CardiacAnaesthesiaandICMPocketbook

UniversityHospitalSouthampton

Name………………………………………….

AssignmentNumber……………………

�

NGoddardandJHuber

June2019

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TableofContents

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Ch.1-Usefulcontacts 10............................CardiacTheatres 11.........................................

TheatresContacts: 11......................................

TheatreLists: 11..............................................

CatheterLabs: 12.............................................

Wards: 12........................................................

CICU: 13...........................................................

CICU-relatedusefulcontacts: 14.....................

CICUEmergencies: 16......................................

Anaesthe6cContacts: 17............................Consultants 17.................................................

Traineesandfellows 18...................................

Alliedstaff: 18..................................................

Hospitalusefulcontactinfo 20....................IT: 21..........................................................Scheduledmee6ngs: 22..............................Management: 23........................................UsefulCodes: 24.........................................

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Ch.2–CardiacTheatres(Periopera6ve) 24.PreoperaVveAssessment: 25..........................

AnaestheVcRoom: 26.....................................

CPB: 34............................................................

ComingoffCPB: 36..........................................

‘Product’Types: 42..........................................

Ch.3-Echocardiography 43........................Intraopera6veTOEGuide: 43......................GeneralOverview: 45......................................

AVRProtocol(StructuralViews): 46................

AVRProtocol(ASdopplerviews):AVRProtocol(ARdopplerviews): 48......................

LVAssessment: 50...........................................

MitralvalveProtocol1(2DViews): 52............

MVProtocol2(RV+/-TVA): 54.......................

LAAO: 55..........................................................

OtherStructures: 56........................................

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ProstheVcAorVcvalvesatUHS: 57.................

TOE:Mapofviews 60......................................

20StandardTOEviews 61...............................

Chamberandfunc6onquan6fica6on 63.....Lecatrialsize 63..............................................

LecVentricularsizeandfuncVon 64...............

AorVcStenosis(reference): 64........................

AorVcRegurgitaVon(reference): 65................

Rightventricularsizeandfunc6on 66.........LecventriculardiastolicfuncVon 68...............

Ch.4-Postopera6ve: 69.............................CardiacTransfusionProtocol 70......................

HaemofiltraVon: 71.........................................

LowCardiacOutputState: 74..........................

SupportforLowCO/ECMO: 75.......................

-Inotropes,IABP,ECMO 75.............................

-ECMOmaintenance(mainlyonCICU): 75.....

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HCT40-45% 75................................................

Plts>80 75......................................................

ACT180-240 75...............................................

LowTVIPPV<5mL/Kg 75................................

1.Clamparterialline 75..................................

2.Clampvenousline 75..................................

3.stoppump 75...............................................

4.Runcystalloidintocircuit+drain/purge75

5.manipulatepumpheadtoencourageairtowardsoxygenator 75....................................

PulmonaryHTN: 76.........................................

Heparin-inducedthrombocytopenia 78..........

Ch.5–Congenitalinforma6on 81...............Aclassifica6onofcongenitallesions 81......1.‘Simple’lec-to-rightshunt(Qp>Qs),withincreasedpulmonarybloodflow 81................

2.‘Simple’right-to-lecshunt(Qp<Qs),withdecreasedpulmonarybloodflow&cyanosis.

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82

3.‘Complex’shunts,withcomplexmixingofpulmonaryandsystemicblood,andthusacomplexinterplaybetweenpulmonary(Qp)andsystemic(Qs)bloodflow 82.....................

4.ObstrucVvelesions 83.................................

Qp:Qs 84....................................................FactorsincreasingPVR 87................................

FactorsdecreasingPVR 87...............................

APossiblecirculatorytroubleshooVngstrategypostNorwoodbasedonSvO2: 88.....

TroubleshooVngdifferenValdiagnosispostSCPA/Glenn 89.................................................

TroubleshooVngdifferenValdiagnosispostFontan 90.........................................................

Congenitalheartdisease–Anintroductoryglossaryofterms 91....................................Ch.6–Druginforma6on 98........................An6microbials: 98.......................................

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Seda6vesandanxioly6cs: 106....................Shiveringassociatedwithhypothermia: 111..

Acid/basespecialsituaVons 112.....................

Cardiovasculardrugs: 113...........................Adrenaline: 113...............................................

Amiodarone: 115.............................................

AproVnin: 117..................................................

Atenolol 118....................................................

Atropine: 120...................................................

CalciumGluconate: 122...................................

Digoxin: 124.....................................................

Dopamine: 125................................................

Ephedrine: 128................................................

Esmolol: 130....................................................

GTN: 132..........................................................

Isoprenaline: 134.............................................

Levosimendan: 135.........................................

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Ch. 1 - Useful contacts

Theatre/Catheter/WardAreas

Lidocaineinfusion: 137....................................

MethyleneBlue: 139.......................................

Milrinone: 141.................................................

Noradrenaline: 143..........................................

Phentolamine: 144..........................................

Phenylephrine: 146.........................................

SodiumNitroprusside(SNP): 148....................

Vasopressin: 150..............................................

Ch.7–Notes 151........................................

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Cardiac Theatres TheatreA 1986 TheatreB 1987TheatreC 1988 Theatre3 3413Theatre4 8949 CoffeeRoom 4528TheatresOffice 4531

Theatres Contacts: CaseManagers bl2166 Office 5333/8686Coordinator bl9217 Office 4531O/CCTRegistrar bl9211 O/CCTSHO bl2311CTRegistraroffice 3674MainThCoord bl2894 Perfusion 6930PPMTechs bl9073 Office 3639ICUTechs bl2317 Office 6890Transfusion 4620 Theatre12 4073AnSupportODP bl9266 FLevRecov 4396TAs 07795306370/bl1489NB4 1062 AngioVRoom 4200[Send>08:00.Teambrief08:20]

TheatreLists: Casemanagersoffice(D-levelNorthwingadminoffices,EndofCICU,throughaccessdoor)daybeforeprovisional>approx1600.

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Catheter Labs: CathLab1 4547/3459 Recep 4233CathLab2 4535/3126 CLDU 4420CathLab3 8206/3124 CLDUSR 3434CathLab4 4534/1081 Hybrid 5602CathLab5 3996 HybAR 5600

Lists->CLDU(Paper)or‘cardss’login->Gdrive->cathlabs->lists

Wards: CHDU(Med) 6835 CHDU(Sur) 6836CHDU(SR) 6903 CCU 8570/8572CLDU 4420 HFUnit 3140E1 6470/3267 E2 6473/3206E3G(Right) 6472 E3B(lec) 4111E4 6498/3206 D4 8468EDResus 4979 F10/SDU: 6471(RecepVon)Green 3809 Orange 3722Purple 3710 Yellow 348Blue 8066

WardTeamcontacts:ANP:bleep12315/bleep22330/Office8182/3872CTSHObl1511/OCbl2311,SpRbl2472,OCbl9211

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CICU:

BlueSide: PinkSide:

Nursingstn 6122 5080

3574 4394

Office 4158 4273

WardClerk 6121 5923

CoffeeRoom 1240

Copier 6121/3245

BedSpaces:

Blue8 1889 Pink8 1895

Blue7 1890 Pink7 1899

Blue6 1896 Pink6 1900

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Blue5 1897 Pink5 1901

Blue4 1891 Pink4 1838

Blue3 1892 Pink3 1869

Blue2 1893 Pink2 1904

Blue1 1894 Pink1 3688

Telephoneredirect *3

Staff:

Fellow bl1660 SPR bl2310

Cons bl2251 Sisteri/c bl1491

CICU-related useful contacts:

AcutePainTeam bl2974

CardiologySpR bl2390

ChestXR (Day/Northwing) 8347

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ChestXR(OOH=A+E) 3294

CISTeambl1794/Office 4496CTHeadRequests 6588

CTScanner(BLevel) 3479

Echo(Requests) 6368

Endoscopy(TOEprobes) 4791

GeneralSurgerySpR bl9990

MainXR 4040

Microbiology 4203/6408/bl2216

NeuroSpR bl2580

NursepracVVoners 8182/bl9195

PacemakerTechs 3639/bl9073

Pharmacy 6313/bl2408

RadiologyRegistrarsRoom 3657

StrokeTeamSN bl1592

TechsICU(Trauma) 1874

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TechsICU(Other) 9297

TraumaScannerRegistrarsSeat 8002

VascularDayBleepholder bl1322

CICU Emergencies:

1.Chestopening/returntotheatre:

-CardiacCoordinatorbl9217

-CardiacTheatresOffice4531

-PerfusionOffice6930

-Perfusionbl2322

-ODPSupportbl9266

-Transfusion4620

-TheatreCoordinatorbl2894

2.CrashCall–2222

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Askfor“CardiacSurgicalTeam+CardiologyRegistrar”+locaVonCICU

3.Otherneedforoncallperfusionistoutofhours:

-NameslocatedonBluesideWhiteboard

-Numbers(+Cons/Regs)BluesideFlipcharts

Anaesthe?c Contacts: Emergencytheatresteam 2222

Consultants

CardiacCICUconsultant bl2251

MajTraumaAnaesConsultant bl1783

NamedAnaesConsultant bl1646

ObstetricAnaesDayConsultant bl2372

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Trainees and fellows

AnaestheVcCoordinatorSpR bl2265

CICU(Anaes)SpR bl2310

CICUFellow bl1660

GICUSpR bl2110

NeuroAnaesSpR bl2510

ObstetricAnaesSpR bl2410

PaedsAnaesSpR bl2210

TraumaAnaesthesiaSpR/CEPODSHO

bl2050

Allied staff:

ODP(Anaessupport) bl9266

ODP(MajTrauma) bl1784

Theatrecoordinator bl2894

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Anaesthe?c Admin Team

�Theadminoffice

……………………………………………………………………

DepartmentofAnaestheVcs

MP24,E-levelCentreBlock,

SGH,TremonaRoad,Soton.SO166YD.

