ANAESTHESIA

FOR CARDIAC
SURGERIES
• History and physical examination
Evaluating the patient's
cardiovascular and pulmonary
status, comorbid conditions, and
previous surgical history
• Diagnostic tests
PREOPERATIVE Performing
ASSESSMENT echocardiography, coronary
angiography, and other relevant
imaging studies to assess the
heart's anatomy and function
• Laboratory tests
Checking complete blood
count, coagulation profile,
electrolytes, renal, and liver function
tests
Pain and anxiety – anxiolytic
( alprazolam, midazolam ) or
narcotic
During radial artery
PREMEDICATI cannulation, sedation with
ON midazolam and fentanyl (IV)
with local infiltration
Patients with low EF – to be
cautious – only incremental
doses of drugs to be given
slowly
• ECG, Lead II and V5
• Capnometry, Pulse oximeter

INTRA •
•
Temperature (lower oesophageal)
Urine output
OPERATIVE • Arterial line for IBP and ABG
MONITORING • CVP or PA catheters
• TEE
• ACT
INDUCTION OF ANAESTHESIA

Hypertension
Smooth induction
maybe due to
is essential to
Fall in BP > 20% of anxiety or
prevent
baseline requires sympathetic
hypotension,
use of ionotropes stimulation due to
hypertension or
laryngoscopy and
tachycardia
intubation
INDUCTION OF
ANAESTHESIA

High dose narcotics – fentanyl 3-5 mcg/kg or

sufentanil 15-25 mcg/kg
Total intravenous anaesthesia – Midazolam
0.05 mg/kg with Propofol 0.5-1.5 mg/kg or
Etomidate 0.1-0.3 mg/kg
Inhalational anaesthesia – Iso/Sevo/Desflurane
at 0.5-1.5 MAC
Pre CPB period
1. Check B/L breath sounds
2. Adjust fresh gas flow
3. Protect eyes and pressure points
4. Check monitors and tubings
5. Administer antibiotics
6. Check baseline ECT, ABG,
electrolytes and hematocrit
Pre CPB period

Skin incision  sympathetic response. So

adequate depth of anaesthesia is necessary

Sternal incision & splitting  pain and

sympathetic response  Treated with
fentanyl or Nitroglycerine bolus

Lungs deflated during sternal splitting to

avoid injury
Due to
• Hypovolaemia
• Impaired
myocardial
contractility
• Ischemia
• Arrythmias

Treatment
• Find the cause
• IV fluids
HYPOTENSION • Decrease
inhalational agents
• Ionotropes
Causes
• Light plane of anaesthesia
• Hypoxia
• Hypercapnia
• Hypervolemia

HYPERTENSION
Treatment
• Increase depth of anaesthesia
• Vasodilators – NTG
• Beta blockers
TACHYCARDI Causes Treatment
A • Light plane of • Increase depth of
anesthesia anaesthesia
• Hypovolemia • Volume loading
• Hypoxia • Beta blockers
• Hypercapnia
• Ischemia
BRADYCARDIA
Treatment
Causes • Treated if fall in BP or
HR<40bpm even if no fall
in BP
• Vagotonic
• Atropine 0.4-0.6mg IV
effects of
narcotics
• Beta blockers
• Ischemia
ARRYTHMIAS

Causes Treatment
• Mechanical • Treat underlying
stimulation of heart causes
• Electrolyte imbalance • Lidocaine,beta
• Ischemia blockers and
cardioversion used if
necessary
PRIMING THE CIRCUIT

Done by balanced salt

Deairing the CPB
solution (1200 –
circuit
1800ml)

