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Anaesthesiology
Anesthesia for Cardiac Surgery
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
12 sections · 199 slides
Overview
- What this topic covers
- Core skills and key messages
Coronary artery disease
- Goals of care and the oxygen balance
- Determinants of myocardial oxygen balance
- Reading the oxygen balance diagram
- Regulation of coronary blood flow and perfusion pressure
- Aortic and left ventricular pressure determine coronary perfusion pressure
- Ischemia, stunning and hibernation
- Distinguishing viable from necrotic myocardium
- Hemodynamic goals in coronary artery disease
- Coronary artery disease: hemodynamic goals
- Principles of anesthetic selection and opioids
- Inhalation anesthetics and how the three compare
- Intravenous sedative hypnotics
- Vasoactive drugs and 2021 guideline statements
- Treatment of intraoperative ischemia
- Treatment of intraoperative ischemia (continued)
- Nitroglycerin
- Sodium nitroprusside
- Cyanide toxicity from nitroprusside
- Vasoconstrictors in ischemia
- Beta-blockers in ischemia
Valvular heart disease
- Burden and management of valvular heart disease
- Causes and pathophysiology of mitral stenosis
- Pathophysiology of mitral stenosis
- Treatment and anesthesia in mitral stenosis
- Mitral stenosis: hemodynamic goals
- Primary, secondary and structural classification of mitral regurgitation
- Mechanisms of mitral regurgitation
- Mechanisms of mitral regurgitation (continued)
- Pathophysiology of mitral regurgitation
- Chronic and acute mitral regurgitation
- Two outflow tracts and the unmasking of dysfunction
- Mitral regurgitation: hemodynamic goals
- Hemodynamic goals and systolic anterior motion risk
- Tricuspid stenosis and regurgitation
- Management of tricuspid regurgitation
- Hypertrophic cardiomyopathy
- Pathophysiology of left ventricular hypertrophy in hypertrophic cardiomyopathy
- Dynamic outflow tract obstruction
- Hypertrophic cardiomyopathy: hemodynamic goals
- Anatomy, causes and grading of aortic stenosis
- Transesophageal short-axis view of the aortic valve
- Prognosis of symptomatic aortic stenosis
- Aortic stenosis: classification of severity
- Early and late stages of aortic stenosis
- Concentric hypertrophy and diastolic dysfunction
- Anesthetic considerations in aortic stenosis
- Aortic stenosis: hemodynamic goals
- Classification of aortic insufficiency
- Acute and chronic pathophysiology of aortic insufficiency
- Aortic insufficiency: acute, chronic, and on bypass
- Anesthetic management of aortic insufficiency
- Aortic insufficiency: hemodynamic goals
Diseases of the aorta
- Origins of aortic disease
- Classification and mortality of aortic dissection
- Presentation, diagnosis and anesthetic priorities in dissection
- Surgical treatment of aortic dissection
- Hypothermic circulatory arrest and cerebral protection
- Acute aortic dissection: hemodynamic goals
- Classification and repair of aortic aneurysm
- Spinal cord protection in descending aortic repair
Heart failure and cardiogenic shock
- Burden, definition and classification of heart failure
- Diagnosis of heart failure
- Diagnosis of heart failure (continued)
- The New York Heart Association classification
- Staging of heart failure
- Staging of heart failure
- Staging of heart failure (continued)
- Temporal categories and pathophysiology of heart failure
- Cardiogenic shock
- Definition of cardiogenic shock
- Stages of progression of cardiogenic shock
- Stages of progression of cardiogenic shock (continued)
- Why mechanical support beats drugs alone
- Categories and indications for circulatory support
- Design and physiology of the intra-aortic balloon pump
- Timing of intra-aortic balloon inflation and deflation
- Impella device decompressing the left ventricle
- How the left ventricular Impella works
- Blood path in veno-arterial extracorporeal membrane oxygenation
- Retrograde perfusion, venting and device complications
- Design and flow path of durable left ventricular assist devices
- Pressure targets with a continuous-flow device
- Suction events and supporting the right ventricle
- Durable left ventricular assist device patients for noncardiac surgery: anesthetic considerations
Cardiopulmonary bypass
- Purposes and components of cardiopulmonary bypass
- Cardiopulmonary bypass circuitry
- Following the blood through the circuit
- Venous cannulae and cannulation strategies
- Venous reservoir and mechanical pumps
- Oxygenators and control of gas exchange
- Arterial cannulation and recognising dissection
- Signs of aortic dissection after starting bypass
- Composition, volume and reduction of the pump prime
- Managing hemodilution on bypass
- Why anticoagulation is essential and how heparin works
- Heparin resistance from antithrombin deficiency
- Heparin-induced thrombocytopenia and alternatives
- Rationale and preoperative optimisation for blood conservation
- Antifibrinolytic drugs
- Acute normovolemic hemodilution
- Retrograde autologous priming and transfusion thresholds
- Cell salvage and ultrafiltration
- Three pillars of myocardial protection
- Strategy of myocardial protection
- Cardioplegia solutions and delivery
- Timing and variants of cardioplegia
- Onset of arrest and left ventricular venting
Preoperative assessment and monitoring
- Purpose of the preoperative visit
- Perioperative medication management
- Communication and premedication
- Electrocardiographic monitoring and localising ischemia
- Temperature monitoring
- Arterial catheterization and the post-bypass pressure discrepancy
- Central venous and pulmonary artery catheters
- Uses of echocardiography before bypass
- Uses of echocardiography after bypass
- Burden, mechanisms and monitoring of neurological injury
- Risk factors for neurological complications
- Surgical strategies for a severely diseased aorta
- Cerebral oximetry and treating a desaturation
- Origins and shape of contemporary cardiac anesthesia
- Anesthetic depth and drug handling on bypass
Intraoperative management
- Surgical steps of conventional on-pump bypass grafting
- Cannulation, cross-clamping and graft patency
- Preparing the operating room
- Anesthetic preparation for cardiac surgery
- Anesthetic preparation for cardiac surgery (continued)
- The preinduction period and invasive access
- Induction and intubation
- The preincision period and incision to bypass
- Recognising ischemia before bypass
- Initiating cardiopulmonary bypass
- Checklist during cardiopulmonary bypass
- Checklist during cardiopulmonary bypass (continued)
- Checklist during cardiopulmonary bypass (continued)
- Cooling and interpreting labs on bypass
- Rules for rewarming
- De-airing and removing the aortic cross clamp
- Checklist before separation from cardiopulmonary bypass
- A checklist approach to separating from bypass
- The A to H preparation for separation
- Etiology of right or left ventricular dysfunction after cardiopulmonary bypass
- Coronary air embolism during weaning
- Vasoactive drug doses used during separation
- Diagnosing and treating low pressure after weaning from bypass
- Reading the low-pressure diagnostic table
- Predictors of inotrope use and low output syndrome
- Protamine and its adverse reactions
- Test dosing protamine
- Residual pump blood, bleeding and chest closure
Minimally invasive and percutaneous approaches
- Principles of minimally invasive cardiac surgery
- Minimally invasive direct coronary artery bypass
- Off-pump coronary artery bypass grafting
- Verticalization, risks and outcomes of off-pump grafting
- Anesthetic considerations for off-pump coronary artery bypass surgery
- Robotic valve surgery and transcatheter aortic valve replacement
- Structural risks and percutaneous mitral repair
Postoperative considerations
- Problems in the cardiac intensive care unit
- Indications for re-exploration
- Anesthesia for emergency re-exploration for tamponade
Children with congenital heart disease
- Scale and challenge of congenital heart disease
- Physiologic effects of congenital cardiac lesions
- History, examination and records
- Laboratory and imaging evaluation in cyanotic lesions
- Premedication and monitoring in children
- Induction and balancing the two circulations
- Features of the neonatal myocardium
- Bypass coagulopathy and separation in children
- Tracheal extubation and ventilatory failure
- Regional anesthesia in pediatric cardiac surgery
- Fontan ventilation and low cardiac output syndrome
- Pulmonary hypertension crisis
- Recognising a pulmonary hypertension crisis
- Adults with congenital heart disease
Summary and references
- Summary: the coronary oxygen balance
- Summary: hemodynamic goals across valve lesions
- Summary: bypass and its risks
- Summary: separating from bypass
- Summary: heart failure, shock and support
- Summary: children with congenital heart disease
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition