# **Preoperative assessment** #1-DAY-BEFORE==> Use the Case Management sheet in the Cardiology section of "Chart Review" in Epic as a good resource for the patient's anatomy. #1-DAY-BEFORE==> Check for updated studies (echoes and other imaging) between the conference date and the OR date. # **Room preparation:** #2-EARLY-MORNING==> Put the same drugs in the same place every time. #2-EARLY-MORNING==> Include circumferential and longitudinal taping if you want to be extra organized. Indicate the dilute epinephrine syringe with yellow or red tape. Know where it is when you need to immediately give an epinephrine bolus! ## Medications to draw up before the patient enters the room: - Rescue drugs - Draw up full strength epinephrine (10 mcg/ml) and dilute epinephrine (**1 mcg/ml, special label**) - Draw up full strength phenylephrine (100 mcg/ml, for bigger patients) and dilute phenylephrine (10 mcg/ml, 2-3 syringes for patients under~30 kg) - Draw up calcium chloride (100 mg/ml) in an appropriately sized syringe (i.e. TB syringe for neonate, 3 mL syringes above 10 kg, etc.) - Draw up +/- atropine - "maintenance" drugs - Draw up Paralytic agent (at least 2 doses, 1 for induction, and 1 for as you finish lines or for TEE placement) - Draw up Opioid - Draw up Heparin (see dosing/transfusion sheet) ## Monitors: - Set up SpO2 monitor x2 (Massimo probe is in the glass cabinet) - Set up BIS monitor (for adult/teenager cases) - NIRS will be set up by perfusion prior to induction, on room air ## Intravenous fluids: - Put all IV fluids in the cardiac ORs on an infusion pump. - Set the rate to low rate (5ml/hr). Set the volume to be delivered at maximum of 10ml/kg. This way if you decide to give a bolus, that maximum volume that will be given will be about 10 ml/kg. - Run any infusion into a central line or an RA line through one of the small filters *before* connection to a trifold (1 filter for every central infusion). ## Redo procedures: - Make sure that blood is in the room and available prior to incision. Send blood back to the OR refrigerator once the chest is open safely. - See separate file for current blood management protocol for blood products recommendations. If you are blood priming the bypass circuit, have the PRBC and the FFP already in the room, ideally by the time the patient is in the OR. --- # **Lines** ## **Arterial line**: Use a sterile technique during the A line insertion. After you open the sterile towels, use it as a field to drop the remaining equipment. For neonates, access the artery with a 24 gauge catheter. Upsize to a 22 over one of the Cook wires. You will need (and shown, starting at the top left): 1. sterile towels; 2. 1-2 catheters; 3. the cook 0.015 wire (in the glass cabinets); 4. a small ultrasound probe cover (in the back of the ultrasound machine); 5. mastisol; 6. roll to support the wrist; 7. extra gauze to be opened onto the sterile field; and 8. a full, unopened IV start kit. Use the chloroprep stick in the IV kit to clean the wrist prior to draping with the towels. ![A bunch of items that are on a table Description automatically generated](attachment:2002fa0a-d14f-4e69-8eb4-2ddccc544deb:image4.jpeg) **Figure 3.** Equipment for arterial line placement At the end of the case, for neonates, infants, and toddlers, place an arm board on the arterial line prior to emergence. This helps the stability of the arterial line, and it is easier for us to place on a sedated child versus the ICU. ## **Central line:** Discuss the size with the attending per standards. Place only the 5 cm length line in the smallest neonates. Note that Dr. Carrillo, in particular, prefers the 8 cm length line when possible. You will need: 1. The central line; 2. large probe cover (back of the ultrasound machine); 3. set of sterile towels to drape out any area not covered by drape; 4. 2 Tegaderms; 5. mastisol; 6. 1 clear clave for each lumen of the central line; 7. biopatch (difficult to drop onto the sterile field, can be easier to have someone open it for you), 8. and a 6 inch pressure line from perfusion (personal preference). The trifold can also be opened onto your sterile field, so that you can flush it and attach it in a sterile fashion to the distal lumen of the central line after the line is secured. ![Figure 4. Equipment for CVL placement.](attachment:03eeb232-8d4e-4344-a21c-a81ce0e2cfa6:image.png) **Figure 4.