Other components
like albumin or Priming causes
hetastarch, mannitol, haemodilution which
heparin(3–4 units/ml) improves flows during
and bicarbonate are hypothermia
added
HEMODILUTI Benefits Risks
ON • Decreased • Decreases BP
viscosity • Dilution of
improves drugs and
microcirculatio clotting factors
n
• Edema
• Decreased
oxygen carrying
capacity
INITIATION OF CPB
Heparin 300 U/kg IV is administered before arterial cannulation
with a target ACT (measured after 3 min) of more than 480 S.
During arterial cannulation, systolic pressure should be 90–100
mm Hg to reduce the risk of aortic dissection.
The aortic cannulation is done first to provide volume
resuscitation in case of hypotension associated with venous
cannulation.
Once the aortic cannula is connected to the tubing, line
pressure is checked to rule out dissection.
After venous cannulation, venous clamp is gradually released to
establish full CPB and then ventilation is discontinued.
1. ACT value minimum 480 sec
2. Position of cannulae to be
checked
3. Urine output noted and
urobag emptied
PREBYPASS 4. Equality of carotid pulse to
be checked
CHECKLIST 5. Supplemental anaesthetic
agents to be administered
to compensate for
hemodilution
MAINTENANCE OF BYPASS
CPB  deep hypothermic circulatory arrest (DHCA)

ACT repeated every 30-40 mins

ABG repeated every 30-60 mins

PaO2 maintained between 100-300 mm Hg

PaCO2 maintained between 35-40 mm Hg

Blood glucose to be checked every 30-60 mins

Depth of anaesthesia maintained by adding anaesthetic agents and
muscle relaxants directly into CPB circuit
Ventilation stopped during bypass
• Pump flow rate to be maintained at
50-70 ml/kg/min
• Urine output should be atleast
0.5ml/kg/hr
• Monitor core temperature
MAINTENAN • MAP to be maintained between 50-
CE OF 70 mm Hg
• Blood glucose maintained between
BYPASS 120 – 180 mg/dl
• De airing of the heart is to be done
before weaning from CPB. TEE is
done for confirmation
WEANING

Weaning is the process Several steps are required

where extracorporeal for successful completion of
support is gradually weaning.
withdrawn as the heart
takes over the circulation.
PREPARATION FOR WEANING (Pneumonic CVP)

COLD – Patient’s temperature to be 36-37 degrees. Rapid

rewarming and hyperthermia are associated with cerebral
injury.

CONDUCTION – HR of 80-100 bpm is optimal. Bradycardia

may need epicardial pacing or ionotropes. Tachycardia
needs treatment of cause, medications and cardioversion

CONTRACTILITY – Estimated by TEE. Inodilators such as

milrinone, dobutamine and levosimendan can be used in
the setting of ventricular dysfunction
CELLS – Hb should be atleast 7-8 g/dl

COAGULATION – Long bypass period

PREPARATIO and extreme hypothermia increases
N FOR risk of bleeding. PT,APTT AND
Platelet count should be normal
WEANING
CORRECTION - Acid-base balance,
electrolytes, PaO2, PaCO2 and
sugar are corrected and kept within
normal limits.
PREPARATION FOR WEANING

VENTILATION – VISUALISATION
of lungs must – of heart and VOLUME
be established TEE for regional EXPANSION – if
after PA flow is and global necessary
restored contractility
PACER and PRESSOR
AGENTS – should be readily
PREPARATIO available
N FOR
WEANING POTASSIUM – Must be
corrected as hypokalemia
causes arrythmias and
hyperkalemia causes
conduction blocks
WEANING FROM CPB
• Patient should be rewarmed.
• Heart is de aired.
• Regular cardiac electrical activity
confirmed.
• Lab values confirmed and
corrected.
• Lung ventilation established.
• Venous drainage is slowly
reduced.
• Cardiac filling volume is
gradually increased.
• Vasopressors and inotropic
support maybe needed
WEANING FROM CPB

When patient is 1-1.3 mg of Protamine per

hemodynamically stable, 100 units of Heparin is
Protamine is administered given slowly over 10-15
to reverse anti coagulation mins

