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Department of Anesthesiology - Residents Section

Survival Tools - Cardiac Setup

Cardiac Setup

Welcome to your rotation in Cardiac Anesthesia — "introductory" for the CA-1's (you must be good to be there while digesting the basics of anesthesia), "basic" for the CA-2's (definitely no excuse from reading) and "intermediate" for the CA-3's (you are the supervisors to your juniors). Well for the CA-4/Fellows it's a different and "advanced" line of thinking – you chose to be here and it will be so for the rest of your life, so you might as well learn to be the CONSULTANT and grab all the ropes you can (NO MORE SPOON FEEDING).

The basic facts of anesthesia do not change even in Cardiac anesthesia, and being organized, meticulous and well - some reading despite the busy schedule, will make it interesting.

BEFORE INITIATING OR SETUP – PLEASE CHECK WITH THE OR DESK TO VERIFY CANCELLATIONS AND/OR POSTPONEMENT OF SURGERY

THIS IS THE STANDARDIZED SETUP FOR ALL ELECTIVE AND EMERGENCY CARDIAC SURGICAL CASES.
Any further additions are at the discretion of the concerned Cardiac Anesthesia attending assigned for the case–this must be discussed before, to avoid any misunderstanding.
ROOM SETUP FOR THE EMERGENCY BRINGBACKS IS SEPARATE – DO NOT USE THIS MENU!!

Before departing for the day it may be useful to gather a few essentials and leave them in the assigned CT OR, to avoid unnecessary delay the next morning when more important last minute checks can be made for better performance and patient care (transducer manifold, 5 LEAD ECG cable, pulse oximeter sensors, pacing box and infusion pumps to name a few)

We strive to have the rooms ready by 6.30 am every day. (Mandatory M&M Conference on alternate WEDNESDAYS for all CT anesthesia residents – schedule/location will be notified) which means your presence is required in the OR by 5.30 am

Before proceeding to setup the OR please check the Air Cylinder connected to the Anesthesia ventilator. Open the Air cylinder by turning the knob in the required direction, check the quantity and pressure. If the Air cylinder is empty please notify the Anesthesia workroom personnel - under no circumstances, DO NOT swap the Air cylinder connected to the Cardiopulmonary bypass machine. Notify the CT anesthesia attending if the workroom personnel do not change the Air cylinder!

Do not forget to attach and assure a functioning suction equipment, laryngoscope blades Mac #3 & #4, Miller straight blade #3–keep ONLY one blade on the ventilator and the other within easy reach (?? difficult intubation)–Mac # 4 is the preferred choice (the first attempt is the best attempt and the usable length of the blade can always be regulated by the user).

Oral Endotracheal tube #7.5 for females and #8/8.5 for males — DO NOT CUT THE TUBE. Please check the cuff. Keep an oral and a nasal airway with a tongue depressor along with the ETT.

Check the Anesthesia machine Narkomed 6000. The vaporizer should be filled using the appropriate equipment

Make sure that the Siemens monitors are turned on and that all cables are connected. Check the ETCO2 monitor by breathing into the sampling tube and ensure that the ETCO2 curve is displayed.

The sensitivity for both ischemia and arrhythmia increases with the number of leads monitored, thus in the cardiac OR we use the 5 lead cable system and monitor lead II and V (90% sensitivity). Also consider using ST segment monitoring for identifying intraoperative ischemia in all patients undergoing CABG surgery. (Use the pull down menu from the ECG channel and proceed to extended ECG >> ST segment monitoring. Prearrange all the leads in their respective positions (White-RA, Black-LA, Green-RL, Red-LL, Brown-Chest). Also have 5 Tegaderms to cover the leads and avoid soakage from the surgical scrubbing solution.

