Anesthesia For Cardiac Surgery - General Principles - UpToDate

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Anesthesia for cardiac surgery: General principles

AUTHORS: Atilio Barbeito, MD, MPH, Eric A JohnBull, MD, MPH
SECTION EDITOR: Jonathan B Mark, MD
DEPUTY EDITOR: Nancy A Nussmeier, MD, FAHA
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2024.

This topic last updated: Sep 05, 2023.
INTRODUCTION
Anesthetic management for different types of cardiac surgical procedures such as coronary
artery bypass grafting (CABG), cardiac valve repair or replacement, surgery involving the
ascending aorta, heart transplantation, and procedures for surgical repair of congenital
heart defects has many shared principles. This topic will discuss general principles for
anesthetic management of adults undergoing cardiac surgery with cardiopulmonary bypass
(CPB). Similar techniques are employed for patients undergoing cardiac surgery without the
aid of CPB (eg, off-pump CABG).
Anesthetic management issues for specific types of cardiac surgical procedures are
discussed in separate topics:
● (See "Anesthesia for coronary artery bypass grafting surgery" and "Anesthesia for
coronary artery bypass grafting surgery", section on 'Off-pump coronary artery bypass
surgery'.)
● (See "Anesthesia for cardiac valve surgery".)
● (See "Anesthesia for aortic surgery with hypothermia and elective circulatory arrest in
adult patients".)
● (See "Anesthesia for heart transplantation".)
● (See "Anesthesia for surgical repair of congenital heart defects in adults: General
management" and "Anesthesia for surgical repair of congenital heart defects in adults:
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Management of specific lesions and reoperation".)
For cardiac surgical procedures requiring CPB, key steps are noted in the table ( table 1),
and intraoperative management during and after CPB is discussed in individual topics:
● (See "Blood management and anticoagulation for cardiopulmonary bypass".)
● (See "Initiation of cardiopulmonary bypass".)
● (See "Management of cardiopulmonary bypass".)
● (See "Weaning from cardiopulmonary bypass".)
● (See "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass".)
● (See "Intraoperative problems after cardiopulmonary bypass".)
Multidisciplinary approaches including standardized preoperative, intraoperative and

postoperative care protocols to enhance recovery after cardiac surgery (ERACS) are discussed
separately. (See "Anesthetic management for enhanced recovery after cardiac surgery
(ERACS)".)
PREANESTHETIC CONSULTATION
Preanesthetic consultation involves assessing cardiac and overall health risks to identify
issues that could cause problems during and after cardiac surgery. The anesthesiologist
works with the cardiologist and cardiac surgeon to optimize medical conditions, develops an
anesthetic care plan, educates the patient and family regarding anesthetic care, and
alleviates patient anxiety. These issues are discussed in detail separately. (See "Preoperative
evaluation for anesthesia for cardiac surgery".)
PREMEDICATION
Some cardiac surgical patients benefit from premedication with small incremental doses of a
short-acting intravenous (IV) benzodiazepine anxiolytic (eg, midazolam 1 to 2 mg) and/or
opioid (eg, fentanyl 50 mcg), administered under the anesthesiologist's observation,
particularly during placement of intravascular catheters (see 'Intravascular cardiac monitors'
below). Extra caution (ie, careful titration of smaller doses) is warranted for many cardiac
surgical patients. Examples include those with critical aortic stenosis or severe ventricular
dysfunction, or those of extreme age (>80 years old).
Protocols for enhanced recovery after cardiac surgery typically emphasize minimal anxiolytic
medication before or during surgery. (See "Anesthetic management for enhanced recovery
after cardiac surgery (ERACS)".)
MONITORING
Cardiac surgery is conducted using standard American Society of Anesthesiologists (ASA)

monitors ( table 2) [1], as well as intra-arterial and central venous access. We also monitor
urine output, degree of neuromuscular blockade (using a peripheral nerve stimulator), and
temperature.
Furthermore, for most cardiac surgical cases, we use transesophageal echocardiography