When pre loading is

optimal and heart
ACT is brought to baseline
contractility is adequate,
value
aortic cannula is clamped
to separate from bypass
• Elevated BP should be avoided to prevent
stress on suture lines
• If cardiac output is optimal, preload can
be increased in 100 ml increments as
rewarming the patient causes
vasodilation
• Increase in hemodynamic instability and
use of ionotropes may need reinstitution
of CPB
WEANING
FROM CPB
EVENTS IN POST BYPASS PERIOD

Cardiovascula
r Pulmonary Metabolic
Coagulopathy
decompensati complication disturbances
on

Neurological Temperature
Renal injury
injury disturbances
• Ischaemia/infarction
• LV dysfunction
CARDIOVASCUL • RV dysfunction
AR • RV failure – requires
DECOMPENSATI ionotropes plus
ON pulmonary Treated with
vasodilators
• Ionotropes
• Hypotension
• Vasoconstrictors
• Arrythmias – AF (most
common), VF, V • Pulmonary
flutter, bradycardia or vasodilators – NTG,
heart blocks Nitroprusside,
inhaled NO,
Prostaglandin E1
• Arrythmias –
cardioversion,
amiodarone, pacing
PULMONARY COMPLICATIONS

Atelectasis – requires ventilation

Hemothorax/Pneumothorax – needs ICD
insertion
Pulmonary edema -
• Platelet dysfunction
• Consumption of
clotting factors
• Caused by
hypothermia,
hemodilution, platelet
sequestration

• Treated with FFP

and platelet
concentrates

COAGULOPATHY • TEG (Thrombo

elastography) is
done to find the
cause of bleeding
Hypokalemi
a – Treated
with Inj. KCL
at 10-20
mEq/hr
Hyperglyce Hyperkalemi
mia – BG > a – Treated
200mg/dl with insulin,
treated with calcium
gluconate,
METABOLIC
Insulin
diuretics DISTURBANC
ES

Hypomagne Hypocalcem
semia – ia – Treated
Treated with with
Magnesium Calcium
sulfate chloride
NEUROLOGICAL INJURY

• Transient(temporary)
neuropsychiatric disturbances
common
• Causes are emboli,
hypoperfusion, cerebral
hyperthermia or cerebral
edema
• Hypothermia causes
TEMPERATUR coagulopathy and shivering
(shivering causes increase in O2
E consumption and hence to be
DISTURBANC avoided)
ES • Normothermia should be
achieved at the end of bypass
• Rewarming should be gradual
• Hyperthermia should be
avoided as it causes
neurological injury
CAUSES
• Fluid loss
• Myocardial depression
• Reduced renal perfusion
• Vasodilatation by anaesthetic
agents
• Inflammatory response
RENAL INJURY

TREATMENT
• Fluid replacement
• Vasoconstrictors
COMPLICATIONS
WHILE TRANSPORT
FROM OT

• Accidental extubation
• Loss of IV lines
• Pull off of monitors
• Injury to body parts
• Disconnection of pacemaker wires
• Dislodgement of chest tube and
foleys
• Removal of arterial line and CVC or
PA catheter
Portable monitoring equipments

Infusion pumps

Full oxygen cylinder with self inflating

TRANSPO bag (AMBU) for ventilation should be
ready

RT TO ICU On arrival to ICU, patient is attached to

ventilator and breath sounds checked

Monitors and infusions should be orderly

transferred to the nursing staff
CARE IN ICU
• Most patients require mechanical
ventilation for 2-12 hours.
• Hence sedation and analgesia to be
continued
• Hypertension unresponsive to
analgesics should be treated with
vasodilators
• Extubation is considered when patient
becomes conscious, muscle paralysis
wears off, ABG values are acceptable,
surgical hemostasis is adequate and
patient is hemodynamically stable
• CABG procedures relieve
cardiac symptoms and enable
patents to resume a healthy
life style
• However they do not prevent
coronary artery disease from
recurring.
• Hence medications with
appropriate lifestyle
modifications are necessary to
prevent recurrence