OR Workflow

Pre-incision

• First case room time usually 7am (8am Mondays)
• Give pre-OR sedation cautiously. Severe cardiopulmonary disease may cause precipitous decompensation prior to arrival in OR with “normal” anxiolytic dosing
• Position change (eg, from semi-recumbent to supine) or mild exertion (eg, moving between beds) may also precipitate decompensation. Full-assist movement to OR table may be necessary in many of your patients
• Standard monitors, NIBP usually contralateral from intended invasive BP limb
• Pre-induction arterial line, sew it in
  • Consider pre-induction/oxygenation ABG +/- ACT
• Induction & intubation
• OGT placement and stomach contents suctioned, remove OGT
• TEE probe placement (a little jaw thrust by assistant helps a lot)
• Position for central lines, prep neck for lines
• Sterile scrub, gown/glove. Place central lines(s), PA catheter. Biopatch + dressing.
• Antibiotics and ACT (if not given to perfusionist already)
  • Consider starting vancomycin prior to line placement to allow slow-infusion time and appropriate plasma levels prior to incision
• Pad/tuck arms – pay attention to pressure areas and neutral positioning, and ensure IV/arterial line can run/draw back after tucking
• Check shoulder roll positioning (may be in place prior to induction – if placing post-induction control of head + ETT + TEE + central lines is necessary)
• Connect temp probe monitor (usually foley/bladder)
• Connect infusion line to TLC and start carrier (50mL/hr)
• Ensure CVP is connected, identified, easily accessible (most bolus meds given here)
• Calculate cardiac output (method differs based on type of PA cath)
• Connect volume line (usually Level 1 to Cordis)

Surgical sequence

• Skin incision – stimulating. Rebolus analgesia +/- propofol bolus
• Sternotomy – disconnect the ventilator circuit during sternotomy (sternal saw + lungs = problem). Not necessary for oscillating saw used for redo sternotomy
• Mediastinal dissection (stay alert for bleeding and arrhythmias)
• Heparinization – perfusionist will advise the calculated heparin dose. Ensure blood aspiration through line before and after heparin administration. Give through CVP line. Draw ACT 3 minutes later and give to perfusionist. Send an ABG
• Aminocaproic acid bolus and infusion if not already administered
• Cannulation – this varies with procedure, pathology and surgeon
  • Titrate vasodilators/anesthetic depth to obtain SBP 90-100mmHg if anticipating central aortic cannulation
  • Arterial cannula: most commonly central aortic, entrance at anterior ascending aorta, end of cannula sits in proximal descending aorta. TEE confirmation of end sitting past left subclavian artery
  • Venous cannula: usually 2 (dual) stage or bicaval. TEE confirmation of intrahepatic IVC portion (turn right from TG SAX to find liver)
  • Coronary sinus cannula: used in most cases to provide retrograde cardioplegia. TEE confirmation (“deep ME 4C”) to ensure balloon in CS
  • Connect retrograde/CS pressure line from over the drapes to PA transducer with male-to-male connector. Transduce CS pressure continuously until aortic cross clamp is removed
  • LV vent: used in many cases to avoid LV distension. TEE confirmation of trans-mitral position in most mid-esophageal views
  • Antegrade cannula / root vent: placed in ascending aorta proximal to arterial cannula. For cardioplegia and de-airing

Cardiopulmonary Bypass

• See separate handout
• Go on bypass > cooling > surgery > rewarming > wean from bypass > hemostasis

Post-CPB

• Confirmation adequacy of biventricular function and surgical repair (TEE)
• Heparin reversal – administer protamine slowly and carefully only after surgeon requests. See protamine section in Guide to Managing CPB handout. Can cause anaphylaxis or acute pulmonary hypertension amongst other things. Make sure surgeon and perfusionist are aware of your intention and dosing of protamine.
• Decannulation (work with perfusionist to get pump blood into patient)
• Check ACT and ABG 3mins after completion of protamine
• Stop the bleeding. Talk with the surgeon about hemostasis. Escalate (blood replacement, platelets, FFP, cryo, factor concentrates) PRN. If patient has not received any blood products and you think you need to start, check with attending prior to administering
• Calculate cardiac output
• Start postoperative sedation (usually dexmedetomidine, sometimes propofol)
• Close sternum – monitor RV function cardiac output and CVP/PAP
• Keep potassium >4mEq/L and ionized calcium levels normal
• q30-45min ABGs – immediately talk with attending if acidotic or decreasing UOP
• Confirm final post-CPB TEE images are saved. Check for effusions and intact aorta
• Replace TEE probe with OGT (leave OGT in for ICU). Suction the oropharynx

Transfer to ICU

This is a high-risk period. Patient should be continuously monitored. Do not remove OR monitors until transport monitors are on and working. Beware hypotension during transfer from OR bed to ICU bed. Have volume and vasoactives (uppers and downers) immediately available. Watch chest tube output and UOP. If patient anuric prior to leaving OR, consider placing trialysis line for urgent postop CVVH