Fax:02381204348Tel:206135/6720

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Coffeeroom 3367

Switchboard 02380777222

SueDenton 8707

Hospital useful contact info

MedicalHR@uhs.nhs.uk RecepVon 02381206525

PayrollHelpdesk 03031231144

SylviaRichards(tradminmanager) 6741

TravelwiseTravelwise@uhs.nhs.ukor4133

Mon–Thurs9-5pm,Fri9-3pm(lines4.30pm)

OOHSecurity 02381204122orsecurity@uhs.nhs.uk

Spire (02380)775544or#7473direct

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SpireICU 2297 SpireHDU2353

SpireICU (02380)764353

Ward1 2373/4 Ward2 2372

Pathology 2328

IT: HelpDesk (IT) 6000

JAC 4190

eprescribing@uhs.nhs.uk bl1800

PACS 4390

Metavision 4496

CLWRota uhs.clwrota.com

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-PACSShortcutforWRs:

ThesecanbefoundinWorklists-->RoleWorklists-->Clinician-->Wards-->CICUlessthan3days

ThiswillpickupallpaVentswhohavehadanyscans(includingCXRs)inthelast3days-fairlysensiVveforpaVentswhoareontheCICUcurrently

-MetavisionTeam:

CharliePugh,RyanBeecham,Sophie,Ma~Cordingly:

Ext4496/criVcalcareCIS@uhs.nhs.uk

-Desktop/ipadLogin:

www.ccmv.uk

Scheduled mee?ngs:

MonAM-CardiacM+M(1stofMonth,7.30am)

TuesPM-SPR/fellowsTeaching(pm)

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WedAM-EchoTeaching(7.30am)

FridAM–CardiacEdMeeVng(7.30am)

--------------------Noncardiac:-------------------------------------

FridAM–CardiologyGrandRound08:30,heartbeat

CardiacMDT

TAVIMDT

AorVcMDT–1st+3rdTuesdays/month(GMToffice)

Thoracic/RespiratoryRadiologyMeeVng(BigScreen)–TUESlunchVme,FridayPM

Management: CaseManagers 8686/5333

bl2166

BedManager(Cardiac) bl2365

Matron’soffice(Jenny/Kate)5943/pa1846

FionaLidell 8727/pa4241

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Site(JakeorSarah) 3531

MaterialsManagement(Daryl) 3561

Useful Codes: (Writedownyourownusefulcodeshere…

Ch. 2 – Cardiac Theatres (Periopera?ve)

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Preopera?ve Assessment:

Premeds(guideonly):

>80years:

-Oxygen

-Oramorph5-10mg(ornone)

-Temazepam5–10mg(ornone)

70-80years:

-Oxygen

-Oramorph10-20mg

-Temazepam10-20mg/Lorazepam1mg

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<70years:

-Oxygen

-Oramorph10-20mgORMorphIM5-10mg

-Lorazepam1-2mgORTemazepam20mg

OtheropVons:

-hyoscine0.2-0.4mgIM

-*CauVonobese/elderly*

Anaesthe?c Room:

‘Standard’Drugs(subjecttovaria6on):

-Fentanyl1000(20mLsyringe)

-Midazolam10mg(10mLsyringe)

-Musclerelaxant–PANC/ROC/VECuronium

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-Saline(10mLsyringe)

-PhenylStrong=10mg/10mL

-Phenylweak=100mcg/mL

-TranexamicAcid2g(20mLsyringe)+1g(10mL)

-Cefuroximex2(1.5g+1.5g)

-Heparin300mcg/kg

-Propofol1%10mL+50mLviapump

(2ndLineAbx=Vancomycin1g+Gent120-160mg)

EquipmentChecks(standard):

-TOEMachineworking/on+probeavailable

-AnaestheVcmachinecheckx2

-Metavisioncheckon/workingx2

-HaemocronJunior(ACT)

-Doubleplate(Art/CVC+spare),lines,fluids

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-BIS/NIRS/DCVPads-ifindicated

-Pacingboxba~ery+Defibsworking

-Warmer(indi+/-B.Huggerx2)

DHCA(Arch,dissec6on,descendingAorta):

-Considerdexamethasone0.5mg/kg

-ICE

-NIRS

-ArteriallinespreandpostArch(red=proximal)

-Linespli~er

TATAVI:

-Asperstandardopenprocedurebutheparin100mcg/kg

-Bodyguardpump(yellow)+Bupivicaine0.125%8mL/hrtoprescribeonJAC(extrapleural=Localother)+arrangeviaAcutepainservice(bleep2974)

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-Norad4mg/50mLatstart

-SeecathlabanaestheVcroomwallforfurtherinformaVon+equipment–ref:TATAVIv9b

TFTAVI:

-Midazolam5mg/5mLsyringe

-Fentanylx2ampoules(unopened)

-Rocuronium100mg/10mLsyringe

-Strong/Weakphenyl

-Propofol1%in20mL/50mL(viaTIVAset)

-Phenyl100mcg/mL50mL(viaTIVASet)

-Cefuroxime1.5g

-Lidocaine1%2mLsyringe

-ConsiderBupivicaine0.25/0.5%x3vials10mLsforblock

-Protamine(atend)

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-SeecathlabanaestheVcroomwallforfurtherinformaVon+equipment–ref:TFTAVIv9b

EP: -Midazolam1-2mg2mLsyringe

-Fentanyl100-200mcg5mLsyringe

-Propofol1%20mL

-ROC/VECuronium

-Dexamethasone/ondansatron+/-paracetamolIV

-Phenylephrineinfusion+10mL+pump

-Bluevalve,NOT3wayoctopusforIV–usedoublelinespli~erinsteadasnofluidflowthroughoctopus

-Reversalagent

-Fluidshanging(butmaygiveligleduetoablaVonfluids+riskHFincontextpoorLV)

-OcenlistedasAFablaVon(redo)+/-TOE.SomeVmesVTablaVonorsyndromes(WPWcommon).SomepoorLV’s

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+/-leadextracVons(CRTD/PorSCICD).MayneedCICUbed…

TAAA:

-NAC=10gneatvia50mL+Dex0.5mg/kgifDHCA

-SeeguideforLHBcases(intheatreCAR)

-OLV+scopes/catheters

-Spinaldrain+monitoringset

-Spli~ers+longcables

(seeoverforDLTselecVon)

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DLTSelec6on:

Averagedepthofinser6on: 29cmattheteeth,+/-1cmper10cm above/below170cmheight(Ref:SlingerP.LungSepara;onTechniques.AvailableathBp://www.thoracic-anesthesia.com/?p=20)AverageUKheight:

-Males:175.5(5’9’’),83kgvsFemales:161.6(5’3’’),70kg

Tricky6ps:

-Usevideolaryngoscope+LsideTube

-Uselargesttubepossible+fa~estexchangecatheter

-(11Fvs14Frcatheter/100cm),don’tinsertpastcarina(25cm)

-LeavebronchoscopeinTracheawhenredirecVngtube

-NoBougies!

-BronchialBlockers->Arndt/E-Z/Cohen(Vpflex)

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-largestETTtube/4cmabovecarina/nofinaladjustmentsunVlinposiVon

ThoracicSupport:

----------------------------------------------------------------ThoracicCasemanagers 5394

TheatreS 3115

TheatreT 3120

NorthWingRecovery 3100

---------------------------------------------------------

ListsavailableviaThoracicCasemanagers

Usuallyx1inptmax,remainderDoSTCI0730

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CPB:

Heparinisa6onpriortoCPB:

-300units/kgHeparin,followedbyACTat2-3minstocheckresponse.ACT>400secondsisneededtosafelygoontobypass.

Predic6ngHbonCPB:

-(GasHbing/dLxBloodvolume(70mLxweight))/(ptbloodvolumemL+primevolumemL)

-STANDARDPRIME=~1400mLclearfluid:

-5000iuheparin

-250-500mLCSL(lactatebuffer)

-0.5g/kgmannitol10%(400mLfor80kg)

-500mLgelofusine

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ImprovingHbonCPB:

-Aim8-10g/dL

-AddiVonofCellsavervolume

-Bankblood

-HaemofiltraVon

-RAP(retrogradeautologousprime)

-MECC(minibypass)/Smalladultcircuit

-MUF(modifiedultrafiltraVon)

CheckswhenonPump:

1.Propofolinfusionincrease

2.Productsrequested

3.Pacemakeravailable

4.Pressorsready/drawnup

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5.Paperworkuptodate(Metavision)

6.PremedprescribedfornextpaVent

7.PerfusionParameters(MAP>65-70/Hb/NIRS/ABG)

Coming off CPB:

CVS:

1.FixSVR(phenyl/NAinfusion)+HR(pacing)

2.Assessresponsetofilling(visual/Echo/CVC/BP)

3.Inotropy:(DA+/-Milrinone)

4.Mechanical:IABP+/-ECMO

5.Monitoring:PAcatheter

ReversalofHeparin:

-1mgProtamineper100unitsHeparin

1)Onlygiveattherequestofthesurgeons

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2)Telltheperfusionist(‘Suckersoff’)

3)Giveslowly–ascancausesignificanthaemodynamicinstability

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CloingTargets(Don’ttreatifnotbleeding):

1.AimHb90-100g/L

2.Aimplts>75

3.INR<1.5(Octaplex/

FFP)

4.R-Vme<8-12mmon

TEG

TEGTrace:

Ref:CurryANGandPierceJMT.ConvenVonalandnearpaVenttestsofcoagulaVon.CEACCP2007)

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StandardTEGPagerns:

Parameter

Normalrange

(Kaolin-acVvatedsample)

Increased Decreased

R-time 8-12mm

AnticoagulantsClotting factor deficienciesSeverely low fibrinogen Hyper-coagulable conditions

K-time 2-4mmAnticoagulantsLow FibrinogenLow Platelets

High fibrinogenIncreased platelet function

α-angle 66-77o High fibrinogenIncreased platelet function

AnticoagulantsLow FibrinogenLow Platelets

MA 60-75mmHyper-coagulable states

High platelet count

Low PlateletsPoor platelet function/platelet

inhibitorsFibrinolysis

Factor deficiencies (lesser extent)

LY30 <7.5% Fibrinolysis e.g. t-PA given Anti-fibrinolytics given e.g. TXA

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TEG6s:

TEG6machinesallowtheuseofthefollowing2cartridges:

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• GlobalHaemostasisCartridge(Bluetopcitratedspecimentube)

• PlateletMappingCartridge(Greentopheparinisedspecimentube)

GlobalHaemostasis

Test Componenttested

Parameterofinterest

Deficiency/Abnormality

Therapy

CK(CitratedKaolin)

ClotformaVonrate

↑RVme Clo�ngfactors*

FFP/FFP96(Octaplas)/PCC(Octaplex)

CKH(CitratedKaolin+

Heparinase)

ClotformaVonratewithoutheparineffect

↓RVme(comparedwithCK-RVme)

Heparineffect(ifCKH-RVme<CK-RVme)

Protamine

CRT(CitratedRapidTEG)

ClotstrengthduetoPlateletandfibrin

↓MA Platelets(ifCFF-MAnormal)

Platelets

ClotStabilitydueto

fibrinolysis

↑LY30 Fibrinolysis TranexamicAcid

CFF(CitratedFuncVonalFibrinogen)

Clotstrengthduetofibrin

↓MA Fibrinogen Fibrinogen(Cryoprecipitateor

FibrinogenConcentrate)

*InthepresenceofHeparin(whereCKH-RVme<CK-RVme),refertoCKH-RVmeforclo�ngfactoradequacy.