** Equipment for CVL placement. **Optional**: The pressure line for the CVP is prepared with two stopcocks: the one at the transducer and one at the very end of the line. A 6 inch pressure line from perfusion `(yellow arrow)` can be attached to the end of the distal stopcock, to allow you to reach this site more easily (helpful during RAP/VAP, see below). ![image.png](attachment:8b8eada5-a3a4-4832-ba7a-74a3b21a6691:image.png) --- # **Timeline for case** ## Pre-incision After the arterial line is placed, perfusion will be getting an ABG and determining whether to take off **ANH**. Once the central line is in place, call cardiology to perform the TEE before the patient is prepped and draped. Re-dose the paralytic agent at this time. Add in additional opioid. Between the central line completion and incision, **start the Precedex drip (with or without bolus)**. Administer the TXA. When you see the surgeon, administer the cefazolin. Aim to administer your planned opioid dose prior to incision. ## Post-incision For first time sternotomies, be ready to drop the lungs for the sternotomy. Turn the vent off. Open the circuit to air by disconnecting the inspiratory limb from the anesthesia machine. ## Cannula Placement After the stay sutures are in place, and the surgeons are ready to place the cannulas they will give the heparin or ask you to give it, if there is a CVL. Quickly get an ACT/ABG for perfusion (**OK to draw shortly after heparin is administered**). Have the lab drawn before the actual placement of the aortic cannula since you are drawing off of the arterial line. This allows you to monitor the arterial blood pressure during the cannula placement. ## RAP/VAP This is where the Perfusionists back fill the circuit and your blood pressure usually drops significantly (VAP>RAP). Note that a blood prime is used instead for patients under 3 kg, or larger patients but with unstable/tenuous physiology. For RAP/VAP, be ready with 2-3 phenylephrine syringes and several flushes. For the smallest of the central lines, note that the pressure bag itself is sometimes inadequate to overcome the resistance of the CVP port. Manually flush with a syringe in these cases. To avoid having to disconnect and reconnect the syringes, attach the phenylephrine syringe to the stopcock closest to the patient. Attach the flush to the stopcock by the transducer (see below). ## CPB While on pump, set up your Milrinone. Give drugs to perfusion. If RA lines are going to be placed, set up a trifold on one of the infusion lines to connect to RA. Connect Milrinone and carrier to this trifold. Order a PCA/NCA, or speak with the pain team. If you need to re-dose antibiotics, hand them to the perfusionists. ### **Blood ordering** Make sure that you have all blood products ordered and available before rewarming. Order the products at any time under "will notify blood bank." Vocera the bank when you are ready for them to be prepared. Time that phone call by watching where the surgeon is in the progression of the operation. Call the blood bank when there is 1 anastomosis or component left, as this is usually a good time. Do not wait until you are already rewarming, as the blood products may not arrive in time. Remember that for patients who require irradiated blood products, i.e. neonates, the preparation of the blood products requires additional processing time. ## Coming off Bypass When the surgeon tells perfusion to start rewarming, **call your attending if not already in the room.** If you have a CVL, start your Milrinone after perfusion administers the loading dose to the patient. If you do not have a CVL, the surgeon will place RA lines and will hand them to you. First, connect one to CVP pressure transducer. Flush to him when he asks. Then zero (may take a few tries). Connect the other to your trifurcated line on the pump. Then flush with pump or syringe. Start Milrinone if you haven't already. Verify that it is appropriate to separate from bypass (i.e. TRAVEL pneumonic [Temperature, Rhythm, Air on TEE, appropriate and acceptable Ventilation, Electrolytes from warm ABG, table Level]). The surgeon will clamp partially and then fully, with cardiology evaluating the repair. Once off bypass, MUF is initiated (for neonates, infants, and children up to a certain