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Anesthesia for Cardiovascular Surgery

CARDIOPULMONARY BYPASS. CPB? ???? ?? venous blood? ???? oxygenation ??? CO2? ???? large a. (?? aorta)? ????? ???CPB period ?? ?? ??? ??? systemic hypothermia(20-32

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Anesthesia for Cardiovascular Surgery

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    1. Anesthesia for Cardiovascular Surgery -R1 ???

    2. CARDIOPULMONARY BYPASS CPB? ???? ?? venous blood? ???? oxygenation ??? CO2? ???? large a. (?? aorta)? ????? ??? CPB period ?? ?? ??? ??? systemic hypothermia(20-32°c), topical hypothermia (ice slush solution) , cardioplegia ?? ??? CPB? ??? highly specialized technician ? perfusionist? ??? ??? ???? surgeon, anesthesiologist, perfusionist?? ??? ??? ??? ???

    3. Basic Circuit • CPB? 5 basic components? ??? -venous reservior, oxygenator, heat exchanger, main pump, arterial filter • ???? machine? cardiotomy suction, Lt. Ventricle venting, catdioplegia? ?? acessory pump? ?? ?? • CPB ? ???? bubble? ??? ?? fluid( ??? ?? 1200-1800ml)? ??? ??? ? - Plasma-lyte A?? balaned salt solution??? ???? colloid, mannitol, heparin, bicarbonate, Aminocaproic acid, aprotonin ?? ?? ??? • CPB? onset?? hemodilution ???? hematocrit? 22-25%??? ??? - ?? ??? severe anemic pt. ??? blood ? priming solution?? ???

    4. Reservior • reservior? Rt. Atriumn ?? sup. ,Inf.vena cava?? ?? ?? ??? venous cannula? ?? blood? ?? •blood flow? gravity? ??? ??? ??? reservior??? ?? ??? ??? •reservior?? fluid level ? ???? ?? ??? - reservior? ???? air? mian pump?? ???? fetal air embolism? ??? ? ?? ??

    5. Oxgenator • reservior ? ??? ?? gravity? ??? oxygenator? drain ? • oxygenator ?? blood? gas-mixture(?? ??) ? ??? ????? blood- gas interface? ???? ?? - volatile anesthetic? oxygenator gas inlet?? ??? • modern, membrane type oxygenator? blood-gas interface? very thin, gas permeable silicone membrane?? ???? - arterial oxygenation? memb. ? ??? ?? blood film? ??? ????? ?? arterial co2 tension ? total gas flow? ?? ??? ??? ???? PO2 , PCO2 control ? ???

    6. Heat Exchanger • Heat exchanger? water flow temperature( 4-42°c)? ??? blood? cooling ?? warming? - ?? heat transfer? conduction ? ?? ??? • rewarming?? blood temperature ??? ?? gas solubility? ???? air bubble? ??? ? ?? ?? catch ? ? ?? filter ??????

    7. Main pump • Roller pumps - roller head? turn??? main pumping chamber?? large-bore tubing? ?????? flow? ??? -roller pump? ??? ??? ??? constant nonpulsatile fiow? ????? • centrifugal pumps - plastic housing ?? ??? cone?? ???? ??? cone? spin?? ??? centrifugal force? blood ? central ?? periphery? ??? - blood flow? pressure sensitive??? electromagnetic flowmeter? monitoring ???

    8. Main Pump(2) • Pulsatile Flow - roller head ? roatation ??? ??? ?? Pulsatile flow? ???? - some clinician? pulsatile flow? tissue oxygenation? ????? stress H. ??? ???? CPB ??? SVR ? ???? ?? ??? ?????? renal , cerebral blood flow? ?? ?? ?? ???

    9. Arterial Filter • CPB ?? thrombi , fat globule , calcium, tissue debris ?? particulate matter? circuit? ????? final, in-line, arterial filter? ??? ???? • filter? ?? ??? ?? ascending aorta? ??? cannula? ?? ???? ??? • filter? clogged ??? high resistance ??? ???? bypass limb?? ???? ??

    10. Accessory Pumps & Devices • Cardiotomy suction - surgical field ? ?? blood ? aspiration ?? reservior ? ???? • Lt. Ventricular vent - CPB ??? bronchial a., thebesian vessel, aortic regurgutation ??? flow? Lt. Ventricle ? ??? ??? ?? ??? myocardial preservation ? ???? - ??? ??? center?? Lt. Ventricle? catheter? ???? ??? filter? ?? reservior? ???? • Cardioplegia pump - cardioplegia ? ?? CPB machine? accessory pump? ??? ??? ?? ??? ??? ?? infusion pr., rate, temp. ? optimal control? ??? • Ultrafilter - ultrafiltration?? blood?? aqueous phase ? ???? ??? CPB ?? trasnfusion ?? ?? hematocrit? ?? ??? ??

    11. Systemic Hypothermia • CPB? ??? ?? intentional hypothermia? ????? ???? core body temp.? 20-32°c ? ?? - body temp. ? 10 °c ????? metabolic oxygen requirement? ??? ??? • ??? ? ???? heat excahnger? ??? ?? normal body temp.? rewarming ?? • adverse effect of hypothermia - platelet dysfuction, citrate toxicity, ionized calcium ??, reversible coagulopathy, myocardial contractility ??

    12. Myocardial preservation(1) • cardiac surgery? ?? ??? ??? perfect surgical repair ?? ??? CPB ??? myocardial damage? ???? normal cellualr integrity? ???? ?? ??? • myocardial damage?? ?? ???? ???? ????? ?? cell ischemia? ischemia ?? reperfusion injury?? ??? ??? ? • CPB??? aortic cross clamping? coronary blood flow? ???? - ??? cross clamping time ? ???? ???? ??? ??? ??? ??? ??? 120? ??? CPB time? undesirable ???? ???

    13. MYOCARDIAL PRESERVATION(2) • Ischemia? high- energy phosphate? ????? intracellualr calcium ? ??? ?????? ??? ??? ?? ???? •??? normal cellular integrity? funtion? ???? ???? ??? ??? ??? high energy phosphate? ????? ???? - ??? ??? ??? ?? systemic hypothermia , topical hypothermia, potassium cardioplegia?? ??? ??? ? ?? •ventricular fibrillation? distension ?? myocardial damage? ??? ??? ? ? ??? ??? ????? ? ?? damage? ???? ??

    14. POTASSIUM CARDIOPLEGIA(1) ??? ??? ??? ?? K rich crystalloid or blood ?? CPB initiation, hypothermia induction, aortic cross-clamping ??, coronary circulation? cold cardioplegia? ?? ??? K?? ??? transmemb. potential(less negative inside) ????, ??? transmemb. potential? depol.?? ???? Na current? ?? -> action potential? ???? ??? diastole?? arrest cold cardioplegia? ? 30????? ???? ->??? ?? wash out ?? rewarming ?? ??, washout - pericardial vessel?? ??? noncollat. coronary bl. flow ??(intercostal a. br. )

    15. POTASSIUM CARDIOPLEGIA(2) K - 50mEq/L ??? ?? -> ? ??? ????? myocardial energy ???? paradoxic increase ??? ?? ??? K load? ? ? ?? ?? Na - plasma?? ?? ??, ischemia? ??? Na content? ????? ?? Ca - cellular integrity ??? ?? ?? Mg - ???? Ca? ?? influx ????? ?? bicarbonate - ?? ?? ?? buffer, acid metabolite? ?? ?? ??, alkalotic perfusate? ?? ??? ? ?? (histidine, tromethamine? buffer? ??? ?) *??.. mannitol - ?? ?? ??, free radical scavenger glucocorticoid - memb. stabilizing effect prostacyclin - antiplatelet effect Ca Ch. B & beta B - metabolic demand ?? Glc, glutamate, aspartate - energy substrate

    16. POTASSIUM CARDIOPLEGIA(3) ??? ischemic damage? ?? - reperfusion injury -> reperfusion?? ?? extensive cell injury, ???? ???? ?? => reperfusion injury? ??? ???? reperfusion ?10??, ??? cardioplegia? arrest?? ???? ???, hyperCa? ??? ?, ?????? ??? -> CPB??? weaning?? 5-10??? ??? empty & beating state ??? ?, acidosis, hypoxia ?? excessive cardioplegia - electrical activity ??                        AV conduction block                        poorly contractile heart                        ???? systemic hyperK ??

    17. PHYSIOLOGICAL EFFECTS OF CARDIOPULMONARY BYPASS

    18. HORMONAL, HUMORAL, & IMMUNOLOGICAL RESPONSES CPB initiation? stress H ??(catechol., cortisol, arginine vasopressin, angiotensin)? variable systemic inflammatory response? ?? -> hypothermia & exclusion of pulmonary circulation?? ?? metabolism?? ?? CPB initiation ?? ???? humoral system? ???         eg. complement, coagulation, fibrinolysis, kallikrein           * CPB? int. surface? bl.? ?? - alternative pathway via C3, classic pathwa via XII          ?? ???? mechanical trauma - PLT, neutrophil ??? systemic inflammatory response syndrome(sepsis, trauma?? ??) ?? CPB? PLT surface? glycoprot. receptor? ?? -> ???? PLT dysfunction? periop. bleeding? ??, ????? ??