(TEE), processed electroencephalography (EEG), and point-of-care (POC) testing of laboratory
values. Additional monitoring with a pulmonary artery catheter (PAC) to monitor pulmonary
artery pressure (PAP), cardiac output, and mixed venous oximetry, or a cerebral oximetry
monitor may be employed in selected patients.
Noninvasive standard monitors
● Standard noninvasive monitors – Prior to induction, we place standard noninvasive

continuous monitors, including pulse oximetry (SaO2), electrocardiogram (ECG), and
noninvasive blood pressure as a backup monitor for intra-arterial blood pressure. After
endotracheal intubation, end-tidal carbon dioxide as well as airway pressure and
volume measurements are continuously monitored.
Both ECG leads II and V5 are employed, with computerized ST-segment trending to
facilitate optimal detection of myocardial ischemia, as in other patients with ischemic
heart disease (see "Anesthesia for noncardiac surgery in patients with ischemic heart
disease", section on 'Monitoring for myocardial ischemia'). In high-risk patients for
whom pacing, defibrillation, or cardioversion may be necessary, defibrillator/pacing
pads should be placed prior to anesthetic induction ( figure 1).
A peripheral nerve stimulator is positioned along the course of the facial nerve to
intermittently elicit contraction of the orbicularis oris muscle for monitoring
neuromuscular function. This ensures that appropriate muscle relaxation is maintained
throughout the case. (See "Management of cardiopulmonary bypass", section on
'Maintenance of anesthesia and neuromuscular blockade'.)
Other standard monitors
● Bladder catheter – A bladder catheter with a temperature probe is inserted after

induction to measure urine output and core temperature.
● Temperature monitors – Temperature is monitored at several sites (see "Management

of cardiopulmonary bypass", section on 'Temperature'):
• A nasopharyngeal or tympanic membrane temperature probe is typically employed,

particularly as a monitor of brain temperatures during cardiopulmonary bypass
(CPB) and the weaning process [2-4]. However, the oxygenator arterial outlet
temperature is the most reliable surrogate for cerebral temperature during cooling
and rewarming [2-5].
• A bladder catheter with a temperature probe is used to monitor "core temperature";

a rectal temperature probe may be substituted if no urine output is expected (eg, in
a patient with end-stage kidney disease). During the cooling and rewarming phases
of CPB, bladder (or rectal) temperatures typically lag behind oxygenator,
nasopharyngeal, tympanic membrane, and blood temperatures; thus, bladder
temperature poorly reflects temperatures in the highly-perfused organs (eg, brain
and kidneys) [3,5].
• If a PAC is inserted, pulmonary artery blood temperature is also monitored before

and after CPB [6].
● Point-of-care laboratory testing – Routine intraoperative laboratory point-of-care

(POC) testing includes intermittent blood gas analysis, hemoglobin, electrolytes,
calcium, glucose, activated whole blood clotting time (ACT), and in some institutions,
other coagulation assays [7]. (See "Clinical use of coagulation tests".)
Intravascular cardiac monitors — Cardiac surgery requires continuous monitoring of the

cardiovascular system because:
● Critical cardiovascular disease (eg, coronary artery obstruction or cardiac valve lesions)
necessitates close hemodynamic monitoring to avoid and rapidly correct myocardial
ischemia or dysfunction.
● Sudden and/or severe hemodynamic changes may occur due to mechanical

manipulations during the surgical procedure itself.
● Effects of anesthetic and pharmacologic manipulations of the cardiovascular system

must be assessed rapidly.
The following cardiovascular monitors are typically employed:
● Intra-arterial catheter – An intra-arterial catheter is inserted before anesthetic