The NIBP cuff is placed on the Right arm — use the appropriate size (Avoid using the left arm or the non-dominant hand, because the Radial artery is frequently harvested as a conduit for grafting during CABG surgery. The Pulse oximeter is also placed on the Right arm/dominant hand for the same reason (BASICALLY LEAVE THE LEFT/NON-DOMINANT HAND ALONE!!!–IF NEEDED PLEASE CHECK WITH THE CTA ATTENDING & SURGEON)

The transducer setup is an important part for cardiac surgical patients who are monitored very aggressively. The transducer tubing comes boxed as a customized set of 3 transducers attached to a single spike. HEPARINIZED SALINE BAGS of 500ml volume are premixed by pharmacy and available at the satellite pharmacy. A PRESCRIPTION ORDER NEEDS TO BE FILLED BY THE MD AND PLACED IN THE PATIENTS CHART–NO ECEPTIONS TO THE RULE !!!. For emergency purposes ONLY a few bags are kept in the refrigerator next to the blood bank refrigerator in the OR. Before spiking a heparinized bag (0.9% NS 500cc + heparin 500 units), please make sure that all connections are secured tight. Spike the heparin bag and pressurize to 250-300 mm Hg. using a pressure bag–remove all air from the bag before pressurizing. After flushing the transducers free of air and zeroing them, turn lever on the transducer to a 45o angle to avoid a pool of saline on the floor (the transducers flush constantly at a rate of 3ml/hr). The transducers are arranged sequentially as follows (please do not go by attached labels): The colors are just for reference

CVP

The pressure tubing extension on the CVP transducer is used for coronary sinus pressure monitoring during conduct of CPBP–PLEASE DO NOT DISCONNECT/DISCARD. Connect a male-to-male connector at the other end of the pressure tubing extension.

Having paid attention to most of the equipment requirements for the cardiac operating room setup lets proceed with the emergency drugs and the IV infusion drugs.

Make a stock solution of Neosynephrine and Epinephrine (mix one ampoule of 1mg. Epinephrine or one vial of 1% Neosynephrine–10mg, with 9cc of 0.9NS–discard 1cc from the 10cc vial before adding the drug). Label, date and sign the vials accordingly – DO NOT USE FOR ANOTHER CASE OR ANOTHER DAY. Use this stock solution to make your emergency syringes as required.

NOTE: THIS IS STANDARD FOR ALL ATTENDINGS AND ALL CASES, HOWEVER IT IS RECOMMENDED THAT THE RESIDENT DISCUSS FURTHER REQUIREMENTS OR ADDITIONS TO EXISTING SETUP BEFOREHAND.

ONE SYRINGE EACH (except NTG – 2 syringes):
(label - drug, concentration and date and sign each syringe)

1) EPINEPHRINE 10 mcg/cc
2) NEOSYNEPHRINE 100 mcg/cc
3) CALCIUM CHLORIDE 100 mg/cc (premixed vials)
4) NITROGLYCERIN: 100 mcg/cc (draw 5cc of NTG from the infusion bottle – 200mcg/cc; dilute with 5cc 0.9NS to make 100mcg/cc) Keep one extra syringe to avoid drawing up from the NTG Bottle.
5) HEPARIN 20,000 UNITS x 2 SYRINGES
6) LIDOCAINE 2% 2 SYRINGES

All the above emergency syringes (# 1 - #6) can be made and stored in a sealed and labeled bag (date & time drugs made, initials and name of MD) in the workroom refrigerator and used within 24 hours.

» Keep Esmolol, Atropine, Succinylcholine, and Etomidate on the side cart.

Discuss with the CT anesthesia attending the anesthetic plan, so that the appropriate medications are withdrawn from the CD module or issued by the satellite pharmacy.

Syringes for Anesthesia:

  • 20cc syringe for Narcotic
  • 10cc syringe for Versed
  • 10cc syringe for Muscle relaxant

» The antibiotic of choice is also mixed beforehand and given as soon as the IV access is acquired.

PLEASE DOCUMENT ANTIBIOTIC ADMINISTRATION IN THE ANESTHESIA RECORDS.

In patients with NO ALLERGIES:

Ancef 1 gm. IV after iv access & 1 gm. after placement of the PA catheter.
Ancef 1 gm. repeated every 4 hours till patient leaves the OR.

Patients with PCN allergy are given Vancomycin 1gm diluted in 150cc D5W/0.9NS over 1 hour preferably via the infusion pump.


IV INFUSION DRIPS:
(Label all infusion bottles with drug label, dose added, date and initial)

The cardiac OR's have special IOMED pumps with 4 outlets. These are specially designed for use in OR #5 & #8. Be careful when moving these pumps around. DO NOT ATTEMPT TO REMOVE/DISMANTLE THESE PUMPS. PLEASE PLUG THEM IN BEFORE USE.

NTG – 50MG IN 250cc D5W – 200mcg/cc

In the morning once the OR case is confirmed – AMIKAR infusion is mixed: 5gm/20cc x 5 vials diluted in 150ccD5W (25gm/250cc – 1gm/10cc) – DISCUSS WITH ATTENDING BEFORE MIXING DRUG.

Attach infusion tubing to the pump after flushing all air and run the pump to make sure that it works – the worst thing to happen is a nonfunctioning pump – IT IS A NECCESSITY

Well we have covered most of the CT OR setup – the last thing to do is to set up the saline bag for cardiac output measurements – it is a separate boxed kit. DO NOT UNCOIL ALL THE LOOPS. Spike it a 500cc 0.9 NS bag and remove all the air from the tubing. Hook it to the underside at the head end of the table.

Uncoil the bladder temperature probe and leave it under the OR table, so that the PA/OR nurse connects it.

Now its time for the IV fluids:

(A) Spike a 1-liter bag of Plasmalyte with the Arrow Walrus Hi-Flo Stopcock Y blood set. Connect it to the HOTLINE fluid warmer, with the stopcocks positioned after the warming coil/tubing. Do not forget to plug in the Hotline and turn it on. Note the temperature on the front panel of the device – should read not more than 41° Celsius.

(B) Spike a 1-liter bag of Plasmalyte with two tubing's:
- A regular 20 drop/min drip set
- A micro-drip set with 4 stopcock

The micro-drip set with stopcock manifold will be connected to the VIP port of the PA catheter through which all infusions (inotropes, vasopressors, vasodilators) will be given uninterrupted!! The 20-drop/min set will be connected to the side port of the introducer – connect a three way stopcock, all medications given as boluses will be given through this route.

Have available the following – 2-3 rolls of 1" clear tape, _" and 1" pink tape, lacrilube or artificial teardrops for the eyes. Attach the Right side arm board to the OR table and cover it with a clean towel. Place the NIBP cuff, pulse oximeter cable and electrodes on this arm board so that may be conveniently and quickly attached to the patient. Place the left arm board under the OR table.

Before you step out of the OR to collect your medications, review the patient's chart in the holding area or even to fetch the patient from the CCU NS 26/CTICU NS 24, do not forget to turn the Anesthesia machine to the STANDBY mode. Attach a facemask of appropriate size to the patient end of the breathing circuit.

Finally the operating room table should be positioned so that enough room is left at the head end of the table – enough for the Attending and resident, and all the clutter!!. There should be two IV poles on the left side and two on the right side. On the left side accommodate the poles for the IV fluids and the Ivac pumps. The IV pole with the IV fluids (2 bags of Plasmalyte and Hotline is placed closer to the OR table and the pole with the Ivac pumps is placed farther from the patient. Keep your IV bags and infusion bottles out of the surgical field. On the right side closer to the patient hook up the pressure bag for the transducers and leave the outer one empty.

Also please make sure that a functioning pacemaker box is available and hook it on the IV pole with the transducer pressure bag.

This is not as difficult as it sounds. A senior or the CT attending will show you the setup on your first day. Please concentrate on setting up the room for the first few days of your rotation. Initial it may take an hour to setup the OR, but believe it or not, only a _ hour is needed.

All other medications not needed to start the case may be prepared later on while the patient is on the pump – these are medications used generally to assist in weaning the patient from CPBP and for metabolic control.