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Cardiothoracic Anesthesia Rotation Guide ​

Attendings: Lyndsey Grae, Ben Abrams, Bryan Ahlgren, Nathan Clendenen, Tamas Seres, Breandan Sullivan, Barb Wilkey, Sarah Alber, Doug Rooke, Broc Burke, Markus Kowalsky

TIP

Some attendings have provided specific preferences for how they like staff and/or run their cases

The cardiothoracic month can be one of the more grueling rotations for residents during their anesthesia training. The combination of elaborate case setups, long call shifts, high acuity cases with the sickest patients in the hospital tends invoke a level of anxiety when first rotating through. You will endure a gauntlet of complex patients testing your physiology, pharmacology, and procedural skills. Yes, it’s tough, but with committed teamwork amongst your resident co hort and support from attending/fellows for the month, the CT rotation can be the most rewarding and beneficial to your anesthesia training.

WARNING

New as of 12/2024 there will be required education modules where the expectation is to complete 2 for every month on CT You can search for these modules on cupropofol.com or (maybe) using this direct link and links to the quizzes for each module should be sent out in your CT welcome email.

Rotation Breakdown ​

  • Residents are assigned CT1 CT6 shifts throughout the week on a rotating schedule and can be assigned to the general OR pool if there are not enough cardiac and/or thoracic cases.
  • Typically, CT fellows will be CT1 on Monday / Wednesday.
  • All residents are on (home) call until 7am the following morning.
  • Relief is in a waterfall system the highest number leaving first (CT5, then CT4, etc)
    • The CT1 resident is the last to leave, very unlikely that you will be called back in as a CT 3 or 4
    • The culture (and your expe rience) on CT can be defined by how you and your CT co residents collaborate and help each other with breaks, preops, consents, etc. This is very much a team sport rotation.
  • If a resident stays till past 9pm they will have a post call day the next day.
    • If you are postcall, please send an email to the chiefs email and charge email prior to leaving the hospital, as well as writing your name and postcall on the board. Further in structions can be found under the House Keeping Items section
  • During some weeks/rotations, night float will be available to provide relief for cases running late, however their duties are split between CT and Liver transplant, so availability depends on what else is going on in the OR.
  • Cardiac conference (via Zoom) is every Thursday morning at 6:30 am and Echo rounds are Friday morning at 6:30am. Att endance is required for both. You can find these links in your calander emailed to you.

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To significantly improve everyone’s experience and wellbeing while on the rotation teamwork is a key aspect

  • When you are finished with your cases, or at any point when you have extended downtime, help comp leting CT preops and consent inpatients for the following day (even if they are not your patients).
  • Call your co residents to offer breaks prior to leaving or relieve the higher number call resident if applicable.
  • Beneficial to start a CT group chat to communicate with one another on completing preops and breaks.

IMPORTANT

Discuss the specifics of the anesthetic plan with your attending or CT fellow prior to each case, including which medications to have prepared vs readily available

  • When you first start, focus on learning how to take care of the patients and understanding the cardiothoracic pathophysiology, pharmacology, and types of procedures. This will help when you’re rotating in the CTICU.
  • Your most important role is to take care of the patient. If you are ever unsure of anything, ask the fellow or attending. These patients are SICK, and things move quickly in the operating room. It is your responsibility to respond to changes in the patient’s condition and vital signs, including during line placement, and communicate them effectively when needed.

Cardiac Commandments ​

  1. Remember to place “TEE for Anesthesia” order morning of case. This pulls patient into TEE machine for techs.
  2. A well set up and organized room makes the difference in response and flow in complex cases
  3. Heparin is an emergency should be drawn up and close by in case you need to crash onto bypass.
  4. Ensure blood products discussed with attending/fellow are order before patient arrives to room.
  5. Epicardial wires on right side are atrium and left side are ventricular. Label them!
  6. Know your patients echo pathology (i.e. Aortic Stenosis), your hemodynamic goals for this pathology, and how you will achieve this pharmacologically.
  7. Never give calcium chloride while on bypass unless directed by CT surgeon.
  8. Thou shalt send rewarming labs (fibrinogen + platelets) at 34 degrees.
  9. Patient will not come off bypass until 35.5 degrees.
  10. NEVER EVER give protamine while on bypass do not even have it near cart. You’ll get it from OR RN when appropriate. Send labs post protamine (ACT, ABG, TEG w/ and w/o heparinase, PT/INR, PTT, Plt count)