    19. ALTERED PHARMACOKINETICS ???? ???? plasma & serum ??? CPB onset? ??? ?? (but, unbound fraction? ?? ????? ?? ?? ?? ??) CPB? ?? effect? hemodillution?? ?? distribution vol.? ??? ??, ??? prot. binding, pph.? central compartment ?? perfusion & redistribution? ???? opioid - CPB component ? ?? heparin - prot. binding? ???? CPB?? ??? constant infusion - ??? ? & ?? pefusion, hypothermia? ??? ?? level ???? ?? ??(propofol? ??) alpha1 acid glycoprot.(CPB ?? ??)? ??? postop. drug binding? ??

    20. ANESTHETIC MANAGEMENT OF CARDIAC SURGERY

    21. ADULTS cardiac surgery? ?? ??? ????? advanced dis.??? ?? cardiac reserve? ???? ??? ?? ?? -> exercise tolerance, myocardial contractility, coronary stenosis ??, ??, ventricular wall motion abnormaility, cardiac end diastolic pressure, CO, valvular area & gradient ? noncardiac surgery? ??, cardiac surgery? ???? ???? cardiac function? ??

    22. 1.PREINDUCTION PERIOD

    23. PREMEDICATION relatively heavy premedication - ?? coronary a. disease light premedication - frail pt. c valvular disease or ischemic CMP -> ??? sympathetic tone? ???? pt? ?? - BDZ(MDZ : 2-10mg IM, Diazepam : 5-10mg PO, Lorazepam : 2-4mg PO), ?? BDZ +opioid(morphine 4-10mg IM or hydromorphine 4-10mg) -> opioid ? ??? BDZ??? half ??? ?? ?? - poor cardiac reserve, ?? ? ?? scopolamine - 70? ???? ??(confusion ?? ??? ??) O2 - nasal cannula? 2-3L/min , premed ?? hypoxia??? ??

    24. VENOUS ACCESS multiple drug infusion ?? -> 2 large-bore(16G ? ? ??) IV cath. -> ??? large central v. ? ????(?? int. jugular v.) - SVC?? entry? ext. jugular v.??? ?? ??? ? ??? good site for pph. iv route central venous cannulation - awake, sedated, ?? induction ?? ?? -> during catherization, face mask ?? supplemental O2 drug infusion - central cath.? ??(cath.? ????? cath.? ??? ??? injection port? ??)   -  multilumen central venous & pulm. a. cath.? multiple drug infusion, vascular pressure ??? ?? * IV port ? ??? drug infusion?? ??, ?? port? drug & fluid bolus? ??, pulm. cath.? ?? introducer sheath? side port? drug infusion? ?? ??? large bore introducer?? fluid bolus line?? ? ??.

    25. MONITORING(1) * Arterial cannulation? induction?? ??. ????? central venous cannulation? induction ????? A. Electrocardiography B. Arterial blood pressure - Radial a. cath.? ??(nondominant hand) Lt. hand?? ???, clavicle? 1st rib ??? subclavian a.? compression????   sternal retraction ? falsely low reading ? ???? ??. - brachial a. cutdown? ?? radial a.? ???? ?? -> a. thrombosis? wave distortion ? ?? ??? ?? - backup manual or auto BP cuff - ???? ??. direct measurement? ??

    26. MONITORING(2) C. Central venous and pulmonary artery pressure - central venous pressure - ?? ???? ?? - pulm. a. cath. – pt, procedure? ?? ???? ?? - LV filling pressure - bypass ?? surgeon? ?? ???? LA pressure line?? ???? - pulm a. cath. – compromised ventricular function(EF<40-50%), pulm. HTN, ??? ???? ???? ?? -> pulm.a.pressure, wedgepressure, thermodillution CO int. jugular v. – prefered central venous cannulation approach(subclavian ?? ext. jugular ? (eg.Lt) sternal retraction ?? cath.? kinking ?? ??.)

    27. MONITORING(3) D. Urinary output : indwelling urinary cath.? hourly output monitor - ???? red urine ?? - CPB? ??? ?? ???red hemolysis ?? E. Temperature : multiple temp. monitor - bladder, rectum, esophagus, pulm. a.-> ?? bladder, rectum ?? ??, pulm. a. ?? ?? ?? ??, nasopharyngeal & tympanic? ? ?? ??, myocardial ?? CPB?? ?? ??

    28. MONITORING(4) F. Laboratory parameters : intraop. lab monitoring –blood gases, Hct, K, ion Ca, Glc, Mg? ??? ? *ACT(activated clotting time) - anticoagulation monitoring G. Surgical field : ?? ??? monitoring ??

    29. MONITORING(5) H. Transesophageal echocardiography - ??? cardiac anatomy, function ? ?? ?? ?? -> eg. regional & global ventricular abnor., chamber dimension,  valvular anatomy, intracardiac air ?? I. Electroencephalography - ????? ???? ?? J. Transcranial doppler(TCD) - brain? basal a.(?? middle cerebral a.)? ???? ??

    30. INDUCTION OF ANESTHESIA * anesthetics ??? ?? ???? ????? ?? -> extremely variable dose requirement(????? ???), ????? ???, ????? ?????? ?? BP & HR?? - unconsciousness(eyelid reflex ??), airway ??, urinary cath. ?? ? -> BP? HR? ???? ??? light anesthesia ??( BP? HR? ??, ?? ??? -> ready to subsequent stimuli) BP 20%?? ???, vasopressor ?? ?? ???? - ?????? ?? intubation ? vasodilation & sym. tone ??? lack ofsurgical stimulation??? ??????? ?? BP? ??? ??? ?? ??? ?? preop. fasting? ??? ??? vol.depletion - vol. ?? ???? colloid ?? bleeding ?? ???? bypass?? ??? IV fluid ??? CPB?, hemodillution ?? phenylephrine(25-50ug), ephedrine(5-10mg) - ??? hypotension??? ?? intubation & controlled ventilation ?? , ACT, ABGA, Hct, K ??

    31. CHOICE OF ANESTHETIC AGENTS Anesthetic technique - volatile inhalation anesthesia - high dose opioid infusions - totoal intravenous anesthesia - mixed intravenous/volatile anesthesia - combined neuraxial/light general anesthesia

    32. CHOICE OF ANESTHETIC AGENTS A. High-dose opioid anesthesia * Fentanyl or sufentanyl? ??? - postop.resp. depression? pt. awareness? ???? ??, ??? ?? hypertensive response control? ?????. BDZ????? hypotension, myocardial depression? ???? ??

    33. CHOICE OF ANESTHETIC AGENTS B.total intravenous anesthesia(TIVA) * short acting agent – cost of drug? ? ???, early extubation, decreased ICU stay, early hospital discharge? ??????? ??? ??. * propofol 0.5~1.5mg/kg bolus? 25~100ug/kg/min infusion & remifentanyl 0~1ug/kg/min infusion-> target controlled infusion(TCI)? ???? ?? -> ?? ?? ???? ?? ?? ??? ???? ?? IV morphine ?? ?? intrathecal morphine? ??? ??

    34. CHOICE OF ANESTHETIC AGENTS D. Other techniques -  ketamine & MDZ ?? - induction & maintenance : ?????? ??? ??, good amnesia, analgesia, minimal postop. resp. depression     ? ??? ? ???? ?? 20:1 ??? ??, induction - ketamine 1-2mg/kg , MDZ 0.05- 0.1mg/kg iv bolus maintenance – ketamine 1.4mg/kg/hr ,  MDZ  0.07mg/kg/hr infusion     * intubation or surgical stimulation ?? ?? HTN ->??? propofol, opioid, ?????, vasodilator ?? ?? -> poor ventricular function ???? ??

    35. CHOICE OF ANESTHETIC AGENTS C. mixed intravenous/inhalation anesthesia- agents? ??? hemodynamic stability? early extubation? ? ??? ?-> propofol or etomidate? induction? ?? ?? ???, thiopental? midazolam ??? ?? ?? - volatile agents? opioid? ???? ??? ?? -> bolus, infusion or both

    36. CHOICE OF ANESTHETIC AGENTS E. Muscle relaxants   - airway ??? ??? ?? intubation? nondepol. agent? ??   - ???? ?? - ??? ???? ??? ?? ??, ??? ??? ??? ??? ?, rocu, vecu : m/c ?? - pancuronium : high dose opioid anesthesia?? ??? ??     (vagolytic effect? opioid induced bradycardia? ??? ??)

    37. 2.PREBYPASS PERIOD induction & intubation ? skin prep. & draping ?, ???? ??? ?? hypotension ??? ? ?? ??? ?? ???? tachycardia, HTN ??? ? ?? accentuated vagal response - bradycardia, hypotension ?? -> sternal retraction or pericardium opening ?  ?? ?? ??, beta blocker, diltiazem, verapamil ?????? ?? Deeply anesthetized pt.?? chest ???? CO? ??? ??? ?? ? ??  - normal negative intrathoracic pressure? atmospheric?? ?? ->  venous return? ?? -> IV fluid? ????? reverse ?? prebypass period ? myocardial ischemia->tachycardia, HTN, hypotension ?? ???? ?? ????

    38. ANTICOAGULATION acute DIC? CPB pump? clot ??? ?? ?? CPB ?? ??  - ??? ?? -> ACT,   400-450 ? ???? ??     * heparin - 300-400 U/kg,   cannulation ? aortic purse-string suture?  ???? ??. surgeon? ?? RA? ?? ? ??, ????? ???, central line?? ??, ACT 3-5??? ??,  ACT? 400? ???? ?? heparin 100 U/kg ??  aprotinin - kaolin ACT ??,  kaolin ACT ?????, heparin ??? pt.??? CPB???  ??? fixed dose? ??