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‘Product’ Types:

Calciumgluconate10%Clo�ngfactorIV.Chelatedbycitrateinbloodproducts(includingpackedredcells,platelets,octaplas,andoctaplex).Willtypicallyrequirereplacementpostcitratedblood/producttransfusion.Alsoincreasesinotropy.AimionisedCalcium(ABG)>1.15.Cryoprecipitateasourceoffibrinogen,factorVIIIandvonWillibrandfactor.2PoolsshouldraisethepaVent’sfibrinogenlevelbyapprox1g/LFreshFrozenPlasmaThenon-cellularcomponentofblood.ContainsfactorsII,V,VII,VIII,IX,X,XI,fibrinogen,proteinsCandS,andATIII.Takesapprox.30-40minutestodefrostinthelaboratory.Novo7(rFVIIa)Off-licenceuseOctaplas(FFP96)Pathogen-reducedFFPsourcedfromoutsideUKforpaVentsbornacer1Jan1996,inordertominimisethetransmissionofvCJD.Octaplex(Prothrombincomplexconcentrate)ProthrombinComplexConcentrate=vitaminK-derivedclo�ngfactors(II,VII,IX,X)inasmallvolume(comparedwithplasmatransfusion).Platelets2hrturnaround.Onepooltypicallyraisescountby30x109/L.TranexamicAcidAnanVfibrinolyVc,whichpreventsclotlysis.

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Ch. 3 - Echocardiography Intraopera?ve TOE Guide:

1.TurnonTOEmachine 2.InputpaVentdetails 3.ConnectECG

Includetheminimumdatasetforall

4.Followalgorithms(seefollowingpages): a.GeneralOverview+LV/RV b.AVR–structural/dopplerviews c.MVR–UsuallyMR+/-TVA/LAAO d.LAAO+/-otherstructures

Adaptedfrom:WheelerRetal.2015.Aminimumdatasetforastandardtransoesophagealechocardiogram:aguidelineprotocolfromtheBriVshSocietyofEchocardiography.EchoResearchandpracVce.Dec1;2(4):G29-45

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Notes–TheseguidesareNOTcomprehensive.Eachalgorithmdesignedtocoverstructurefora‘quick’procedureomthese�ngofadultacquireddisease.IffurtherinvesVgaVon/detailsrequired,toundertakefurthermeasurements.

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General Overview:

Image(2D): Reference:

Territories:

1.Pullbackprobeslightly2.LVOT/MitralCFD(sameVmeifrush)3.OrientateAVtocentreofview4.Omniplaneangle->50°forAVSAX(seeAVRprotocol)…

�

�

---------� 45

‘AVRProtocol’(ifAS/ARmainproblem)

‘MVprotocol’(ifMR/MS)mainproblem+/-TVA+/-LAAO

‘LV/RVprotocol’ifIHD

AVR Protocol (Structural Views):

---------� 46

Image(2D): Aims/Ref:

� 1.Inspectleaflets

(movement,thickening,calcium)2.CountnumbercuspsBi/Tri/Quad3.Planimetrymid-systoleforAVA4.CFDAnyRegurgitaVon/where?

�

�

120

50

135

LRN

LVOT

LA

-Annulus-Sinus-STJ-AscAorta

Mid-syst

(Mid-syst0.5-1cmfromvalveorifice

INFLAT

ANTSEPT

ARR?>5.5cmor>5.0cmifsyndrome>4.5cmifothersurgery

A

E

---------� 47

DimensionlessIndex(SimilartoVelocityraVo):

-VTILVOT/VTIAV(<0.25=severe)

OR..

AVR Protocol (AS doppler views): AVR Protocol (AR doppler views):

Image(2D): Aims/Ref:

�

�

�

�

�

---------� 48

---------� 49

Image(2D):Aims/Ref:

� 1.Venacontracta2.Jetwidth/LVOTdiameter%3.Lengthjet+describedirecVon

�

�

120 Normal=<2.0m/sec

Otherparameters:

-EROA(cm2)≥0.30=severe-RegurgfracVon(%)≥50=severe

*Nyquistlimit50-60cm/s*

LV Assessment:

---------� 50

INF

INFLATIS

AS

ANT

AL

1. 2.

Em

Am

AE

Em/Am

1-2

<1

<1

<<1

E/Em(Lateral)<10Norm>10Mod

E/Em(Septal)<8Norm>15Mod

Inflow

N

Mild

Mod

Severe

SystolicblunVng

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Mitral valve Protocol 1 (2D Views):

---------� 52

Angle:

Tips: Image(2D):

ME0

-Annulus/leafletmorphology/leafletmoVon/Sub-valvularapparatus-Pathology-A1/P1(Withdrawal/anteflexion)-A3/P3(InserVon/retroflexion)-Commissure(anterolateral)

ME60

-AssessP3/A2/P1-Majoraxisdimension(enddiastoleandendsystole)-VisualinspecVonofMR/MS

ME90

-AssessP3/A3,A2,A1-commissure(posteriomedial)-VisualinspecVonofMR/MS

ME120

-Minoraxisdimension(enddiastoleandendsystole)-VisualinspecVonofMR/MS

TG0

-A1,A2,A3Bo~omtotop-P1,P2,P3Bo~omtotop

�

�

�

�

�

---------� 53

MV Protocol 2 (RV +/- TVA):

---------� 54

Image(2D): Aims:

� -RVsize(Enddiastole):

-@base<4.2-@midpoint<3.5-length<8.6cm

-TricuspidValve:-Leaflets(Ant/Sept)-Annulussize(EDD+ESD):

� -CFDTR:Mild<1cm/narrowjet,severe

=wide/largejet-CWjet:soc/slow=mild,dense/variable=intermed,dense/steep=severe

50

120

PostLeaflet

SeptorAntLeaflet

RVRA

(TGRVInflow)SeptorAntLeaflet

PostLeaflet

PApressures

TAPSE>16mm

LAAO:

LAATypes/Morphology:

ME2Ch(90)

2D -LAAassessment(inatleast2planes).-AssesstheextentofLAAcavity+EmptyingvelociVes

MELAA(60-130)

2D

CFD

PW

-PWtoprox1/3rd-ClotassocwithvelociVes<20cm/s-Assess‘coumarinridge’-OffCPBconfirmclip/occlusiondevice

�

---------� 55

Other Structures:

---------� 56

EustachianValve(lec)+CristaTerminalis(Right)

CoronarySinus:-Normal12mm+/-2mm->15mmHg,suspectPAPVD

Prosthe?c Aor?c valves at UHS:

PericardialValveswithleafletsinsidethestent:

1.Perimount-Carpen6er-Edwards

-Bovinepericardialleaflets

-CoCralloystent-Polyestercloth,siliconerubbersewingring-19mm–29mmsizes(odds)-Variant=Magnavalve(23%greaterEOA)

2.PerimountMagnaEase–Carpen6er-Edwards-Lowerprofile:easesinserVon+aortotomyclosure-Supra-annulardesign(opVmalhaemodynamics)-Sleekcommissureposts(easeinserVon/knottying)-Suturemarkers(orientaVon+sutureplacement)-LowStentBase(coronaryosVaclearance)

PericardialValveswithleafletsoutsidethestent:

1.CrownPRT–Sorin-Bovinepericardiallayermountedoutsidestent

Gradient

19mm 21mm 23mm 25mm 27mm 29mm

Perimount

Peak 32.5±8.5

24.9±7.7

19.9±7.4

16.5±7.8

12.8±5.4

N/A

Mean 19.5±

5.5

13.8±

4.0

11.5±

3.9

10.7±

3.8

4.8±2.

2

N/A

---------� 57

-Flatprofile(lowerknotsandcoronaryclearance)

2.Trifecta-StJude

-‘LinxACtechnology’(anV-calcificaVon)-Tissuebovineleaflets-Titaniumalloystent

Composite:

1.BioIntegral-Compositerootconduitwithporcinevalve

Mechanicalbileaflet:

1.MCRIOn-X(Aor6cshown)

-PTFESewingring-PyrolyVccarboncoaVng-Leafletguards,‘flared’inlet+Actuatedpivotdesign(90˚opening)-LowerINR1.5-2(longtermmgtonly)-MostcommonlyusedinUHS

Gradient

19mm 21mm 23mm 25mm

On-

X

(AorVc)

Peak 21.3±

10.8

16.4±

5.9

15.9±

6.4

16.5±

10.2

Mean 11.8±

3.4

9.9±3.

6

8.6±3.

4

6.9±4.

3

EOA(c

m2)

1.5±0.2

1.7±0.4

1.9±0.6

2.4±0.6

---------� 58

2.CarbomedicsTopHat–Sorin-Supra-annularaorVcvalvewithgoodhaemodynamics-AlternaVvetoaorVcenlargement

DataadaptedfromEchoCalc.BriVshSocietyofEchocardiography.2015.Availableath~ps://itunes.apple.com/gb/app/echocalc/id468166426?mt=8

Gradient

21mm 23mm 25mm

Toph

at

Peak 30.2±

10.9

24.2±

7.6

NA

Mean 14.9±

5.4

12.5±

4.4

9.5±2.

9

EOA(c

m2)

1.2±0.

3

1.4±0.

4

1.6±0.

32

---------� 59

TOE: Map of views TorontoGeneralHospitalDepartmentofAnaesthesiaandPainMedicine.2008.

Availableath~p://pie.med.utoronto.ca/TEE/TEE_content/assets/PDF/TEE-help-sheet-100910-high.pdf

---------� 60

�

20 Standard TOE views FromShanwiseJetal.ASE/SCAguidelinesforperformingacomprehensive

intraoperaVvemulVplanetransesophagealechocardiographyexaminaVon:recommendaVonsoftheAmericanSocietyofEchocardiographyCouncilfor

IntraoperaVveEchocardiographyandtheSocietyofCardiovascularAnesthesiologists

TaskForceforCerVficaVoninPerioperaVveTransesophagealEchocardiography.AnesthAnalg1999;89:870–884

---------� 61

Southampton CICU Focused TOE

---------� 62

�

Chamber and func?on quan?fica?on

(Ref:Masanietal.BriVshSocietyofEchocardiographyEducaVonCommi~ee.Echocardiography:guidelinesforchamberquanVficaVon.G407.BriVshHeartfoundaVon.2011.Availableat:h~ps://www.bhf.org.uk/publicaVons/tests-for-heart-condiVons/echocardiography-guidelines-for-chamber-

quanVficaVon-poster)Note:ThefollowingtablesarebasedonTTEimaging.

Le\ atrial size

�

---------� 63

Le\ Ventricular size and func?on

!

Aor?c Stenosis (reference):

AVA (cm2)

Indexed valve area (cm2/m2)

Peak velocity (m/s)

Peak gradient (mmHg)

Mean gradient (mmHg)

AHA ESC BSE

---------� 64

(ref: Vegas, A. Perioperative Two-Dimensional TOE. Adapted from: Baumgartner H et al. J Am Soc Echocardiogr 2009;22:1-23.) (ref: Vegas, A. Perioperative Two-Dimensional TOE. Adapted from: Zoghbi W et al. J Am Soc Echocardiogr 2003;16;777-802.)

Aor?c Regurgita?on (reference):

Normal

3.0-4.0

1.4-2.2 8-20

Mild >1.5 >0.85 2.6-2.9 20-40 <20 <30

Mod 1.0-1.5

0.6-0.85

3.0-4.0 40-70 20-40 30-50

Severe

< 1.0 <0.6 >4.0 >70 >40 >50

Method Mild Moderate Severe

Jet/LVOTwidth* <25% 25-64% >65%

PHT(ms) >500 500-200 <200

DescendingAoReversal Earlybrief Intermediate Holodiastolic

VenaContracta*(mm) <3 3-6 >6

EROarea(cm2) <0.10 0.1-0.29 >0.3

---------� 65

Right ventricular size and func?on

RequrgitantVolume(cc) <30 30-59 >60

RegurgitantFracVon(%) 20-30 30-49 >50

*Nyquistlimit50-60cm/s

---------� 66

MitralStenosis:(EAE/ASA Guidelines)

(ref: Vegas, A. Perioperative Two-Dimensional TOE. Adapted from: Baumgartner H, et al. J Am Soc Echocardiogr 2009;22:1-23)

MitralRegurgita6on

(ref: Vegas, A. Perioperative Two-Dimensional TOE. Adapted from: Zoghbi W et al. J Am Soc Echocardiogr 2003;16;777-802.)

Valve area(cm2)

Mean gradient(mmHg)

PHT(msec)

Peak pulmonary artery P(mmHg)

Normal 4-6 40-70 20-30

Mild >1.5 <5 70-150 <30

Mod 1.0-1.5 5-10 150-200 30-50

Severe < 1.0 >10 >220 >50

Method Mild Moderate Severe

CWDopplersignalstrength Faint Mod Dense

Jetareamapping(cm2)* <4 4-10 >10

PulmonaryvenousDoppler(Swave) Normal Blunted Reversed

VenaContracta*(mm) <3 3-6 7+

EROarea(cm2) <0.2 0.2-0.39 >0.4

PISAradius(mm)(Nyquistat40cm/s) <4 4-9 >10

RegurgitantFracVon(%) <30 30-49 50+

*Nyquistlimit50-60cm/s

---------� 67

Le\ ventricular diastolic func?on (deflecVonsbasedonTTEacquisiVon)

---------� 68

�

Ch. 4 - Postopera?ve:

Bleeding/Clo�ng/ICUCare

---------� 69

Cardiac Transfusion Protocol

�

---------� 70

Haemofiltra?on:

Dose:35ml/kg/hror>25ml/kg/hrsufficientformost.Highervolumesmayreducevasopressorrequirements,butincreaseelectrolytedisturbances.

Noevidenceforactualvsidealweight

CRRTachieves~25-50mL/minCrCl

Replacementfluids(prescribe):

-HemosolBO

-Prismasol4

An6coagula6on:

1.Heparin.UsuallyavoidgivingheparinbolustopaVent.Juststartinfusion.AimaPTT1.5-2.0

2.Inpeoplewithheparin-inducedthrombocytopenia,considerusing:

---------� 71

A.Epoprostenol

CompaVblewith0.9%salineonly

Dose:1-5nanograms/kg/min

PreparaVon:MakeupaconcentraVonof2mcg/ml(100mcgin50mlsyringe).Runat:

Note:2mcg/kgdilutedsyringesareonlystablefor12hinthefridge.

B.Argatroban(directthrombininhibitorIVprep)=licensed

-NoIVbolus

-Infusion2mcg/kg/min->RptaPTT4hrdoseadjustment

PaVentWeight(kg) ml/h[4ng/kg/min] ml/h[5ng/kg/min]

50 6.0 7.5

60 7.2 9.0

70 8.4 10.5

80 9.6 12.0

90 10.8 13.5

100 12 15.0

---------� 72

-MonitorAPTT(1.5-3)

-HepaVcmetabolism(LiverFailure0.5mcg/kg/minstart)

C.Heparinoids(DanaparoidIVprep)=licensed

-IndirectAnVXa+/-li~lethrombin

-24halflife

-MineffectonaPTT/NoneonPT

-MonitorwithAnVXaAssayifRenalFailure

-750unitsBDorTDS*prophylaxis

-1250–3750unitsbolusIVthen400units/hrinfusionfor4hrs,then300/hrfor4hrs,then150-200units/hrmaintenanceIV*Treatment

D.Citrateregional

-Remember,separateDVTprophylaxisrequired.

-JuststartedusinginCICU..

---------� 73

E.Fondaparinux(notlicensed)

F.Bivalirudin(notlicensed)

G.Lepirudin(notlicensed/availableatUHS)

Low Cardiac Output State:

Monitoring:Cardiacoutput=SVxHR (4–8L/min)CI=CO/BSA (<2,2–2.5,>2.5L/min/m2)PAWP≤15mmHg

Causes:PoorLV,preload,highacerload,rhythm+rate(Physiology)Airembolism/tamponade+/-bleedingStunningPerioperaVveMIIncompleterevascularisaVon/grackinkingPHTNOther:SAM(MVrepairs),drugreacVon,HOCM,vasoplegia

---------� 74

SupportforLowCO/ECMO:-Inotropes,IABP,ECMO-ECMOmaintenance(mainlyonCICU):HCT40-45%Plts>80ACT180-240LowTVIPPV<5mL/KgNewdoseforECMOcannulaVon75iu/kgIf>30minsunVlonECMO,repeatACTandgiveextra25iu/kgifACT<300

Airentrainment(*Emergency*):

Diagnosecause/site+purgepump+circuit

1.Clamparterialline2.Clampvenousline3.stoppump4.Runcystalloidintocircuit+drain/purge5.manipulatepumpheadtoencourageairtowardsoxygenator6.Onceairdrained->closetubingtobag+openAVbridge,inspectforair

---------� 75

Pulmonary HTN:

NormalPAP:PAP <25/10mmHgPAPm 14±3mmHg(<20mmHg)

pHTN: Pre-capillaryPH PAPm≥25mmHg

PAWP≤15mmHgPost-capillaryPH PAPm≥25mmHg PAWP>15mmHg

Classifica;oncomplicatedandmanydifferentsubsetsofdiseasewithspecificmanagement–seekadvice.

Classifica6on(Non-congenital):1.PAH(idiopathicvsassocwithsystdisease)2.PAHduetolecheartdisease3.PAHduetolungdiseases/hypoxia4.ObstrucVve/thromboembolic5.PHunclearormulVfactorialmechanisms

ICUTreatment(Seekexpertadvice!):

A) Maintainpa6ent’snormaltherapywherepossibleB) MaintainPAPm25mmHg<SystemicMAPC) ForrisingPAPs,addin:

1.NO:5-25ppmviaNoxbox2.Prostanoids:

---------� 76

-Iloprostnebs(20mcg3hrly)-IloprostIV(50mcgin250mL5%dextrose)-0.5-2mcg/kg/min(approx.12-48mL/hour).-Increasedose½hourly3.Vasodilators-PDEType5inhibitors:-Sildanefilpo/NG(20mgTDS,increaseupto50mg)4.Endothelinreceptorantagonists:-Ambrisentanpo/NG(5mgod,increasedto10mgod)-N.B.Livermetabolised4.Surgical/CardiologyInterven6on:-Balloonatrialseptostomy>failuremaxmedtherapy-+/-lungtransplantaVon

---------� 77

Heparin-induced thrombocytopenia 4T’sassessmentpointsystem

---------� 78

Category 2points 1point 0points

Thrombo-cytopenia

>50% fall or Nadir of

20-100 x 109

/L

30% - 50% fall or Nadir of 10-19x 109/L

<30% fall or Nadir of < 10 x

109

/L

Timingoffall Days 5 – 10 or less than or equal 1 day if there is heparin exposure within the past 30 days.

Greater than day 10 or unclear or less than 1 day if heparin exposure within past 30 – 100 days

Less than or equal to 1 day with no recent heparin therapy

Thrombosis(orothersequelae)

Proven thrombosis, skin necrosis, or other heparin bo- lus, acute systemic reaction

Progressive, recurrent, orsilent thrombosis; erythematous skin lesions

None

Othercauses None evident Possible Definite

Score 0-3 Low probability

4-5 Intermediate probability

6-8 High probability

Steele J, Kadosh B, Gulkarov IM, Salemi A (2011) Heparin Induced Thrombocytopenia and Cardiac Surgery: A Comprehensive Review. J Blood Disord Transfus S2:003.

---------� 79

---------� 80

Ch. 5 – Congenital informa?on

A classifica?on of congenital lesions

1. ‘Simple’ le\-to-right shunt (Qp > Qs), with increased pulmonary

blood flow

Atrialseptaldefect

Ventricularseptaldefect

Atrio-ventricularseptaldefect

Patentductusarteriosus

Aorto-pulmonarywindow

AlargeVSDorAVSDcandemonstratemorecomplexbalancingbetweenQp:Qs.

AlargereducVoninSVR,orapulmonaryhypertensivecrisisaretwoexamplesthatcausealec-to-right(Qp>Qs)shunttoreversetoa

right-to-lecshunt(Qp<Qs),resulVngincyanosis.

---------� 81

2. ‘Simple’ right-to-le\ shunt (Qp<Qs), with decreased pulmonary

blood flow & cyanosis

TetralogyofFallot

Pulmonaryatresia

Tricuspidatresia

Ebstein’sanomaly

3. ‘Complex’ shunts, with complex mixing of pulmonary and systemic

blood, and thus a complex interplay between pulmonary (Qp) and systemic (Qs) blood flow

ExamplesofparallelcirculaVonsaremarkedwithan*

TransposiVonofthegreatarteries*

Truncusarteriosus*

Double-outletrightventricle*

HypoplasVclecheartsyndrome*

PresenceofaBTshunt*

Totalanomalouspulmonaryvenousdrainage

---------� 82

4. Obstruc?ve lesions

CoarctaVonoftheaorta

InterruptedaorVcarch

PulmonaryoraorVcstenosis

---------� 83

Qp:Qs thera;oofpulmonarytosystemicbloodflow

SimplifiedshuntcalculaVon

�

S=saturaVon,sa=systemicarterial,mv=mixedvenous,pv=pulmonaryvein,pa=pulmonaryartery

Note:Inthepresenceofashunt,SmvO2≠SpaO2

FormulaforesVmaVngmixedvenousSatswhencalculaVngashunt:

Inadults:�

Ininfants/children:consideraccepVngSmv≡SSVC

Qp :Qs =  (SsaO2 − SmvO2)(SpvO2 − SpaO2)

Smv =(3SSVC + SIVC )

4

---------� 84

ForauniventricularheartwithonlyaorVc-pulmonarybloodflow

�

Inter-atrialshunts:Qp:Qsisdependentprimarilyonthecompliancedifferencesbetweenthetwoventricles.

