Department of AnesthesiologyCardiothoracic Anesthesia Rotation Manual

TABLE OF CONTENTSIntroductionGoals of the RotationsObjectives of the RotationsEnvironment

Physical SettingPersonnelSet-upCommunication

Procedure for Cardiac AnesthesiaPre-operative EvaluationPre-medication

SPECIAL NOTE ON SERUM GLUCOSETime Sequence of Patient PreparationMonitoring

IschemiaTransesophageal EchocardiographyCare of Arterial Lines

Induction of AnesthesiaPre-bypassHemodynamic PerturbationsCardiopulmonary BypassAfter BypassTransport to CTICU

Management of Off-pump CABG (OPCAB)Re-do sternotomy casesAnticoagulation and CoagulationFluidsPharmacy SupportDidactic ProgramAdditional ReferencesEvaluation Procedures

Revised 12/15/09

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Introduction

Welcome to your Cardiothoracic Anesthesia Rotation. Cardiac surgery is a complex field of medicine, with the potential for significant patient morbidity and mortality. Quality anesthetic care, with appropriate attention to detail, can enhance patient safety and outcome. A team approach to patient management is ideal. When you first begin on the CT Anesthesia service, you will work with both a CT anesthesiologist and a senior resident. Once you gain confidence in managing cardiac patients on your own, the senior resident may have other cardiothoracic assignments. Although senior residents on the rotation can expect much more independence, the faculty CT anesthesiologist will always be present in the OR at all critical points during surgery, and for transport of patients to the intensive care unit.

Goals of the Rotations

The Junior Resident will acquire knowledge, skills, and experience sufficient to administer anesthesia with confidence to patients undergoing elective coronary revascularization, valve repair, lung resection, video-assisted thoracoscopic surgery (VATS), and mediastinoscopy with supervision.

The Senior Resident will acquire additional knowledge, skills, and experience sufficient to administer anesthesia with confidence to patients undergoing urgent or emergency cardiac and thoracic procedures, including some of the following: exploration for post-operative bleeding, sternal repair, heart transplantation, and insertion of ventricular assist devices.

Objectives of the Rotations

Junior Resident 1. Develop a level of competence in the comprehensive evaluation of patients scheduled

for cardiothoracic surgery (*PC)2. Acquire an understanding of

a. cardiac physiology (*MK)b. pathophysiology of ischemic and valvular heart disease (*MK)c. pharmacology and hemodynamic effects of inotropic and vasoactive drugs (*MK)d. mechanics of cardio-pulmonary bypass and pathophysiology of extracorporeal

circulation (*MK)2. Improve skills in placement of radial and pulmonary artery catheters using sterile

technique (*PBL, PC)3. Improve skills in placing thoracic epidural catheter and endobronchial tubes (*PBL,

PC)4. Design a safe plan for the anesthetic management of a patient for coronary artery

surgery with and without cardiopulmonary bypass (*PC)5. Recognize and react appropriately in emergency situations and demonstrate sound

judgment (*SBP, PC, MK)

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6. Demonstrate compassion, sensitivity and ethically sound practice (*PR)7. Demonstrate effective communication with patients, their families, CT surgeons and

nurses, physician assistants and perfusionists (*ICS, SBP)8. Use textbooks, handbooks, and online material, and continue to develop an ability to

read the literature critically (*PBL)

(* Denotes core competency area: PC-patient care, MK- medical knowledge, ICS-interpersonal and communication skills, PR-professionalism, SBP-system based practice, PBL-practice based learning and improvement)

Senior Resident1. Provide anesthesia and hemodynamic management for coronary revascularization

procedures with minimal supervision (*PC)2. Acquire an advanced understanding of the sequence and implications of different CT

surgical interventions, cardiopulmonary bypass and circulatory arrest (*MK, PBL, PC)

3. Organize, direct, and teach junior residents in the care of an elective patient for coronary revascularization (*PBL, ICS, SBP)

4. Demonstrate proficiency in providing anesthesia care for exploration for post-operative bleeding (*PC)

5. Place a transesophageal echocardiogram probe and successfully perform an abbreviated TEE examination (*PC, PBL)

6. Know the pathophysiology and management of adult patients with congenital heart disease and thoracic aortic dissection / aneurysm (*MK, PBL)

7. Demonstrate proficiency in vessel cannulation and catheterization (PC)8. Participate in teaching medical students and student nurses (*PC, ICS)9. Demonstrate competence in using pacemakers and the intra-aortic balloon pump

(*MK, PC)10. Choose anesthetic plans that minimize the cost/benefit ratio (*SBP)1. Critically evaluate the literature in cardiothoracic anesthesia (*PBL, MK)

Environment

Physical Setting At Hahnemann University Hospital (HUH), CT surgery usually occurs in operating rooms 7, 8, or 10 on the 8th floor OR suite. After operation, we transport patients to the CTICU, located on 8th floor South Tower. Because access to the CTICU requires a hospital ID badge, be sure to have yours with you at all times, in case you need CTICU access in an emergency. The CT operating room anesthesia set-up differs slightly from that of general surgical rooms. Learn to set-up the heart room for CPB and off pump cases. Familiarize yourself with the supplementary red carts and red controlled substance bags – they contain special drugs and equipment commonly used in the heart rooms.

Intraoperative Safety : Cardiac surgery can be bloody. Spattering and splashing of blood demand that you wear barrier gloves and eye protection at all times in the operating room. Keep the anesthesia record clean; change gloves when contaminated, and before

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touching the anesthesia machine, TEE machine, or drug cart. Use the alcohol-based hand cleanser when entering and when leaving the room.

Personnel When you first start your rotation, please introduce yourself to the nurses, cardiothoracic housestaff, surgeons, and perfusionists. They value your participation in the care of CT surgery patients. Their trust and respect is earned, not expected. The CT residents and fellows have completed five or more years of surgery training and are very knowledgeable about cardiac physiology and pharmacology. If you have disagreements about patient management, consult your anesthesia attending. Our anesthesia technicians constitute a valuable resource regarding the equipment and the supplies in the heart room. Develop a cordial working relationship with them.

Set Up Start with a standard room set up including suction, machine check, and airway

equipment. However, a standard drug cassette is not needed. Red cart: Every cardiothoracic case utilizes a red cart to supplement the equipment in

the standard anesthesia carts in every operating room. Know the contents of every drawer of this cart before your first case.

Drugs include opioid (fentanyl 40 mL or sufentanil 5 mL, but not both), etomidate, pancuronium, phenylephrine, epinephrine, norepinephrine, antibiotics, and heparin (300 U/kg). Patients may decompensate necessitating a rapid conversion of an off-pump to an on-pump case. Protamine should not be drawn up until preparing to wean the patient from bypass (or until the off pump grafting is nearly complete) to minimize risk of a potentially fatal syringe-swap.