    39. ANTICOAGULATION  high dose thrombin time(HiTT)h - aprotinin? ?? ?? ?? ??,  kaolin ACT?? ?? ? ???, preheparin control? ???? ??  protamine ?? reversal?  ???? ??? ????, heparin resitance - ?? ??. ???? antithrombin III def.?? ?? ??           antithrombin III : circulatory serine proteas, thrombin? ?????? ??, ??????        heparin? antithrombin III? ???, ??? anticoagulation ??? 1000 ? ??, antithrombin III def.??? FFP 2 ??, ?? antithrombin III, antithrombin III ??? ???? ??(adequate) anticoagulation ??.  heparin induced thrombocytopenia - heparin dependent Ab ??, ? Ab? PLT? agglutination ??? thrombocytopenia ????? thromboembolic phenomenon? ???? ???? ??. history? ???? Ab? ???? ??? heparin? ???? ??? CPB?? ??       Ab titer? ???? ???, plasmapheresis ??? ??.

    40. BLEEDING PROPHYLAXIS antifibrinolytics? anticoagulation ? ?? ?? ?? aprotinin - ?????? ??, ???? ???, ?? ASA??? postop.bleeding???, coagulopathy, long & complicated procedures(heart & aorta?)?? ??      serine protease? inhibitor(plasmin, kallikrein, trypsin) PLT ?? ??? ?? ??? ??,periop. bl. loss, ?? ?????? ???, CPB? ??? ?? ???? ????      anaphylxis? ?? ?? ??? ?? ??? ? ??? ?? * celite-ACT - heparin ??? aprotinin? ?? ???? ??? ?? ??- ?? heparin? CPB?? ???? coagulation ??? ? ?? *  kaolin-ACT - aprotinin? ?? ? ?? ??  EACA(epsilon aminocaproic acid), transexamic acid  - aprotinin ?? ?? - ACT? ?? ??. allergy ? ??,  PLT ?? ?? ??       -> ???? CPB?? pheresis? PLT rich plasma? ???????  ??? bypass ?? reinfusion? bleeding? ??? ??????

    41. CANNULATION(1) heparinization ?? , hemodynamic problem? venous cannulation? ???? ?? ?? - aortic cannulation? ?? ??, rapid infusion? ? aortic cannulation? ?? ??? ? ?? (ascending aorta - m/c use) jet stream - ???? arterial cannula ? small opening ? ????        ???? ???? ???, CPB?? aortic dissection?? innominate a.? blood? preferential flow? ?? - systemic ??? ?? - aortic cannula ?? ?? ? - bubble - arterial cannula?? ?? ???? ?. arterial line?? blood? backflow? ?? ?? bypass initiation ?? ????? ?,  bubble? ????? air emboli??? coronary or cerebral circulation??  ???? ?.

    42. CANNULATION(2) - cannula? aorta ? ??? ???? ??? aortic dissection ?? - 1?? 2?? venous cannula? RA? ??. ?? RA appendage? ???. 1?? cannula? ???? coronary a. bypass, aortic valve op.? ??? single cannula? ?? 2 port? ??? ???? ??? ??, ? ?? RA, ? ??? IVC? ???? ? - venous cannulation? atrial, ventricular(less) arrhythmia? ????        ( eg. premature atrial contraction, burst of SVT ) sustained paroxysmal atrial tachycardia or atrial fibrillation - ?? ?????? ?? venous cannula? malposition - ??, ?????? venous return ??(SVC synd.) *CPB ??????, venous return ???? ?? reservoir? poor venous return?? ???? ??, ????? venous drainage ???? ?? head & neck edema? ??

    43. 3.BYPASS PERIOD

    44. INITIATION cannula ? ??? ????, ACT acceptable, perfusionist ?????? CPB??. cannula? ???? ?? clamp? ???? CPB pump ?? pump reservoir? venous return ??? ??? ?? reservoir level? ???? CPB pump flow? ?? ?? venous return? ???? pump prime? ?? ?? ?? air? pump circuit? ??????, cannula? clamping, kinking, air lock, ???? ?? ??? ?. ??, pump flow? ??? ??? ??? ????? ?,  reservoir ? flow vol.??? ??? ??. - Full CPB? ??? heart? ?? ???? ??? ?? ???? ?? ??? ????? venous cannula? malposition?? aortic regurgitation ?? -> aortic regurgitation? ??, ???? aortic cross clamping & cardioplegia ??

    45. FLOW & PRESSURE(1) pump flow? ?? ??? ? systemic BP? ? ????? ? CPB onset?, sys. BP? ?? ??? ????. eg. initial mean sys.BP 30-40mmHg? ??? ?? -  ?? : abrupt hemodillution(blood viscosity ??, SVR ????? ??) ???  blood viscosity? ????? subsequent hypothermia? ?? ????? ??? persistent & excessive BP ?? - ???? aortic dissection? ??? ?? -> dissection? ??? aorta ? distally recannulation ? ??? CPB ?? ??    ->poor venous return , pump malfunction, pressure-transducer error? ??

    46. FLOW & PRESSURE(2) factitious HTN - Rt. radial a. ? monitoring? ????? aortic cannula? innominate a.??? ???? ??     * MAP = pump flow * SVR ? ??                 ?? SVR???, MAP? pump flow? ?? CPB ??? pump flow? SVR? manipulation ?? ?? ???? ??? ????? ????? ? -> ???, ??? 2-2.5 L/min/m2,  MAP? 50-80mmHg ?? flow requirement - ?? ?? ??? ??       deep hypothermia??, 30mmHg?? ??? mean BP? ?? ???? ??? ? ?? ?? ?? ?? ?? high systemic a. pressure(>150mmHg) - ???, aortic dissection??                                           Cb hemor.?????. ????? MAP 100mmHg ?? - HTN ??? ?? pump flow?????? oxygenator inflow gas? isoflurane ??? ??     ?? ??? ????? pump flow? ?? ??? vasodilator(nitroprusside) ??

    47. MONITORING(1) CPB?? ?? monitoring pump flow rate, venous reservoir level, arterial inflow line pressure, blood & myocardial temperature, in-line oxygen saturation, CO2 tension, in-line pH, oxygen tension sensor blood gastension & pH - ? ?? hypoxia ???, low venous oxygen saturation(<70%), ???? meta. acidosis, low UO ? low rate? ????? ?? bypass?? arterial inflow line pressure - ?? ?? radial a. ? aortic cath.? ???? sys. a. pressure?? ? ??. - ?? pressure ?? - arterial filter? ???? ??? pressure drop, arterial tubing, aortic cannula? narrowing ??

    48. MONITORING(2) inflow pressure -300mmHg ??? ????, ? ?? ?? clogged arterial filter, a. tubing or cannula? obst., aortic dissection ?? serial ACT, Hct, K ?? - ACT? bypass ??? ???? ?? 20-30??? ?? cooling - heparin ???? ?? ????? ??? ?? -heparin dose response curve? ??? heparin dose ??, protamine reversal? ????. Hct - 20 - 25 % ?? K ?? ?? - lasix? ??

    49. HYPOTHERMIA & CARDIOPLEGIA ?? moderate(26-32?) or deep(20-25?) hypothermia - ??? ????, cooling & rewarming ?? ???   ?? ??? CPB flow? ????? ?? *ventricullar fibrillation - 28-29? ???? ?? ??,VF? ??? high energy phosphate? ???? myocardial preservation? ???? ??? cardioplegia?? ?? ?? cardioplegia? aortic inflow cannula? ??? ??? ascending aorta? cross clamping?? cross clamp? ??? ??? small cath.? ?? cardioplegia sol.? ???? ??? ????. ??? ????? aorta? ???? coronary aorta? ?? cardioplegia sol.? ??? ??.

    50. VENTILATION ?? pump flow? ???? ??? blood? ejection??? ?????? ??. - full CPB institution ??, ventricular ejection? LV vol.? critical low level? ?????? ?? ??. - ??? ventilation? ???? ???? pulm. bl. flow? R-L shun? ???? ??? ????? hypoxia? ??? ? ??. ?? ??? ???? ???? pulm. bl. flow? pump flow? ??? ?? ?? ????. - ?????? ?? ventilation? ????, O2 flow? postop. pulm. dysfunction? ???? PEEP(5cmH2O) ?? ?????? ????. - ??? ?? gas flow? ?????? O2 low flow(1-2L/min)? ??. - ventilation? ??? ?? blood? ejection ????? CPB ??? ??.

    51. MANAGEMENT OF RESPIRATORY GASES(1) hypothermic CPB?, corrected arterial gas tension? ??, uncorrected? ??? controversial.-> gas? ???? hypothermia?? ????? ?? ?? - total content? ??? ???? gas ???? ??? ??? ? ???? ???? ??? ?? ?? CO2 tension? ?? pH? ???? ??? ??? ?? - ??? ??? ? HCO3??? ??? ?? ?? CO2 tension ??? pH? ????? blood? alkalotic ?? ??

    52. MANAGEMENT OF RESPIRATORY GASES(2) pH-stat management         - temperature-correcting gas tension           hypothermia ?? normal CO2 tension 40mmHg & pH 7.4 ????? ??           CO2? onygenator gas inflow? ???? ?? ??? ??.           total blood CO2 content? ????          ? ????? ???? O2 consumption ?? CO2 tension? MAP? ? ?? alpha-stat management        - hypothermia?? uncorrected gas tension ??,  ? ?? ??           ?? prot. function ? preservation? intracellular electroneutrality?           constant state? ???? ?? ????? ?? ??? ??      - pH-stat management? ?????, alpha-stat management? ???     cerebral autoregulation? ???? myocardial preservation? ????     ??? ???.