Inter-ventricularorgreatvessellevelshunts:Qp:QsisdependentprimarilyontherelaVveresistancesofthepulmonaryandsystemiccirculaVons.ManipulaVonstrategiesinclude:

Toincreasepulmonarybloodflow:ReducePVR(+/-increaseSVR)

Todecreasepulmonarybloodflow:IncreasePVR(+/-decreaseSVR)

Qp :Qs =  (SsaO2 − SmvO2)(SpvO2 − SsaO2)

---------� 85

---------� 86

Factors increasing PVR Hypoxia

Hypercarbia

Acidosis

Hypothermia

SympatheVcsVmulaVonorcatecholamines

Loworhighlungvolumes,oratelectasisorhyperinflaVonrespecVvely

Highairwaypressures

Factors decreasing PVR IncreasingFiO2

DecreasingPaCO2

Alkalosis

Avoidanceofhypothermia

Pulmonaryvasodilators(iNO,Milrinone,Sildenafil)

Avoidanceofcatecholaminesurges(pain,sympatheVcsVmulaVon)

LungvolumeatfuncVonalresidualcapacity

---------� 87

A Possible circulatory troubleshoo?ng strategy post Norwood based on SvO2: SaO2 SvO2 Qp:Qs Suggestedinterven6on

80 60 1 None;weansupportslowly

80 40 2 DeepensedaVon/warmth/vasodilator

70 50 0.67 Resolveatelectasis,raiseSVR

70 40 1 Raisecardiacoutput,raiseHb,reduceO2consumpVon

70 20 2 Raisecardiacoutput,lowerSVR

60 40 0.5 Resolveatelectasis,raiseSVR,consideriNO,considershunt

augmentaVon

87 70 1.5 Weansupport

87 40 3.6 DeepensedaVon,vasodilaVon,considershuntrestricVon

---------� 88

Troubleshoo?ng differen?al diagnosis post SCPA/Glenn

Status

PAP LAP TPG SpO2 Ae6ology

Normal

10-15 2-6 <10 80±5 Ideal

ElevatedPAP

>15 2-6 >10 <75 HighPVR;PAorPVobstrucVon

ElevatedLAP

>15 >8 <10 <75 VentriculardysfuncVon,sub-AS,AVVR,tamponade

Cyanosis

10-15 2-6 <10 <75 Decreasedcerebralbloodflow;PVdesaturaVon,decompressingveins;hypovolaemia,anaemia

---------� 89

Troubleshoo?ng differen?al diagnosis post Fontan

Status PAP LAP TPG SpO2 BPsys Ae6ology

Normal 10-15 2-6 <10 95±5 85-95 Ideal

DecreasedPAPandLAP

8-10 0-4 <10 90±5 <80 Hypovolaemia

ElevatedPAP >15 2-6 >10 90±5 80±5 HighPVR;PAorPVobstrucVon

ElevatedLAP >15 >8 <10 90±5 80±5 VentriculardysfuncVon,AVdissociaVon,AVVR,tamponade

Cyanosis 10-15 2-6 <10 <85 85-95 ExcessivefenestraVonsizeorFontanbaffleleak;PVdesaturaVon;decompressingveins;hypovolaemia;anaemia

---------� 90

Congenital heart disease – An introductory glossary of terms

Anomalous pulmonary venous drainage: partial - at least one, but not all, pulmonary veins connect to the right heart, often via the superior or inferior vena cava, leading to varying degrees of left-to-right shunt (Qp:Qs>1). Total - all pulmonary veins abnormally drain to the heart. Types include: supracardiac – where they eventually drain to the SVC, intracardiac – where they drain through the coronary sinus, and infracardiac – where they drain beneath the diaphragm to the portal venous system.

Aortopulmonary window: a window (communication) between aorta and main or right pulmonary artery. May be associated with interrupted aortic arch.

Atrial septal defect: types include patent foramen ovale (PFO), secundum, primum (a type of AV defect), sinus venosus (superior: at SVC to RA junction, associated with PAPVD of right upper and middle PVs; inferior: at IVC to RA junction, associated with PAPVD right lower PV), coronary sinus (unroofed coronary sinus leading to communication between left atrium and coronary sinus). Leads to left-to-right shunt.

AVSD: atrio-ventricular septal defect due to incomplete fusion of the endocardial cushions, leading to malformation of the mitral and tricuspid valves, atrial and ventricular septal defects. A common atrioventricular valve straddles the ventricular septum.

Balanced circulation: equal pulmonary and systemic blood flow (Qp:Qs = 1).

---------� 91

Bidirectional Glenn/bidirectional cavopulmonary shunt/superior cavopulmonary shunt (SCPC)/hemi-Fontan: SVC disconnected from RA and anastomosed to PA, causing pulmonary blood flow to comprise SVC venous blood. It is bidirectional because SVC blood is free to flow through either right or left PA (in contrast to a unidirectional/original Glenn shunt where the SVC was directly anastomosed to the right PA that had been disconnected from the main PA, thereby preventing SVC blood from flowing to the left PA).

Blalock-Taussig (-Thomas) shunt (BT shunt): original - transection of subclavian artery and end-to-side anastomosis to ipsilateral pulmonary artery. Modified - a graft conduit placed between either the innominate or subclavian artery and the ipsilateral pulmonary artery. Designed to allow some pulmonary blood flow through a systemic-to-pulmonary connection.

Brom repair: a 3-patch technique that allows repair of supra-aortic narrowing with enlargement of all 3 sinuses.

Carpentier’s procedure: a method for tricuspid valve repair of Ebstein’s anomaly, characterised by mobilisation of anterior leaflet, vertical plication of the atrialised RV, advancement of the anterior leaflet across the plicated area to reduce orifice size, and insertion of an annular ring for additional valve strength.

Central shunt: small tubular connection created between ascending aorta and main pulmonary artery. Designed to provide some pulmonary blood flow through a systemic-to-pulmonary connection.

Coarctation of the aorta: a narrowing of the thoracic aorta, usually distal to the left subclavian artery. Associated with bicuspid aortic valve.

---------� 92

Cone procedure/reconstruction: a method for tricuspid valve repair of Ebstein’s anomaly, characterised by mobilisation of valve leaflets, maximisation of leaflet tissue through delamination of the valve tissue from the myocardium whilst maintaining chordae attachment, rotation and suturing of the leaflet complex to create a cone with base at the TV annulus and vertex in the right ventricular apex, and plication of atrialised RV.

Cor triatriatum: a restrictive membrane in the left atrium, dividing the atrium into two chambers. Blood from the upper chamber, where the pulmonary veins enter, drains into the lower chamber through one or more orifices in the membrane, with symptoms dependent on the degree of restriction through the membrane.

Damus-Kaye-Stansel operation: a proximal PA to aorta anastomosis (above their respective valves). It provides systemic flow in situations where there is LVOT obstruction or subaortic stenosis in functional univertricular hearts. Usually combined with either a BT shunt or a RV-PA conduit, which supplies pulmonary blood flow.

Double inlet left ventricle: both atria drain into a single ventricle, which is commonly connected to an additional hypoplastic ventricle via a bulboventricular foramen. The most common subtype is a double-inlet LV, which is anatomically right-sided, and has ventricular-arterial discordance (TGA).

Double outlet right ventricle: a defect in which both pulmonary artery and aorta arise from the right ventricle. A VSD is present, positioned either in a sub-pulmonary, sub-aortic, doubly-committed, or remote location. The resultant physiology can mimic that of tetralogy of Fallot, transposition of the great arteries, or a VSD, depending on the relation between the position of the VSD to the great arteries.

Ebstein’s anomaly: abnormality of the tricuspid valve resulting in abnormal downward and rotational displacement of the valve orifice into the RV, with

---------� 93

atrialised portion of the RV between the annulus and abnormal leaflet attachments.

Fontan operation/Fontan completion/total cavopulmonary connection (TCPC): final stage in univentricular palliation (after a previous Glenn/SCPC/hemi-Fontan procedure. The IVC is connected to the PA in one of 3 ways; originally through a RA-PA direct anastomosis, or through a lateral tunnel within the RA, or through an extra-cardiac conduit (now most common approach). A fenestration between the IVC and RA may be created to provide a right-to-left ‘pop-off’ pathway from the cavopulmonary circuit to the heart in order to lower the pressure in the circuit, albeit at the expense of lower saturations.

Heterotaxy: a complex syndrome of malformation, due to abnormal sidedness of thoracic and abdominal organs. Potential abnormalities include atrial or lung isomerism, single ventricle, poly- or a-splenia, bilateral or persistent left SVC, TAPVD, left-sided or interrupted IVC, and intestinal malrotation.

Holmes heart: a specific sub-type of DILV, with a hypoplastic morphological right ventricle, and normally related great arteries.

Interrupted aortic arch: interrupted or atresic arch, leading to complete distal disruption or obstruction to flow.

Jatene procedure: this procedure is an arterial switch operation and is a definitive treatment for transposition of the great arteries. Both the aorta and pulmonary arteries are transected. The aorta is anastomosed to the residual proximal pulmonary artery, which becomes the neo-aorta. The distal pulmonary artery is anastomosed to the residual proximal aorta. Commonly a Lecompte manoeuvre is carried out during this step. Crucial to the success of the procedure is the successful transfer of the coronary origins from the native aorta to the neo-aorta.

---------� 94

Konno procedure: in order to relieve LVOT obstruction associated with aortic valve annulus hypoplasia, the aortic valve is excised and an incision in the ventricular septum is made and patched open. The creation of a widened LVOT allows a larger aortic valve to be used. This can be with either a mechanical (Konno-Rastan), homograft, or autograft (Ross-Konno) replacement.

Lecompte manoeuvre: the distal main pulmonary artery is brought anterior to the aorta so that the left and right PA bifurcation straddles the anterior ascending aorta.

MAPCAs: major aorto-pulmonary collateral arteries. These vessels are likely dilated bronchial arteries and provide a degree of pulmonary blood flow. They can provide a portion or all pulmonary blood flow depending on the degree of pulmonary arterial flow, or presence (or absence) of alternative conduits for pulmonary blood flow (e.g. PDA, BT shunt). They are prone to stenosis.

Mustard procedure: an atrial switch procedure for patients with transposition of the great vessels that creates an intra-atrial baffle made of native pericardium or synthetic material. This redirects pulmonary venous blood through the tricuspid valve into the right ventricle, and systemic venous blood through the mitral valve into the left ventricle. By surgically creating atrio-ventriclular discordance, physiologic (but not anatomical) correction is achieved.

Norwood procedure: first of a three stage palliative process for patients with univentricular hearts. It involves transection of the pulmonary artery, amalgamation of the proximal pulmonary artery with aorta, aortic arch augmentation, atrial septectomy, and provision of pulmonary blood flow either through a systemic-to-pulmonary artery shunt (BT shunt), or via an RV-PA conduit (Sano shunt/modification).

