Cardiac OR Setup

This guide is an introduction and should be individualized to patient pathology, surgical approach and attending preference. As with non-CVT cases, you should have the setup complete prior to the patient’s arrival in the OR. Heparin and vasoactives at a minimum.

Drugs

Sedation and induction agents should be determined in your preop discussion. For a typical pump case, midazolam 2-10mg, fentanyl 500-1000mcg is sufficient. Propofol is our typical induction agent unless exceptional circumstances exist. Do not draw up etomidate unless specifically discussed.

Vasopressors premixed epinephrine, ephedrine and phenylephrine syringes are available from pharmacy. Sometimes we will use vasopressin or norepinephrine boluses you mix yourself. See Standard Dilutions worksheet.

Vasodilators should be chosen on a case-by-case basis. Have at least one syringe ready for bolusing per case. See Standard Dilutions worksheet. Remember you have an inhaled vasodilator available for most cases (iso/sevo)

Heparin (30,000units/30mL x 1 + extra 30mL bottle) for all cases. Drawn up. Usually sits on top of anesthesia machine ready to go

Aminocaproic acid (10g/40mL x 2) for all pump cases. Drawn up. Bolus (5-10g) and infuse (1g/hr) usually after heparin bolus administered. May be given earlier per attending preference

Cardiac bucket from pharmacy (after hours go to Pyxis in Core outside OR8, look under “Emergency Cardiac Anes”). Contains heparin, aminocaproic acid, NaHCO3, CaCl2, KCl, 5% albumin, dopamine, NTG bottle, protamine

Infusions typically include epinephrine + judiciously selected other bags

Protamine is a high risk drug in the cardiac OR. If given prior to weaning CPB the pump will clot. This is bad. Do not ever draw it up at the beginning of a case. It may be drawn up (250mg/25mL x 1) prior to weaning from CPB only when labeled meticulously, taped over the cap on the end, and stored on the Pyxis away from actively-used medications

Hot neo is a phenylephrine bag we prepare for our perfusionists at 200mcg/mL (20mg in 100mL bag). Hand off to them at beginning of the day (thank you)

Antibiotics – doses are for normal baseline renal function

  • Non-valve or implant cases: typically cefazolin
  • Valve or graft placement: typically cefazolin + vancomycin
  • VAD or MCS: typically vancomycin + cephalosporin (ceftazidime 1g q4-6h or cefepime 2g q6h) + fluconazole 400mg
  • Heart transplants: typically cefazolin +/- vancomycin
  • Lung transplants: Zosyn + cefepime/vancomycin +/- others

Note for transplants and VADs, be sure to check with surgical team as prior cultures may alter regimen suggested above

  • ICU patients: continue current antibiotics + discuss with surgical team re any additional needs depending on clinical scenario

Weight Based Dosing

Cefazolin

  • 2g is default
  • >120kg = 3g
  • Redose q4h

 

Vancomycin

  • <80kg = 1g
  • 80-99kg = 1.25g
  • 100-120kg = 1.5g
  • >120kg = 2g
  • Redose q12h if normal renal function

Equipment

Lines

  • Arterial – kits available for both radial (20G 2.5cm) and brachial (20G 12cm) access, or make your own sterile setup
  • Central access – 9Fr Cordis kit + 16Ga triple lumen catheter for most cases
  • Place both wires first, Cordis wire (shorter one) more cephalad
  • Confirm both wires with TEE +/- ultrasound
  • Cordis placed first, then TLC (secure TLC at 12-15cm depth)
  • Biopatch for each line is mandatory – should loop between catheter and skin, not just sitting on top
  • Accessories needed for central line placement include claves (x4-5), flush syringes (2-3), small Tegaderms (x2-3), Biopatch x1 (TLC kit comes with one inside)
  • Pulmonary artery catheter
  • Two models available – continuous cardiac output (CCO) or intermittent thermodilution
  • Calibrate CCO ahead of time by plugging into module and entering basic information (takes <2mins)
  • Always double glove for central lines so outer layer of gloves may be removed for PA catheter placement

Monitors

  • Standard ASA monitors – remember to place EKG pads on posterolateral parts of chest wall and shoulders. Do not place where patient will be laying on it or creating a pressure area
  • Pressure transducers – at least 3 (arterial, CVP, PAP). Others may include a planned secondary systemic pressure line or CSF pressure
  • Cerebral oximetry – Foresight is the module available on campus. Best applied prior to oxygenation or induction of anesthesia to get baseline. Bilateral forehead stickers, #1or 3 = left, #2 or 4 = right
  • Awareness monitors – use either BIS or Sedline. Our patients are high risk for awareness
  • TEE – ensure is powered on, enter patient name + MRN + case abbreviation under “Patient Data”

Other equipment

  • Blood in the room – not necessary in every case. Recommended for redo sternotomys or anemic patients. Discuss with your attending during preop talk
  • Ultrasound for line placement
  • Rapid infusion system – either a Level 1 or a Belmont
  • 8 channel Alaris pump system
  • ABG syringes
  • ACT syringes (get a bundle from the perfusionist)
  • Peripheral IV start supplies/kit
  • Normosol blood pumps (at least 2) +/- extra bags Normosol
  • Orogastric tube
  • Epicardial pacemaker box (Medtronic) – check it turns on, replace battery if not

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