induction for continuous monitoring of blood pressure and to facilitate intermittent
blood sampling for specific POC tests during the operation. (See "Intra-arterial
catheterization for invasive monitoring: Indications, insertion techniques, and
interpretation".)
The radial artery is the most common cannulation site due to its superficial course,
consistent accessibility, and redundant blood supply of the hand via the ulnar artery. If
the cardiac surgical plan includes radial artery harvest, the contralateral radial artery or
ulnar artery is also suitable. Despite concerns for hand ischemia or ulnar nerve injury
(due to its proximity to the artery), complications associated with ulnar artery
cannulation rarely occur [8-11]. Other alternative sites may be selected in some
patients, including brachial, axillary, and femoral arteries. These more proximal
monitoring sites have the advantage of providing better estimates of central aortic
pressure, particularly following CPB, and complications are rare [12,13]. (See "Intra-
arterial catheterization for invasive monitoring: Indications, insertion techniques, and
interpretation", section on 'Complications'.)
If an intraaortic balloon pump (IABP) is in place, intra-arterial blood pressure may be

monitored at the tip of the balloon catheter in the descending thoracic aorta to avoid
any delay in beginning surgery. Insertion of a peripheral intra-arterial catheter can then
be accomplished as soon as possible after induction of anesthesia.
If surgery on the aortic arch or repair of aortic dissection is planned, it may be

necessary to obtain a second upper extremity intra-arterial catheter after induction.
(See "Anesthesia for aortic surgery with hypothermia and elective circulatory arrest in
adult patients".)
● Central venous catheter – A large-bore central venous catheter (CVC) is useful given
the frequent need for infusion of vasoactive medications and the potential for high-
volume administration of fluids or blood products. Typically, we cannulate the internal
jugular vein using ultrasound guidance for vein localization ( movie 1 and movie 2)
[14,15].
We insert an introducer sheath such as a multi-lumen access catheter or sheath

introducer (eg, Cordis) that functions as a large-caliber CVC and/or as a means to place
a PAC, even if insertion of a PAC is not initially planned. Thus, if the patient becomes
hemodynamically unstable in the postbypass or postoperative period, the introducer
sheath facilitates later insertion of a PAC without interruption of vasoactive infusions.
We typically insert the large-bore CVC shortly after induction of general anesthesia if
there is adequate peripheral intravenous (IV) access for use during induction. Insertion
after induction avoids patient discomfort due to pain and Trendelenburg positioning,
which might result in hypertension, tachycardia, dyspnea, and myocardial ischemia in
an awake patient. However, in a patient with difficult peripheral IV access or risk factors
for hemodynamic instability during induction, we may insert the introducer sheath
and/or PAC before induction of general anesthesia [16].
In other institutions, the sheath introducer and CVC or PAC are routinely placed before
induction in order to expedite surgical care. During large-bore CVC placement in an
awake patient, small bolus doses of an anxiolytic agent (eg, midazolam 1 to 4 mg)
and/or an opioid (eg, fentanyl 50 to 150 mcg) may be judiciously administered to
reduce patient discomfort.
● Pulmonary artery catheter – In selected patients, a PAC may be inserted to provide

dynamic information regarding pulmonary artery pressure (PAP), cardiac output, and
mixed venous oxygen saturation (SVO2) [16-20].
We insert a PAC in patients with acute hemodynamic instability, preferably before

induction of anesthesia or surgical incision [16]. Also, PAC monitoring is often employed
in patients with moderate to severe pulmonary artery hypertension, reduced left
ventricular (LV) ejection fraction (<30 percent), severe coexisting pulmonary or kidney
disease, planned coronary artery bypass grafting (CABG) surgery in combination with
valve repair or replacement (due to longer CPB and aortic cross-clamp times that may
result in increased potential for postbypass myocardial dysfunction), and in patients
undergoing heart and/or lung transplantation. However, routine use is avoided in many
centers because of absence of evidence for mortality benefit in cardiac surgical and
other patient populations, as well as several potential risks [21-27]. (See "Pulmonary
artery catheterization: Indications, contraindications, and complications in adults",
section on 'Complications'.)
Selection of the type of PAC to be inserted is based on institution-specific availability

and preferences. We prefer a continuous cardiac output catheter with continuous
mixed venous oximetry (SvO2) capabilities to facilitate management in the intensive
care unit in the highest risk patients who have a greater likelihood of continued
hemodynamic instability following surgery. (See "Pulmonary artery catheterization:
Indications, contraindications, and complications in adults", section on 'Physiologic
measurements' and "Evaluation of and initial approach to the adult patient with
undifferentiated hypotension and shock", section on 'Pulmonary artery
catheterization'.)
Brain monitors
● Electroencephalography – We routinely employ a raw and/or processed

electroencephalography (EEG) device (eg, a bispectral index monitor) [28]. Although
such monitoring may help detect "light" anesthesia or awareness, EEG indices cannot
reliably confirm that a patient is adequately anesthetized [29]. (See "Accidental
awareness during general anesthesia" and "Management of cardiopulmonary bypass",
section on 'Maintenance of anesthesia and neuromuscular blockade'.)
Another use of EEG is to establish a neurophysiologic endpoint for the cerebral effects
of cooling (electrocortical silence) in patients undergoing cardiac surgical procedures
with deep hypothermia and circulatory arrest (DHCA) (see "Anesthesia for aortic surgery
with hypothermia and elective circulatory arrest in adult patients", section on
'Electroencephalography'). Furthermore, EEG data may supplement near-infrared
spectroscopy (NIRS) to detect cerebral hypoperfusion [30].
● Cerebral oximetry – NIRS cerebral oximetry monitoring and maintenance of regional

cerebral oxygen saturation (rSO2) within 20 percent of baseline may be employed to
detect regional cerebral malperfusion events and intraoperative catastrophe. The
algorithm describes management of significant decreases in rSO2 during CPB
( algorithm 1). A large retrospective multicenter cohort study from the Society of
Thoracic Surgeons Adult Cardiac Surgery Database noted that adult cardiac surgical
patients monitored with intraoperative cerebral oximetry had lower rates of major
organ morbidity and mortality compared with those without such monitoring [31].
However, other meta-analyses of randomized trials have found there is insufficient
evidence to recommend its universal use to reduce mortality or organ-specific
morbidity [32]. For this reason, use of cerebral oximetry may be optimally used in
selected patients such as those with significant cerebrovascular disease or other risk
factors for neurologic or renal complications, and during selected procedures such as
cardiac surgery with a concomitant procedure involving the ascending aorta or arch
[31,33]. (See "Management of cardiopulmonary bypass", section on 'Neuromonitoring
modalities' and "Anesthesia for aortic surgery with hypothermia and elective circulatory
arrest in adult patients", section on 'Cerebral oximetry'.)
TRANSESOPHAGEAL ECHOCARDIOGRAPHY
Prebypass transesophageal echocardiography — Practice guidelines of the American

Society of Anesthesiologists (ASA) and Society of Cardiovascular Anesthesiologists suggest
using transesophageal echocardiography (TEE) to confirm and refine preoperative
diagnoses, detect new or unsuspected cardiovascular pathology that may alter anesthetic or
surgical plans, as well as guide PAC insertion and final positioning [34,35]. Although useful
for many types of cardiac surgical procedures, intraoperative TEE may have particularly
important clinical benefits in patients undergoing cardiac valve repair or replacement or
proximal aortic surgery [36,37]. In a retrospective cohort study that included 114,871
patients undergoing isolated coronary artery bypass grafting (CABG) surgery, intraoperative
use of TEE was associated with lower 30-day mortality (3.7 versus 4.9 percent) or combined
incidence of stroke and mortality (4.5 versus 5.5 percent) compared with no use of TEE [38].
(See "Anesthesia for cardiac valve surgery", section on 'Transesophageal echocardiography:
General considerations' and "Anesthesia for aortic surgery with hypothermia and elective
circulatory arrest in adult patients", section on 'Transesophageal echocardiography'.)
In the postbypass period, TEE is used to assess results of all surgical interventions while the
patient is still in the operating room [34]. (See 'Postbypass transesophageal
echocardiography' below.)
We conduct an initial comprehensive prebypass TEE examination, followed by continuous

use of the TEE to monitor ventricular function and volume [39]. (See "Transesophageal
echocardiography: Indications, complications, and normal views" and "Intraoperative
transesophageal echocardiography for noncardiac surgery", section on 'Components of a
basic TEE examination (noncardiac surgery)'.)
Even if TEE is not used electively, rapid deployment may be needed to diagnose causes of
acute, persistent, and life-threatening hemodynamic instability (ie, "rescue" TEE). (See
"Intraoperative rescue transesophageal echocardiography (TEE)".)
Initial transesophageal echocardiography examination
● Global systolic LV function is assessed and ejection fraction is evaluated using a

qualitative grading system (eg, mild, moderate, or severe global LV hypokinesia and
systolic LV dysfunction) or estimated LV ejection fraction ( movie 3 and movie 4).
There is also some evidence for the use strain-based indices of LV dysfunction to predict
adverse postbypass and postoperative outcomes [40-42]. (See "Intraoperative
transesophageal echocardiography for noncardiac surgery", section on 'Global LV
systolic function' and "Transesophageal echocardiography in the evaluation of the left
ventricle", section on 'Systolic function'.)
The presence of spontaneous echo contrast in the left atrium (LA) or aorta indicates low
cardiac output.
● Global LV diastolic function is assessed using a quantitative grading system (grade 1,

impaired relaxation; grade 2, pseudonormal; grade 3 restrictive filling) ( image 1). The
pre-bypass evaluation of the diastolic function of the LV is most important for
prognostic reasons rather than specific therapeutic interventions. Diastolic dysfunction
has been shown to be associated with major adverse cardiac events, in-hospital
mortality, and prolonged mechanical ventilation after cardiac surgery [43-46]. Details
regarding a comprehensive assessment of diastolic function are discussed elsewhere.
(See "Echocardiographic evaluation of left ventricular diastolic function in adults".)
● It is also possible to obtain estimates of cardiac output using the LV outflow tract or
aortic valve area combined with Doppler-based methods [47]. Such estimates may be
particularly useful when thermodilution measurements of cardiac output are not
available in the absence of a PAC. Details regarding calculation of hemodynamic

parameters are discussed elsewhere. (See "Hemodynamics derived from
transesophageal echocardiography", section on 'Cardiac output'.)
● The LV is also assessed for regional wall motion abnormalities (RWMAs), characterized
as hypokinesis, akinesis, or dyskinesis. These may be chronic (preexisting) or may be
new changes, indicative of myocardial ischemia. RWMAs indicate specific territories of
myocardium perfused by each of the major coronary arteries supplying the LV
( figure 2 and figure 3) [48]. In each of the 16 segments (17 minus the apical cap)
of the LV wall, function may be graded as:
• Normal
• Hypokinetic (ie, reduced and delayed contraction)
• Akinetic (ie, absence of inward motion and thickening)
• Dyskinetic (ie, systolic thinning and outward systolic endocardial motion)
Although rigorous quantitative grading of each myocardial segment is not typically

performed during cardiac operations, a qualitative assessment of regional ventricular
function is noted and recorded. Further details regarding TEE assessment of regional LV
systolic function are available elsewhere. (See "Intraoperative transesophageal
echocardiography for noncardiac surgery", section on 'Regional LV systolic function'
and "Transesophageal echocardiography in the evaluation of the left ventricle", section
on 'Evaluation of regional wall motion'.)
● The LV is assessed for mural thrombus in patients who have an akinetic or dyskinetic
myocardial segment, most commonly involving the ventricular apex ( image 2 and
movie 5 and movie 6). (See "Left ventricular thrombus after acute myocardial
infarction".)
● RV function is assessed. Myocardial ischemia or exacerbation of pulmonary

