, such as ASD repair, most surgeons just use a cross-clamp to get the
benefit of an immobile heart
Monitor for LV distension. If the heart fibrillates (or just stops), it is crucial to
restore the cardiac rhythm (zap or pace) or
apply a cross clamp and give cardioplegia or
insert an LV vent
The heart should bounce off bypass. Problems should prompt a search for factors that
have changed since pre-bypass specifically, technical issues with the grafts.

Redo Cardiac Surgery

Re-operation months or years after cardiac surgery is moderately common, and confers
substantial additional risk such that special consideration of the issues is warranted. In
particular, the pericardial sac is largely obliterated after cardiac surgery. The RV can be
adherent to the sternum. It is usually impossible to deploy internal paddles in the pre-bypass
phase, so external defib pads are applied in case defibrillation is required. Internal cardiac
massage can be impossible. Sudden, massive blood loss can occur, and can be effectively
uncontrollable (refer audible haemorrhage in the Bleeding section.)
Non-cardiac factors:
Patients will generally be older
Conduit may be in short supply
Anaesthetic:
Consent often a little easier (had it all before) but surgical risks are substantially greater.
Much greater likelihood of transfusion of blood or products; use of coagulation
factors or platelets post-bypass almost universal
Possibly risk of drug reaction (protamine, aprotinin) with previous exposure
Apply external defib pads pre-induction
Have blood in room for sternotomy
Use of antithrombolytics almost universal
Discuss with surgeon
cannulation pre-sternotomy?
cannulation sites?
conduit at risk (e.g. graft crossing beneath sternotomy)?

23

Cardiac and surgical factors:

May require establishment of CPB pre-sternotomy (e.g. via femoral cannulation)
Modified sternotomy technique
Painstaking dissection of adhesions, identification of old grafts.
No ready access to cannulation sites (RA, ascending aorta)
Patent existing IMA grafts must be clamped in addition to application of cross-clamp
Patent existing IMA grafts must be unclamped on r/o cross-clamp!
Typically, sternotomy is followed by enough dissection to cannulate, then more
dissection performed on bypass (allowing more aggressive manipulation of the heart).
Adhesiolysis leaves bleeding raw surfaces. Everything bleeds.

Removal of Permanent Pacing Lead Systems

These procedures are performed in the operating theatre by a cardiologist16, because the
potential complications are serious and may require urgent cardiac surgical intervention,
including sternotomy and/or institution of CPB. A cardiac surgical team is on standby, and
during difficult stages a surgeon is in attendance.
Patients are of all ages but tend toward the elderly. Infection is the commonest reason for lead
extraction, and can be limited to the site of the generator or involve the leads with frank
endocarditis. In younger patients lead failure is a common indication.
Patients with ICDs often have poor ventricular function. Clearly, some patients will be
pacemaker dependent; a temporary pacing system must be placed before the PPM is detached
in these patients.
Removal of the generator is straightforward but the leads are not designed for easy removal,
and tend to be firmly adherent to endocardium and adjacent great vessels. The recent advent
of laser dissection systems has significantly reduced the operating time and the degree of
traction required for lead removal.
TOE and II are used throughout the procedures, which generally take from 1 to 3 hours.
Many patients have had previous cardiac surgery: on the one hand, they are less likely to
develop cardiac tamponade because the pericardial sac is obliterated; on the other, if
sternotomy is required for salvage, this is extremely difficult.
Complications include:
cardiac perforation +/- tamponade
acute tricuspid valvular incompetence
pulmonary embolism (e.g. of lead vegetations)
rhythm disturbances
blood loss is rarely spectacular but over the course of a long case can be significant.
Check that a valid group & screen has been performed, and a cross-match for high-risk
cases.
Rarely, extrapericardial vessel perforation can result in haemothorax. If this involves the
SVC, surgical control can be problematic. In difficult cases, volume access via a femoral
vein can be required.
inadvertent activation of an ICD. Check with the proceduralist that the ICD has been deactivated.
16

Readers may note that reference to a specific cardiologist has been deleted; nevertheless I would like to
express my gratitude to Dr Neil Strathmore for his contribution to this section, and for many interesting cases!
24

In general, the difficulty of removal, likelihood of serious complications, and duration of

surgery are all proportional to the time the lead system has been in place.
WARNING: the general cardiac workup of these patients is sometimes incomplete, tending
to focus on the PPM lead system. It is often worth chasing echocardiograms, angiograms etc,
which may have been performed in other institutions.
Set-up:
Mostly as for a routine heart
Table rotated 180 (for II to fit)
Large-bore peripheral IV (or IV on side-arm of CVC, if placed)
Arterial line
External defib pads
CVC (can often be inserted after patient asleep) if
target PPM leads in-situ for 5 years
patient sick and needing one anyway
inadequate peripheral venous access
proceduralist worried
Routine non-invasive cardiac monitoring
5-lead ECG, temp, BIS
usually no IDC unless proceduralist really worried
ETT
TOE
Head frame, shoulder roll, head-ring
Conduct:
Routine GA with a view to extubation & PACU.
traction on lead system cardiac distortion hypotension.
cases not intrinsically very painful.
TOE:
used to monitor for complications, as above
sometimes will need to withdraw probe if obscures II of leads.

Interventional Cardiology
The RMH Cardiology Dept performs both electrophysiological and structural procedures.
The former range from ICD implantation & testing, to minor pathway ablations, through to
extensive 3D mapping that can take 6 8 hours. Structural procedures include ASD & PFO
closure, and stenting coarcts. The unit has also started performing percutaneous valvular
procedures. We also have an occasional role in the salvage / resuscitation of patients with
acute crises such as coronary dissection.
Some fundamentals:
In cath lab on 2nd floor
one lab has been set up for EP work; the other has better imaging and is used for the
structural stuff
Patients usually DOSA via 2E.
Despite several attempts at educating them, cardiologists are unable to appreciate the
difference between their (cardiology) preadmission process, and ours. As a result, the
patient will generally not have had an anaesthetic assessment and from time to time
significant anaesthetic issues are only picked up at the last moment.
25

Usually GA, occasionally proceduralist will request IVS

on rare, blissful occasions, standby
for ICD & test, ICD implantation under LA/sedation then single-shot propofol for
ICD test is often reasonable.
For most procedures the proceduralist stands to the patients right and we end up on the
patients left near the head. Peripheral vascular access via the left upper limb is generally
suitable.
ICDs the proceduralist stands at the patients left and we need to move to the right.
The anaesthetic machine needs a very long O2 (white) supply hose
Sometimes access via the R IJV is required, for placement of a coronary sinus electrode.
II is extensively used. Since we do not necessarily face the X-ray source, wrap around
lead protection is required.

Monitoring:
3-lead ECG (in addition to ECG of external defib & EPS surface electrode array.)
Defib pads (placed by EP technician)
Art line for most cases (can be done asleep for well patient)
BIS & neuromuscular monitoring
IDC for long cases e.g. pulmonary vein isolation for AF, or 3D mapping (Carto)
really (despite the potential disinclination of the cardiologists)
Induction & Maintenance:
Rotate table to permit access to head/airway
ETT if TOE required
Route airway tubing away from the area that the X-Ray tube needs to rotate.
for EPs the X-Ray tube rarely needs to move beyond 45%; for structural work true
laterals may be required move equipment to provide clearance.
Long and frequent apnoeas are required.
maintain on 100% O2
opportunistic ventilation between burns
(IIPPV = Intermittent Intermittent Positive Pressure Ventilation)
beware the patient with limited respiratory reserve, who cannot catch up again before
the next apnoea
if necessary, suppress spontaneous respiration with NMB or opioid.
Trans-septal approach to LA may require TOE guidance
Cardiologists may occasionally request TOE examination to exclude haemopericardium.
Beware excessive administration of crystalloid. With an irrigated ablation catheter, pt can
have 1 2 L fluid in addition to what we give.
Inform the cardiologists if hypotension occurs. Often pacing related, but can trigger a
request to check for cardiac perforation.
The patient will often be paced (from various sites within the heart) for most of the case.
The pacing rate is often given as cycle length, in milliseconds. Hence pace at 600 means
100 bpm.
Ask the cardiologist for some pacing if bradycardia is a problem.
Heparin ~ 100 - 150 U/kg will be requested if catheters are to be placed in the LA. The
target ACT will generally be 300 350 seconds, monitored hourly. Low dose heparin ~
2500 U may be requested for less critical work.
Protamine is usually not given.
Isoprenaline is often to initiate the target dysrhythmia. The cardiology staff will make up
a syringe (100mcg/ml 6ml/hr = 1 mcg/min ) & provide a pump.
Structural work sometimes requires that the patients arms are positioned above their
heads. Ensure adequate IV/art line tubing lengths & freedom of movement.

26

Emergence & Recovery:

To 3rd-floor PACU. Give them a ring a few minutes before turning up.
Post-procedure pain rarely severe, but may sometimes require IV paracetamol +/- opioid.

Appendix A:

Induction in Selected Pathophysiological states

Patients with chronic conditions have generally been optimised preoperatively. Get your head
around their haemodynamic balance preop and aim to maintain this at induction and beyond.
Unstable patients can be trickier and require acute resuscitative measures during transport,
institution of monitoring, and induction.
AORTIC STENOSIS
PRELOAD
AFTERLOAD
CONTRACTILITY
RATE
RHYTHM
POST-CORRECTION

NEED TO FILL NON-COMPLIANT VENTRICLE.

ADEQUATE DIASTOLIC BP TO MAINTAIN CORONARY
PERFUSION.

AVOID EXTREMES. RAPID ISCHEMIA. SLOW CO.

SR CRITICAL FOR PRELOAD. ATRIAL KICK, NB FOR VENT.
PRELOAD.
SAME GOALS. VENTRICULAR HYPERTROPHY & DIASTOLIC
DYSFUNCTION STILL VERY MUCH PRESENT.

AORTIC REGURG.
PRELOAD
AFTERLOAD
CONTRACTILITY
RATE
RHYTHM
POST-CORRECTION

NEED ADEQUATE VENOUS FILLING.

TO PROMOTE FORWARD FLOW.

CO & MAINTAIN SMALLER CHAMBER SIZE.

NOT CRITICAL.
PERSISTENT MR, PHT, RV DYSFUNCTION.

HOCM
PRELOAD
AFTERLOAD
CONTRACTILITY

RATE
RHYTHM
POST-CORRECTION
MITRAL STENOSIS
PRELOAD
AFTERLOAD
CONTRACTILITY
RATE
RHYTHM
POST-CORRECTION

MAINTAIN LARGER END-SYSTOLIC VOLUME & REDUCE

INTRACAVITY VELOCITIES & PRESSURE GRADIENTS

SR CRITICAL.
SAME GOALS. DIASTOLIC DYSFUNCTION REMAINS.
MAINTAIN GRADIENT BUT AVOID PULMONARY OEDEMA.
RIGHT SIDE (AVOID HYPOXIA, HYPERCARBIA, ACIDOSIS).
RV MAY NEED SUPPORT. LV USUALLY OK.

USUALLY IN AF CONTROL VENT. RESPONSE

IF IN SR, ONSET OF AF CAN PRECIPITATE DECOMPENSATION.
RV SUPPORT IF SEVERE PULM. HYPERTENSION.
LV DYSFUNCTION MAY BE UNMASKED.

27

MITRAL REGURG.
PRELOAD
AFTERLOAD
CONTRACTILITY
RATE
RHYTHM
POST-CORRECTION

MAINTAIN AVOIDING PULMONARY OEDEMA.

TO REDUCE REGURGITANT FRACTION.
MAINTAIN; BE WARY OF MASKED DYSFUNCTION.
IMPROVES CO & VENTRICULAR SIZE.
NOT CRITICAL. SOMETIMES IN AF.
LOSS OF REGURG. EFFECTIVELY IN AFTERLOAD; UNMASKS LV
DYSFUNC.
SO, AFTERLOAD, +/- INOTROPE, RX PHT.

CARDIAC TAMPONADE
PRELOAD
AFTERLOAD
CONTRACTILITY
RATE
RHYTHM
POST-CORRECTION

PATIENTS SYMPATHETIC TONE IS HIGH. MAINTAIN

THIS.
AT THE LEAST, MAINTAIN. CRITICAL.
CO IS RATE DEPENDANT IN THESE PATIENTS.
CRITICAL.
SINUS TACHY
ANTICIPATE REBOUND BP. DEEPEN ANAESTHETIC,
ANALGESIA, SUPPORT AS INDICATED.

If there are mixed lesions, consider the dominant, most critical or symptomatic lesion.
Some lesion combinations are a headache for example, AS & MR. Throw in some
coronary pathology and the stage is set for an eventful case!

Memory jogger:
Regurgitant lesions: Full, Fast & Forward
Stenotic lesions:
Slow & Steady

The patient with IHD: you already have your head around the balance of O2 supply &
demand from your regular lists. Unless the patient is acutely ischaemic or
haemodynamically compromised, the general rule is that maintaining the patients
haemodynamic state at baseline, day-to-day values patient is reasonably safe. If variation
are required, gradual changes are better tolerated than sudden ones.
Congenital lesions are infrequently seen at RMH. You may see the occasional ASD,
bicuspid aortic valve for Ross in a young person, Marfans, or redo in young adult with
past paediatric cardiac surgery. It is sensible to appreciate the basic concepts of:
Cyanotic and Non-cyanotic lesions
PDA
PFO / ASD
Tetralogy of Fallot
Non-cardiac surgery for the patient with a transplanted heart.

Appendix B:

Anticipating the Surgical Steps

Cardiac anaesthesia must cope with a wide range in the degree of surgical stimulation, from
intubation to prepping, from sternotomy to harvesting the LIMA. The surgeon is also
uniquely prone to interfere with what we usually consider our exclusive territory
manipulation of the heart and great vessels can even result in transient circulatory arrest, and
it is not uncommon for the surgeon to require prolonged periods of apnoea during the
harvesting of the IMA.
28

In general, it is better to anticipate rather than react to the results of these events. Failure to do
so may result in rollercoaster haemodynamics: unanticipated surgical insult precipitous
physiological response late response with over-correction on your part physiological
response requiring correction again potential surgical sarcasm. On the other hand it is
important not to over-anticipate; sometimes sitting tight is called for.
Always have an eye on the surgical field (stand on a step if you need). There is no other
way to put into context what you are seeing on your monitors.
STEP
PRE-INDUCTION
INDUCTION
PREP/DRAPE
INCISION/STERNOTOMY
CARDIAC MANIPULATION
IMA HARVEST