Physiologic monitor: Rooms 7, 8, and 10 employ a Marquette monitor. This differs from the Hewlett-Packard monitors in other 8th floor operating rooms. Be sure to familiarize yourself with the operation of the selector knob and the menu options before your first cardiothoracic case.

Communication Cardiac anesthesia involves a series of repetitive tasks that must be performed correctly. The operation requires a team approach and you are a member of the team. Communicate with the other personnel in the OR:1. Ask questions. Tell others what you are doing and thinking. Don’t let your activities

or concerns be a mystery to the surgeons. When you sample from the arterial line, announce over the drapes, “…on the A-line.”

2. If you are having trouble, call your attending. Cardiac surgeons thrive on stress. This may manifest as criticism when you show your inexperience or ignorance. Do Not let this upset you -better to ask and risk criticism than harm the patient.

3. Confirm receipt of requests whether or not you can or intend to fulfill them at the time the request occurs. If the surgeons asks you to raise the table height and you are busy filling a syringe, simply reply, “…table coming up in a moment” rather than have him/her wonder whether or not you heard the request.

4. Make sure the perfusionist knows when you begin, change, or discontinue vasoactive medications, so that he/she can manage and anticipate changes in the reservoir volume. Likewise, you determine the setting of the vaporizer connected to the pump;

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request changes for it politely from the perfusionist and expect to know whenever it is changed.

Procedure for Cardiac Anesthesia

Pre-op EvaluationMake every effort to see your patients the day before surgery. Do a thorough pre-op evaluation and obtain informed consent for anesthesia. Evaluate the patient for IV and arterial line access. Evaluate the airway and landmarks for right internal jugular catheterization. Esophageal surgery or esophageal stricture is a contraindication for TEE. Communicate with the CT resident or fellow if there are any patient issues that have to be resolved. Do not assume that it will be addressed. Call your anesthesia attending to discuss the patient and anesthetic management. A full pre-anesthetic history and examination should be performed with particular reference to the following points which may affect anesthetic management or indicate patient’s risk: Present illness : Angina (stable or unstable), dyspnea (systolic or diastolic dysfunction),

recent myocardial infraction (has it occurred since decision to operate), episodes of cardiac failure, flash pulmonary edema.

Co-existing disease : H/O asthma, diabetes, hypertension, or cerebro-vascular disease? Has this patient had: convulsions, episodes of fainting, visual disturbances, peripheral vascular disease (claudication), renal insufficiency, coagulation disorder, dental check up performed for valve replacement? Does he/she understand the co-operation required for line placement?

Allergies : Especially to Heparin, Protamine, organic Iodine or antibiotics? Medications : Is the patient on anti-hypertensives, anti-anginals, anti-arrhythmics, specific

regimens for diabetes and asthma? Were aspirin, plavix and/or NSAIDS stopped? OPCAB patient may sometimes remain on aspirin. Clopidogrel ( Plavix) should be stopped 5-7 days preop.

History of Reflux/Dysphagia: Rapid sequence induction in these patients may pose particular challenges. The placement of TEE probes is contraindicated in patients with esophageal disease (strictures) or history of esophageal surgery.

Physical Examination: Generally do they look unwell? Are they short of breath at rest? Do they look grey or ashen as if they have peripheral vascular shut down? Have the signs of left ventricular dysfunction been masked by diuretic use? Airway, dentition – anticipated difficult intubation? Chest: CHF? Murmurs? Head & Neck: neck movement, carotid bruits: JVP, previous carotid surgery scars, beards- will trimming be required for line placement? Periphery: pulses; is radial artery from the non-dominant hand being considered as a bypass conduit? Is there arterial insufficiency in either leg. Does the BP reading differ in different limbs? Venous access?

Investigations o CXR – cardiomegaly, effusions, aortic calcification, lung lesions?o ECG – rate, rhythm, conduction abnormalities, pacemaker dependent, ischemia, recent

infarction, territory of infarcts? If patient has an AICD, EPS has to be consulted and the device interrogated and anti-tachycardia function disabled in the holding area on the day of surgery.

o CBC – Hb, Platelet count – especially in patients on heparin therapy (HIT?) o Chemistry: K+, serum creatinine, glucose. Recent peaks of CK, CKMB, and Troponin.

ABGs and LFTs.o Coags : Prolonged PTT in the absence of heparin (lupus antibody?). INR, if patient was

taking vitamine K antagonist (warfarin/Coumadin®).o Xmatch – Does blood bank have suitable blood for antibody positive patient?

Cardiac Catheterization & Echo Report – note the order:

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o Pressures (R →L)o Valves (R →L)

Mitral Valve: Normal 4-6 cm2. <2=moderate MS. <1=severe mitral stenosis. Mean gradient >15 = severe stenosis

Aortic Valve Area: Normal= 2-4 cm2. <1=moderate AS; <0.75=severe aortic stenosis. Mean gradient >50mmHg = severe stenosis

o Coronaries (LMain, LAD, LCx, R and any known carotid artery stenosis): number, site, and severity of stenoses, including LMCA disease equivalent.

o LV Function – LV Ejection Fraction, LVEDP, pulmonary artery pressures.

Inform patients about fasting, medications, A-line, CVP, PA catheter, TEE, possible intra-operative awareness, and post-operative ventilation. Patients for cardiac surgery have serious and frequent complications including infarction, stroke, and death. The risk of stroke increases with age, hypertension, diabetes and previous stroke. Mortality is 1-10% (depends on risk stratification). You should discuss these risks. Warn diabetics that insulin requirements may change markedly, and that non-insulin dependent diabetics may require insulin. Tell patients with renal failure they may require temporary dialysis after operation.

Risk Stratification: Greatly increased risk: age>80 years, uncompensated cardiac failure, cardiogenic shock,

acute renal failure. Moderately increased risk: Age>70, re-operation, emergency surgery, pulmonary

hypertension, chronic renal failure. Other factors increasing risk: Diabetes, hypertension, obesity, Ejection fraction<40%, valve

surgery, LV aneurysm and female gender.

Pre-medication These patients are apprehensive. They understand there is real risk. They also may become ischemic with stress. Do Not let these patients suffer from anxiety (and ischemia) during line insertion. Fast all adult patients from midnight as the order of the schedule may change unpredictably.

All patients should receive by mouth their usual antianginals, antiarrhythmics and antihypertensives. Specify by name in the chart the medications the patient should receive with a sip of water at 6 AM. Discontinue aspirin and NSAIDs. Heparin may be discontinued in the holding area if critically needed up to that time.