Patent ductus arteriosus: Persistence of a patent ductus arteriosus results in left-to-right shunt from aorta to pulmonary artery, and can lead to pulmonary overcirculation, pulmonary hypertension and heart failure.

---------� 95

Potts shunt: fenestration-type direct communication created between descending aorta and left pulmonary artery. Designed to provide some pulmonary blood flow through a systemic-to-pulmonary communication.

Rastelli procedure: in situations such as certain sub-types of double outlet right ventricle, LV outflow is accomplished by routing blood across a VSD patch, which serves as a baffle. An RV-PA conduit provides pulmonary blood flow.

Ross procedure: for some cases of aortic valve replacement, the patient’s own pulmonary valve (pulmonary autograft) is transposed to the aortic position. A cadaveric or bioprosthetic pulmonary valve is then used to replace the patient’s native pulmonary valve. The advantage of this procedure is the superior longevity of an autograft compared with currently available homografts, and is the only option that provides the possibility of growth, thereby appealing for use in children.

Sano shunt: an RV-PA conduit.

Senning procedure: a similar procedure to the Mustard procedure, although autologous tissue from the right atrial wall or inter-atrial septum is used rather than the pericardium or synthetic material used in the Mustard procedure.

Starnes procedure: as an alternative to biventricular repair of Ebstein’s anomaly, the Starnes procedure involves patch closure of the TV, reduction atrioplasty and/or RV plication, formation of an unrestrictive ASD, and creation of pulmonary blood flow through a mBT shunt, thereby creating single ventricle physiology.

Taussig-Bing anomaly: a heart with a double outlet right ventricle with a

---------� 96

subpulmonary VSD. Left ventricular oxygenated blood is preferentially streamed into the pulmonary artery, and therefore behaves physiologically as a heart with transposition of the great arteries.

Transposition of the great arteries: in d-transposition, there is ventricular-arterial discordance, whereby the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. Treatment historically involved either a Mustard or Senning procedure. Current definitive treatment is a Jatene procedure (arterial switch). In the rarer l-transposition (synonymous with ‘congenitally-corrected transposition’), there is both atrio-ventricular and ventricular-arterial discordance. The right atrium drains blood through a mitral valve into a right-sided morphological left ventricle, which ejects into the pulmonary artery. The left atrium drains blood through a tricuspid valve into a left-sided morphological right ventricle, which ejects into the aorta. Treatment may include a double switch, involving both a Senning and a Jatene procedure, to allow the morphological left ventricle to become the systemic pump.

Truncus Arteriosus: a defect in which the pulmonary artery and aorta exit the heart as a single trunk. There is a VSD, which the trunk overrides.

Ventricular septal defect: a defect in the ventricular septum. When large and unrestricted, this commonly leads to significant left-to-right shunting and pulmonary overcirculation. A number of types exist depending on position within the septum and relation to intracardiac structures, including inlet, outlet, perimembranous, muscular, and apical.

Waterston shunt: fenestration-type direct communication created between ascending aorta and right pulmonary artery. Designed to provide some pulmonary blood flow through a systemic-to-pulmonary communication.

Congenital references:

Andropoulos D, et al. Anaesthesia for congenital heart disease. 3rd edition. 2010. Wiley: USA.

---------� 97

Barry P, Morris K, Ali T. Paediatric intensive care (oxford specialist handbook). 2010. Oxford University Press: UK.

Everett A, Lim D. Illustrated field guide to congenital heart disease and repair. 3rd edition. 2015. Scientific Software Solutions, Inc: USA.

Lake C, Booker P. Pediatric cardiac anesthesia. 4th edition. 2004 Lippincott Williams and Wilkins: London.

Ch. 6 – Drug informa?on

Generalreferences:TomlinM,etal.Aguidetoparenteraldrugsusedonadultintensivecare.2008.SouthamptonGeneralHospital.AshleyC,CurrieA.2009.Therenaldrughandbook,3rded.RadcliffePublishing:Oxford.

An?microbials: Caspofungin:

Wt<80kg:70mgodday1,then50mgodthereacer

Wt>80kg70mgod

---------� 98

ModeratehepaVcinsufficiency:70mgday1,then35mgod

Renalimpairment/CVVH:

-GFR<10:DoseasinnormalrenalfuncVon.

-CVVHDF:Notdialysed.Doseasinnorm.renalfuncVon

Cefotaxime:

1-2gBDorTDS

MeningiVs:2g4hourly

Renalimpairment/CVVH: -GFR<10-20:DoseasinnormalrenalfuncVon -GFR<10:1gevery8-12hours -CVVHDF:Dialysed.2Gevery12hours

Cerazidime:

1-2gTDS

Renalimpairment/CVVH: -GFR31-50:1-2gevery12hours -GFR16-30:1-2gevery24hours -GFR6-15:500mg-1gevery24hours -GFR<5:500-1gevery48hours -CVVHDF:Dialysed.2gevery12hours

---------� 99

Cefuroxime:

1.5gramTDS Renalimpairment/CVVH: -GFR10-20:750mg-1.5gevery8-12hours -GFR<10:750-1.5gevery12-25hours -CVVHDF:Dialysed.DoseasinGFR=10-20

Chloramphenicol:

(IV)12.5mg/kgQDS(max1gramQDS) Renalimpairment/CVVH: -GFR<10:DoseasinnormalrenalfuncVon -CVVHDF:Notdialysed.DoseasinnormfuncVon

Ciprofloxacin:IV:200-400mgBD

oral:250-750mgBD

Renalimpairment/CVVH: -GFR10-20:50-100%normaldose

---------� 100

-GFR<10:50%normaldose(100%doseforshort periodsunderexcepVonalcircumstances) -CVVHDF:Dialysed.Oral500-750mgevery12hours.IV:200-400mgevery12hours.

Clarithromycin:

IV/oral250-500mgBD

Renalimpairment/CVVH-Usewithcau6on: -GFR10-30Oral/IV:250-500mgevery12hours. -GFR<10:Oral/IV:250-500mgevery12hours. -CVVHDF:Unknowndialysability.DoseasinGFR=10-30

Co-amoxiclav:

IV:1200mgTDS

PO:375-625mgTDS

Renalimpairment/CVVH: -GFR10-30:IV:1200mgevery12hours -GFR<10:IV:1200mgstatfollowedby600mgevery8hoursor1200mgevery12hours. -CVVHDF:Dialysed.DoseasinGFR=10-30

Co-trimoxazole(Septrin):

---------� 101

IV/Oral:120mg/kg/dayin2-4divideddoses

Renalimpairment/CVVH: -SeeRenalDrugHandbookDaptomycin:

Renalimpairment/CVVH: -GFR30-50:DoseasinnormalfuncVon -GFR<30:4mg/kgevery48hours -CVVHDF:Slightlydialysed.4-6mg/kgevery48hours.

Erythromycin:(Prokine6cuse)IV/Oral:500mgbd

Renalimpairment/CVVH: -GFR<10:50-75%normaldose.Max2gramdaily -CVVHDF:Unknowndialysability.DoseasinnormalrenalfuncVon.

Flucloxacillin:

IV/Oral:250mg-1000mgQDSUpto8gram/daymaybeusedinsevereinfecVonssuchasendocardiVs

Renalimpairment/CVVH: -GFR<10:DoseasinnormalfuncVonupto4gmaxdaily.

---------� 102

-CVVHDF:Notdialysed.Doseasinnormalrenal funcVon.

Fluconazole:

Invasivecandida:400mgIVstat,then200-400mgIV/oralod(cauVoninhepaVcandrenalfailureandinteractswithwarfarin,phenytoin,ciclosposinandtheophylline)

Renalimpairment/CVVH: -GFR<10:50%normaldose. -CVVHDF:Dialysed.400-800mgevery24hours

Gentamicin:SeeUHSmicroguide

Meropenem:

Renalimpairment/CVVH:

-GFR20-50:500mg–2gevery12hours

-GFR10-20:500mg-1gevery12hoursor500mgevery8hours

-GFR<10:500mg–1gevery24hours

-CVVHDF:1gevery12hours

---------� 103

Metronidazole:

IV500mgevery8hours Renalimpairment/CVVH:

-GFR<10:DoseasinnormalrenalfuncVon -CVVHDF:Unknowndialysability.DoseasinnormalrenalfuncVon.

Rifampicin:

600-1200mgdailyin2-4divideddoses Renalimpairment/CVVH: -GFR<10:50-100%ofnormaldose -CVVHDF:Unknowndialysability.DoseasinnormalrenalfuncVon.Tazocin(Piperacillin/Tazobactam)4.5gevery8hoursRenalimpairment/CVVH: -GFR10-20:4.5gevery8-12hours GFR<10:4.5gevery12hours-CVVHDF:Dialysed.4.5gevery8hours

Teicoplanin:

400mg12hourlyfor3doses(loading),then400mgdaily.

Renalimpairment/CVVH:---------� 104

-GFR10-20:Givenormalloadingdose,then200-400mgevery24-48hours -GFR<10:Givenormalloadingdose,then200-400mgevery48-72hours -CVVHDF:Unknowndialysability.DoseasinGFR10-20

Vancomycininfusion:

1gloadingover2hours(consider500mgif<40kg)

Thenforinfusion:makeup500mgin100mL0.9%NaCl.

CreaVnine<120=Startat13mL/hr

CreaVnine>120orCVVH=Startat8mL/hr

Doleveldailyat6am(unlessstartedwithin6hours)

Iflevel<15mg/L Increasedose/ratebynextlevelupintable

Iflevel15-25mg/L Nochange

Iflevel>25mg/L Decreasedose/ratebynextleveldownin table

Iflevel>30mg/L Stopinfusionfor6handd/wconsultantor pharmacist.

---------� 105

Seda?ves and anxioly?cs:

Chlorpromazine:

25mgIMmaxTDS(CauVoninParkinson’s,epilepsy,Myastheniagravis)

Clonidine:seebelow

Dexmedetomidine:seebelow

DailyDose

3500

mg

3000

mg

2500

mg

2000

mg

1500

mg

1000

mg

500

mg

250

mg

Equivalentrate(5mg/ml)

29

ml/h

25

ml/h

21

ml/h

17

ml/h

13

ml/h

8

ml/h

4

ml/h

2

ml/h

---------� 106

Haloperidol:

1.25-5mg(contraindicatedinparkinson’sdisease.CauVoninliverdiseaseandrenalfailure,epilepsy,andphaeochromocytoma)

Lorazepam

IV1mg

Olanzapine:

IV/IM2.5-5mgPRN(unlicensed)

Procyclidine:

2.5mg–5mg

Que6apine:

po12.5mgPRN

Clonidine

---------� 107

Introduc6on:

-PotentcentralAlpha2agonistwithweakalpha1acVvity,leadingtosedaVon,analgesia,bradycardiaandhypotension

-IncreasesTSHandGH,butdecreasesADHandinsulinsecreVon

Indica6on:

-AgitaVon/-Hypertension

DoseRange:

-300-900mcg/24hrs

-Max1200mcg/24hrs

-PO50-200mcgTDS(max300mcgatVme)

Presenta6on:

-CompaVblewith0.9%NaCland5%dextrose

-Makeup450mcgin50mls

-Runat0-6ml/h

---------� 108

Notes:

Sideeffectsinclude,hypotension,bradycardia,depression,drowsinesswithdrymouthandconsVpaVon.

Cancausereboundhypertension,tachycardiaandrestlessnessorwithdrawal.ThereforeVtratedosedownoverafewdays

---------� 109

Dexmedetomidine:

(ref:Guy’sandThomas’NHSFT)

Introduc6on:

-a2agonistsimilartoclonidine

-NotfordeepsedaVon

Indica6on:

-Failedtrialclonidine(BPdrop,HR)

-Difficultairway/extubaVon

-Highriskdelirium(PRODEX/MIDEXstudies)

-NIV(lackrespdepression)

DoseRange:

-0.4-1.4mcg/kg/hr

---------� 110

-Start0.8mcg/kg/hrmajority

-30-60minsbetweendosechangesof0.1mcg/kg/hr

-Reduceby0.1mcg/kg/hrincrements->0.4mcg/kg/hrthenstop

Presenta6on:

-100mcg/mL(10mL)->prepareto20mcg/mLconcentraVonin50mLsyringewithsaline0.9%

Shivering associated with hypothermia: Skincounter-warming

Paracetamol

Pethidine25mgIV

Magnesium

Chlorpromazine25mgIM

Opiatesincl.Meperidine50-100mgIM/IVorfentanylinfusion

---------� 111

propofolinfusion

ClonidineorDexmedetomidineinfusion

Neuromuscularblockingagents(lastresort)

Acid/base special situa?ons

Acetazolamide

Introduc6on:

-Carbonicanhydraseinhibitor.ReduceshydrogenionexcreVon,raisingurinarypHandacidifyingplasmapH

Indica6on:Rhabdomyolysis

SVmulatesrespiraVonbyacidifyingplasmapH

Treatmentofmetabolicalkalosis

DoseRange:

-IVslowly500mgBDfor3-5/7

Notes:

Causesflushing,headaches,thirstandacid/base/electrolyteimbalance,paraesthesia,ataxia,andhypervenVlaVon.

---------� 112

Contraindicated/cau6onmetabolicacidosis,tachypnoea,sulphonamidehypersensiVvity,livercirrhosis(increasesriskofencephalopathy)

Cardiovascular drugs: Adrenaline: Introduc6on:

-Alpha,Beta1+2agonist.Increasescardiacoutput,peripheralvascularresistance,coronarybloodflow,andheartrate.

-IncreasesmyocardialO2consumpVon,plateletadhesivenessandbloodcoagulaVon,bloodglucose,andisametabolicandmildrespiratorysVmulant.

Indica6on:

-ToincreaseinotropyandSVR

DoseRange:

-0.01mcg/kg/min–1.0mcg/kg/min

Presenta6on:

-NotetwoconcentraVonsavailable:

---------� 113

1mgin1mlampule(1:1000)

AND

1mgin10mlampuleorminijet(1:10,000)

-Add1mgtoatotalof50mls5%glucose.AlsocompaVblewithdex/salineand0.9%saline.

-Runat0-20ml/h.ConcentraVoncanbedouble(2mg/50ml)orquadrupled(4mgin50mls)asrequired.

Notes:

- GICUusesastrongerconcentraVon(10mgin100ml,equivalenttoquintuplestrengthCICUstrength).

- IncompaVblewithSodiumBicarbonate

Renalimpairment/CVVH:

-GFR<10DoseasinnormalrenalfuncVon

-CVVHDF:Notdialysed.DoseasinnormalrenalfuncVon

---------� 114

Amiodarone:

Introduc6on:

-ClassIIIanV-dysrhythmic,alsowithclassIacVvity

-SlowsAVnodalconducVon.AlsodecreasesSVRandincreasescoronarybloodflow

Indica6on:

-Tachydysrhythmias,includingsupra-andventriculartachycardias,atrialflu~erandatrialfibrillaVon,andthoseassociatedwithWPWsyndrome

DoseRange:

-Loadingdose:IV5mg/kg(usually300mg)over1hour,followedby900mgover23hours

-Maintenance:IV300-600mg/day(inareducingdose),andconsiderswitchingtooral/ngformulaVonwhenappropriate

Presenta6on/compa6bility:

-150mgor400mgvial/ONLYCOMPATIBLEwith5%DEXTROSE

-IVLoadingdose:makeup5,g/kg(300mg)in100-250ml5%dextrose(Consider100mldiluentforCVCadministraVon,

---------� 115

whereasuse250mldiluentforperipheraladministraVonvialargeborecannula),thenmakeup900mgin500mls5%dextrose

Notes:

Useadedicatedline,shouldbegivencentrally.

Peripheraluse–usealarge-borecannula,andavoidlongtermadminperipherally.Risksofhypotensionandbradycardia,photosensiVvity,GIupset,andlongterm,cornealmicrodeposits,hypothyroidism,pneumoniVsorlungfibrosis,andcirrhosis

Renalimpairment/CVVH:

-GFR<10DoseasinnormalrenalfuncVon

CVVHDF:Notdialysed.DoseasinnormalrenalfuncVon

---------� 116

Apro?nin:

DoseRange:

-TestDose10,000units(1mL)

-LoadDose2millionunits(x4syringes)

-Pumpdose2millionunits

-Infusion½millionunits/hr(50mL/hr)

-TOTDose=7millionunits(max14amps)

---------� 117

Atenolol

Introduc6on:

-Cardio-specificbeta-blocker(Beta1)

-CausesreducVonininotropy,leadingtoafallinO2consumpVon

AnVhypertensiveandanVdysrhythmicproperVes

Indica6on:

-Angina,hypertension,tachydysrhythmiasinacutephaseofMIandprevenVonofre-infarcVon

DoseRange:

-IVBolus:1-2.5mg(maxrate1mg/min),repeatedat5minintervalstoamax10mgtotal

IVinfusion:150mcg/kgover20mins,12hourly

BewareIV/POdosesvarybyafactorof10.

---------� 118

Notes:

Sideeffectsincludebronchospasm,bradycardia,heartfailuredeterioraVon,posturalhypotension.

Contra-indica6ons:

SecondorThirddegreeheartblockorsicksinussyndrome

Uncontrolledheartfailure/Cardiogenicshock

CauVoninCOPD/Asthma

Reducedoseinrenalfailure

Renalimpairment/CVVH:

-GFR<10:DoseasinnormalrenalfuncVon

-CVVHDF:Dialysed.DoseasinnormalrenalfuncVon

---------� 119

Atropine:

Introduc6on:

-AnVcholinergic/anVmuscarinic

-BlocksvagalacVvityleadingtoarelaVvetachycardia

Indica6on:

-Counterbradycardia

DoseRange:

-IV/IM600mcg

Presenta6on:

-600mcgvial

---------� 120

-1mgminijetsavailable

Notes:

PainfulonIMinjecVon

Causesdrymouth,andreducedsalivary,bronchialsecreVons,andsweaVng

---------� 121

Calcium Gluconate:

Introduc6on:

-EssenValforintracellularmuscleandnervefuncVon,includingcardiomyocytecontracVon

-CoagulaVonfactorIV–EssenValco-componentofClo�ngcascade

Indica6on:

-Hypo-calcaemia.AimionisedCa2+(onbloodgas)>1.15

-ToincreaseheartcontracVlityandvascularsmoothmuscletone

-Asacardiacmyocytemembranestabiliserinhyperkalaemia

DoseRange:

-SlowIVbolus10-20mls(atmaxrateof2mlsof10%(0.44mmol)permin)

Presenta6on:

---------� 122

-10mlampuleof10%Calciumgluconate,containing2.2mmolin10mls

-CompaVblewith0.9%Salineand5%dextrosesoluVons

Notes:

Cancause:

nausea/vomiVng/flushing/

vasomotorcollapse/hypotension/tachycardias

CauVoninpaVentswithhyperphosphataemia

Renalimpairment/CVVH:

-GFR<10:DoseasinnormalrenalfuncVon.Titratetoresponse

-CVVHDF:Dialysed.DoseasinnormalrenalfuncVon

---------� 123

Digoxin: Introduc6on:

-AnanVdysrhythmicdrugthatslowsAVnodalconducVon,therebyslowingventricularresponsetoAF.AposiVveinotrope.AlsodepressesSAnodedischarge

Indica6on:

-AtrialfibrillaVonoratrialflu~er/ChronicCCF/PrevenVonofsupraventriculardysrhythmiasfollowingthoracotomy

DoseRange:

-Loadingdose:500-1000mcgin24h

-Maintenancedose:62.5-250mcgodaccordingtolevels

IV/POswitch:Note100mcgIV=125mcgoral

Presenta6on:

-CompaVblewith0.9%NaCland5%dextrose.Dilutein50-100mldiluent(Maxconc.50mcg/ml)

Notes:

SEincludevasoconstricVon,hypertensionanddecreasedcoronarybloodflowwithrapidinjecVon,Anorexia,N&V,diarrhoea,headache,drowsiness,Dysrhythmias,2Oand3oAV

---------� 124

block,Ectopics,atrialorventriculardysrhythmiasindicateoverdose,Ventricularbi-ortri-geminy.Conatraindicatedin2Oor3oAVblock

Monitoring:

Checklevel6hpostdose.-Aim0.9-2.6micromol/litre

MonitorPotassium:HypokalaemiasensiVsesthemyocardiumtodigoxin.ThereforeAimk>4

Renalimpairment/CVVH:

-GFR20-50:125-250mcg/day.10-20:125-250mcg/dayandmonitorlevelsclosely.<10:62.5mcgdailyoralternatedaysandmonitorlevelsclosely.Notdialysed.DoseasinGFR10-20.

Dopamine:

Introduc6on:

-Anoradrenalineandadrenalineprecursor

-Hasdirectdopaminergicagonisteffects,withaddiVonalbeta-adrenergicandalphaadrenergicagonismwithincreasingconcentraVonrespecVvely.

---------� 125

Indica6on:

-Toincreaserenal(andmesenteric)bloodflow

-Forinotropyinlowcardiacoutputstates

DoseRange:

1-3mcg/kg/min:DAagonistincreasesrenalbloodflow

3-10mcg/kg/minaddiVonalBetaagonism inotropicandchronotropy

>10mcg/kg/minaddiVonalalphaagonism increasesSVR,PVR

Presenta6on:

-200mgin5mlvial

-CompaVblewith0.9%sodiumchlorideand5%dextrose

-Drawup200mgin50mls.

