ANAESTHESIA FOR CARDIAC SURGERY
PREOPERATIVE VISIT
• Ensure that the patient receives the
education pamphlet published by the
Department of Cardiothoracic
Anaesthesia of NHC, and are
available in our 4 official languages in
wards 56 and 44.
• Explain as much as patient wants to
know regarding GA
• Inform regarding: intravascular
cannulations, intubation and
postoperative course and criteria for
extubation, bladder catheterisation
and postoperative experience; use of
numeric pain score while intubated,
and risk of postoperative hoarseness
of voice following placement of
transoesophageal echocardiography
probe.
PREOP ASSESSMENT
• Allergies: heparin, protamine,
antibiotics, seafood, iodine?
• Check platelet count if the patient has
heparin infusion (HITTS)
• Has antiplatelet therapy been stopped
• Any dysphagia: contraindication for
transoesophageal echo probe
placement
• Review reports: 2DE, MIBI, coronary
angiography
• Airway assessment: loose teeth?
• Symptoms of cervical spondylosis?
PREOPERATIVE SEDATION
• Consult supervisor regarding
medication
• If sedation is to be prescribed: The
patient should not be sedated to the
extent that patient safety is
compromised. If there is any risk of
the patient getting airway obstruction
or hypoventilation as a result of the
sedative prescribed, oxygen 40% via
face mask and pulse oximetry
monitoring must be arranged and
anaesthetist must be in the OT early to
manage the patient.
USUAL MEDICATIONS
• Continue: beta-blockers, nitrates,
calcium channel blockers, heparin
• Omit: hypoglycaemic agents
• Consult supervisor regarding:
continuation of ACEi, ARB, diuretics,
and digoxin; and timing for
discontinuation of heparin infusion for
patients with unstable angina and
aortic dissection
SCHEDULE FOR ORAL MEDICATION
• 0600h: for surgery scheduled between
0830h to 12noon
• 0800h: for surgery scheduled from
12noon onwards.
CONSENT
• On the Anaesthesia consent booklet,
document any dental issues
separately. Recommend having the
patient sign against the separate
entry to acknowledge the
conversation and advice.
DAY OF OPERATION
PATIENT PREPARATION
• Confirm with the patient identity
details and that there has not been
any change in clinic condition since
preoperative visit.
• Demonstrate care and concern for
the patient: thermoregulatory needs,
modesty, safety on the operating
table (lap-strap), support for both
arms and comfort during vascular
cannulations (note height difference
between operating table and working
table during cannulation of vein and
artery).
CANNULATION
• Routine (single FA, preferably right
arm)
– 16G or 18G venous cannula
– 20G intra-arterial line
– 3 lumen 7 Fr CVP
(recommend placement guided
by ultrasound)
– Keep all lines on one forearm
for convenience of patient
• If bleeding ++ expected, recommend
extra 16G cannula on contralateral
forearm, or 16G Angiocath (a type of
cannula) in internal jugular vein
• Find out if left radial artery is to be
used as graft
• Monitor HR, NIBP, SpO2 while
inserting lines, O2 via F/M 4L/min
• Check zeroing of pressure
transducers
• If difficult siting arterial cannula at reg
sites, d/w surgeon alt sites : left radial
art or femoral art; femoral vein for
CVC
• For aortic dissection and descending
aorta surgery, discuss with supervisor
and surgeon the optimum site for
second arterial cannulation (left radial
artery or femoral artery) for
monitoring
PATIENT POSITION FOR
SURGERY
– CABG with LIMA harvesting, align
patient toward right side of
operating table, position gel pad
along left humerus to avoid
unintended focal pressure on left
radial nerve damage when the
Piling sternal retractor (a type of
sternum retractor) device is
applied and the table has to be
tilted “away” from surgeon during
harvesting of LIMA.
PATIENT POSITION FOR SURGERY
– Placing shoulder roll: ensure that the
head and neck is in neutral position
and the cervical vertebral column is
supported (long duration of surgery
with variation of blood pressure puts
someone with subclinical cervical
spondylosis at risk of tetraparesis,
Beware of cervical spondylosis in
patients > 40 years old.. Recommend
placement of another pillow instead
of “doughnut” under the head, and
tuck the pillow comfortably to support
the neck.
GASTRIC SUCTION TUBE
• do not fix the tube tightly against ala
of nose. When bag gets heavy or
when connected to drainage suction
in ICU, traction and ischaemia to ala
may occur.
• care with nasal route (bleeding after
heparinisation); can be placed via oral
route. It will be withdrawn at
extubation in CTICU.
• do not insert yet if TOE is to be
inserted
THERMOREGULATION
• Underbody water blanket
• Bair Hugger with suitable convection
air current blanket
• Monitor oesoph / nasal, rectal and
skin temperatures. Skin temp probe
should be placed away from warming
blankets to avoid direct measurement
errors. Recommend placing skin
temperature probe at thenar
eminence
• Vasodilator may be used for
rewarming (GTN, SNP)
ARTERIAL LINE
• Ensure easy backflow during
aspiration after wrapping arms and
positioning of patient
INFUSION FLUID
• peripheral: Hartmann solution
• central: N/S
ANTIFIBRINOLYTIC AGENT
• Tranexamic acid (recommend loading
dose of 30 mg/kg, with or without
continuous infusion, at this dose TPA
is inhibited, in addition to inhibition of
plasminogen and plasmin)
DRUG INFUSIONS
• Dilute drugs in normal saline
• Do not share nitroglycerin and
propofol at the same three-way tap,
(leaks at join-line of three way taps
have occurred).
 ANAESTHESIA FOR CARDIAC SURGERY
PRE-BYPASS
• Sternotomy: very stimulating;
deflate lungs
• Low tidal volumes during LIMA
harvesting, maintain normocapnia
to avoid vasoconstriction
• heparin at LIMA clamp: 3mg/kg via
CVC, aspirate before giving to
confirm systemic administration of
heparin
• check ACT > 400 before going on
bypass
• SBP 90-100 for aortic cannulation
• inc CVP, BP for venous cannulation
(avoid air entrainment, may dev
arrythmia)
• Going on bypass, maintain on
volatile anaesthesia until patient is
on full bypass
BYPASS
• Maintain anaesthesia with propofol
6mg/kg/h OR midazolam
0.1mg/kg/hr
• stop ventilation, turn off air, leave
min flow O2, open APL valve fully
• phenylephrine +/- morphine to
perfusionist
• record ABG, Hct, K, Ca throughout
CPB (measured half hourly, mixed
venous blood sample is used)
• GTN infusion - titrated to keep MAP
< 90
BEFORE WEANING OFF OFF BYPASS
BYPASS • Ventilate with O2/Air (No N2O)
• If Hct < 22%, warm 1 unit of RBC • volatile / propofol anaesthesia
• HR should be >90/min, ECG should • protamine 3mg/kg given slowly, only
show sinus rhythm with conduction after:
• HR < 80, try atropine 0.6 to 1.2mg – surgeon’s request (confirm with
• if pacing reqd - 90/min, pacing surgeon)
chamber d/o requirements – venous cannula removed from
• K>4.5 , pH >7.3, rectal T >36.0C, atrium
esoph T > 36.0C – suction roller pump is stopped
• ventilate with 100% O2 after last
anastamosis upon surgeon’s request • If CVP < 10, blood from pump
with volatile agent transfused via aortic cannula
• Turn on agent monitor • GTN / SNP to keep SBP 90 - 120
• Do not reduce rate of propofol or
• Adren to keep SBP > 80
midazolam infusion until ET agent is
• ABG, ACT, K, Ca
adequate
• Do no administer CaCl2 routinely (to
• Use low flow rates to prevent
min reperfusion injury)
overinflation, tension in LIMA graft
• Hct > 24%, K > 4.5
• Poor LV
• CABG with arterial graft (IMA, radial
• adrenaline 0.1 to 0.2 mcg/kg/min
artery), cont GTN 0.1-1mg/h
• consider IABP / milrinone
• transfer patient to PACU or CTSICU
after AVR for AS
• consider NA 0.05 to
0.1mcg/kg/min to keep DBP >
50mmHg
• plt +/- FFP for aortic surgery, re-op
PACING
• Objectives: Sinus, rate approximately
90/min, AV conduction
• Other than for pre-existing atrial
fibrillation, atrial pacing if not in sinus
rhythm stimulation. Adjust voltage to
just above threshold
• Ventricular pacing for pre-existing AF,
or in additional to atrial pacing (AV
sequential pacing) in AV conduction
block. Adjust voltage to just above
threshold. For AV sequential: set PR
interval at 140ms
• Asynchronous or fixed mode to avoid
interference from application of
diathermy.
INTERNAL DEFIBRILLATION
• Charge at 5 - 10 J
 ANAESTHESIA FOR CARDIAC SURGERY

REPEAT OP
• Risk of bleeding ++, VT during
sternotomy and adhesiolysis
• 2 x 14G venous cannulae
• ext defib self adhesive pads and
connection ( VT- start at 200J)
• 2U of blood to be in OT: checked;
return to blood bank only after
commencement of CPB; no need
to warm up
• Arrange for FFP, plt
• Aprotinin (d/w surgeon)
• oscillating sternal saw (no need
to deflate lungs)

DEEP HYPOTHERMIC
CIRCULATORY ARREST
• Arrange for FFP, plt
• heated humidifier
• cool head with ice packs (in
freezer in perfusionist’s office)
• Do not allow cold pack to come
into contact with eyes/eyelids

AORTIC SURGERY
• 2 x 14G cannulae
• PA sheath for blood transfusion
• 2U blood in OT - checked
• FFP, plt
• aprotinin
• BIS monitor
• desc thorac aorta: R vs L DLT,
fem art cannula
• Subarachnoid catheter drainage
for desc aorta and thoraco-abdo
aortic surgery

OFF PUMP CABGs

• Heparin 1.5mg/kg for
heparinization

DIABETICS
• Maintain BSL 4 – 8 mmol/L
• insulin infusion 1U/ml, diluted
with normal saline