Special note regarding management of blood glucose: Current guidelines dictate that no measured serum glucose peri-operatively exceeds 200 mg/dL, and that patients arrive for operation with serum glucose < 140 mg/dL. We target a maximum of 140 mg/dL at all times peri-operatively.

Diabetics receiving insulin should be first on the schedule if possible. Although we rarely administer insulin to patients before they arrive in the holding area, we do frequently administer infusions of regular insulin intra-operatively; do not hesitate to commence an insulin infusion in the holding area as needed.

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Time sequence of Preparing Patients on the Day of Surgery1. Make sure the OR is set up completely. Be sure to arrive early enough to accomplish this

task. If someone else has set-up the room, confirm all is to your and your faculty’s expectations. Proper set-up is YOUR responsibility alone.

2. Greet the patient by name; introduce yourself by name. 3. Check the patient’s chart for anesthesia evaluation and consent.4. Place the intravenous and radial arterial catheters with the patient in the holding area. Use a

#16G or #14G IV catheter and a #20G arterial catheter. Use sterile technique at all times. Remember that barrier gloves are not sterile; you should NOT touch the insertion site with a gloved finger. Should you be unsuccessful initially in cannulating either vessel, seek assistance early. Never delay entry to the operating room to place the IV or arterial catheter.

5. If a radial artery graft is planned, the specified upper extremity must remain free of catheters and devices; place the IV and arterial catheter in the opposite arm. (Ask pharmacy to prepare a diltiazem infusion; take it with you when bringing the patient into the operating room.)

6. Check for allergies. Timing antibiotic administration is tricky for these cases: rapid infusions (e.g., cefazolin) must complete less than 60 minutes prior to surgical incision; slowly infused drugs (e.g., vancomycin) must commence well before incision. DOCUMENT the start and end times of each antibiotic in the designated area of the anesthesia record. Always infuse vancomycin over 30-40 minutes using a small drop administration set.

7. Antibiotic AdministrationPREOPERTIVE

All patients receive mupirocin (Bactroban) 1 g divided between nostrils daily, at least one day prior to operation.

PERIOPERATIVEPatients without penicillin allergy1) Ancef (1 gram for patients < 60 kg, 2 g for patients > 60 kg) is given preoperatively, within 1 hour of incision.2) Ancef 1 g is given every 3 an 4 hours if the procedure is on-going (with normal renal function)3) Vancomycin 1 g is given in patients getting a surgical implant (valve or graft), or at higher risk for MRSA infection:a. Preoperative hospitalization > 3 daysb. Transfer from another inpatient facilityc. Already on antibiotics for infectiond. Known colonized with MRSAe. Diabetics This dose should be completed within 1 hour of skin incision, and is not repeated intraoperatively.Patients with Non-IgE-mediated penicillin allergy (rash): proceed with regimen for patients without penicillin allergyPatients with IgE-mediated penicillin allergy (anaphylaxis, hives, angioedema):1) Vancomycin 1 g is given, and should be completed within 1 hour of skin incision. This dose is not repeated intraoperatively.2) Gentamycin 4 mg/kg can be used as a single dose for gram negative coverage

POSTOPERATIVEAll patients continue mupirocin (Bactroban) 1 g divided between nostrils daily, for 2 days.Patients without penicillin allergy1) Ancef 1 g IV q8 hours, for a maximum duration of 48 hours2) Vancomycin 1 g IV 12 hours after operation, as a single dose (may need to adjust for

renal function)

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Patients with IgE-mediated penicillin allergy1) Vancomycin 1 g IV q 12 hours, for a maximum duration of 48 hours (adjust for renal

function2) Consider Gentamycin 4 mg/kg to provide gram negative coverage (adjust for renal

function).8. Sedation. All patients undergoing coronary revascularization must have a heart rate less than

80/min prior to induction of anesthesia. Sedate all patients as necessary to achieve this goal; provide supplemental oxygen and monitor with pulse oximetry. A second IV may be started in the OR for re-do sternotomy cases. Patients should be in the OR no later than 7AM on usual days and 8:15 AM on conference days.

Monitoring Currently, all cardiac cases require, in addition to standard ASA monitors, arterial and PA catheters, the former usually via radial artery and the latter usually via the right internal jugular vein. Float the PA catheter with the balloon inflated until you achieve an occlusion pressure. Note that pressure (it is the ONLY occlusion pressure you will obtain in the operating room), deflate the balloon, and then pull back 3 to 5 cm of catheter to ensure an unoccluded vessel with the balloon deflated. When using pressure monitors, always look at the tracing before looking at the numbers: strange tracings usually reveal an artifact as the cause of strange numbers.

The TEE machine and probe should be in the OR if TEE is planned or requested. Should the dedicated O.R. machine be claimed for another room, ask our anesthesia technicians to secure another machine from cardiology.

Preinduction Hemodynamic Measurements : In high risk cases consider inserting a PA catheter prior to induction. If you do so, measure CO and record SBP, HR, CVP, PAP and CO as it may be necessary to initiate or continue inotropes prior to induction. Otherwise the PA catheter is best inserted post induction.

Monitoring for Ischemia : EKG. Patients undergoing CABG surgery have intra-operative episodes of myocardial ischemia. Leads II and V5 pick up the majority of ischemic episodes detectable by EKG. Place the chest lead in the 5th intercostal space along the anterior axillary line. PA Catheter. Insufficient blood flow to the myocardium causes wall motion abnormalities within 5 to 10 seconds. Increases in the PA occlusion pressure eventually result, including new V-waves from new mitral regurgitation. Increased PAD pressure reflects this. We do not “wedge” the catheter during surgery; instead, we follow the PAD. Transesophageal Echo. TEE monitoring will detect ischemia earlier than elevations of either ST-T waves or pulmonary arterial pressures. Abnormal wall motion due to ischemia may occur without EKG changes. The transgastric, short-axis mid-papillary TEE view best monitors for ischemia. However, it will not detect ischemia in the basal or apical segments of the heart; use mid esophageal views for this purpose.

Transesophageal Echocardiograhy : Following intubation, suction the stomach with an orogastric tube, remove the OG tube, and insert the TEE probe. Probes are expensive and easily damaged – handle them with extreme care. Always use a bite block and plenty of lubricant. The 3 EKG wires of the TEE machine also must be applied to your patient. TEE can detect air, ASD, VSD, AS, AR, MR, MS, volume status, aortic plaque, myocardial ischemia, regional and global ventricular function and valvular function. It takes time and effort to gain facility with TEE, and is well worth the effort. TEE can detract from patient care if one ignores the patient and other monitors while using TEE. Use it to supplement patient care – not as a substitute for fundamental monitors. At the end of the case, protect the TEE probe when removing it from the patient.

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Return it to the anesthesia work room for cleaning. Insert an OG tube to suction the stomach. Ascertain that the echo study has been uploaded to the main computer via Ethernet port in room 8 or 10.