HEPARINISATION
EPIAORTIC SCAN
AORTIC CANNULATION
ATRIAL PURSE-STRINGS
CORONARY SINUS
CANNULATION
POST-CANNULATION
ON BYPASS
(SEE SECTIONS
SPECIFICALLY RELATING
TO MANAGEMENT OF PT
ON CPB)

ANTEGRADE CPLEGIA
DE-AIRING
LUNG INFLATION
DEFIBRILLATION
PACING
WEAN FROM BYPASS
DECANNULATION
PROTAMINE

POST BYPASS CV
CHANGES
CHEST CLOSURE

ACTION
MANAGE ANXIETY
CONTROL PRESSOR RESPONSE TO INTUBATION
ANAESTH DEPTH
ANAESTH DEPTH
SIT TIGHT!
TV
100% O2 LONG APNOEAS
ANAESTH DEPTH
HEPARIN READY (0.4 KIU / KG)
EXPECT BP
CHECK ACT AFTER 3 MINS
HELP WITH IMAGE ACQUISITION AND INTERPRETATION
BP ~ 100/- FOR MOST SURGEONS
LUNGS OFF FOR RETROGRADE SUTURE.
MAY PRECIPITATE AF.
IMAGE WITH TOE
CHECK FOR AIR IN LINES; VOLUME OR PRESSOR FOR BP
LUNGS OFF
MONITOR & VENTILATOR TO CPB MODE
IV OFF
GTN OFF
PA CATHETER BACK
CONFIRM ANAESTHESIA MAINTENANCE WITH PERFUSION
MONITOR FOR LV DISTENSION
MANOEUVRES AS REQUIRED MAY INCLUDE VENTILATION,
PARTIAL BYPASS, MOVING THE TABLE, ASSESSMENT OF
RESIDUAL AIR WITH TOE
(CARE WITH LIMA GRAFT UNDER SURGEONS SUPERVISION)
10 20 J; ANNOUNCE WHEN CHARGED; ZAP IMMEDIATELY ON
SURGEONS GO
SEE PACING SECTION
SEE COMING OFF BYPASS SECTION
MAINTAIN ANAESTHESIA
PRESSURE ~ 100/SUBJECT TO SURGICAL CLEARANCE:
10 20 MG AS TEST DOSE
1/3RD OF DOSE PRIOR TO AORTIC DECANNULATION
REST OF DOSE AFTER AORTIC CANNULATION SITE SECURED
VOLUME LOADING; PRESSORS; GTN FOR MAINTENANCE OF
CIRCULATION; INOTROPES IN CONSULTATION WITH SURGEON
LUNGS DEFLATED FOR STERNAL APPROXIMATION
EXPECT BP WITH MEAN INTRATHORACIC PRESSURE
PARALYSIS

29

Dont forget that drugs especially fentanyl take a while to have their peak effect. With
a little effort it is possible to give the drug too late, resulting in ineffective control of the
surgical stimulus, with subsequent hypotension.
Tricks for BP acutely include:
GTN bolus (0.5 1.0 ml = 300 600 mcg)
reverse Trendelenberg
ventricular pacing, if wires in-situ
phentolamine 0.5 - 1mg like Aramine in reverse
transiently increasing depth of anaesthesia
If the lungs get in the way the surgeon may ask for deflation. With the lungs out of the
way, there is nothing to remind the surgeon to permit ventilation again. Keep an eye on
what theyre doing, and remind them that you need to ventilate when theyve finished
their lung-free delicate bit. Ensure apnoea or ventilator alarms are enabled to remind you
to ventilate before embarrassment occurs.
Things vary from case to case and from surgeon to surgeon, and the above list is not
exhaustive. After doing a few of these lists, youll get into the swing of things and will
anticipate well enough.
Valve surgery is generally similar. Differences include: no vessel harvest shorter prebypass period; TOE assessment focus on relevant valve/s; aggressive de-airing required.

Interpret all observations in the light of what the surgeon is doing.

Anticipate and pre-empt but dont over-react.

Appendix C:

Cardio-pulmonary bypass

This is intended to complement the section on CPB in the main text.