weight). Administer Protamine through a peripheral IV. Follow with the TXA. Then start with blood products--ANH first, then other products as needed. If "hemobag" is administered (in teenagers and older patients), administer an extra 50 mg of protamine at that time. Draw an ABG after the protamine is in, and ANH/Cell saver has been administered. As the sutures are going in or about to go in for sternal closure, administer the IV acetaminophen. Document the time for the ICU! Write down the last gas for the ICU. Give Ondansetron and additional pain medications if needed. Administer reversal after the drapes are all the way down (this is usually when reversal is administered). Place an arm board on the arterial line for neonates, infants, and young children; this is easiest if it happens before they fully emerge from anesthesia. --- ## **OR to CTICU transport and sign out** - Make sure that there are monitors on the patients at all time during the transport process from the OR table to the bed. - Make sure that there is at least one line infusing fluid to the patient for resuscitation in case of emergency. - **TRAVEL WITH AT LEAST ONE SOURCE OF VOLUME TO BOLUS**. - Note that the ICU actually can't get albumin immediately (at the time of this writing, July 2020). Travel with a syringe, needle, and 50 mL bottle of albumin for neonates and infants, and a 250 mL bag of albumin for older patients. Do not arrive in the CTICU with a hypotensive patient who needs volume, and not having any, as this is NOT the situation you want to be in. If you don't use the albumin, just return it to the Pyxis machine. - Make sure that a bag, mask and transport circuit is available during transport, even if the patient is on nasal cannula. - Take resuscitation and intubation drugs and equipment (blade, ETT, oral airway and stylet) during transport to the CTICU. - Monitor and treat any instability during transport and until a complete sign out is given to the CTICU staff. - Fill and use the attached OR to CTICU sign out form during the sign out process. Note that as you get familiar with the process the flow will be much easier. --- # **Drugs** ## Opioids Discuss the plan clearly with your attending, since we aim to extubate almost all of our patients at the end of the procedure. Note that a typical fentanyl dose would be 10-15 mcg/kg between induction and incision. ## Tranexamic acid: Note that Dr. Shinoka, Carrillo, and McConnell use tranexamic acid in all their bypass cases. Note that Dr. Galantowicz uses tranexamic acid in selected cases (check with your attending). Give the dose of 20 mg/kg up to 1g prior to incision and after protamine. Note that a third dose is given by the perfusion team on bypass. ## Dexmedetomidine: Note that exact infusion rate and the use of a loading bolus is attending-dependent; it is usually run at 0.5-1 mcg/kg/hr. Stop the infusion during weaning from bypass (this is typically when it is stopped). ## Antibiotics: Follow the guidelines per pharmacy. Note that Cefazolin is 50mg/kg up to 2 gm and is given every 3 hours. Give first dose within 30 minutes from incision. Time this to give the antibiotic when the attending surgeon enters the room. ## Drips: Prepare most of the drips while on CPB. Note that Milrinone is used in almost all bypass cases. Prime your Alaris pump tubing with milrinone. Draw up 25 mcg/kg and label it to give to perfusion, who will administer it during rewarming. Give Magnesium at a dose of 50mg/kg after cross clamp is removed if custom cardioplegia is administered. Note that some attendings will not administer Mg if Del Nido cardioplegia is used, but you can check to verify. ![A picture containing indoor, sitting, small, mirror Description automatically generated](attachment:702e3c88-ac42-4df9-904b-3c163ecef1ab:image8.jpeg) **Figure 5.