    53. ANESTHESIA hypothermia ??? anesthetic ??, CPB???? ?? ?? ???  rewarming?? ? ???. CPB?? ??? ?? ??? ?? ?? light anesthesia? ???? awareness?? ???. - HTN? ?? ???? ????? ??? ??? ???? ????? ??. ??? ????? ???? ??? CPB??? ????? ??. -  oxygenator? ?? volatile agent(isoflurane) ??? ??? ?? ????. -  volatile agent? ????? residual myocardial depression? ??? ?? bypass ????? ?? ???? ??. -  poor ventricular function? ??? cardioplegia? volatile agent? combined residual effect? ?? ??? ?? ??. narcotics ????? ??? BDZs? ?? ???? ????. -   ? ??? opioid? ketamine-MDZ infusion? CPB?? ????? ??. -   rewarming?? sweating? ?? ??? ??? ?? light anesthesia? ??? ?? ??? 39???? blood? ?????? ?? hypothalamic response?? ????.

    54. CEREBRAL PROTECTION CPB?? ???? ??? - 40% ?? ?? ?? ??, ??? transient neuropsychiatric dysfunction,   stroke?? ??? Cx? 2-5 % ??? ?? ???? ???? ???? ?? ->intracardiac(valvular) procedures, advanced age, preexisting CVD, mbolism * prophylactic thiopental infusion - ?? ??? ??? ??? ??     intracardiac procedure ??? ??? neurologic defecit? ??, ??? ????? ??? ??. ??? CPB ?????? inotropics? ?? ???. - very deep hypothermia ??? circulatory arrest?? ??, corticosteroid(MPD 30mg/kg), mannitol(0.5g/kg), phenytoin 10-15mg/kg? ?? ???? ??? ice bag?? ???.

    55. 4.TERMINATION OF CPB() bypass ??? ???? 1.rewarming ???? ? 2.air? ??? bypass graft?? ????? ? 3.aortic cross-clamp? ???? ? 4.? ??? ????? ?

    56. 4.TERMINATION OF CPB(2) ?? rewarming ??? ?? - ?? rewarming? ??? ????? ?? ?? rewarming?? ?? hypothermia? ????? ?? ???? ? rapid rewarming? ?? well-perfused organ? pph. vasoconstricted tissue?? ? ???? ???? CPB??? ???? equilibration? ????? ???? * vasodilator(NTG, nitroprusside) infusion -> rewarming process? ??? ?? ? ???? ????, rapid rewarming?, gas? ???? ??? ???? ??? ???? gas bubble??? ??. ??? rewarming?? ??? ?? ?? defibrillation ??? ??.  aortic cross-clamping ?? ?? lidocaine 100-200mg ? Mg sulfate 1-2g ??? fibrillation ????? ??????.

    57. 4.TERMINATION OF CPB(3) lung inflation? pulm. vessel? ?? Lt. heart? ?? ??? ?? ?? intracardiac air? expulsion? ????? * TEE - residual intracardiac air ??? ?? ?? ?? reinflation? ????? ?? airway pressure?? ? ?? ??? ??? ?? ??? ???? int. mammary a. graft? ??? ? ?? ??? ?? direct visualization??? ????? ? CPB?? ??? ?? ?? ?? - ???? - ?? 37? - stable rhythm - AV pacing? ??? ?? ?? ??? properly timed atrial systole ? ???? AV block? ???, ?? K ??? ??? ?. hyperK ??? Ca, NaHCO3, lasix, Glc & insulin?? ?? - HR - 80-100 ? ??? ??, slow HR? rapid HR?? ? ???? ??? pacing, inotropics? HR ???? ?? - SVT?? ????? DC cardioversion ?? - lab ?? - acceptable limit ?? ??? ? - acidosis(pH<7.2), hypoCa(ionized), hyperK(>5.5) : Tx?? - Hct : ?? 22-25% , 100% O2? ?? ??? ????? ?

    58. WEANING FROM CPB(1) CPB dicontinuation - gradual as sys.a.pr, ventricular vol., filling pr. and CO. are assessed. - central aortic pressure - ?? ?? ???? radial a. pressure ? cuff pressure? ???? ???? ? - central aortic root pressure - surgeon? palpation?? ???? - ventricular vol. ? contractility? ???? ??????, filling pressure? central venous, pulm. a, Lt. atrial cath.? ?? ?? - CO - thermodillution?? ?? - TEE - chamber vol., contractility, valvular function? ?? ?? ??

    59. WEANING FROM CPB(2) weaning - vena cava ??? tape?? release?? venous return line? ?? clamping ?? ???? - beating heart? filling ? ?, ventricular ejection? ???, arterial pressure? ????? pump flow? ?? ??, ?? venous line? ??? occlusion?? systolic a. pressure? >80-90mmHg? ????? ????, pump flow? ???? ? ???? ?? ?? ??

    60. WEANING FROM CPB(3) ???? ???? bypass?? ??? 4?? ???? ?? (?) - good ventricular function ?? - BP, CO ?? ??, CPB?? ?? ?? ?? * hyperdynamic pt. - ?? weaning ??, ??? very low SVR ??? CPB?? ???? good contractility, adequate vol.? ??? low a. pressure, low Hct(<22%)? ?? - ?? - CO ?? - ultrafiltration or red cell transfusion - a. BP ???? * hypovolemic pt - normal ventricular function pt. + varing degrees of impairment pt. preserved myocardial function? ?? pt.? aortic cannula? ?? infusion?? bl. 100ml? ?? ??. BP, CO? ? bolus?? ???? ??? ?? ? sustained. ?? ???? ???? LV filling pressure? 10-5mmHg ????? ?? BP, CO? ???

    61. WEANING FROM CPB(3) - ventricular impairment? ????? BP? CO? ???? vol. infusion?? filling pressure? ????? 10-15 mmHg??? filling pressure? ??? ? ????? * pump failure pt. - ?? ???? sluggish & poorly contracting heart ??? CPB?? ??? ?, ?? ???? inotropics? ????? CPB? ????? ? - SVR? ???, afterload reduction? ?? nitroprusside? inodilator? ??? ?. - pt.? ???? ischemia, valvular dysfunction, shunting,RV failure ??? ?? - partial bypass - Lt. or Rt. ventricular assist device ?? - refractory pump failure pt.?? ??? ??. - ????? ??? ??? ?? ???? 12-48???? complete weaning? ???? ? ??.

    62. WEANING FROM CPB(4) Ca? routine ?? - ischemic injury? ???? ??? ?? coronary spasm? ??? ??.(?? Ca Ch. B? preop.? ??? ????) dopamine, dobutamine - ?? ?? ?? inotrope - dobutamine : dopamine? ?? filling pressure? ????? ?? tachycardia? ? ???? ??? ???, ???, CO? ??? BP ??? ?? ?? ?? - dopamine : ????? ??? ??? ??? CO ??? ??? BP ???? ?? ? ??? epinephrine - ?? ??? inotrope, ?? ???? ????? sys. BP & CO ???? ???, ?????, ?? beta agonist ? ??,

    63. WEANING FROM CPB(4) amrinone & milrinone - selective phosphodiesterase type III inhibitor - arterial & venodilator effect? ?? inotrope, milrinone? PLT count ????? ??? amrinone?? ??, ? inotrope? ??, LV afterload? ?????, HR? ????? ????? ?? ??? ???????? ?????? ?? ??? ?? inodilator & beta agonist? ?? - synergistic inotropic effect ??? norepinephrine - SVR ?????? ???? high dose? ???? ??? arginine vasopressin - refractory hypotension, low SVR, norepi.?? ??? inhaled nitric oxide & PGE1 - refractory pulm. HTN & RV failure? ??? ??? ?, nitric oxide? sys. a. pressure ????? ?? ??? ??

    64. 5.POSTBYPASS PERIOD(1) bleeding control, bypass cannula remove, anticoagulation reverse, chest close sys. a. pressure - bleeding? ????? ?? 90-110mmHg? ?? bleeding check - ?? ??? post. surface? ??? ?? ???? ??? ? ?? ?? ?????? ????. ????? surgeon? hypotension?  ??? ????? ?? ???? atrial cannula - aortic cannula? pt.?? ??? vol.? ??? ??? aortic cannula ?? ?? ??? - ???? ???? bypass ???? ?? blood vol.? ??? ?

    65. 5.POSTBYPASS PERIOD(2) blood, fluid ? ?? - filling pressure & postbypass Hct? ?? guide, ?? Hct? 25-30%??? ?? - CPB reservoir?? ?? ?? - aortic cannula? ??? ????? cell saver device? ?? ???? IV? ??? ??? frequent ventricular ectopy - ??? ??? residual ischemia? ????? ?? - lidocaine, procainamide, amiodarone? Tx. - hypoK, hypoMg - ??? ? - ventricular arrhythmia - ??? VT, VF? ??? ? ??