30

The machine is primed with ~ 2l of heparinised crystalloid or colloid. Blood prime is

occasionally used for small or anaemic patients.
Going on bypass:
Aortic (ascending aorta) & venous cannulae (RA to IVC +/- SVC) in place.
Antegrade (ascending aorta below cross clamp) & retrograde cardioplegia cannula
(coronary sinus) are placed.
ACT checked.
Perfusionist gradually releases clamp on venous line.
Right heart return reduces as blood is diverted to the venous reservoir
The arterial pump returns this blood into the aorta, via the oxygenator / heat
exchanger
Right heart return & ejection fall. The left heart empties.
Ventricular ejection decreases. Pulsatility at this stage implies:
obstruction of the venous line (may be deliberate)
significant aortic regurgitation
unusual things like PDA
Flow ~ 2.4 3 l/min/m
Pressure at 50-80mmHg
hypotension lasting for a few minutes often occurs with running on. Large doses
of metaraminol may be required
Cross-clamping with cardioplegia is another separate step see Appendix D
some surgery can be performed on bypass with the heart still beating
renders the heart ischaemic and therefore the need for myocardial protection
antegrade and retrograde cardioplegia
Some real disasters can occur on bypass. Clean kills in Perfusion include:
Massive air embolus
No oxygen in the oxygenator
No heparin.
Mechanical pump or circuit failure
Get the perfusionist to show you the safety protocols that avoid these.
Review the plan for massive air embolus on pump (stop pump, steep Trendelenberg,
thiopentone, rapid cooling, de-air pump, retrograde perfusion).

Maintenance on CPB:
BP control: Pressure 50 80 mmHg. Some patients (e.g. impaired autoregulation,
diseased cerebral arteries) may need the pressure kept on the higher end. Managed by
altering flow, administration of vasoactives and anaesthetic agents including opioids.
ACT every 30 min. > 480. More frequent if normothermic
Blood gases
PaCO2 40mmHg set by altering gas flow (sweep) through oxygenator
PaO2 > 100mmHg set with O2 % through oxygenator
BE 2.5. Acidosis can be due to inadequate perfusion or poor distribution.
Hb 7.5 10 g/dl
Temperature:
Somewhat dependent on surgical philosophy
usually ~ 34C
16-18C for deep hypothermic cardiac arrest (DHCA).
If DHCA, monitor central 2 sites (usually nasopharynx & bladder). Differences are
due to differential flow.
ECG
asystole is generally good
ventricular electrical activity signifies the need for repeat cardioplegia.
31

Urine output: Oliguria ( 1ml/kg/hr)

Pump flow adequate?
MAP adequate?

The above are managed by the perfusionist. Although you do not control the pump, being
ignorant to them is not kosher either.
During CPB, drugs are injected directly into the pump reservoir via the perfusionist.
At RMH, Bypass Time is useful for
catching up on the paperwork
short tea break (or lunch)
getting the next patient around & plumbed

DHCA:
Infrequent several cases per year, mostly for aortic arch work (dissections etc)
Meticulous glucose control required to risk of neurological injury
Slow rewarming no more than 1C core temp per 3 mins.
Stop rewarming at core temp. of 36-37C
These patients bleed and will usually get aprotinin tranexamic acid and generally need
platelets & factors, sometimes even Novo 7
These operations are subject to meticulous planning; where possible, antegrade or
retrograde cerebral perfusion is used to minimise cerebral ischaemic time.
Adverse effects of CPB:
General: loss of pulsatile perfusion peripheral perfusion mismatch
CNS: micro & macro emboli
Resp: blood flow; deflation / atelectasis impaired gas exchange mechanics
circulating mediators capillary permeability extravascular lung water
Systemic: Activation of humoral cascades (coag, fibrinolytic, complement, kallikrein)
SIRS
Haematological: dilutional anaemia; platelet activation & dysfunction. DIC
Endocrine: catecholamines, stress hormones; hyperglycaemia
GIT: splanchic blood flow; gastric pH; endotoxaemia
Renal: tubular function

Appendix D:

Cardioplegia

Merely running onto bypass will not interrupt the electrical activity of the heart or stop the
(empty) heart from beating; if there is significant aortic regurgitation or obstruction to the
venous drainage, significant pulsatile output can occur. To actually stop the heart, it is
necessary to administer a cardioplegic solution17. The aortic cross-clamp is required to
maintain asystole (by preventing washout of the cardioplegia solution), to permit a bloodless
surgical field, and to prevent filling and distension of the arrested ventricle.
Composition:
At RMH we generally use a tepid blood cardioplegia, based on a commercially prepared
hyperkalemic crystalloid solution. High and Low compositions are available.

17

Other techniques such as deliberately inducing VF, or permitting profound hypothermia to cause asystole
without a cross-clamp, are used so infrequently at RMH that they will not be considered further here.
32

The High solution is used to induce cardiac arrest or if recurrent electrical activity
occurs, but can result in systemic hyperkalemia. The Low solution is used for
subsequent doses to maintain asystole. Both are mixed with arterialized blood, typically
in a ratio of 1:4 (crystalloid to blood). Lower ratios of cardioplegia/blood can be used
(1:6, 1:8 or even 1:10) if hyperkalemia is a problem, in the absence of recurrent cardiac
activity.
Supplied
Administered18 Units
High
Low
High
Low
+
Na
154
154
143
143 mmol/l
K+
80
34
20
10 mmol/l
++
Mg
30
10
7
3 mmol/l
glucose
22
22
9
9 mmol/l
HCO3
50
10
30
20 mmol/l
aspartate
56
56
11
11 mmol/l
lignocaine
520
0
100
0 mg/l
Hb
0
0
6.5
6.5 g/dl
Table 1: Typical composition of cardioplegic solutions at RMH