hypertension may cause severe RV dysfunction ( movie 7). Some clinicians obtain
strain measurements of RV dysfunction [49]. Details regarding a comprehensive
assessment of the right heart are discussed elsewhere. (See "Echocardiographic
assessment of the right heart".)
● The thoracic aorta is evaluated for atheromatous disease, calcification, or dilatation

prior to aortic cannulation, and cross-clamping ( image 3). Some centers also
perform epiaortic scanning prior to aortic cannulation and cross-clamping ( image 3),
either selectively or routinely, as a supplemental and possibly superior technique for
identifying disease in the ascending aorta. Further discussion can be found in a
separate topic. (See "Initiation of cardiopulmonary bypass", section on 'Aortic
cannulation'.)
● Structure and function of the four cardiac valves are assessed. (See "Intraoperative
transesophageal echocardiography for noncardiac surgery", section on 'Valvular
structure and function'.)
TEE can play an important role in determining the surgical plan in patients with cardiac
valve disease (eg, confirming the preoperative diagnosis, decisions to repair versus
replace a valve, or whether an additional valve requires repair). One study noted that
TEE influenced cardiac surgical decisions in more than 9 percent of all patients, with the
greatest observed impact in patients undergoing combined CABG and valve procedures
[50].
Identification of significant aortic regurgitation (AR) is particularly important

( movie 8 and image 4 and image 5 and image 6). AR may limit delivery of
adequate antegrade cardioplegia solution into the coronary artery ostia after the
ascending aorta is cross-clamped since much of the cardioplegia solution will
regurgitate through the incompetent aortic valve back into the LV. This may cause
distention of the LV as it fills. Management of patients with significant AR during CPB is
addressed separately, including the possibility of inadequate delivery of antegrade
cardioplegia and alternative options (eg, retrograde cardioplegia and/or insertion of an
LV vent to maintain LV decompression) (see "Management of special populations
during cardiac surgery with cardiopulmonary bypass", section on 'Aortic regurgitation').
Significant (more than mild) AR is also a relative contraindication to the placement of an
IABP, since the degree of AR may be increased with diastolic balloon inflation during
counterpulsation. (See "Intraaortic balloon pump counterpulsation", section on
'Contraindications'.)
● The interatrial septum is interrogated for presence of a patent foramen ovale (PFO) or
atrial septal defect [51]. This is accomplished using two-dimensional (2D) imaging, as
well as color-flow Doppler imaging. If there is equivocal evidence of a PFO, confirmation
by injection of IV agitated saline contrast (known as a "bubble study") is a maneuver
used to detect right to left atrial shunting through a PFO ( movie 9). Transient atrial
pressure reversal achieved with release of a sustained positive pressure breath may
enhance sensitivity of this maneuver. Although repair of an incidentally discovered PFO
is not warranted unless the surgical plan includes right atriotomy [52], its presence
should be documented as useful information in case the patient suffers a future
embolic stroke.
● The LA and left atrial appendage (LAA) are assessed for thrombus, particularly in
patients with current or past history of atrial fibrillation ( movie 10). The finding of
spontaneous echo contrast, indicative of stasis that predisposes to thrombus
formation, is used to differentiate thrombi from normal variants such as a multilobed
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LAA or prominent trabeculations ( movie 11 and movie 12). Identification of LA or

LAA thrombus may lead to a decision to institute postoperative anticoagulation to
reduce the risk of stroke. (See "Echocardiographic evaluation of the atria and
appendages", section on 'Transesophageal echocardiography'.)
Monitoring with transesophageal echocardiography — Subsequently, throughout the

prebypass period, and again during the postbypass period, we continuously monitor
ventricular function and volume status. We monitor LV and RV function and filling. Goals
include rapid detection and assessment of:
● New RWMAs (eg, hypokinesis, akinesis, or dyskinesis), which are highly suggestive of
myocardial ischemia ( figure 2 and figure 3) [48]. (See "Anesthesia for coronary
artery bypass grafting surgery", section on 'Avoidance and treatment of ischemia'.)
● Development of hypovolemia or hypervolemia ( movie 13). (See "Intraoperative

transesophageal echocardiography for noncardiac surgery", section on 'Volume
status'.)
● Development of low systemic vascular resistance as a cause of arterial hypotension.