    66. REVERSAL OF ANTICOAGULATION(1) hemostasis? ???? pt.? ??? ??? ??,heparin activity? protamine?? reverse (protamine - highly positive charged prot. heparin? ??? ?????? * heparin : highly negative charged  polysaccharide    heparin-protamine complex? ???? RES? ?? ?? protamine ???? - ?? ??? ?? - reversal ?? ACT 3-5 min ??? ???? ????? - protamine? additional increment? ??? ??. *?? ??? ?? - ??? ACT ???? ??? ???? heparin? ?? protamine dose? ??? ?, ???? protamine? 1-1.3 mg/ heparin 100 u?? ?? automated heparin-protamine titration assay - ????? residual heparin conc.? ???? protamine dose? ??? ? ??,? ??? protamine? ?? ?????? protamine? anticoagulant activity(heparin? 1/100)? ?? ??? ??? ??

    67. REVERSAL OF ANTICOAGULATION(2) ??? ??? protamine? ?? well? ??? ??? ???? ??? blood sample? ????. protamine ??? heparin ??? ?? ? match?? well? ? ??? clot ??. protamine? ?? ??? ??? clotting? ????. protamine dose? ??? ??? blood vol.? ??? clot ? tube? ??? ??? ????. * protamine ?? - adverse hemodynamic effect? ?? ? ?? - ??? immune ?? idiosyncratic nonimmune - protamine? ??? ???? ?? ???? effect? ???, acute systemic vasodilation? ?? ????? ?? pulm. HTN? ??? ?? ??. - protamine-containing insulin?? ??? ???? DM pt.? allergy ?? ??? ??.

    68. PERSISTENT BLEEDING(1) ?? ? bypass period(>2??) ?? ??       ?? - inadequate control of bleeding sites        inadequate reversal of heparin, absence of clot formation        reheparinization, thrombocytopenia, PLT dysfunction, hypothermia, undiagnosed preoperative hemostatic defect, newly acquired defect ACT? protamine ??? baseline? ???? ?? ?? protamine(25-50mg) ???? hypothermia(<35?) - hemostatic defect ?????? ?? PLT & coagulation factor ?? - ?? coagulation study guide ?? ???? ??? ??? ?? oozing - ??? ??? ?? ACT ???? heparin-protamine titration assay?? residual heparin ??? ????? ?????, thrombocytopenia? PLT dysfunction ? ??? ?? -  ? ?? ?? CPB Cx?? ??? -  Tx : PLT ??? ??? ? ?? PLT 10??? ????? - CPB ?? coagulation factor(?? V, VIII) ?? - ??? bleeding? ??? ??  ??? FFP? Tx ??? -  ?? PT, PTT ?? ???

    69. PERSISTENT BLEEDING(2) hypofibrinogenemia - fibrinogen < 100 mg/? ??                      residual heparin ?? PTT ??                       Tx : croprecipitate Desmopressin(DDAVP) - 0.3ug/kg, IV over 20?                          VIII, XII? ????? ??                 Von Villebrand factor? ?????? ???? ?? ??? accelerated fibrinolysis - CPB ?? ?? ?? ??.                      Tx : EACA( 5g ??? 1g/???)                              transexamic acid (10mg/kg)                    Dx : FDP(> -32mg/ml)??   thromboelastography?, clot lysis ??(+)

    70. ANESTHESIA continuous IV infusion ??? ???? ?? ??, CPB ?? additional anesthetic agent? ???? ??? CPB ?? pt.? hemodynamic response? ?? unstable pt. - ??? opioid, BDZs, scopolamine hyperdynamic pt. - volatile agent * narcotics bolus? volatile agent? ???? ?? HTN - NTG ? nitroprusside ?? fenoldopam - ??? ???? ?? early postop. ? Cr clearance ???? ??  ?? ?????. - CPB?? volatile agent??????, opioid? ICU? ????? sedation? ???? emergence?? analgesia? ???

    71. TRANSPORTATION OR?? ICU? ?? ??? ? - ??. monitoring ?? ??? ?? drug infusion? overdosing ?? interruption, hemodynamic instability? ?? portable monitor ??, infusion pump, full oxygen cylinder????. ???? ?? monitoring - ECG, a.BP, pulse oximetry ??? endotracheal tube, laryngoscope, succi, ?? ??? ???? ?? ???? ? ICU ?????? ventilator ?? ??? ???? monitoring & infusion ??? ?

    72. 6.POSTOPERATIVE PERIOD ???? ???? postop. 2-12??? ???? ?? -> sedation - morphine(2-3mg), propofol infusion(20-30ug/kg/?) - postop. ? ???? hemodynamic stability ???? ?? ???? ??? postop. bleeding monitoring?? ?? ?? - chest tube drainage - ? 2??? 250-300ml/??(10ml/kg/??)???? surgical reexploration ?? ??? drain?? ?? ???? intrathoracic bleeding -cardiac tamponade ?? -> ?? reopen - HTN - bleeding, myocardial ischemia ????? ??? ?? ????? ->  nitroprusside , NTG - fluid - filling pressure? ?? guide ???? -> ???? ???? ?? - hypoK, hypoMg - Tx ?? - Extubation - ???? ??? ?????? ??????? ??? ?               ??, ??, ????? ???? ??? ? * thoracic procedure - FRC , postop. diaphragmatic function ???? - ???? ??? ??? extubation

    73. OFF-PUMP CORONARY ARTERY BYPASS SURGERY

    74. Octopus - advanced epicardial stabilizing device - CPB ?? CABG ???? - anastomotic site? compress down ?? ?? lifting ?? stabilizing??     suction? ???? ? ?? ???? ???? ?? -  HR ????? ?? beta B ???? ??  -  CPB?? full ?? half dose heparinization ?? CPB machine? ?? priming?? ???? ?? -  vasopressor : intermittent or low dose infusion? ?? IV fluid loading?      distal anastomosis ? ??? ??. -   vasodilator : prox. anastomosis ? aorta? partial clamping ?? sys.BP 90-100mmHg? ???? ?? -  good ventricular function pt.?? one or two vessel bypass graft? ??      ?????? multi-graft surgery, redo-op., LV function ??? pt.???       routine use?? ?? -  long-term graft patency - CPB? ??? ?? -   OPCPB - postop. neurologic & pulm. Cx ??? ???? ??

    75. PEDIATRIC PATIENTS ???? ?????? ??? ??? Starling relationship? ?? plateau? ?? stroke vol. - relatively fix, ??? CO? ?? HR? ?? ?? ???? ??? ??? ?? - pressure ? vol. overload? ? ??? ? ??? ?? - ?? ? interdependent , ? ?? failure? ??? failure? ? ??

    76. PREOPERATIVE EVALUATION(1) lesion? full hemodynamic significance & surgical plan - preop. ? ??? ?? ? pt.? ????? ??? ??? ? cong. heart failure & pulm. inf. - control ??? ? PGE1 infusion - 0.05 - 0.1 up/kg/?, ductal flow? ???? ???? ductus arteriosus closure ???? ?? op indication severe hypoxemia, pulm. bl. flow ?? ??, refractory cong. heart failure severe LV obst., ventricular function ?? disease activity assessment clinical & laboratory evaluation infant?? ???? - tachypnea ??, cyanosis, sweating, ?? feeding?? older child?? ???? - easy fatigue

    77. PREOPERATIVE EVALUATION(2) BW? ???? disease activity? ?? ?? ?? hypoxemia - ABGA, Hct? ? ?? ?? polycythemia - IDA ?? ??, hypoxemia? severity & duration ? ?? ?? clubbing - cyanotic defect?? pt.?? ?? ?? cong. heart disease ??? 30%?? ?? echo, heart cath., ECG, CXR ?? lab - CBC, PLT count, coagulation study, electro, BUN/Cr, ionized Ca, Glc

    78. PREINDUCTION PERIOD(1) A.fasting 1? ?? - ??? 4????? feeding ??            ??? 2???? liquid ? ???. 1-2 ? - ?? 6????? feeding ??          induction 4?? ??? liquid ?? 3??? - ??? 8?? ?? preop. IV fluid infusion - ?? delay? ??? ??, ??? ??? ??? ?? polycythemia ???? ?????

    79. PREINDUCTION PERIOD(2) B.premedication atropine - 0.02mg/kg IM (?? 0.15mg) -??? vagal tone? counteract ?? ?? ?? ?? ?????? ??, ???, 6????? atropine ? ?? sedation - 6?? ???? ?? ?? cyanotic lesion(TOF) ?? ???? ????? agitation? crying? R-L shunt? ????? ????.     2????? morphine 0.1mg/kg, pentobarbital 2-3mg/kg IM(+atropine) -?????, MDZ 0.5-0.6mg/kg PO or IM

    80. INDUCTION OF ANESTHESIA A. HEMODYNAMIC ANESTHETIC GOALS 1. Obstructive lesions hypovolemia, bradycardia, tachycardia, myocardial depression ????, ??? HR? age? ?? ??, slow rate ? CO ????? fast rate? ventricular filling? ??????? * CoA?? ??? cardiac depression? ??? ? ??. 2. Shunts pulm. vascular resistance ? SVR? ratio? shunt ???? ?????? PVR ????? ?? - R-L shunt ???? ???? eg. acidosis, hypercapnia, hypoxia, sym. tone ??, high mean airway pressure - 100% O2 ? hyperventilation ? PVR ???? ??? specific pulm. vasodilator - not available        sys. vasodilation - R-L shunting ????. ??? ? * phenylephrine - SVR ???? ?????. inhaled nitric oxide - sys. a. pressure ? ?? ?? * L-R shunting ???? sys. vasodilation? PVR ??? ??? ??