The blood/cardioplegia mixture is administered at approx 28C (hence tepid)

Cardioplegia is administered after the placement of the aortic cross-clamp (otherwise it is

quickly washed out from the myocardium and electrical activity resumes), and can be
delivered directly or indirectly into the coronary arteries (antegrade or ante) or via the
coronary sinus (retrograde or retro). Usually both delivery routes are used in each case.

Antegrade:
Usually given via a cannula placed into the aortic root, requiring the aortic valve to be
reasonably competent.
In operations of the aortic valve or root, is often administered directly to the coronary
ostia. This is messy if the heart is still beating. Usually it will be rendered immobile
by prior administration via the aortic root or coronary sinus (see below)
Where a graft has been performed to a useful territory, is sometimes administered via a
cannula placed into the graft, prior to the top end being done.
Advantages:
protection of RV
Disadvantages:
requires active intervention by the surgeon
Can cause LV distension with even trivial aortic incompetence
cant vent the aortic root during administration
monitor LV with TOE
severe coronary disease or intracoronary bubbles can result in mal-distribution and
ischaemia.
Retrograde:
Administered via a balloon-tipped cannula placed into the coronary sinus.
Advantages:
Distribution throughout the LV myocardium is largely independent of coronary
disease
Does not cause LV distension, even in severe AR
Can be given without interrupting surgery.
18

Supplied: the composition of the solution in the bags. Administered: the composition administered to the heart
after mixing with arterialised blood. Assumes normal values for plasma electrolytes and glucose, and no
recirculation.
33

Permits administration of a Hot Shot to restore cardiac rhythm while the crossclamp is still in-situ.
Disadvantages:
Sometimes fiddly/difficult or impossible to satisfactorily place the retrograde cannula.
Rarely can cause trauma to the coronary sinus, requiring repair.
Since the coronary sinus principally drains the LV, retrograde cardioplegia provides
limited right ventricular protection.
May contribute to myocardial oedema
Hot Shot:
A final dose of blood, metabolic substrates, and membrane stabilisers (but not
technically cardioplegic) administered warm, to facilitate return of cardiac rhythm.
Usually glucose, magnesium, lignocaine and aspartate, given retrograde prior to
removal of the cross-clamp.

Appendix E:

Drugs

There is ongoing evolution in cardiac anaesthetic practice; in particular, there is presently a

mixed view of TIVA with propofol, and volatile-based techniques are becoming more
common.
The drug layout in the drawers is somewhat different in the cardiac theatres. Take particular
care that you are drawing up the correct drug!!
Reminder: parecoxib is specifically contraindicated in CABG surgery!
Drugs and preferred concentrations vary, but in general:
Standard Anaesthetic Drugs
fentanyl
500 1500 mcg
morphine
10 20 mg
midazolam
5mg
rocuronium 50 100 mg
pancuronium 8 mg

undiluted in 10 ml syringe
diluted to 1mg/ml
undiluted
red syringe or 10 ml syringe
red syringe

More BP
metaraminol 10 mg
phenylephrine 10 mg
ephedrine
30 mg

diluted to 20ml 0.5 mg/ml

diluted to 50 100 ml
diluted to 10ml 3 mg/ml

Less BP
phentolamine 10 mg
(infrequent use)

diluted to 1mg/ml in 10 ml syringe

0.5 1 mg prn

Bypass management
heparin19
30 kIU
undiluted in 35 ml syringe
protamine
300 400 mg; equal to the original heparin dose
test dose (10 20 mg) after surgical clearance then
rd total dose @ 25 - 30 mg/min then
remainder after aortic cannulation site has been secured.
19

For the purposes of calculating the protamine dose: heparin activity is approx 80 U/mg. If a reference to mg is
made, this is generally rounded to 100 U/mg. Thus if 300mg heparin is given, it really means 30 kIU, actually
closer to 375mg. Partly for this reason, it is common to bump the protamine dose a little.
34

Other routine / semi-routine drugs

GTN
50 mg / 83 ml
noradrenaline 6mg / 100ml
insulin

Alaris pump
1 ml / hr 10 mcg / min
Alaris pump
1 ml / hr 1 mcg / min

50 U / 50ml

Antibiotics
flucloxacillin 2 g
vancomycin 1.5 g
ceftriaxone
1g

slow IV
v slow IV
(Note dose: not 2 g)