Rate1-10ml/h

Notes:

-Riskofarrhythmiasathigherdoses

---------� 126

-AlphamediatedvasoconstricVonoutweighsdopaminergicrenalvasodilaVonathighdoses

Renalimpairment/CVVH:

-GFR<10DoseasinnormalrenalfuncVon.

-CVVHDF:Notdialysed.DoseasinnormalrenalfuncVon

---------� 127

Ephedrine:

Introduc6on:

-PosiVveinotrope

-AlphaagonistleadingtovasoconstricVon

Indica6on:

-Hypotensionunderanaesthesia

DoseRange:

-3-6mgevery3-4mins.Max30mg

Presenta6on:

-CompaVblewith0.9%salineand5%dextrose

---------� 128

Notes:

Sideeffectsincludeheadache,tremor,dysrhythmias,N&V

---------� 129

Esmolol:

Introduc6on:

-ArelaVvelycardiospecificbetablockerwithveryshortduraVonofacVon(Half-life9mins).

Indica6on:

-Shorttermtreatmentofsupra-ventriculartachycardias

-PerioperaVvehypertensionortachycardia

DoseRange:

-Usually50-200mcg/kg/minadequate

-Aloadingdoseof500mcg/kg/minfor1min,followedbyamaintenancedoseof50-200mcg/kg/minisreasonableforSVTorimmediatecontrolofperioperaVvetachycardiaandhypertension

Presenta6on:

-10mlvialcontaining100mg(10mg/ml)

-Pre-madebagsof2500mgin250mls(10mg/ml)

-InjecVonconcentrate250mgin1ml–alwaysdiluteinto250mls0.9%NaClor5%dextrosetomakeaconcentraVonof10mg/ml)

---------� 130

Notes:

-Cancausebradycardia,dizziness,heartfailure,andvenousirritaVonorthrombophlebiVs.Thereforegivecentrallyorviaalarge-borecannula.

-Contraindicatedinhypotensionandbradycardia,2Oand3oheartblock,sicksinussyndrome.

-CauVoninasthmaandseverePVD.

-80%HepaVcallycleared.ThereforedoseasnormalinRF.

Renalimpairment/CVVH:

-GFR<10DoseasinnormalrenalfuncVon.

-CVVHDF:Unknowndialysability.DoseasinnormalrenalfuncVon

---------� 131

GTN:

Introduc6on:

-VasodilaVonofarteriesandveins

Indica6on:

-Hypertension

-Unstableangina

DoseRange:

-10-100mcg/min

Presenta6on:

-Comesas50mgin50mlsNeat

-Rate1-10ml/h.Tachyphylaxisoccursin8-24h

Notes:

---------� 132

Sideeffectsincludehypotensionandpossiblereflextachycardia,N&Vandheadaches.

CancausevenVlaVon/perfusionmismatchleadingtoincreasedright-to-lecshuntandreducedoxygensaturaVons(duetouncouplingofhypoxicpulmonaryvasoconstricVon)

Contraindicatedinseverehaemorrhage,uncorrectedhypovolaemia,severehypotension

Renalimpairment/CVVH:

-GFR<10DoseasinnormalrenalfuncVon.

-CVVHDF:Notdialysed.DoseasinnormalrenalfuncVon

---------� 133

Isoprenaline:

Introduc6on:

-Beta1andBeta2agonistproducinginotropyandchronotropy.Thebeta2acVvityalsocausesvasodilataVonandbronchodilaVon.

Indica6on:

-Chronotropyforbradycardiarefractorytoatropine

-Forthetreatmentofcompleteheartblock

DoseRange(Bridgetopacing):

-0.05-0.5mcg/kg/min

Presenta6on:

-1mgin10mlampuleor2.25mgin2mlampule

-CompaVblein0.9%salineand5%glucose

---------� 134

-Makeup4.5mgin50mls.

-Runat1-10ml/h

Notes:

-Cancausehypoxiaanddecreasedrenalbloodflow,hyperglycaemia,palpitaVons,angina,dysrhythmias,hypotension.

EPexperience:

200mcg(=1vial)makeupto50mLsaline

Conc=4mcg/mL

Run50mL/hr->100->150->300mL/houraccordingtoelectrophysiologist

Levosimendan:

Introduc6on:

-AcardiacmuscleCalciumsensiVzer.

-WorksindependentlyofcAMPandthereforeshouldnotinteractwithbetaagonistsorphospodiesteraseinhibitors

---------� 135

Indica6on:

-Acuteheartfailure,usuallywhenrefractorytootheragents

DoseRange:

-0.1mcg/kg/min+/-loadingdose3-24mcg/kgover10mins(3pracVcal->upto6)

-Cangodownto0.05orupto0.2mcg/kg/minmax

Presenta6on:

-2.5mg/mLin10mLvials

-Addx1vialto250mLdextrose5%

-Finalconc=50mcg/mL

---------� 136

Lidocaine infusion:

Introduc6on:

-ClassIanVdysrhythmic(Na+channelblocker)

Indica6on:

-Arrhythmia

DoseRange:

-Bolus/loadingdose50-100mgIV

-4mg/minfor30mins(60ml/h)

-2mg/minfor2hrs(30mL/hr)

-1mg/minfor24hrs(15mL/hr)

-Max200-300mg/hr

---------� 137

Presenta6on:

-2000mgin500mLglucose5%

=4mg/mLconcentraVon

Notes:

- ContraindicatedinPorphyria

Renalimpairment/CVVH:

-GFR<10DoseasinnormalrenalfuncVon.

-CVVHDF:Notdialysed.DoseasinnormalrenalfuncVon

---------� 138

Methylene Blue:

Introduc6on:

-MethyleneBluecanincreaseSVRbyinhibiVngtheacVvaVonofsolubleguanylatecyclaseandtherebyblockingthesynthesisofthepotentvasodilator,nitricoxide.

Indica6on:

-CanbeusedtoincreaseSVRthatisrefractorytonoradrenalineandothervasopressors.

DoseRange:

-1-2mg/kgboluswith1-2mg/kg/hrinfusion

-SmalleramountsmayhavedramaVcclinicaleffect

Presenta6on:

-Availableas1%w/vsoluVon(10mg/ml).

---------� 139

-Diluteintoasuitablevolumeof0.9%salineor4%glucose0.18%saline.

Notes:

-Contraindicatedinglucose-6-phosphatedehydrogenasedeficiency.

-CauVoninsevererenalfailureduetoaccumulaVon

-Donotmixwithotherdrugs

-WillcausediscolouraVonofskinandurine.

-CancausehaemolyVcanaemia,andmethaemoglobinaemiaacerprolonged/highdoseuse,reducVoninplateletcount,andVssuedamageifextravasaVonoccurs.

---------� 140

Milrinone:

Introduc6on:

-AphosphodiesteraseIIIisoenzymeinhibitorofcardiacandvascularmuscle

-ProducesposiVveinotropyandvasodilataVon-Alsocauseslusitropyanddromotropywithli~leornoincreaseinchronotropy.

Indica6on:

-Lowcardiacoutput,parVcularlyinthese�ngofincreasedLVEDP,pulmonaryhypertensionorRVfailure

-Asanadjuncttobetaagonists

DoseRange:

-0.375-0.75mcg/kg/min

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Presenta6on:

-Availableas10mgin10mls.

-CompaVblewith0.9%salineand5%glucose

-Drawup10mgofdruginto50mlsdiluent.

-Rate5-10ml/h

Notes:

-Renallycleared.Thereforereducedoseinrenalfailure.

-4hhalflife

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Noradrenaline:

Introduc6on:

-Beta1andalphaagonist.CausesincreasedSVRwhilstalsomaintainingcardiacoutput.

Indica6on:

-Refractoryhypertensionsecondarytovasoplegia

-ModulaVonofvasodilaVngdrugs

DoseRange:

-0.01-0.5mcg/kg/min

Presenta6on:

-UsualdiluVonis4mgin50mlsor8mgin100mls.

-CompaVblewith0.9%NaCland5%glucose.

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-Runat0-10ml/h.

-ConcentraVonsmaybedoubledorquadrupled

Notes:

-Cancauseperipheralischaemia,reducedrenal-bloodflowathighdoses,andhyperglycaemia

Phentolamine:

Introduc6on:

-Alphaantagonist,leadingtoadecreaseinSVR

Indica6on:

-Acutehypertension

DoseRange:

---------� 144

-IVBolus:2-5mg,repeatedasrequired

Notes:

-Cancausereflextachycardiaanddysrhythmias,diarrhoea,nauseaandvomiVng,increasesgastricacidsecreVon.

-ContraindicatedinmyocardialinfarcVonandhypotension.

---------� 145

Phenylephrine:

Introduc6on:

-Alphaagonist,leadingtoariseinSVR.

Indica6on:

-Hypotensionsecondarytovasoplegia

DoseRange:

-IVbolus:100mcgrepeatedasrequired

-IVinfusion:30-180mcg/minVtratedaccordingtoresponse

Presenta6on:

-1mgin10mls(100mcg/ml)

---------� 146

-Beware10mgin1ml(strongphenylephrine)available.RequiresdiluVon.

CommondiluVons:

-10mgin100ml0.9%NaClbag(100mcg/ml)

-10mgdilutedto10mls0.9%Nacl(1mg/ml)foruseonlyinCPBcircuitbyperfusionist

Notes:

-Causesreflexbradycardia,hypertension,dysrhythmias,nauseaandvomiVng,sweaVng,increasedsalivaVon,urinaryretenVon.

-Contraindicatedinhypertensivestates.CauVonwithhyperthyroidism.

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Sodium Nitroprusside (SNP):

Introduc6on:

-Potentarterialandvenousvasodilator,reducingSVR.

-CausescerebralvasodilaVon

Indica6on:

-Severehypertension

-Acuteheartfailure

DoseRange:

-Hypertension:0.5-8mcg/kg/min

Presenta6on:

-Makeup50mgin50mls

-CompaVblewith0.9%NaCland5%glucose

---------� 148

-Runat2-20ml/h

Notes:

Cancausescyanidetoxicity,tachycardia,dysrhythmiasandmetabolicacidosis.

AnVdoteforcyanidetoxicityissodiumthiosulphate(onCTITU,ED,andpharmacy)

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Vasopressin:

Introduc6on:

-ActonV1areceptorsonsmoothmuscletoproducevasoconstricVon.

Indica6on:

-RefractoryhypotensionsecondarytolowSVR

DoseRange:

-CompaVblewith5%dextrose.

-DONOTMIXwithotherinotropes

-Makeup40unitsin40mls.

-Runat2-3units/h

Notes:

---------� 150

CausespulmonaryvasodilaVon,increasedcorVsol,diuresisatlowdoses,plateletaggregaVonathighdoses.

Ch. 7 – Notes

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