    81. INDUCTION OF ANESTHESIA B.MONITORING EtCO2? arterial CO2?? ? ???? ??? dead space??? large R-L shunt ?? ???? ????. induction ??, intraarterial & CVP monitoring? thoracotomy?CPB?? ?? procedure? ????. 20-22G cath.? radial a. cath.? ?? - 24G cath.? small neonate, premature infant? ??. cutdown? ??? ?? ?? - int. or ext. jugular v. - central venous cannula ? ?? ?? ??? ???? surgeon? ?.  pulm. a. cath. - ???? ?? ?? - TEE - ?????? ?? ??. CPB ?? surgical repair assess? ?? - 12kg ??? ??? ?? ?? ??? ?? ??? ?? probe? ???? ????. - intraepicardial echo. - TEE ??, ?? ?? ??

    82. INDUCTION OF ANESTHESIA C.VENOUS ACCESS ?? ??? induction? ?? ??? ? ?? - EMLA(eutectic(easily melted) mixture of local anesthetics) cream  induction?? venous cannula placement ???? ? - agitation, crying - R-L shunt? ????? ??? cyanotic lesion ???? ?? ??? - IV access - induction ?? ???? ??? ??? intubation ?? ?? ?? 2???? IV access ??. ??? ?? central venous cath. air bubble ???? ???? ? - shunting lesion? venous air? ?????? ???? ?? ???? paradoxical embolism? R-L shunt ?? for. ovale ?? ??? ?. - injection?? aspiration - injection port? trapped air dislodgement ???

    83. INDUCTION OF ANESTHESIA D.ROUTE OF INDUCTION(1) premature & young neonates - ??? ?????, ??? preoxygenation?? intubation - older pt. - inhalational, IV, IM induction? intubation ?? ?? - premed ??? venous access? ??? induction technique? ?? - intubation -> nondepol. agent? ?? ?? succi.(less commonly)? ?? ??? 1. Intravenous - thiopental 3-5mg/kg, propofol 2-3mg/kg, ketamine 1-2mg/kg, - fentanyl 25-50ug/kg, sufentanil 5-15ug/kg - high dose opioid - ?? ?? ??? ??? pt?? ??? ??. - IV agent? onset - R-L shunt pt.?? ? ????. - drug bolus? ????? ?? a. blood level? ??? ?? ??? ???? ? * L-R shunt : a. blood conc.? ???? IV agent onset? ????

    84. INDUCTION OF ANESTHESIA D.ROUTE OF INDUCTION(2) 2. Intramuscular - ketamine 4-10 mg/kg , ?? ?? ??, onset 5? ?? - preop. atropine? ??? secretion? ??? - ketamine? agitated & uncooperative pt., cardiac reserve ??? ???? ?? - cyanotic lesion?? ketamine? ??? - ketamine? ???? PVR ????? ?? ??? ?? 3. Inhalational - halothane? ?? ?? ?? - ??? cardiac depression? ???? ??? ??? ????? ? - good cardiac reserve ???? halothane, sevoflurane? ?? - cyanotic heart disease?? halothane? ???? sys. a. vasodilation? ????? ????? - halothane induction? ?? ?? ??? low CO pt.?? ???? ?? - N2O - cyanotic heart lesion ?? 50% ??? ?? - ?????? PVR ????? ?? ??? ?? - N2O?? less soluble agent?? uptake? R-L shunt?? ??? - L-R shunt?? ?? ??? ??

    85. MAINTENANCE ANESTHESIA induction ?? ,opioid? inhalational agent? maintenance? ??? - fentanyl, sufentanil -> ?? ?? ??? IV agent - halothane, isoflurane, sevoflurane, N2O - ?? ?? ??? ????? - ?? ??? ??? ???? ??? ???. - isoflurane, sevoflurane - halothane ?? myocardial depression? ?? HR??? ?? vasodilation? ? ? - N2O - poor cardiac reserve ???? cardiac depression??? ?. - IV air bubble ?? ??? ??? bypass?? ?? ???? ???

    86. CARDIOPULMONARY BYPASS(1) ??? ??? ???? ??. ?? ?? circuit vol.? blood vol.? 3? - blood? ??? hemodilution? ?? ?? machine? prime ??? ?? - CPB -> intracardiac & extracardiac shunt, very compliant a. system? ?? ??? ???? ??? ???? MAP? ??? ??? ?? systemic perfusion? ????? ?? ??. shunt - bypass ??? ???? control??? - high flow rate -> ?? ?? pt.??? ??? perfusion? ?? ??? ?. - pH-stat management - ???? ? ?? neurologic outcome? ?? ??? ?? - CPB weaning - ??? ??? ???? ? ?? ?? - primary pump failure - unusual - weaning? ??? ? - ?? repair check, ??? lesion ??? ?? - intraop. echo., pressure & O2 saturation ???? ?? - CaCl2 - critically ill pt.? ??. ion Ca ??? ?? - Glc - ???, ???? ??? ? ???? ??

    87. CARDIOPULMONARY BYPASS(2) - dopamine, epinephrine - ???? ?? ?? ?? - phosphodiesterase inhibitor - PVR?? SVR ??? ?? - hypocapnia, sys. alkalosis, high inspired O2 conc. - pulm. HTN ???? PVR ???? - PGE1, prostacyclin - Nitric oxide - refractory pulm. HTN? ?????. - ??? ??? ????? ?? ?? ? artificial surface? blood? ???? CPB?? ?? ?? ?? ?? ??? ?? ->Tx : steroid - weaning ?? modified ultrafiltration - ????? hemodillution? ???? inflammatory vasoactive substance? ?? - complex congenital lesion? surgical correction - deep hypothermia??? complete circulatory arrest ??? ?? - CPB ???, cooling? surface cooling? cold perfusate ? ?? ?? - ???? 15? , 60? ????? ??? ??? ?? - ?? ??? ice packing? ?? surface cooling? ?? - MPD  30mg/kg,  mannitol 0.5 g/kg,  phenytoin  10mg/kg? ???? ??

    88. POSTBYPASS PERIOD large priming vol.(?? bl. vol.? 2-3?)? ???? ??? cloting factor & PLT? dillution?? ?? ?? hemostatic defect? CPB ?? ??? ?? -> Tx : heparin reversal, FFP & PLT fresh whole blood ?? - PLT & cloting factor ? ?? ?? ?? ???? - 6?? ?? - ??? ????? ?? intubation ??? ?? - extubation? patent ductus closure, ASD, CoA?? ??? ??? ? ???? ??? ???? ??? ?? ??.

    89. CARDIAC TRANSPLANTATION

    90. PREOPERATIVE CONSIDERATIONS intractable heart failure - EF 20%??, NYHA class IV        ??? ??? cardiomyopathy, coronary a. disease transplant candidiate - ???? end-organ damage? ?????         ?? major systemic illness ??? ? -  chr. hypoperfusion & venous congestion ??? reversible renal & hepatic dysfunction? ?? -  PVR? ????? ?? ???, O2? vasodilator? ????? -  tissue cross-matching : ?? ???? ?? -  donor-recipient compatibility : size, ABO, CMV??? ??. -   HBV, HCV, HIV ?? ??? donor organ? ??

    91. ANESTHETIC MANAGEMENT(1) proper timing & coordination - donor organ retrieval team ? transplant center ??  ?? - premature induction - ????? CPB ?? ?? delaying induction - ischemia ?? ???? graft ??? ?? -???? ???? ?? ???? ?? ??, ?? full stomach ???? ??? ?? - preop. oral cyclosporine ???? ? - antacid, H2 B, metoclopramide - monitoring - ? ????? ??. induction? ?? ?? - strict asepsis ??? ? Rt. int. jugular v. ?? - postop. endomyocardial biopsy? ???? ?? pulm. a. cath. - routine - ???? ?? rapid sequence induction? ??? slight head up & induction ?? cricoid pressure ?? - aspiration ?? ?????? ???, CPB?? ?? ??? organ perfusion ???? ?? ???

    92. ANESTHETIC MANAGEMENT(2) induction  - ??? opioid c/s etomidate ?????         ketamine-MDZ tech. - succi(1.5mg/kg) or Rocu(1mg/kg) - ???? ???? ? - pancuronium - opioid induced bradycardia counteract - opioid - ?? bolus? infusion?? maintenance? ?? * TEE probe - induction ?? ?? azathioprine IV infusion? ?? induction ?? hypotension - ????? ??? inotrope, vasopressor, fluid ?? sternotomy, cannulation         1-2?? ?? ??.   ??? ????? ?? complicated aprotinin  - postop. bleeding ?? ?? ??

    93. ANESTHETIC MANAGEMENT(3) CPB? aorta ? both cavae? cannulation ?? ?? - pulm. a. cath.? ???? ????, ??? ???? ????? pulm. a. cath.? CPB ?? pulm. a.? refloating ??? sterile, protective sheath? ??? ? - recipient' heart? ???? excision?? ???? ??? ???? ? - donor? ??? atria? recipient heart? remnant? anastomosis - aorta? pulm. a.? end to end anastomosis ???? heart? saline?? flush?? intracardiac air? evacuation - MPD? aortic cross-clamp ????? ?? - inotropics - CPB??? ???? ?? ?? - prolonged graft ischemia - transient myocardial depression ????? - slow junctional rhythm - common,    epicardial pacing ????? - ???? ??? ??? denervation ?? direct autonomic influence? ???? ?? catechol.??? ??? ???? - pulm. a. cath.? CPB ?? ?? ??? refloating?? ?? ?? ?? ?? TEE? ???? ?? ?? ?? CPB??? ?? - pulm. HTN? ??? RV failure                 Tx : hyperventilation, PGE1, nitric oxide, RVAD - bleeding - ?? ??.   extensive suture line & preoperative hemostatic defect ?? - ??? ??? ?? ???

