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Cardiac Anesthesia Made Ridiculously Simple

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    Posted: 03 Sep 2009 at 3:29pm
Cardiac Anesthesia Made Ridiculously Simple  part 1

by Art Wallace, M.D., Ph.D.,
modified by Luis Gallur / Paul Forrest
to reflect local conditions.

Cardiac surgery is a complex field of medicine with significant morbidity and mortality. It is however performed routinely with systems designed to facilitate an ordered throughput of patients. Currently around 80% of cardiac cases at RPAH and Liverpool Hospitals are day-of -surgery admissions. However, operating lists may be changed at short (or no!) notice to accommodate emergency cases. Patients may even be canceled after induction of anesthesia. Quality anesthetic care with specific attention to detail can greatly enhance patient safety and outcome. Conversely, details that are ignored can lead to poor outcomes. This document will attempt to describe the essentials requirements for cardiac anesthesia for adult CAG and VALVE procedures. The intention is not to be definitive but it outline the minimal critical requirements.

Pre-operative Consultation

Most commonly this is performed in the cardiac pre-admission clinic for elective cases. A full pre-anesthetic history and examination should be performed with particular reference to the following points which may affect anesthetic management or indicate the patients risk:


  • Present illness: angina (stable or unstable), dyspnoea (systolic or diastolic dysfunction), recent myocardial infarction (has it occurred since the decision to operate), episodes of cardiac failure, flash pulmonary oedema. Time in hospital or transfer from another center? MRSA risk?

  • Co-existing disease: CAL/asthma, diabetes, hypertension, cerebrovascular disease- has this patient had fits, faints funny turns or visual disturbances, peripheral vascular disease (claudication), renal insufficiency. Coexisting AAA?, Haemostatic disorder. Hypercoagulability disorder. Dental check performed for valve replacements?

  • Social/cultural Will they understand the co-operation required for line placement?

  • Central / PAC best inserted pre ­or post induction.

  • Allergies especially to Heparin, Protamine (seafood), Iodine, antibiotics

  • Medications: anti-hypertensives, anti-anginals, anti-arhythmics

  • Specific regimes for diabetes and asthma, heparin infusions (what have serial platelet counts been (HITTS?) Heparin infusions are usually continued up until patient arrival in theatre.

  • Have they stopped their aspirin and NSAIDS ? OPCAB patients may sometimes remain on aspirin.

  • Beware of newer antiplatelet agents- enoxaparin (Clexane), should be ceased about 24h preop. Clopidogrel (Iscover, Plavix) should be stopped 5-7 days preop. Abciximab (Reopro) ­avoid CPB for 5-7 days. Tirofiban- avoid CPB for 24-48h.

  • Antifibrinolytics: streptokinase- avoid CPB for 2-3h.

  • History of Reflux/Dysphagia: Rapid sequence induction in these patients may pose particular challenges. The placement of TOE probes maybe hazardous in patients with oesophageal disease ( strictures ).

Physical Examination

Do they look unwell? Are they SOB at rest? Do they look grey and shut down? Have the signs of left ventricular dysfunction been masked by diuretic use?

  • Airway, Dentition - anticipated difficult intubation?

  • Chest: CCF? Murmurs? CAL?

  • Head & Neck: movement, carotid bruits? JVP, previous carotid surgery scars, beards ­ will trimming be required for line placement? (usually not).

  • Periphery: pulses, nb: is radial artery being considered from the non-dominant hand? Venous access?


    * CXR - cardiomegally, effusions, aortic calcification, lungs lesions?
    * ECG - rate, rhythm, conduction abnormalities, pacemaker dependent, ischaemia ,
       recent infarction, territory of infarcts.
    * FBC - Hb, platelets
    * Coags. Prolonged APTT in the absence of heparin ( Lupus antibody )
    * Xmatch Does blood bank have suitable blood for an antibody- positive patient?
    * Electrolytes - K+, creatinine
    * BSL, HB A1c
    * Recent peaks of CK, CKMB, Troponin
    * Coags, ABG's, LFT's
    * Carotid Duplex Dopplers especially if patient has had symptomatic cerebral symptoms

Cardiac Catheter & Echo Report - note the following:

    * Coronary vasculature - number, site and severity of stenoses esp. LMCA disease or   
    * LV Function - LV Ejection Fraction, LVEDP, pulmonary artery pressures
    * Valvular lesions - areas and gradients:


Tell patients about fasting, medications, line placement, and post-op ventilation and analgesia.

Patients having cardiac surgery have serious and frequent complications including infarct, stroke, death. Risk of stroke increases rapidly with age over 65, hypertension, diabetes, previous stroke.

Mortality 1-10% (depends on risk stratification - see below), transfusion (< 40%) inevitable in patients less than 50 kg , Chest infections,. You should discuss these risks. Diabetics should be warned that their insulin requirements may change markedly, and that non-insulin dependent diabetics may become insulin-dependent, at least transiently. Patients with renal failure should be warned of the increased likelihood of temporary dialysis post-op.

Risk Stratification:

The following factors greatly increase risk associated with cardiac surgery:

    Age >80, uncompensated cardiac failure, cardiogenic shock, acute renal failure

The following factors moderately increase risk:

    Age >70, re-operation, emergency surgery, pulmonary hypertension, chronic renal failure

Other factors resulting in increased risk:

    Diabetes, hypertension, obesity, Ejection fraction <40%, valve surgery, LV aneurysm,  
    female gender

------------------------------------------------------------------------------------------------------------------- = Doctorate Of Nurse Anesthesia Practice


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