Care of Arterial Lines: The sampling port is close to the transducer, not the patient, because the patients arms are tucked in at his/her side. Follow these rules in use:1. Ensure no air bubbles in the line before flushing to the patient.2. Large, forceful flushes can force emboli retrograde to the central circulation and cause stroke.

Avoid flushing with a syringe; use the pigtail whenever possible.3. When sampling, withdraw a full 10 mL of fluid from the line first, to avoid a sample diluted

with flush solution; return this fluid to the patient via a venous port.4. ALWAYS flush the line after sampling, lest it clot and become useless!5. Use sterile technique at all times. Keep the open stopcock port covered with a sterile syringe,

or a blue, occlusive sterile cap provided in each triple transducer kit. Do not use the non-occlusive caps.

6. Flush stopcocks free of bloody fluid.7. Remember, your barrier gloves are not sterile: watch what you touch!

Anesthesia Induction No form of anesthesia is better than another with two exceptions: desflurane or ketamine induction may cause tachycardia and myocardial ischemia, making them the only anesthetics not recommended for induction in patients with known coronary disease.

Although opioids form the basis for cardiac anesthetics, they alone cannot provide all of the needed elements, viz., analgesia, amnesia, muscle relaxation, and inhibition of noxious reflexes. We use propofol or etomidate, in hypnotic doses, only at induction, and supplemental isoflurane or sevoflurane throughout most of the procedure; an isoflurane vaporizer mounted on the CPB pump provides inhalational agent during bypass.

Never induce a patient without a surgeon and perfusionist in the vicinity, in the event institution of bypass becomes necessary. Be sure all appropriate monitors are in place, including a backup arm cuff should the arterial catheter fail.

The anesthetic goal during induction and intubation is stable heart rate and blood pressure. We avoid nitrous oxide until after chest closure because of potential expansion of any gaseous emboli or intraluminal air when the heart is opened. Inhalation agents may provide ischemic (anesthetic?) preconditioning and ameliorate the effects of reperfusion injury.

Specific Drugs Fentanyl dose ranges in mcg/kg (total): High>100; Medium 20-60; Low 5-10. We tend to use

low-medium fentanyl doses for most cases (usually 1-2 mg total for off-pump cases and 2 mg for on-pump cases) to facilitate early extubation.

Sufentanil : Use 1/10th the dose of fentanyl. Inhalational Agents: isoflurane, sevoflurane supplement the opioid. Benzodiazepines also provide supplementation. Propofol infusion provides on-going sedation for transport to the CTICU, while allowing

early extubation. Avoid the “no-man’s land” upon arrival to the CTICU of hypertension, tachycardia, and bucking with minimal monitoring and tangled IV access: use propofol or other techniques during the transport of intubated patients.

We use pancuronium for muscle relaxation. The slight vagolysis from pancuronium antagonizes the vagotonia from fentanyl or sufentanil to leave heart rate unchanged.

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Planning for Early Extubation : Early extubation (“Fast-Tracking,” i.e., within 6 hours of operation) may reduce ICU length of stay and lower costs without increasing patient morbidity. High-risk cases are not suitable for early extubation. On-table extubation (“very early extubation” = VEE) may be possible in OPCAB patients or following short bypass runs (ASD repair). Discuss plans for fast tracking or VEE with your attending before induction, because each requires planning from the start. Limit intravenous fluids, as well as the total narcotic and benzodiazepine doses. Keep the patient warm: use a forced hot-air warming device as much as possible. Consider VEE only when the patient’s temperature exceeds 35.5C, and when adequate opioid analgesia can provide stability of blood pressure.

Completion of induction. (1) Soon after induction and intubation, draw arterial samples and give them to the perfusionist for baseline ACT and ABG values. See the section on Care of Arterial Lines regarding technique. (2) Determine baseline cardiac output, cardiac index, and SVR. Remember SVR is calculated, not measured, and often reflects flow, rather than determining it. (3) Remember to place the OG tube to gravity drainage using a glove; do not use continuous suction. Remove the OG tube instead, if inserting a TEE probe. (4) Use an oral esophageal, not a nasal pharyngeal temperature probe. Place NOTHING in the unprepared naris of a patient about to receive generous doses of heparin. (5) Double check that antibiotic administration is timely. (6) Get your anesthesia record up to date as soon as possible.

Pre-bypass Events Incision and Sternotomy. Following induction, little stimulation occurs for a long time. Then two graded stimuli follow: incision, followed shortly by a painful sternotomy and (even more stimulating) sternal retraction. Your patient must be adequately anaesthetized prior to incision. Disconnect the patient from the ventilator during sternotomy to avoid tearing the pericardium. Will you remember to recommence ventilation? Develop a plan, such as holding the tubing in your hand while the patient is apneic. During redo sternotomy with an oscillating saw, it may not be necessary to hold ventilation.IMA Dissection. The surgeons usually want the table tilted to the left and elevated. Because lung inflation makes dissection more difficult, surgeons frequently request reduced tidal volumes; increases the rate to maintain minute ventilation. They may also request hand ventilation (“lungs down”): stand at the head of the table, with eyes on the wound and hand on the bag. Squeeze the bag when the surgeon withdraws the electrocautery wand. Watch what they are doing to make sure you are helping, not hindering. If you hold ventilation completely, do not disable alarms, remind the surgeon every 30 seconds that the patient is apneic, and remember to turn the ventilator on again (easily forgotten: have a plan!).Cannulation. Use a small bolus dose of NTG (1-2 mg/kg) or SNP (0.5-1mg/kg) if needed, to obtain a SBP of 100-120 mmHg to prevent aortic dissection during cannulation. Demonstrate that you are paying attention to the procedure by anticipating this need and achieving the target SBP in a timely manner, rather than have the surgeons wait impatiently while the drugs circulate. If you have not yet administered heparin, ask the surgeons if they would like it given (they do, and will wait, this time patiently, until it has circulated, before cannulating). They will place either a single, large venous cannula into the right atrium via its auricle, or 2 moderately large cannulae through the right atrium – one into the inferior and the other into the superior vena cava. Another, small cannula with a balloon at one end is placed into the coronary sinus for retrograde cardioplegia administration. The majority of emboli occur upon placement or removal of the aortic cannula and upon placement and removal of the aortic cross clamp. At these times, high glucose concentrations or warm brain temperatures (37 C) are not desirable. Many patients suffer subtle neuro-psychiatric changes consistent with multiple small emboli.