    94. ANESTHETIC MANAGEMENT OF VASCULAR SURGERY

    95. ANESTHESIA FOR SURGERY ON THE AORTA

    96. PREOPERATIVE CONSIDERATIONS aorta? ????? ??, aorta cross-clamping? ???? large intraop. blood loss ??? ??? - CPB ?? aortic cross clamping? LV afterload? ??? ????? occlusion point? distal ? ??? organ? perfusion? ??? ? - ?? HTN, MI, LV failure, aortic regurgitation ? ?????. - spinal cord? kidney?? blood flow??? paraplegia, renal failure ???? ?? aortic surgery? Ix         aortic dissection, aneurysm, occlusive disease, trauma, coarctation ascending aorta lesion - aortic valve ? innominate a. ?? aortic arch lesion - innominate a. ? Lt. subclavian a. ?? descending thoracic aorta lesion - distal to Lt. subclavian a. & above diaphragm abdominal aorta lesion - below diaphragm

    97. SPECIFIC LESIONS OF THE AORTA

    98. AORTIC DISSECTION(1) intimal tear? ?? blood? aortic wall(media)? ?????, aortic media?? hemorrhage? aortic intima? extension?? disruption??, ?????, dissection? ???? ??? medial cystic necrosis ?? dissection? propagation - intimal tear? ???? hemodynamic shear force? ??? ??? HTN - aortic dissection? ?? ?? Marfan & Ehlers-Danlos synd. - ?? medial cystic necrosis ????                                   aortic dissection ????? ? - atheromatous plaque? hemorrage, ????? cannualtion site??? ???? aortic media? ?? ??? dissection? ?? aorta?? ?????? a.opening? occlusion??? ?? aortic root? extension ?? aortic valve incompetence? ????? ?? pericardium?? pleura? rupture?? cardiac tamponade? hemothorax? ?????. TEE - ??? ??

    99. AORTIC DISSECTION(2) prox. type - Stanford type A, DeBakey type I & II          ascending aorta involve ( type II? not involve beyond innominate a.) ?? ?? ??? ?? distal type - Stanford type B, DeBakey type III           originate beyond Lt. subclavian a. distal?? ??            ????? ??? ??. - ?????, ?????? systolic BP(90-120mmHg???), aortic wall stress ???? nitroprusside(dP/dt? ????? ?????) beta B(esmolol, aortic pressure ?? ??? ???? shear force ??)

    100. AORTIC ANEURYSMS aneurysm - abdominal aorta?? m/c, ???? atherosclerosis ???? medial cystic necrosis? thoracic aortic aneurysm? ??? ?? - syphilitic aneurysm - ascending aorta ??? ?? - ? ? ?? : RA, spondyloarthropathies, trauma aortic root? dilatation - ?? aortic regurgitation ?? upper thoracic aorta? expanding aneurysm? tracheal or bronchial compression?? deviation, hemoptysis, SVC synd. ????. Lt. recurrent laryngeal n.? compression - hoarseness, Lt. vocal cord paralysis normal anatomy? distortion - endotracheal or endobronchial intubation ?? int. jugular and subclavian v.? cannulation? ??? ??. aneurysm? ??? ?? - rupture & exsanguination pseudoaneurysm - intima? media? ??? ?, adventia? blood clot??? outer layer? ??? ? ??? acute expansion - sudden severe pain?? ???? rupture? ?? rupture - ??? ?? ????? ??, 6cm ??? ?? 1???? 50%?? rupture ?? aorta - ?? 2 -3 cm (wider cephalad) - 4 cm ???? ?? prosthetic graft? ?? ?? ??? - 2-5 % (?? leaking or rupture ?? 50 %)

    101. COARCTATION OF THE AORTA - ?? congenital ductus arteriosus ? ??? ???? narrowed seg.? ??? ?? ???? ?? preductal type(infantile)   - ductus? opening? ????? narrowing, ?? ?? cong. defect? ?? ??, infancy ? ????? ???? ????? perfusion ????         : ???? cyanotic - ????? perfusion? aorta ???. - ????? perfusion? pulm. a.??? postductal type    - ????? ?? ??, narrowing? ??? ????? ???? collateral circulation? ??? ?? ??? hemodynamic significance? ?? -  ?????? HTN(c/s LV failure) - ?? ??

    102. ANESTHETIC MANAGEMENT

    103. SURGERY ON THE ASCENDING AORTA ?? median sternotomy? CPB ?? - ??? CPB?? ????? ??? ???? aortic regurgitation, long aortic cross-clamping time, large intraop. blood loss? ?? ??? ?? ?? - TEE - monitoring? ?? ?? - blood loss - aprotinin ??? ??? ?. - concomitant aortic valve replacement & coronary reimplantation? ?? ?? Lt. radial a.? monitoring? ??? - innominate a.? clamping? ??? ????? ?? ?? femoral & dorsalis pedis a.? ???? - BP control - nitroprusside beta B(esmolol) : aortic dissection ??? ????? - bradycardia - aortic regurgitation ????? ?? ???? - CPB?? arterial inflow cannula - aortic dissection?? ????? femoral a. ? ?? -sternotomy? aneurysm? ??????? ????, partial CPB ???? ??? ?

    104. SURGERY INVOLVING THE AORTIC ARCH deep hypothermic circulatory arrest(CPB ???)??? median sternotomy? ?? ?? - 15?? hypothermia, flat EEG???? thiopental infusion, MPD? dexa, mannitol, phenytoin ? ??? long rewarming period - large intraop. blood loss ? ??

    105. SURGERY INVOLVING THE DESCENDING THORACIC AORTA(1) ?? CPB ?? Lt. thoracotomy? ?? ?? abdominal aorta involve ?? lesion?? thoracoabdominal incision? ?? one-lung anesthesia - surgical exposure? ?? ???? ??  retractor? ?? pulm. trauma? ??? endobronchial tube? ??? positioning - anatomy? distortion ??? ?????  ??? flexible pediatric fiberoptic bronchoscope? ??? ? aorta? lesion ?? ???? cross-clamping??? - aucte HTN? clamp ???, Hypotension? ???? ??? a.BP? Rt. radial a.?? monitor ????? Lt. subclavian a. clamping? ????? ?? ????. aortic surgery?? aortic cross-clamping ???? LV afterload? ??? ??? acute LV failure, MI? ??????.(?? underlying ventricular dysfunction?? coronary disease ?? ????) ??? ??? aortic regurgitation? ?????. - CO? LVEDP? LV vol.? ?????? ?? ??? ???? ??? ????? ??? - ??? ?? ???? coamp? ? distal? ????? ???

    106. SURGERY INVOLVING THE DESCENDING THORACIC AORTA(2) nitroprusside infusion - BP ?? ??, CO ??? ??? ?? ?? ?????? ????, cross-clamping??? ????? ????? ?? ??? ??? ? ?? procedure?? management? ??? ?? - ??? intraop. Bleeding, aprotinin?? prophylaxis? ??? ???, blood scavenger? routine ?? venous access & intraop. monitoring? ?? multiple large bore(14G) IV cath. ?? pulm. a. cath. - intraop. fluid replacement guide? ?? TEE - MI monitoring? ?? hemodynamic instability ??? ?? ? ?? - aortic cross clamp ? ?                                                 : release hypotension - bleeding? ?? afterload? ??? ??? ischemic lower body??? vasodilating acid metabolite? release? systemic hypotension? ??????? - Tx : ???? ??, vol. loading, cross-clamping? partial or slow release, ??? vasopressor? ?????, NaHCO3 - hypotension? ?? ??? pH 7.2 ???  metabolic acidosis ? ?????      CaCl2 - massive transfusion ?? ?????.

    107. SURGERY INVOLVING THE DESCENDING THORACIC AORTA(3) paraplegia thoracic aorta clamping? ?? Cx : spinal ischemia, paraplegia - 30??? cross-clamping ??? , extensive surgical dissection???, emergency??? ? ?? ?? classic defecit - motor function & pinprick sensation loss ??  vibration & proprioception ????  ant. spinal a. synd.? defecit? ??  spinal cord - vertebral a. , thoracic & abdominal aorta?? supply - ant. & 2 post. a. ? spinal cord? ?? ?? intercostal a. - upper thoracic aorta??? ant. & post. a. ?? thoracolumbar a. of Adamkiewicz - lower thoracic & lumbar cord??? ant. spinal a. ??, ?? ?? Lt.side?? origin - surgical dissection? ?????? ?? aortic cross-clamping? ?? occlusion? ?? temporary heparin-coated shunt ? partial CPB c hypothermia         - distal perfusion? ???? paraplegia, HTN, ventricular failure?? ??

