Morning setup
Arrive earlier than usual, usually at least 1.5hrs before case start
- Machine is on and tested, suction available, glide scope
- Wet down gtts
- Pressors: Levo/vaso/neo (1-2 pressors)
- Inotropes: (dobutamine or epi)
- Sedation: Precedex
- Fibrinolytics (e.g. TXA)
- Make syringes (i.e. poppers)
- Pressors (levo/vaso/epi)
- Induction (10cc’s of Fent, Midaz, Roc)
- Pre-Op A-line kit
- MAC/Swan prepped
- Orders done? (TEE, blood, etc)
Phases of a bypass case
Induction
- Lines
- TXA (1g load; 1 mg/kg/hr) / Amicar (2g load; 2 g/hr)
- ABG/ACT
- minmize IVF to lessen hemodilution effect of bypass
Pre-Bypass
- Light anesthesia
- Incision/sternotomy - painful
- Hold lungs for virgin sternotomy
- Heparinize prior to CPB (ACT >480)
- Bolus 400 U/kg
- Followup 100 U/kg
On Bypass Mnemonic: HAD2SUE
Heparin, ACT, Drugs/Drips, Swan, Urine, Emboli
Cannulation
- Reduce SBP to 90-100 before aortic cannulation
- Decreases risk of dissection
Bypass
- d/c ventilation once on “full flow”
- ensure perfusion starts some kind of anesthesia
- MAP 60-70 w/ pressor gtts, SvO2 >75%
- Monitor: BG, cerebral ox, UOP
Coming off bypass
Off-bypass mnemonic: WRMVP
Warm, Rhythm (NSR or pace), Monitors (turn on), Vent (turn on), Perfusion
Coagulopathy
- send plt/fibrinogen at 34C
- reverse heparinization w/ protamine when off bypass
- send ACT/ABG/PT/PTT/fibrinogen/Plts after reversal
Support post-bypass stunning
- Pressors ready
- Pacer box ready
- CaCl 10min after xclamp removal (stone heart)
Resuscitation
- Often need aggressive resuscitation (2-3L)
- Have adequate product in room
Transport
- NMB reversal
- OG tube
- adequate resuscitation / hemostasis
- sedation (precedex?)