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Hemodynamic Perturbations . The surgeons can cause profound hypotension with cardiac manipulation. If the pressure suddenly drops or PVCs develop, look at what they are doing. Before you give a drug to treat hypotension, rule out a transient surgical manipulation. State clearly “Pressure is 60/30.” They will get the message and complete or abort their trespass. Be alert for ventricular fibrillation to occur at any time. Always use the EKG and the arterial tracing (not numbers!) in tandem to diagnose critical events. If you detect it first, calmly AND CLEARLY announce the fact to the surgeons. They will provide an electrical cure. Give anti-dysrhythmic only following discussion.

Prebypass Hemodynamic Management: In general you should try to keep the systolic blood pressure (SBP) around 120 mmHg and the heart rate 60-80 /min depending on the clinical situation prior to bypass. During insertion of the aortic purse-string suture, bring SBP down to 100-120 mmHg to prevent aortic dissection during cannulation. Papaverine injection by the surgeon during mammary artery harvest may drop the pressure transiently. Resist the temptation to give phenylephine, lest SBP be 160 mmHg just as the surgeon is ready to cannulate. Treat tachycardia and hypertension first by deepening anesthesia (remember to increase your fresh gas flow transiently to deliver inhalation agent to the lungs), then consider esmolol, labetalol, or metoprolol. Add nitroglycerine or nitroprusside as needed to control hypertension. Gain experience and perspective in using these drugs for this purpose by discussion with your attending.

Specific recommendations for valvular procedures. In general, maintain preload in the normal range. Reduce afterload for regurgitant lesions; maintain it for stenotic lesions. Keep heart rate in the high normal range (80-100/min) in patients with regurgitant valves; low normal (60-80/min) for those with stenotic valves. In severe mitral stenosis, tachycardia can be life threatening.

Bypass Hemodynamics: Keep the MAP 60-70 mmHg during bypass. Exception: patients with significant carotid occlusive disease or chronic renal insufficiency may need higher pressures (70-80 mmHg) for the entire pump run. Control MAP with inhalation agent, vasodilators (NTG / SNP), and vasoconstrictors (phenylephrine or norepinephrine). Do not treat low perfusion pressure with vasoconstrictor when the pump flow is deliberately reduced. Listen to the dialog between surgeon and perfusionist to know what they are doing at all times.

Cardiopulmonary Bypass On initiating bypass, the surgeon removes the clamp from the venous line and a siphon effect drains central venous blood into the venous reservoir. Without this siphon effect, venous return to the CPB machine would cease. With little blood giong into the right ventricle, cardiac output plummets. The perfusionist then turns on the roller head nearest you, pushing blood through the oxygenator and filters back to the patient’s aorta. The perfusionist will announce “full flow” when pump flow has reached around 2.2L/min/m2 . You should then discontinue mechanical ventilation. Pulmonary artery pressures should be low while the patient is on CPB.

Check List for Going on Bypass. Do all of these items:1. Heparin: Always give prior to cannulation for bypass.2. ACT: Always check before going on bypass (>480 seconds).3. Drugs: Do you need anything (neuromuscular blocker, opioid)?4. Drips: Turn off the inotropes and IV fluids. Maintain antifibrinolytics and carrier.5. Pull the PA catheter back 2 cm to avoid pulmonary arterial occlusion/rupture.6. Alarms: Disable alarms tones (ECG, BP, CO2, Pulse Ox etc).7. Ventilator: Turned off once patient is safely on bypass (full Flow).8. Urine: Empty the urimeter and note volume on the anesthesia record.

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The three serious perfusion errors are no oxygen flow to the oxygenator, failure to give heparin, and no fluid in the reservoir with massive air embolism. Other things can happen on bypass. If electrical power fails, we turn the roller head with a hand crank – you may be asked to help crank. If a fluid line breaks, you may have to help replace it. An air lock in the venous drainage (loss of siphon) can eliminate blood return to the pump. If you or the perfusionist note bubbles in the venous return line, check the integrity of the central line sheath. Are all stopcocks closed to air? Is air entering the venous system via any infusion line? The surgeon should check the right atrial purse strings. A temporary reduction in pump flow will increase venous pressure, and decrease any air entry. The venous lines to the pump can be refilled with saline if complete airlock occurs.

Cardioplegia: There are different approaches in both termperature (cold; warm; warm induction + cold maintenance + warm reperfusion) and composition (crystalloid; blood). It is given antegrade via a catheter in the aorta proximal to the cross clamp, or retrograde via the coronary sinus. The only essential ingredient in cardioplegia is a high potassium concentration to induce diastolic arrest. The cold variety (4 C) reduces myocardial oxygen demand.

De-airing Maneuvers: In open ventricle or aortic procedures the surgeon will have you place the patient head-down. You may also be asked to deliver a Valsalva breath (to de-air the pulmonary circulation). At this time, the TEE displays a storm of little bubbles in the ventricle.

Check list for Weaning from Bypass: Call the faculty cardiac anesthesiologist before the urinary catheter temperature reaches 36 C. Check these items. Note than you can form a mnemonic device by imagining that each begins with the letter “P”:1. Positive pressure ventilation. If you forget this, you’ll feel quite stupid.2. Protamine drawn up, ready to administer, but out of sight and reach.3. “Pee” – empty the urimeter and note volume on the anesthesia record.4. Potassium is less than 5.5 mEq/L5. pH, PCO2, and PO2 all acceptable6. Pulse: heart rate and rhythm are optimal (NSR or paced, rate 70-90/min)7. Pressure: a MAP<60 mmHg suggests need for vasoconstrictor

Weaning from bypass: Do you have a plan? Was ventricular function good prior to bypass? Was the cross clamp applied a long time? What does the heart look like now? Communicate your plan with the attending anesthesiologist. The surgeon probably has a plan that should be considered. Remember that heart rate and stroke volume determine cardiac output. (Note the “P” motif continues: pulse, preload, pressure [afterload], and power [contractility].)1. Always have ready epinephrine, or less commonly, a different inotrope. Most (80-90%) first

time CABG patients can wean from bypass without inotropes.2. The perfusionist partially occludes the venous drainage line, reducing the amount of blood

draining into the venous reservoir. Right atrial pressure increases and blood enters the beating right ventricle. The perfusionist, on orders from us or the surgeon, increases the occlusion of the venous return line to the pump, filling the right ventricle more blood. S/he also decreases the pump flow in tandem. For example, when the surgeon or anesthesiologist says “3 and 2,” the perfusionist sets pump flow to 3 L/min and occludes the venous line so that the venous reservoir holds 200 mL.

3. The pulmonary artery and systemic pressures become pulsatile. Careful attention is paid to both the right and left ventricles to make sure they are not distending. When the perfusionist says, “off”, s/he has clamped the venous line. The request “give a hundred” asks the perfusionist to transfuse 100 mL of blood from the reservoir to the patient via the aortic

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cannula. Once both venous and arterial lines have zero flow, the patient is off bypass. Note the clock time.