Most cases: fluclox & ceftriaxone. Vanco replaces fluclox if allergic or inpatient more than
48 hrs or so. Some surgeons request triple antibiotic therapy (fluclox + vanc + cef).
Anti-thrombolytics case by case basis
TXA
3.0 g
undiluted in 30 ml syringe
1 g with sternotomy then 0.5 g/hr
Other infusions
Almost any drug may be required on short notice. Many are pre-programmed into
the Alaris and it is usually ideal to use the preset parameters.
Otherwise either:
use the official ICU protocols if they are known (see wall chart) or:
use a generic formula such as 6 mg / 100 ml (or equivalent)

Appendix F:

IABP

The correctly adjusted intra-aortic balloon pump augments systemic diastolic pressure and
reduces afterload by deflating immediately prior to systole. It is used in unstable coronary
syndromes where other techniques have failed to control ischaemia. Occasionally it is
commenced intraoperatively, when LV performance is poor, to facilitate weaning from CPB
or reduce inotrope requirements.
In general, where the IABP has been established pre-operatively, it is continued
postoperatively even though the indication (e.g. ischaemia) has been addressed.
General principles:
Inflates in diastole, boosting diastolic pressure, typically to levels above those generated
by the heart in systole
systolic pressure on monitor is actually the augmented diastolic pressure.
Deflates in systole, reducing the pressure load on the LV during ejection
Improves coronary perfusion & LV performance.
Serves to decouple myocardial perfusion from myocardial performance
IABP system
console, with tubing and monitoring connections to the patient. The IABP itself consists
of a multilumen catheter with a 20-40 ml balloon.
Catheter size selected according to patient size.
Console incorporates ECG and pressure monitoring
adjustable parameters include inflation/deflation fine-tuning, augmentation volume,
assist ratio, alarm limits.
35

Uses helium for inflation because of its favourable flow (low density) characteristics.

Insertion
Either in the cath lab by a cardiologist and cardiac tech, or by the surgeon in theatre, with
the adjustments made by the perfusionist. You may be part of the decision-making
process (and may have to look after it in ICU on your ICU rotation), so it is worth
becoming familiar with the controls & principles.
Placed in the descending aorta, under fluoroscopic or TOE guidance. The tip of the
catheters should be just distal to the left subclavian artery.
Modern catheters usually sheathless, inserted by cut-down or percutaneous (Seldinger)
technique.
Timing
Usually automatic. Some manual adjustment may be possible/required.
Rapidly inflated during early diastole by the console
Timing is usually by ECG, modern machines can also use the pressure signal and
autoselect the best trigger
tachycardia, AF reduce efficiency of augmentation
diathermy can be a problem in the operating theatre pressure trigger
beware inadvertent disconnection of IABP ECG when setting up a case
may need to set up slave cable from anaesthetic monitor if IABP inserted during case in
theatre.
Mistiming can increase the workload on the heart
Careful attention to balloon synchronisation with ECG and arterial wave.
Inflation: occurs just following the dicrotic notch and results in a distinct M wave
on the arterial tracing.
Deflation: should precede ejection so that a distinct diastole is evident.
Setting the balloon to inflate every other beat (2:1), may help with adjustment of timing,
after which 1:1 assistance can be resumed.
Indications:
unstable coronary syndromes unresponsive to medical therapy
cardiogenic shock
acute LV failure (less useful than VAD)
Absolute contra-indication:
Aortic dissection
Relative contra-indications:
moderate to severe aortic regurgitation
severe aortic atheroma
severe peripheral vascular disease
Risks / Complications include
aortic damage/dissection
embolic complications including CVA
limb ischaemia (relating to the insertion site)

IABP is only a short-term solution and should not be considered for the patient with
irreversible cardiogenic shock. It is a temporising measure to get the patient to surgery or
to get the patient off CPB and give the myocardium a chance to recover.
For severe LV failure (failure to wean despite IABP and inotropes) LVAD may be
required (if the patient is considered salvageable), and can serve as a bridge-to-transplant.

36

Peri-operative management
Clinical perfusionist will generally accompany patient on transfers and take responsibility
for IABP
Make changes in consultation with the clinical perfusionist
Balloon deflation can cause transient subatmospheric pressure in the ascending aorta and
can result in catastrophic arterial gas embolus pause inflation during aortic
cannulation (arterial line, aortic root needle)
It might be necessary to change the augmentation alarm limits as the pressure goals
change during the surgery.
The console will complain as it loses its ECG trigger with cardioplegia. Reduce the
augmentation volume and set the machine to its internal trigger mode.

Figure 1: IABP during systole & diastole

Figure 2: Pressures & Coronary flow

37

Appendix G:

Separation from CPB Flowchart

Optimize:
Electrolytes, Acid-base, Hb
Ventilation, O2
Temp, Anaesthetic state

Evaluate

Heart rate

- Temp.
- Anaesthetic depth

Rhythm

Pacing
Atropine
Determine
type &
cause. Rx

Separate
from CPB

Low MAP
GTN
Remove vol.
Reverse
Trendelenberg
Volatiles
-blockers
Stop inotropes
Vasodilators
Milrinone
IABP

Preload

Satisfactory MAP, preload,

contractility
Volume

CVP, PAOP, TOE

Contractility
Visual, TOE, CI

Afterload
SVR

Catecholamines
Milrinone
IABP

Vasoconstrictors

BP OK?