Heart room setup ​

  • The anesthesia techs will help setup the triple transducer, Level One, Swan box (ex-vivo calibration), pacer box, TEE machine, etc. Would recommend double checking their setup as there are new techs still learning the ropes.
  • Alaris PC unit x2 with infusion pumps x4.
  • Level 1 primed with Plasma-Lyte.
  • TEE machine/probe. Fellow or attending can help with setup.
  • Pacing box (batteries must be replaced the day of surgery and the date must be clearly displayed on the box).
  • Oximetric swan box, plus Swan-Ganz pulmonary artery catheter
  • Cerebral oximeter, plus head monitoring sticker, usually on R side of drug chart
  • Triple transducer.
  • BIS or Sedline - Dr. Seres only
  • There is a higher incidence of intra-operative awareness during cardiac surgery, so if your patient is at high risk, it is a reasonable consideration. Most attendings prefer to start the precedex infusion at 0.5 mcg/kg/hr during CPB for this reason.
  • Check that the lines are zeroed, free of bubbles, stopcocks are properly aligned, and connections are tight.
  • Make sure the patient’s information has been entered into the Swan box (ex-vivo calibration).
  • TIVA may be needed for some aortic cases. (MEP neuromonitorying)

NOTE

Rule of thumb: if it involves anything past the arch (i.e. elephant trunk, Buffalo trunk, and some type As), then TIVA is needed. As the stent may cover the vertebral artery. Alternatively, speak with neuromonitoring for clarification.

CPB case flow ​

Preop ​

  • Consider having a lower threshold for video laryngoscopy in the room as these patients may not tolerate hypoxemia or hypercarbia well. Just get the tube in safely and swiftly.
  • Place A-line in preop or roll back early to OR- since the patients are awake use lidocaine and ultrasound.

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Once A-line is established draw your ABG lab immediately - you’ll have your labs ready to review before induction.

  • After getting standard monitors on remember to put on cerebral oximeter headsets before oxygenation and induction. This aids perfusionist establishing patient baselines.
  • If EP is needed to turn off/reprogram AICD/pacemaker, have them do it in the room and after induction (especially for heart transplants and VAD placements).

Induction ​

  • “Cardiac Induction” to which your attending will say there’s no such thing. Basically, you want a slow + smooth hemodynamically stable induction.
  • Obviously, this is very patient (and attending) specific. You won’t go wrong with benzo and opioid based induction most of the time.

Post-induction ​

  • Usually attending placing 2nd large bore PIV (14 or 16g) while you and fellow establishing/securing airway.
  • OG placement and removal.
  • Fellow or attending will insert the TEE while you gown and glove for central access.
  • Establish cordis or MAC
  • Float Swan (common for most cardiac cases). Fellow or attending will walk you through swan checks and placement.

WARNING

Some exceptions: normal EF CABG, isolated aortic valve replacement, and ASD closures. May park the swan past the thermistor if the patient has LBBB until chest is open

  • Titrate anesthesia to a BP within 20% of baseline.
  • The nurse will place a temperature-sensing Foley - important for establishing core temp during rewarming.
  • Connect Level 1 to the side port of the cordis or distal port (brown) MAC.
  • Connect drips to the VIP (usually white) port of the PAC or SLIC (only after PAC has been floated, otherwise connect it to a side port). Make sure there isn’t too much tension on the central line (tape it to the bed or hook it on to the Christmas tree).
  • Attach the monkey bar (L shaped bar) to bed.
  • Draw baseline ACT (give to perfusionist) and ABG
  • The surgeons will pass you the pacing wires. Connect them to the pacer box (right side is atrial pacer, left side is ventricular pacer). Attach the coronary sinus line to the PA port at the transducer and flush when the surgeons ask you to.

Sternotomy ​

  • Per attending, give fentanyl prior to sternotomy. Hold ventilation. Start TXA bolus then infusion at sternotomy.
  • Prior to cannulation and initiation of CPB, give heparin bolus (300U/kg, confirm dose with perfusionist) and draw ACT three minutes later. ACT goal >400. You may need to re-dose heparin. If unable to achieve goal ACT, consider heparin resistance in the setting of ATIII deficiency.
  • MAP goal ~70, SBP < 110 during aortic cannulation as HTN increases the risk of aortic dissection. Therefore, titrate gas or consider test dose of nicardipine or nitroglycerin or propofol to see how the patient responds.
  • Measure UOP prior to CPB. Usually empty bag prior to cannulation. Perfusionist is going to ask UOP while on bypass.
  • Chart aortic and venous cannulation - Events button -> Cardiac
    • If bicaval cannulation, chart 2 venous cannulation with memo. Usually, SVC then IVC.
  • Chart cross clamp and bypass times (ask perfusionist for times if you miss them) - these are under Timer button
  • You may need to re-dose paralytic, narcotics, or midazolam at initiation of CPB or immediately after (higher risk of awareness during CPB).