4. Once off the pump, determine cardiac index and SVR. Adequate cardiac output despite low systemic pressure denotes a problem not cardiac in nature, but rather low SVR. Hence employ a rather than an inotrope.

5. Make an educated guess as to the inotropic state of the ventricle. With time you will develop the ability to roughly assess cardiac contractility simply by observing the heart. However, you are viewing only the right ventricle. Look at the LV on TEE, if available. If LV contractility was poor prior to bypass, it will most likely still be poor and an inotrope will be necessary. Once hemodynamics are stable, the surgeon will remove the venous cannula. The arterial line is still in place so the perfusionist can continue to transfuse blood if necessary.

6. Intra Aortic Balloon Pump. The IABP may improve ventricular function in a failing heart via afterload reduction and increased coronary perfusion pressure. The pump is synchronized with the EKG or arterial pressure. Failure to improve after IABP placement may necessitate placement of an LV Assist Device.

After Bypass . The goals in this period include maintenance of adequate cardiac output and other hemodynamics, restoration of coagulation and control of surgical bleeding, and achieving a physiologic metabolic state. Remember these items:1. Inotropes and Vasoactive Compounds: Use standard concentrations only. Check the label and

expiration date. Do not choose phosphodiesterase inhibitors (milrinone) as first line inotropes. They produce profound vasodilation and will most likely require a concomitant vasoconstrictor. Remember to turn the stopcock on the multiple infusion manifold so that the fluid enters the patient.

2. Potassium: Low potassium, < 4.0 mEq/L, associates with arrhythmias. Administer 20 mEq KCl by infusion if [K+] < 4.0. ALWAYS use an infusion pump when giving KCl intravenously. [K+] > 5.0 occurs commonly on bypass from the cardioplegia, and will correct with time.

3. Post Bypass Hemodynamics: Systolic blood pressure between 100 and 120mmHg would be ideal. If it is greater than 120 -140mmHg there will be more bleeding. Cardiac index greater than 2.0 is fine. If CVP is ever greater than PAD there is a problem: poor calibration or right ventricular failure.

4. Protamine: Prepare and administer according to guidelines in this manual.5. Post Bypass Bleeding: First, check the ACT. If elevated, administer additional protamine.

Most non-surgical bleeding arises from platelet dysfunction; platelet transfusions may be necessary.

6. Returning to Bypass: Severe hypotension, bleeding, low cardiac output or other problems may prompt a return to bypass. If you have already given protamine, give another dose of heparin, 400 units/kg, and check an ACT.

7. Sternal closure may cause hypotension if volume status is low. If the lungs appear hyperinflated, or if the heart lifts out of the chest, consider bronchospasm with air trapping. Bronchodilators, ventilator and endotracheal tube adjustment may help.

Transport to CTICU is a critical process frought with hazard. Call your attending to the room when the surgeons are closing skin. Expect your attending to accompany you with the patient to the CTICU. Consider these items:1. Get organized to move the patient from the OR table to the ICU bed. Disconnect infusion

pumps from electrical outlets. Assemble emergency drugs to take with you (opioid, vasoconstrictor, vasodilator, inotrope, atropine).

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2. Ready the transducers and pacemaker for movement with the patient. Disconnect the CVP and PA transducers from the grey monitor cables, and transfer the ARTERIAL transducer to the grey cable attached to the transport monitor. Do so with as few missed beats as possible.

3. Make sure the bed’s oxygen tank is sufficiently full (calculate from tank pressure and flow setting). Ensure oxygen flows into the Ambu bag, and that the bag holds pressure before transferring the patient to the ICU bed. Bed transfer often leads to hypotension; be prepared to intervene.

4. Monitor the patient at all times. Do not leave the OR with unstable hemodynamics.5. You cannot push the IV pole with infusion pumps, squeeze the breathing bag, monitor the

patient’s hemodynamics, and watch where you’re walking all at once. Divide these tasks amongst those accompanying the patient.

6. Avoid catastrophic dynamic pulmonary hyperinflation, a situation in which stacked breaths increase thoracic pressure to obliterate venous return. Opening the endotracheal tube to atmosphere will cure this condition.

7. Descend the ramp to South Tower slowly enough to prevent crashing the bed into the wall, but quickly enough to prevent massive lower extremity pooling of venous blood.

8. Watch out for carts, machinery, and other obstacles in your path. You will likely pass visitors, possible your patient’s relatives, on the way. Act with dignity, politeness, and professionalism at all times, and encourage colleagues to do the same by your example.

OFF PUMP CABG (OPCAB)

We accomplish coronary bypass surgery on a beating heart without cardiopulmonary bypass by stabilizing the heart using two arms of the device which has rows of suckers like octopus legs. A different retractor shaped like a small footplate also works. A CO2 gas blower keeps the field dry while the surgeon operates. This technique requires technical expertise from both surgeon and anesthesiologist: the heart moves and must generate flow despite being ischemic during the coronary anastomosis. Hemodynamic instability and arrhythmias occur often as a result of unphysiologic positioning of the heart to gain access to the circumflex and posterior descending coronary arteries.1. A perfusionist should be immediately available if required.2. Positioning of the heart and placement of stay sutures/ may require preload

adjustments. Fluids and vasoconstrictors are frequently necessary. Beta-agonists may produce pro-arrhythmic effects. Trendelenberg’s position aids right ventricular filling.

3. Anticoagulate with 100 units/kg heparin, rather than the usual 300 units/kg. Check the ACT every 20-30 minutes and add heparin to maintain an ACT >300 seconds. Remember that if you need to institute bypass urgently, you must give additional heparin!

4. We currently give all patients antifibrinolytic therapy during OPCAB.5. Keep SBP around 120–140 mmHg during distal anastomoses and <100 mmHg during

proximal anastomoses. Use norepinephrine, epinephrine, NTG, and SNP as needed. Check cardiac output frequently. Be prepared for sudden, unexpected ventricular fibrillation.

6. Be prepared to treat reperfusion arrhythmias.7. Reverse the heparin with protamine. Remember you don’t have a bypass circuit

ready to bail you out. Usually 100-150 mg of protamine is adequate.

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Re-do Heart – Sternotomy

In a redo case, adhesions may bring the ventricle close to the sternum. The surgeons use a different, rotating sternal saw; nevertheless, it may cut through the right ventricle or innominate vein, causing massive hemorrhage. Have 2 large bore peripheral intravenous lines. Make sure you have checked 2 units of blood and replaced them in the OR refrigerator. The surgeon may cut through the IMA or a saphenous graft inadvertently. You should have an idea of what this will do from the catheterization report and a plan. Instant severe myocardial ischemia with rapid deterioration may result. The case is easier if the IMA and grafts are not functional. A functional graft that the patient is dependent on is potentially the most hazardous situation.

