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Cardiac Anesthesia Basics for the “Non-Anesthesiologist”

Cardiac Anesthesia Basics for the “Non-Anesthesiologist”. Kimberly D. Milhoan, MD Assistant Clinical Professor, University of Texas Health Science Center, San Antonio, TX 2011 Cardiac Critical Care Course Kathmandu, Nepal October 16, 2011. Pre-operative evaluation Sedation outside OR

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Cardiac Anesthesia Basics for the “Non-Anesthesiologist”

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  1. Cardiac Anesthesia Basics for the “Non-Anesthesiologist” Kimberly D. Milhoan, MD Assistant Clinical Professor, University of Texas Health Science Center, San Antonio, TX 2011 Cardiac Critical Care Course Kathmandu, Nepal October 16, 2011

  2. Pre-operative evaluation Sedation outside OR Induction in OR Pre-bypass Initiation of bypass Maintenance of bypass Re-warming Separation from bypass Post-bypass (Extubation) Transport to ICU Anesthetic Order of Events: Cardiac Bypass

  3. Pre-operative Evaluation:NPO Guidelines • 8 hours: solid foods • 6 hours: formula • 4 hours: breast milk, formula for infants <6 months • 2 hours: clear liquids

  4. Pre-operative Evaluation:URI • 5x risk of laryngospasm • 10x risk of bronchospasm • 11x risk of adverse perioperative respiratory event • RSV + CPB => post-op ARDs with high mortality • Risks increased in patients with baseline pulmonary condition, e.g. asthma • History of allergic rhinitis or “usual runny nose” reassuring • Consider postponing case until 2 weeks symptom-free

  5. Pre-operative Evaluation:URI • Definite postponement of surgery (until 2 weeks symptom free): • Acute onset • Fever • Mucopurulent nasal discharge • “Wet” cough

  6. Pre-Operative Evaluation • Greatest source of information: pediatric cardiologist! Find their last note! • Evaluate their history, physical, EKG, echo, cath, and radiographic findings

  7. Pre-Operative Evaluation: Required Data • Height and weight (calculate body mass index) • Vital signs • Temperature, heart rate, blood pressure, respiratory rate, BASELINE OXYGEN SATURATION • Laboratory • Complete blood count, coagulation profile, electrolytes, complete blood chemistry, type & screen • Chest x-ray • EKG • Echo • +/- Cath findings

  8. Emergency Meds • Atropine: 20 mcg/kg or 100 mcg minimum • Neosynephrine: 1 mcg/kg • Dilute syringe to 1 mcg/cc if <5 kg, 10 mcg/cc if 5-10 kg, and 100 mcg/cc if over 40 kg • Epinephrine: 1-10 mcg/kg • Same serial dilutions as neosynephrine • Adenosine: 150 mcg/kg • Amiodarone: 5 mg/kg

  9. Sedation outside OR:Philosophy A bad medical experience for an adult is a “story” while a bad medical experience for a child can be a life- or personality-changing event Considerations: e.g., Tetrology of Fallot patients

  10. Induction in OR • Baseline SpO2, EKG, blood pressure • IV or Inhalation induction • If no IV, inhalation induction with sevoflurane or halothane followed by IV placement • Left-to-right shunt physiology: • more sensitive to inhalation agents and less sensitive to IV agents • decreased pulmonary vascular resistance results in pulmonary overcirculation  low inspired oxygen concentration, normocarbia • Cyanotic physiology: • less sensitive to inhalation agents and more sensitive to IV agents NO BUBBLES!!

  11. Induction in OR • Intubation--ETT: • <1 kg: 2.5 uncuffed • <3 kg or <1 mth: 3.0 uncuffed • >3 kg or 1-6 mths: 3.5 uncuffed or 3.0 cuffed • 6 mths – 2 yrs: 3.5 – 4.0 cuffed • Age/4 + 4: round down to lower size and use cuffed tube Baseline SpO2, EKG, blood pressure • Place just enough air in cuff to occlude leak at 20 cm H2O pressure • Second IV • Placement of invasive monitoring lines • Placement of foley catheter

  12. Intraoperative Monitoring • Pulse oximetry • EKG • Blood pressure • Non-invasive prior to induction • Invasive post-induction (usually 24G in neonates, 22G in infants and children, and 20G in adults) • Temperature • Nasopharyngeal • Rectal • End tidal CO2 • Inspired/expired oxygen and inhalational agent concentration • Central venous pressure • Up to 3 kg: 3 Fr single lumen • 4–10 kg: 4 Fr double lumen • 11-40 kg: 5 Fr double lumen • Urine output

  13. Intraoperative Laboratory Monitoring • Arterial blood gas (ABG) • I-Stat • Hematocrit • Sodium • Potassium • Ionized Calcium • Glucose • Activated clotting time (ACT) • Baseline 90-120 seconds

  14. Intraoperative Laboratory Monitoring: Schedule • Base-line, post-induction • After heparinization • Every 20 to 30 minutes during cardiac bypass • Immediately prior to separation from bypass • After protamine given after bypass • As often as deemed necessary during post-bypass phase • Immediately prior to transfer to ICU • On arrival to ICU

  15. Pre-bypass • Heparinization • While placing aortic cannula • Infants: 400-500 units/kg • Children and adults: 300-400 units/kg • Goal Activated Clotting Time (ACT) > 400 seconds (checked 3 minutes after heparin given)

  16. Initiation of Bypass • Discontinue ventilation when heart no longer ejecting • 3-5 mm Hg positive end expiratory pressure (PEEP) with air • Re-dose sedation, muscle relaxant, narcotic

  17. Resources • Andropoulos DB, Stayer SA, and Russell IA. Anesthesia for Congenital Heart Disease. Malden: Futura, 2005. • Cohen MM, Cameron CB. Should you cancel the operation when a child has an upper respiratory tract infection? Anesth Analg 1991;72:282-8. • Cote, Charles J. et al. A Practice of Anesthesia for Infants and Children, 3rd ed. Philadelphia: Saunders, 2001. • Lake CL and Booker PD. Pediatric Cardiac Anesthesia, 4th ed. Philadelphia: Lippincott, Williams, & Wilkins, 2005. • Morgan, G. Edward et al. Clinical Anesthesiology, 3rd ed. New York: Appleton & Lange, 2002.

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