Cardiac Anesthesia Resident Rotation
Cardiac OR Setup
This guide is an introduction and should be individualized to patient pathology, surgical approach and attending preference. As with non-CVT cases, you should have the setup complete prior to the patient’s arrival in the OR. Heparin and vasoactives at a minimum.
Drugs
- Sedation and induction agents should be determined in your preop discussion. For a typical pump case, midazolam 2-10mg, fentanyl 500-1000mcg is sufficient. Propofol is our typical induction agent unless exceptional circumstances exist. Do not draw up etomidate unless specifically discussed.
- Succinylcholine should be available for every case but not drawn up unless you intend on using it (a clean labeled syringe next to an unopened vial is ok)
- Vasopressors premixed epinephrine, ephedrine and phenylephrine syringes are available from pharmacy. Sometimes we will use vasopressin or norepinephrine boluses you mix yourself. See Standard Dilutions worksheet.
- Vasodilators should be chosen on a case-by-case basis. Have at least one syringe ready for bolusing per case. See Standard Dilutions worksheet. Remember you have an inhaled vasodilator available for most cases (iso/sevo)
- Heparin (30,000units/30mL x 1 + extra 30mL bottle) for all cases. Drawn up. Usually sits on top of anesthesia machine ready to go
- Aminocaproic acid (10g/40mL x 2) for all pump cases. Drawn up. Bolus (5-10g) and infuse (1g/hr) usually after heparin bolus administered. May be given earlier per attending preference
- Cardiac bucket from pharmacy (after hours go to Pyxis in Core outside OR8, look under “Emergency Cardiac Anes”). Contains heparin, aminocaproic acid, NaHCO3, CaCl2, KCl, 5% albumin, dopamine, NTG bottle, protamine
- Infusions typically include epinephrine + judiciously selected other bags
- Protamine is a high risk drug in the cardiac OR. If given prior to weaning CPB the pump will clot. This is bad. Do not ever draw it up at the beginning of a case. It may be drawn up (250mg/25mL x 1) prior to weaning from CPB only when labeled meticulously, taped over the cap on the end, and stored on the Pyxis away from actively-used medications
- Hot neo is a phenylephrine bag we prepare for our perfusionists at 200mcg/mL (20mg in 100mL bag). Hand off to them at beginning of the day (thank you)
- Antibiotics - doses are for normal baseline renal function
- Non-valve or implant cases: typically cefazolin
- Valve or graft placement: typically cefazolin + vancomycin
- VAD or MCS: triple coverage: vancomycin + cephalosporin (ceftazidime 1g q4-6h or cefepime 2g q6h) + fluconazole 400mg
- Heart transplants: typically cefazolin +/- vancomycin
- Lung transplants: Zosyn + cefepime/vancomycin +/- others
Note for transplants and VADs, be sure to check with surgical team as prior cultures may alter regimen suggested above - ICU patients: continue current antibiotics + discuss with surgical team re any additional needs depending on clinical scenario
Weight-based dosing |
|
| Cefazolin | Vancomycin |
• 2g is default • >120kg = 3g Redose q4h |
• <80kg = 1g • 80-99kg = 1.25g • 100-120kg = 1.5g • >120kg = 2g Redose q12h if normal renal function |
Equipment
- Lines
- Arterial - kits available for both radial (20G 2.5cm) and brachial (20G 12cm) access, or make your own sterile setup
- Central access – 9Fr Cordis kit + 16Ga triple lumen catheter for most cases
- Place both wires first, Cordis wire (shorter one) more cephalad
- Confirm both wires with TEE +/- ultrasound
- Cordis placed first, then TLC (secure TLC at 12-15cm depth)
- Biopatch for each line is mandatory – should loop between catheter and skin, not just sitting on top
- Accessories needed for central line placement include claves (x4-5), flush syringes (2-3), small Tegaderms (x2-3), Biopatch x1 (TLC kit comes with one inside)
- Pulmonary artery catheter
- Two models available – continuous cardiac output (CCO) or intermittent thermodilution<
- Calibrate CCO ahead of time by plugging into module and entering basic information (takes <2mins)
- Always double glove for central lines so outer layer of gloves may be removed for PA catheter placement
- Monitors
- Standard ASA monitors – remember to place EKG pads on posterolateral parts of chest wall and shoulders. Do not place where patient will be laying on it or creating a pressure area
- Pressure transducers – at least 3 (arterial, CVP, PAP). Others may include a planned secondary systemic pressure line or CSF pressure
- Cerebral oximetry – Foresight is the module available on campus. Best applied prior to oxygenation or induction of anesthesia to get baseline. Bilateral forehead stickers, #1or 3 = left, #2 or 4 = right
- Awareness monitors – use either BIS or Sedline. Our patients are high risk for awareness
- TEE – ensure is powered on, enter patient name + MRN + case abbreviation under “Patient Data”
- Other equipment
- Blood in the room – not necessary in every case. Recommended for redo sternotomys or anemic patients. Discuss with your attending during preop talk
- Ultrasound for line placement
- Rapid infusion system – either a Level 1 or a Belmont
- 8 channel Alaris pump system
- ABG syringes
- ACT syringes (get a bundle from the perfusionist)
- Peripheral IV start supplies/kit
- Normosol blood pumps (at least 2) +/- extra bags Normosol
- Orogastric tube
- Epicardial pacemaker box (Medtronic) – check it turns on, replace battery if not