Anticoagulation and Coagulation

Heparin.In cardiac anesthesia, the only “syringe-swap” guaranteed to kill the patient is that of heparin with anything else. If the patient is not heparinized when the clamp is opened on the bypass machine, the pump and oxygenator will clot. When they ask for heparin, respond with a verbal statement- “the heparin is in”. Always use the CVP line to inject heparin. Aspirate from the CVP line before the heparin dose to check to make sure the line is in a vein. If you can’t aspirate blood choose a different lumen. If you choose the lumen that SNP or NTG has been going through, avoid giving a bolus of vasodilator. If there is another line piggy-backed to the one you are using for heparin, make sure the heparin doesn’t run up the side line.

If an IMA is being harvested, the surgeons will ask for the heparin prior to detaching the distal end, otherwise they will ask during purse string insertion into the aorta or right atrium. Give heparin over 10-15 seconds. Often, a slight decrease in systemic pressure follows.

The dose of heparin is 300 U/kg for on-pump cases. Its onset is immediate, but check the ACT 3 minutes after the dose to avoid a transient peak. You can use an arterial or venous blood sample as long as you aspirate an adequate volume of dead space. You want to check the ACT quickly because it needs to be 480 seconds to go on bypass – that’s 8.5 minutes of waiting if you’ve forgetten to draw the sample. For patients receiving heparin infusions before operation, give 400 units/Kg. If the ACT is less than 400 seconds after the dose, tell the surgeon and perfusionist, and give more heparin until the ACT is above 480 seconds.

Antifibrinolytic.We use epsilon aminocaproic acid (Amicar®), an inexpensive (<$5/dose), synthetic drug to provide antifibrinolytic effects. No surgeon currently uses aprotinin for cardiac surgery at our institution. Both agents work by inhibiting clot breakdown (fibrinolysis) and by protecting platelets from partial activation during CPB by blocking their plasmin receptors.

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The reduction in post bypass bleeding differs slightly for these 2 agents: 30% less bleeding with aminocaproic acid, and 40% less with aprotinin. Prepare aminocaproic acid according to the instruction sheet in the red cart. The total dose is 10g per case.

Aprotinin has received some notoriety recently based on safety issues, particularly with respect to its use in total circulatory arrest, and a potential role in postoperative myocardial infarction. Aprotinin prolongs the celite ACT, but not kaolin ACT, the reason why all ACTs at HUH employ kaolin as the activator. A bovine protein, anaphylaxis from aprotinin can occur: always give a 1 mL test dose 10 minutes before starting an aprotinin infusion.

Protamine.NEVER GIVE PROTAMINE WHILE YOU ARE STILL ON BYPASS! (Sounds obvious but it is surprisingly easy to do and may kill the patient).

Many formulae provide calculation of protamine dosage. Ideally, one wishes to provide 1 mg protamine for every REMAINING 100 Units of heparin activity. Check with your faculty anesthesiologist regarding his/her preferred method before you commit to a specific dose. It may involve giving less protamine than you think.

Dilute the neutralizing dose of protamine in a 50 mL bag of normal saline, attach a small drop administration set, and store it on the back table during CPB. Inform surgeon before starting protamine infusion. Adjust the drip rate initially at < 1 drop/second, advancing the rate only after several minutes have passed without adverse sequelae: hypotension, bronchospasm, rash, or pulmonary hypertension. Stop administration for any of the above problems. The duration of infusion should always exceed 3 minutes, with a minimum of 10 minutes as your target.

Once 1/3 of the protamine has been infused inform the surgeon and perfusionist. They will discontinue suction from the surgical field to the pump to avoid clotting the pump (if it clots, you cannot return the patient to bypass). Two minutes after infusion completion, check the ACT. If it hasn’t returned to baseline, give a small, additional dose of protamine, about ½ mg/kg. You may bolus to 20 mg of protamine every 2 minutes. If you give pump blood after chest closure, you will need to give additional protamine to neutralize the heparin in the pump-blood, up to 0.1 mg/mL.

FluidsAmount. Many theories but few data pertain to fluid management. Cardiac patients can easily receive large amounts of fluid intraoperatively with little obvious benefit. That fluid then must be excreted postoperatively - frequently by administering large doses of furosemide with subsequent electrolyte disturbances. This approach frequently delays post-operative extubation. Please try to limit fluid administration intraoperatively; for on-pump cases, the hematocrit on CPB should always exceed 21%. In off-pump cases, use phenylephrine and norepinephrine and the head-down position to maintain blood pressure during mild hypovolemia; check cardiac index frequently to ensure adequate flow. Vasodilation occurs commonly after bypass; expect to administer fluid at sternal closure and thereafter.

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Type. Discuss with your faculty attending the choices of clear fluid (Isolyte®), 5% albumin, and hetastarch. We limit hetastarch to 500 mL based on its platelet effects.

Pharmacy Support

The 8th OR pharmacy provides all the infusions ordinarily used (epinephrine, nitroprusside, nitroglycerine, phenylephrine) except for norepinephrine. It supplies antibiotics, propofol, and insulin infusions. After pharmacy hours and on weekends, these drugs are available from the refrigerator in the anesthesia workroom.

The induction pack used in CT is different from the one used in the general OR. All of the drugs found in the general OR packs are found in the CT pack, but there are more syringes of phenylephrine and epinephrine in the CT pack, and the pack also contains a dobutamine syringe. All other drugs needed should be available in the CT cart in the room. For all cases, dilute a 4 mg vial of norepinephrine from the CT cart into 250 mL NSS solution to yield 16 mcg/mL. Prepare and label a 10 mL syringe of this mixture. For transplant cases, ask the pharmacy for isoproterenol (1 mg/5 mL), to mix in 250 mL of NSS to yield 4 mcg/mL. The pharmacy will prepare on request a diltiazem infusion for use in CABG cases where a radial artery is harvested.

For thoracic cases where an epidural infusion is planned for postoperative pain, the pharmacy will prepare one of several epidural infusions on request. Most commonly, we use a mixture of bupivacaine 0.125% with fentanyl 4 mcg/mL.

Didactic Program

In the course of your eight week CT rotation, you will discuss the following specific topics with the assigned CT faculty member. Set up a convenient time and date with the assigned faculty member to discuss the following: 1. The CBP machine and pathophysiology of CPB – Dr Okum2. Myocardial oxygen supply, demand and anesthetic management for myocardial

revascularization – Dr Okum3. Anticoagulation (Heparin and Protamine) – Dr Horrow4. Anesthetic management of valvular heart disease – Dr Neilsen5. Pacemakers and Intra aortic balloon pump – Dr Cohen6. Anesthetic management for cardiac transplantation – Dr Lingaraju7. Thoracic aneurysms and aortic dissections – Dr Zonshayn8. Intraoperative Transesophageal Echocardiography – Dr Lingaraju

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Recommended Text Reading

Junior Residents:Pace yourself to complete chapters 1-3, 5-9, 11, 12, 13, 18, and 25 in this outline text:Hensley FA Jr, Martin DE, Gravlee GP (eds.): A practical approach to cardiac anesthesia, 4th ed. Elsevier, Philadelphia, 2000.