CVS collapse

Resume CPB
Consider IABP

38

Appendix H:

Eponyms

Surgeons fear obscurity. They can die happy if they have something named after them20.
They learn and earnestly use eponymous terms in the hope and expectation that one day their
own idiosyncrasies will likewise be propagated along the sewers of time.
Here, for the rest of us, is what Ive been able to make out of their incoherent ramblings:
Ross Procedure: aortic autograft and pulmonary homograft. The native pulmonary valve is
transferred into the aortic position. The coronaries are re-implanted. Somebodys spare
pulmonary valve is implanted to replace the missing valve. Long case.
Bentalls [operation]: compound aortic valve & ascending aorta replacement, often using a
valved conduit (big piece of Dacron graft with a prosthetic aortic valve at the bottom end).
Requires re-implanting the coronary arteries. Moderately long case.
David Procedure: Like a Bentalls, but without the AVR part. Still requires reimplantation of
the coronaries.
OBrien [valve]: stentless aortic valve replacement. Complicated way of doing an AVR.
Alfieri [suture]: technique for mitral valve repair. A cunningly placed stitch converts MR into
MS. Generally combined with other methods of repair (annuloplasty, etc).
Occasionally seen at RMH (survivors of surgery for congenital conditions):
Fontan procedure (rarely performed in adults; Fontan physiology refers to a patient who has
had a Fontan procedure or who has an equivalent physiological state): bypassing the right
ventricle so that systemic venous return is diverted directly to the pulmonary arteries. In the
past the native right atrium was left in-situ, but this is associated with significant thrombosis
risk. Now synthetic conduits are more commonly used.
A small right-to-left shunt is commonly created to reduce systemic venous hypertension, at
the cost of significant reduction in baseline oxygen saturations.
Avoid situations that cause increased pulmonary vascular resistance; IPPV will be tolerated
better than hypoxia or hypercarbia, but minimise airway pressures. Keep fluids up.
Norwood: for hypoplastic left heart essentially, attaching part of the RV outflow to the
aorta. If all of the RV outflow is diverted to the systemic circulation, the patient ends up with
Fontan physiology.
Rastelli: internal Gore-Tex baffle placed to divert oxygenated blood to the aorta, etc. Used in
various forms of scrambled heart.

20

Not wanting to encourage them, Ive made no attempt to find out who any of these people are, except that
Helen Taussig (1898 1986) was a cardiologist, and Vivien Thomas (1910 1985) the surgical technician who
developed and taught the surgical techniques used by Blalock celebrated in the film Something the Lord Made.
39

Rarely seen at RMH (obsolete, done elsewhere, etc):

Blalock ((-Thomas) -Taussig) Shunt: aorto-pulmonary shunt, now often done utilising a
synthetic conduit between the distal aortic arch or its branches, and the left pulmonary artery.
Performed in infancy to improve pulmonary blood flow in many cyanotic congenital cardiac
conditions.
Gott shunt: heparin-bonded shunt bypassing the operative site of the descending thoracic
aorta. Rare because cardiothoracic surgeons would use pump-oxygenator; vascular surgeons
would use a stent.
Glenn (bi-directional) shunt: kind of a half-Fontan, used in single-ventricle situations. The
SVC is plugged into the R PA and the main PA is ligated. Results in low pulmonary flows
(only the SVC return), which is advantageous if pulmonary vascular resistance is high, as in
early infancy. Can be later converted to a Fontan.
Mustard procedure: atrial baffle used for transposition of the great arteries (TGA). It leaves
the arteries transposed, but diverts systemic venous return to the lungs via the LV. The RV
perfuses the body and can eventually fail. Obsolete most patients now have an arterial
switch instead, which gives the patient a normal circulation.
Maze operation: series of incisions made into the atria, intended to control AF by preventing
re-entrant propagation of the action potential. Made largely obsolete by percutaneous
techniques (pulmonary vein isolation) in the EP lab.
And a few eponymous conditions:
Ebsteins anomaly: the tricuspid leaflets are displaced towards the apex of the RV, leaving
an inadequate RV cavity (much of the RV cavity is atrialised). The patient has poor exercise
tolerance because their RV output is limited. May present in adulthood for tricuspid valve
surgery.
Fallots tetralogy, the most common form of cyanotic congenital heart disease with potential
for survival into adulthood (more so now that repairs are done in early childhood): VSD,
overriding aorta (collects output from both ventricles), pulmonary stenosis, RV
hypertrophy. Patients will often have had complete repair, but some patients have had partial
repairs or symptomatic relief with a Blalock shunt.

40