    108. SURGERY INVOLVING THE DESCENDING THORACIC AORTA(3) paraplegia partial CPB - heparinization? blood loss? ????? ??? ?? ???? heparin coated shunt - heparinization ??? ????         ascending aorta, Lt. subclavian a., Lt. ventricular apex  ? ??? ??, common femoral a.? ??? ?? spinal cord? ???? ??? ?? - MPD, mild hypothermia, mannitol, CSF drainage mannitol - CSF ??? ???? CSF pressure ???? spinal cord perfusion pressure : MAP - CSF pressure,  aorta cross clamping?? CSF pressure ???  mannitol? spinal cord perfusion pressure ?????  ??? ???? nitroprusside - spinal cord ischemia?? ????? ???? cross-clamping? ??  hypertensive response ????? ??, nitroprusside?  hypotensive action? cross-clamp ????? ???? ?? cross-clamp ???? ??? BP ??? cross-clamp ???? ??? hypotension? ?? ?? ??? ??.

    109. SURGERY INVOLVING THE DESCENDING THORACIC AORTA(4) renal failure aortic surgery ?? ??? ?? ??         - emergency procedure, prolonged cross-clamping period,         prolonged hypotension ?, ??? ?? ??????? ???? ?????? cross-clamping? mannitol(0.5 g/kg) infusion         - ??? ?? ????. low dose dopamine - not effective      cross-clamping? release ??? ???? low urine output?      ??? adjunct? ??? ??. fenoldopam infusion - renal blood flow ???? ??? ??      postop. renal impairment ???? ???? ??? ?? ?? CO ??? ??

    110. SURGERY ON THE ABDOMINAL AORTA ant. transperitoneal or anterolat. retroperitoneal approach? ?? - ?? ??? ?? cross-clamp? supraceliac, suprarenal, infrarenal aorta? ??? ?, occlusion ?? heparinization? ??? intra-arterial BP - ?? upper extremity??(?????) monitor ? ? ?? ????? clamp? ? distal ? ?????, LV afterload? effect? ?? good ventricular function?? ???? infrarenal aorta? occlusion? ?? minimal hemodynamic change ??? - ?????, clamp release? ?? hypotension ?? large incision & extensive retroperitoneal surgical dissection         - intraop. blood loss ?? ?? ? fluid ???? ???? fluid ?? - CVP or pulm. a. pressure monitoring ?? guide mannitol renal prophylaxis - ?? renal disease ?? ???? ?? infrarenal aorta clamping - ??? ??? ?? ???? postop. renal failure? ?? ???. ??? ?? - epidural anesthesia? RAA blockade? ?? ???? ??

    111. POSTOPERATIVE CONSIDERATIONS aorta ???? ???? ???? postop. 2-24???? intubation & ventilation hemodynamic stability ??, postop. bleeding monitoring? ?? abdominal aortic surgery?? ??? ?? procedure ?? extubation ?? ???? postop. ????? maintenance fluid ???? ??? ?

    112. ANESTHESIA FOR CAROTID ARTERY SURGERY

    113. PREOPERATIVE CONSIDERATIONS(1) stroke - ischemic 80%,   hemorrhagic 20%       ischemic : thrombosis, embolism? ??, vasospasm? ??? ? - stroke? 24?? ?? neurologic defecit ???? ??? ??  * TIA : 24?? ??,   tightly stenotic lesion?? low-flow state ????? extracranial vessel or heart?? ?? emboli ?????. * stroke in evolution - stroke? sign & Sx? ?? ? ??? ?? ?? complete VS incomplete           : involved territory? ??? affect????, ??? ?? ??? ??? int. carotid a. - TIA? stroke ???? atherosclerosis? m/c site       ?? : PLT-fibrin ?? plaque material ? embolization stenosis, complete occlusion complete occlusion - plaque?? hemorrhage ?? thrombosis? ?????. ??? collateral circulation ??? ??

    114. PREOPERATIVE CONSIDERATIONS(2) thrombotic stroke - TIA? minor stroke? ?? collateral blood flow ??? ??? ?? emboli - Sx? ? ?? ??? amaurosis fugax - ophthalmic br.? small emboli? ?? ??       transient monocular blindness ?? ? ? emboli? ?? MCA? ???? contralat. motor & sensory defecit ???? arm & face? ????? ??? ? aphasia - dominant hemisphere? affect ? ? ?? ant. cerebral a. ??? emboli - leg?? ? ??? contralat. motor & sensory deficit ?? carotid endarterectomy Ix         - TIA asso c ipsilateral severe carotid stenosis (>70% occlusion)           severe ipsilateral stenosis in a pt. c a minor(incomplete) stroke           30-70% occlusion in a patient c ipsilateral symptoms

    115. PREOPERATIVE ANESTHETIC EVALUATION & MANAGEMENT carotid endarterectomy?? ???? ??? - ??, HTN, arteriosclerosis ??, ???? DM preop. evaluation & management - preexisting neurologic deficit define       ??? ????? ??? uncontrolled preop. HTN - op ?? ??? deficit ?? ?? uncontrolled hyperglycemia - ischemic cerebral injury? ???? morbidity ?? - ?????? ??? ??? ??? ?(??? ??) - BP & Glc - preop. control ?? ? - angina - stable & controlled - overt cong. heart failure Sx? ??? ? - anxiety ???? ? - tachycardia, HTN ?? ??

    116. GENERAL ANESTHESIA(1) carotid surgery?? ??????? heart? stress ??? ?? ??? ?? cerebral perfusion? ???? ?? ?? - a. BP? close regulation & tachycardia ??? ?? ??, ??? intra-arterial pressure monitoring? ??, EKG monitoring? ischemia? ????? V5? ?? - continuous ST seg. analysis? ??? carotid endarterectomy? ?? ?????? fluid shift? ??? ?? ??? ?? hemodynamic monitoring? ?? underlying cardiac function? ?????, ???? ???? ????, MAP? ??? ??? ???? ?? ??? ?? ??? ???? induction agent - thiopental, propofol, etomidate        cerebral blood flow?? ? ?? cerebral metabolic rate? ????? favorable cerebral effect ??? ?? propofol & etomidate - focal ischemia?? thiopental?? ????? ???? propofol? ? ?? awakening? ??? ? opioid? beta B ??? intubation?? hypertensive response? ??? ?? isoflurane - cerebral ischemia? ?? ?? ? ????? ?? ??? ????        ???????? choice * desflurane - isoflurane? ??? ??? ??? isoflurane ?? ????? ??. But awakening? ??? ?? ????? immediate neurologic assessment?? ? ?? ??

    117. GENERAL ANESTHESIA(2) intraop. HTN - ?? ???? IV vasodilator? ?? ??    NTG : coronary circulation? beneficial effect? ??  mild - moderate HTN? ??    nitroprusside, beta B : marked HTN? ??  tachycardia? ??    ??? ????? ????? IV nifedipine : focal ischemia? protective effect? ??  ??? ?. hypotension - IV fluid & vasopressor? ??, ?????? phenylephrine? ???, ??? ????? ??? HTN? ??? ?? 25 ug increment?       ???? ? atropine -carotid baroreceptor? manipulation ?? ?? ???? reflex bradycardia? heart block? ?? - ?? ?? ??? ?? ?? ?? ?? ???? carotid sinus? lidocaine? infiltration ??? infiltration ??? bradycardia? ???? ? ?? a. CO2 tension - end tidal measurement? ??? ?????? ?? ???        routine?? measurement??? hypercapnea : intracerebral steal ???? ?? hypocapnea : cerebral perfusion ????, ventilation? normocarbia ????? ?????

    118. GENERAL ANESTHESIA(3) IV fluid - ????? Glc free sol.? ??. ??? hyperglycemia? ?????? heparin - carotid a.? occlusion ?? ?? protamine - 50-150mg? skin closure ?? reversal ?? ?? rapid emergence - immediate neurologic assessment? ?? ?? ??, ?? HTN, tachycardia? ??? vasodilator? beta B? ?? postop. HTN - ipsilat. carotid baroreceptor? surgical denervation? ??? ??. carotid body? denervation? hypoxemia? ?? ventilatory response? ??? ? wound hematoma - extubation ?? airway? ??? compromise?? ?? ? ????? transient postop. hoarseness - recurrent laryngeal n.? retraction ipsilat. deviation of tongue - hypoglossal n.? retraction ??

    119. MONITORING CEREBRAL FUNCTION regional anesthesia? ???? ????, carotid cross-clamping?? cerebral perfusion? ???? assess ??? indirect method? ?? ?? surgeon?? shunt? routine?? ?????, ??? postop. Neurologic deficit ??? ?????? ??. ??? shunt insertion? emboli? dislodge ????? shunt ??? ?? - ?? center?? cross clamp ????? carotid stump pressure , EEG, SSEP ???? ?? - distal stump pressure? < 50mmHg?? shunt? indication cross-clamping ?? ischemia? electrophysiologic sign? shunt ???? 10??? ???? ??? ??? postop. neurologic defecit? ??? ??.

    120. REGIONAL ANESTHESIA regional ???? carotid surgery? ??? ?? ??. supf. & deep cervical plexus block - C2-C4 n.? ????? block?? ??? ??? ??? awake ??? ?? ?? - ?? - ??? ????? examination ?? ? ?? ??? temporary shunt ??? ??? ??? ??? neurologic deficit ??? ?? intraop. neurologic exam? carotid cross clamping?? cerebral perfusion, ??? ??? ?? ??? ?? ??       ??? ?? : consciousness level, speech, contralat. handgrip -  ? ???? hemodynamic? ??(??? ??? ??) - ?? - ??? full cooperation ??     airway? ???? ?? ??? ?? ???? airway?? access? ??? - cervical plexus block? ?? ? ??? ipsilat. phrenic n. paralysis? ????? ??? ?? well tolerated & transient

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