Senior Residents:Read chapters 4, 15, 17, and 19-24 in the above mentioned outline text.Also, read the following in Kaplan JA, Reich DL, Lake CL, Konstadt SN (eds.). Kaplan’s Cardiac Anesthesia, 5th ed., Elsevier Saunders, Philadelphia, 2006:Chapter 5, pages 71- 89, Cardiac physiologyChapter 9, pages 165-212, Pharmacology of Anesthetic DrugsChapter 10,pages 213-280, Cardiovascular PharmacologyChapter 14,pages 385-436, Monitoring of the Heart and Vascular SystemChapter 15,pages 437-488, Intraoperative EchocardiographyChapter 19,pages 585-643, Anesthesia for myocardial revascularizationChapter 20,pages 645-690, Valvular Heart DiseaseChapter 26,pages 845-865, Anesthesia for Heart, Lung, and Heart-Lung TransplantationChapter 28,pages 893-935, Cardiopulmonary bypass and the AnesthesiologistChapter 31,pages 1023-1040, Discontinuing Cardiopulmonary Bypass

These texts are available for loan from the department. See the departmental academic coordinator for access to the texts. If you borrow a book, you must (1) read it; and (2) return it.

Recommended Periodical Reading 1. Brodsky J, Lemmens HJ: Left double-lumen tubes: Clinical experience with 1,170

patients. J Cardiothoracic Vasc Anesth 2003; 17:289-98.2. Duggan M, Kavanagh BP: Pulmonary atelectasis. Anesthesiology 2005; 102:838-54. 3. Maslow A, Aronson S, et al: Off-pump coronary artery bypass graft surgery. J

Crdiothoracic Vasc Anesth 1999; 13:764-781.4. Shanewise JS, Cheung AT, Aronson S, et al: ASE/SCA guidelines for performing a

comprehensive intraoperative multiplane TEE examination: Recommendations of the ASE council for Intraoperative Echocardiography and the SCA taskforce for certification in perioperative TEE. Anesth Analg 1999; 89:870-84.

5. Levy JH. Hemostatic agents and their safety. J Cardiothoracic Vasc Anesth 1999; 13:6-11.

6. Cheng DCH, et al: Randomized assessment of resource use in fast-track cardiac surgery, 1-year after hospital discharge. Anesthesiology 2003; 98:651-657.

7. Khan NE, De Souza, et al: A randomized comparison of off-pump and on-pump coronary-artery bypass surgery. N Engl J Med 2004; 350:21-8.

8. Shann KF, Likosky DS, et al: An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution and the inflammatory response. J Thorac Cardiovasc Surg 2006; 132:283-290.

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9. Mangano DT, Tudor IC, et al: Multicenter study of perioperative ischemia research group; Ischemia research and and education foundation. The risk associated with aprotinin in cardiac surgery. N Engl J Med 2006; 354: 353-65.

10. Concato J, Shah N, Horowitz R. Randomized, controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med 2000; 342:1887-92.

Evaluations and Feedback Mechanisms

Resident by faculty. The faculty members assigned to supervise you in CT will evaluate your performance based on the current objectives. Click for CA1 or CA2 or CA3 to view evaluation forms.

INTERIM EVALUATION: At the conclusion of your 2nd week in CT, the Director of CT anesthesia or his/her designate will review available evaluations and recommend areas of concentration for your efforts for the remainder of the rotation. Click here to see the evaluation forms for residents.

FINAL EVALUATIONS: The program director will review all evaluations with you at your next regularly scheduled quarterly meeting.

Resident by CT Personnel. CT operating room personnel will rate you on your patient and interpersonal skills, your ability to function as a cohesive team member, your communication skills, and your professionalism. They will use this evaluation form.

Rotation and Personnel by Resident. You will evaluate the CT rotation on the last day of your rotation. Your evaluation will include an opportunity to provide feedback on individual faculty members, CT personnel, as well as the structure, organization, and topical material in the rotation. Click here to see the form you will use.

Common Mistakes/TipsPlease arrive early enough to check the room that you will be working in for the day. It is imperative that YOU yourself check all the equipment which means the following:-Check if all your IVAC pumps are working-Make sure there is NO AIR in any of your lines that you have primed-Make sure all your drips are NOT EXPIRED (common mistake)-Enter all the height and weight into the computer to calculate cardiac output and index-Make sure you have TEE probe and machine available if TEE is going to be used-If no TEE probe is found on the machine ask one of the technicians to help you find one or you may need to page cardiology (nurse can do it for you also) to bring a probe-Always be aware where you Heparin is and where you Protamine is placed. -Figure out a way to remind yourself when you have turned off the VENT and will have to turn it back on when the patient is coming of CPB-Make sure you have your size sterile gloves to place the lines

-ASK FOR HELP IF YOU HAVE NO IDEA

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Obtaining the 20 Standard Transesophageal Echocardiography Views 0

Hypopharynx

0 UE AA LAX

+ 90 UE AA SAX

90 ME Asc Aor LAX

0 ME Asc Aor SAX

120 ME AV LAX

60 ME RV OT

30 ME AV SAX

0 ME 5C

+ +

90 ME Bicaval

120 90 60 0 + 0 ME LAX ME 2C ME MC ME 4C

R

A +

TG -

Basal SAX

ME Desc Aor SAX

90 ME Desc Aor LAX

0

120 TG RV Inflow

120 90 0 TG LAX TG 2C

Legend

A

R

-

+

Anteflex probe

Retroflex probe

Decrease omniplane depth (display depth)

Increase omniplane depth (display depth)

Change omniplane angle

90

Rotate probe left

Rotate probe right

Increase probe depth

Decrease probe depth

Omniplane angle

0

TG Mid SAX

R

A +

Deep TG

2C - Two Chamber 4C - Four Chamber 5C - Five Chamber AA - Aortic Arch AV - Aortic Valve

Asc Aor - Ascending Aortic Desc Aor - Descending Aortic OT - Outflow Tract (Inflow-Outflow) LAX - Long Axis MC - Mitral Commissural

ME - Mid Esophageal RV - Right Ventricle SAX - Short Axis TG - Transgastric UE - Upper Esophageal

©Toronto General Hospital Department of Anesthesia and Pain Management 2008. All rights reserved.

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