Bypass ​

  • Turn the ventilator to bypass mode and turn gas off when pump flows are adequate. Make sure perfusionist has turned on their volatile agent.
  • The perfusionist will draw labs and transfuse blood when needed during CPB.
  • You need to follow H/H, glucose, UOP, MAP readings between (60-70s), cerebral oximetery treat as indicated (communicate with the attending/fellow, surgeon, and perfusionist).
  • MAP goal >65. Titrate drips as needed (usually vasopressin or phenylephrine). The perfusionist may also give vasopressin or phenylephrine boluses.
  • No fluids running except your infusions.
  • UOP goal ≥100mL/hr. Follow UOP and inform perfusionist if less than goal.
  • TEE on standby.

Weaning from bypass ​

  • During rewarming (33 -34C) and preparation to discontinue bypass, assess the functional status of the heart and peripheral vasculature to determine what pressors, inotropes, or vasodilators will be needed for successful separation.
  • Rewarming labs at (33.5 -34) - Platelets (purple) and Fibrinogen (light blue)
  • Turn on all monitors and alarms.
  • Consider midazolam, fentanyl, or Dilaudid.
  • Depending on the heart rhythm and rate, defibrillation or pacing may be necessary.
    • Cleveland’s CABGs will require lidocaine/magnesium prior to uncross clamp. Discuss if additional lidocaine/magnesium is needed.
  • Give calcium chloride 1g after 10min of the cross clamp being released and the QRS has narrowed - usually surgeon will state when to give.
  • When asked, re-expand the lungs until visually reinflated. Make sure there is no tension on the LIMA graft. Turn the vent back on.
  • The protamine dose will be provided by the OR RN.
  • Confirm dose and timing with attending. If no evidence of reaction, slowly give the remaining protamine. Inform the surgeon and perfusionist when one third of the total dose has been given.
  • Draw an ACT (along with off-pump labs below) three minutes later.
  • After successful wean from CPB, send ABG, PT/INR, PTT, fibrinogen, platelets, TEG with and without heparinase.
  • Continue to follow ABGs.
  • Record UOP while on CPB and tell perfusionist.

Post-bypass/transport ​

  • Follow coags/TEG and bleeding status. Transfuse products as indicated (discuss with attending/fellow).
    • Consider DDAVP for patients with renal failure
  • Continue dexmedetomidine drip.
  • Remove TEE, organize lines, buff cap/disconnect PIVs for transport, leave infusions/carrier running, and have a bolus line hooked up to the side port of the cordis/MAC.
  • Replace dressing on cordis/MAC if necessary (antibiotic disc and Tegaderm).
  • Patient remains intubated 95% of the time.
  • Transport to CTICU (bring emergency drugs).

CTS edge cases ​

Robotic mitral valve ​

  • Exclusions:
    • moderate AI or worse
    • BMI >40
    • EF <30%
    • no femoral vascular access
    • pulmonary function prohibiting one lung ventilation
Major differences ​
  • Cannulation: Peripheral fem access for CPB, usually with a dual stage cannula

WARNING

CTS favors leaving LIJ for them just in case

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You will need to exchange DLT for standard ETT at end of the case

  • Access: LIJ MAC/Swan, LRAL
  • Pain: Pre-op ESP w/ APS

MVproto

Thoracic ​

These are typically straightforward cases, many are robotic. Almost all will get a second PIV

Bronchoscopy ​

WARNING

If its a first case, expect Mitchell to ask to roll back early

Airway: Often LMA or large ETT if NMB needed GA: Usually propofol TIVA, can't rely on consistent gas delivery

Lobectomy ​

WARNING

During Timeout they will ask about SQH and that a T&S is available

  • Airway: DLT Sizing guide
  • GA: Usually sevo
  • Access: usually 2nd PIV, possible A-line
  • Gtts: phenylephrine available but not wet down
  • Pain: Most of the surgeons are ok w/ pre-emergence ESP's

TIP

Ask the tech's for a bronch tower w/ CMAC

Shoot for 3-5cc/kg IBW for tidal volumes with one-lung ventilation. I usually do this using PSV instead of PCV-VG

dotphrases ​

.ctplan
.tavrplan

Resources ​