** Draw up milrinone as a bolus to give to perfusion. Magnesium does not have its own label and you will have to write it out when you use it. ## Anti-hypertensive drips: - Remember that there are some drugs like Nicardipine that has adult and pediatric doses. Discuss with your attending prior to ordering these drips. ## Heparin: - Note that dosing is either with the NCH or the U of M protocol, based on the slope of the HDR curve at the start of the case (see anticoagulation protocol). - Note that it is given by the surgeon if there is no central line placed. - If there is a central line, the anesthesia team gives the heparin. Note that the dose is usually on the white board. Confirm the dose and volume before giving it. Announce it clearly, with the dose, as you are giving the heparin. ## Protamine: - Note that the protamine is dosed by whichever protocol (the NCH or U of M) that was used to guide the heparin administration. Note that in most cases, the dose is based on the heparin concentration and will be reported to you by the perfusion team after the warm ACT is finished running. - Do not exceed a total of 5 mg/kg except in neonates on the U of M protocol who are receiving 1:1 dose of protamine. - Run it through a peripheral IV rather than the central line, with a carrier of 20 ml/hr. - Dilute it 1:1 with normal saline, especially for neonates and infants. Note that Dr. Naguib prefers to add calcium. - Always watch for protamine reactions as you administer the dose. Monitor your tidal volumes and your peak pressures. Note that the earlier you observe the reaction, the faster that you can reverse it. Stop the protamine. Give calcium if you didn't add it to the protamine infusion. You may need to give a small dose of epinephrine (usually 1-2 mcg total would reverse it). --- # **Catheterization suite guidelines**: - Perform the preoperative evaluation, assessment and discussion with the attending the same as for cardiac OR cases. - Note that most of the patients will not require placement of A-lines or central lines, since we rely on the lines provided by the interventional cardiologist. - Note that most of our patients will require one intravenous line, preferably in the upper extremity so that any sheathes placed in the femoral vessels will not interfere with the return of medications or fluids to the IVC. - Organize in the cath lab, as organization is a must. Ask your attending if you are not sure about anything. - Wear a headset at all times during the case. Turn on your microphone only when communicating with the cath lab staff. - Before giving drugs that are requested by the interventional cardiologists (heparin – see following instructions and antibiotics), always double check the dose and concentration with your attending. Then read back the dose and volume that you are giving through the headset. Wait until your hear back the acknowledgment of the person in the monitoring room. - During the huddle, if the plan is to have blood in the room, then make sure that the blood warmer is available and ready to go. - At the end of the case, follow the transportation process as for the OR. Always have the transport monitors attached to the patients and on, before disconnecting the monitors in the cath lab. - If you are transporting to the PACU, call ahead for the perioperative technicians to bring the monitors from the PACU. - If you are transporting to the CTICU, follow the same expectation as for the cardiac ORs with resuscitation drugs, equipment and fluids. ## **Drugs** - Midazolam 2mg - 2%Lidocaine - Propofol/Etomidate - Fentanyl - Rocuronium - Cefazolin (for Intervention case ) - Ondansetron - Heparin 100unit/kg ## **Administration of Heparin in the Cath Lab:** - Turn the headset on and the "talk" button ON during administration of heparin. - Note that heparin dose will be determined by the interventionist and verbally given to the anesthesia fellow. - Before heparin is given to the patient, verbally make contact with the Monitor Person. Announce the dose of heparin both in UNITS and in MLs through the microphone. Do not give heparin until the Monitor Person has acknowledged that he/she can hear the CRNA/anesthesia fellow. Read back the dose and mL's by the interventionist and confirm as correct before it is given. Record the dose in units and in mL's by the Monitor Person in Siemens Sensis. If at any time, you feel that an error is being made or you are questioning anything, speak up to the interventionist. Note that this process will be reviewed during team huddle, prior to the procedure, and all will be reminded to wear headsets and to practice closed loop communication. Note that when the anesthesia fellow is new to the cath lab, this will be announced by the anesthesia attending during huddle so that we can all help orient him/her to the cath lab practices.