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Department of Anesthesiology - Residents Section
Survival Tools - 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
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
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):
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:
» 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.
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: