Key periods during cardiac surgery

Period Anesthetic goals

Prebypass Induction and Maintain optimal myocardial O2 supply and
period maintenance of minimize demand to prevent or treat
anesthesia ischemia

Antibiotic Timely administration of selected antibiotics

prophylaxis

Positioning Careful arm, hand, and head positioning to

avoid injuries

Fluid Restrict fluid administration since initiation of

management CPB causes significant hemodilution

Prebypass TEE Assess regional LV wall motion abnormalities

examination Assess global LV function
Assess global RV function
Assess structure and function of cardiac
valves
Evaluate thoracic aorta, interatrial septum,
and left atrium with left atrial appendage
Detect development of ischemia,
hypovolemia, hypervolemia, or low SVR

Incision and Treat hypertension and tachycardia due to

sternotomy painful stimuli
Briefly interrupt ventilation during
sternotomy to avoid lung injury

Harvesting of Reduce tidal volume

the internal
mammary
artery

Anticoagulation Administer heparin and ensure adequate

for CPB anticoagulation (confirm with ACT)

Antifibrinolytic Administer antifibrinolytic agent to minimize

administration microvascular bleeding
 Perfusionist Confer with perfusionist if indicated
completes CPB
circuit setup,
priming,
testing of
alarms and
circuit,
adherence to
checklist

Aortic Reduce systolic BP to <100 mmHg to reduce

cannulation risk of aortic dissection

Venous Treat hypotension or initiate CPB for

cannulation malignant arrhythmias

Initiation of Retrograde Gradual onset of CPB to reduce hemodilution

CPB autologous from crystalloid prime
priming

Control of O2 Discontinue controlled ventilation and

delivery, CO2 anesthetic administration via the anesthesia
removal, and machine
pump flow Discontinue cardiac support (eg, inotropic
assumed by agents, IABP)
perfusionist

Anesthetic Initiate volatile anesthetic administration via

administration vaporizer attached to CPB circuit, or use TIVA
technique
Monitor raw and/or processed EEG and
expired anesthetic gas from the oxygenator
to prevent awareness
Monitor neuromuscular function; administer
NMBAs to prevent movement or shivering

Placement of Ensure complete myocardial arrest (absence

aortic of ECG electrical activity)
crossclamp and TEE monitoring for aortic insufficiency and LV
administration distension during antegrade cardioplegia
of cardioplegia delivery
 Placement and TEE assessment of coronary sinus catheter
monitoring of placement for retrograde cardioplegia
coronary sinus delivery
catheter and LV Monitor coronary sinus pressure
vent TEE assessment of correct LV vent placement
and effective LV decompression

Maintenance Cooling Maintain temperature gradient between

of CPB venous inflow and arterial outlet <10°C

Maintenance Maintain MAP ≥65 mmHg (or ≥75 mmHg for

patients with cerebrovascular disease or
severe aortic atherosclerosis)
Monitor temperature at oxygenator arterial
outlet temperature (surrogate for cerebral
temperature) and other sites (eg,
nasopharyngeal, bladder, blood)
Maintain Hgb ≥7.5 g/dL (Hct ≥22%); suggest
hemoconcentration if Hgb <7.5 g/dL, then
transfuse PRBC if necessary
Maintain SvO2 ≥75%; suggest increase in
pump flow if SvO2 <75%

Rewarming Slow rewarming ≤0.5°C/minute, with

temperature gradient between venous inflow
and arterial outlet ≤4°C
Avoid hyperthermia; target temperature is
37°C at nasopharyngeal site and 35.5°C at
bladder site
Monitor for awareness or return of
neuromuscular function

Removal of Defibrillate and administer antiarrhythmic

aortic agents if necessary to treat ventricular
crossclamp fibrillation

Weaning from   Refer to UpToDate topic on weaning from

CPB cardiopulmonary bypass (CPB)

Post-bypass Venous Ensure initial reinfusion of blood drained

decannulation from the venous tubing into the pump
 reservoir in 50- to 100-mL aliquots
TEE assessment for adequate ventricular
filling

Anticoagulation Administer protamine slowly, treat protamine

reversal, pump reactions
suckers turned Ensure complete reversal of anticoagulation
off,
intravascular
vents removed

Aortic Reduce systolic BP to <100 mmHg to reduce

decannulation risk of aortic dissection

Pacemaker Ensure optimal pacemaker settings

management

Postbypass TEE Assess regional LV wall motion abnormalities

examination Assess global LV function
Assess global RV function
Monitor LV and RV chamber sizes to assess
intravascular volume status
Evaluate the ascending aorta to rule out
dissection

Hemostasis Ensure absence of residual heparin

Check point-of-care and laboratory tests of
coagulation if bleeding persists
Manage anemia, thrombocytopenia, and
coagulopathy if necessary

Chest closure Observe for RV compression and dysfunction,

coronary graft compromise, pacing wire
displacement, or lung compression

Transport to   Ensure optimal patient condition prior to

ICU and transport
handover Immediate availability of airway equipment,
emergency drugs, and defibrillator on the
transport bed
Continuous monitoring of ECG, SpO2, and
intraarterial BP during transport
 Use of a formal protocol for communication
and transfer of technology during handover
to the ICU team

O2: oxygen; CPB: cardiopulmonary bypass; TEE: transesophageal

echocardiography; LV: left ventricular; RV: right ventricular; SVR: systemic vascular
resistance; ACT: activated clotting time; BP: blood pressure; CO2: carbon dioxide;
IABP: intraaortic balloon pump; TIVA: total intravenous anesthesia; EEG:
electroencephalography; MAP: mean arterial pressure; Hgb: hemoglobin; Hct:
hematocrit; SVO2: mixed venous oxygen saturation; ECG: electrocardiogram;
SpO2: peripheral oxygen saturation; ICU: intensive care unit.

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