(See "Intraoperative transesophageal echocardiography for noncardiac surgery",
section on 'Systemic vascular resistance'.)
● Factors causing hypotension, including abnormalities in:
• Preload or volume status (ie, hypovolemia or hypervolemic congestive heart failure)

• Afterload or vascular resistance (ie, low systemic vascular resistance)
• Contractility or ventricular function (ie, poor LV or RV function)
• Valvular structure and function (ie, structural abnormalities or poor function)
• Other less common causes of hypotension, such as aortic dissection or cardiac
tamponade
Transesophageal echocardiography considerations for patients with COVID-19 — Since

transesophageal echocardiography (TEE) examination is an aerosol-generating procedure, it
should be avoided in patients with known or suspected novel coronavirus disease 2019
(COVID-19) unless the findings are likely to be critically important [53-57]. (See
"Transesophageal echocardiography: Indications, complications, and normal views", section
on 'COVID-19 precautions'.)
Thus, careful procedure-specific scrutiny is warranted regarding indications for TEE during
cardiac or noncardiac surgery [54]. Examples of procedures for which TEE is usually
warranted include:
● Type A aortic dissection.
● Myocardial infarction with anatomical complications (eg, papillary muscle rupture,

ventricular septal defect).
● Infective endocarditis with valvular and perivalvular involvement.
● Insertion of a ventricular support device.
● Need to diagnose acute, persistent, and life-threatening hemodynamic instability (ie,
"rescue" TEE). (see "Intraoperative rescue transesophageal echocardiography (TEE)")
To reduce the risk of aerosolization, the airway should be secured prior to insertion of the
TEE probe. Some centers employ a sheath for the TEE probe to further reduce the risk of
provider and environmental contamination [56], and/or cover the ultrasound system
(controls) with a plastic barrier. During TEE examination, airborne, contact, and droplet
personal protective equipment (PPE) should be worn to prevent infection, which consists of
an N95 or higher level respirator or powered air purifying respirator, eye protection (eg,
goggles or face shield that goes around the side of the face), gloves, disposable gown,
operating room cap, and shoe covers [53-55,57]. Additional precautions include minimizing
the number of personnel performing TEE examination, limiting TEE use by performing a
focused examination, and using dedicated TEE equipment for COVID-19-positive patients.
(See "Overview of infection control during anesthetic care", section on 'Considerations during
aerosol-generating procedures'.)
In some cases, alternative echocardiographic imaging modalities (eg, transthoracic

echocardiography, point-of-care ultrasonography) may be considered. For example,
transthoracic echocardiography may be employed immediately before and after the cardiac
surgical procedure to confirm left ventricular (LV) and right ventricular (RV) function. (See
"Overview of perioperative uses of ultrasound".)
INDUCTION OF GENERAL ANESTHESIA
Induction techniques — The goals of general anesthetic induction are to produce and
maintain unconsciousness, attenuate the hemodynamic responses to endotracheal
intubation and surgical stimulation, and prevent or treat hemodynamic changes that lead to
myocardial oxygen imbalance and ischemia. Specific hemodynamic and physiologic goals for
different types of cardiac disease (eg, coronary artery disease, cardiac valve lesions) are
discussed in individual topics.
Regardless of the induction technique employed, hypotension may occur post-induction

when a volatile inhalation anesthetic agent is administered to increase anesthetic depth in
anticipation of the surgical incision. Hypotension occurs because of the long context-
sensitive half time for high doses of an opioid such as fentanyl [58], and synergistic
interaction of opioids with volatile agents (see "Maintenance of general anesthesia:
Overview", section on 'Analgesic component: Opioid agents'). Significant hypotension is
avoided by reducing the dose of volatile agent, or treated by administering a vasopressor in

small bolus doses (eg, phenylephrine) or as a low-dose infusion ( table 3).
Balanced technique — The most common anesthetic induction techniques for cardiac
surgical patients includes use of a low dose of a sedative-hypnotic agent combined with a
low dose of opioid and volatile anesthetic agent ("balanced technique"). For example, a small
dose of propofol (eg, 0.5 to 1.5 mg/kg) may be administered in combination with a moderate
dose of fentanyl 2 to 4 mcg/kg and a neuromuscular blocking agent. Since a bolus injection
of propofol typically produces dose-dependent hypotension due to venous and arterial
dilation as well as decreased myocardial contractility, administration of a vasopressor such as
phenylephrine is often necessary. (See "General anesthesia: Intravenous induction agents",
section on 'Propofol'.)
Owing to its minimal hemodynamic side effects, etomidate may be selected as the anesthetic
induction agent for patients with cardiogenic shock, hemodynamic instability, critical left
main coronary disease, severe aortic stenosis, or severe cardiomyopathy. A possible concern
with the use of etomidate is that it inhibits the biosynthesis of cortisol, an effect that lasts
<24 hours following a single dose. Although this finding may not be clinically significant [59],
etomidate is not routinely administered. (See "General anesthesia: Intravenous induction
agents", section on 'Etomidate'.)
A neuromuscular blocking agent is also administered during induction. During the few
minutes required for adequate relaxation for endotracheal intubation, a volatile inhaled
anesthetic is typically titrated to its effect on anesthetic depth. Anesthetic depth should be
sufficient to assure unconsciousness and attenuate the sympathetic response to
laryngoscopy and intubation. Lidocaine 1 mg/kg intravenous (IV) is often included in the
induction sequence to further blunt this sympathetic response. (See "General anesthesia:
Intravenous induction agents", section on 'Lidocaine' and "Anesthesia for noncardiac surgery
in patients with ischemic heart disease", section on 'Induction'.)
Higher-dose opioid technique — An alternative induction technique that is used less

commonly includes administration of a higher dose of a synthetic opioid (eg, fentanyl 10 to
25 mcg/kg) for patients who will remain intubated with controlled ventilation for several
postoperative hours. This technique results in minimal direct myocardial depressant effect
and only a small decrease in blood pressure. One important adverse side effect of high-dose
opioid administration is chest wall rigidity, which may make ventilation difficult [60]. (See
"Perioperative uses of intravenous opioids in adults: General considerations", section on
'High-dose opioid induction technique'.)
Patient positioning — Patients are typically in the supine position during cardiac surgery.
The arms may either be tucked at the patient's side, or, less commonly, in an abducted
position. A shoulder roll is typically placed under the scapulae to extend the neck. (See
"Patient positioning for surgery and anesthesia in adults", section on 'Supine' and "Patient
positioning for surgery and anesthesia in adults", section on 'Particular concerns with the
supine position'.)
Patients are susceptible to positioning injuries during CABG surgery due to a prolonged
duration in an unchanging position [61]. Theoretically, nonpulsatile flow and induced
hypothermia during cardiopulmonary bypass (CPB), as well as intermittent hypotension
during the prebypass and postbypass periods, may exacerbate nerve, skin, and other
positioning injuries. Although there is no definitive evidence for the roles of these potential
risk factors, extra precautions are taken to prevent such injuries. For example, the head is
initially positioned on a cushioned pillow or "donut" pad, with frequent repositioning to
prevent scalp ischemia and resultant occipital alopecia. If arms are tucked, the olecranon
groove and fingers should be padded and protected from the metallic edge of the operating
table to avoid pressure injuries. If arms are abducted, overextension beyond 90 degrees is
avoided to prevent excessive tension on the pectoralis major muscle and brachial plexus
injury [61]. (See "Patient positioning for surgery and anesthesia in adults", section on 'Nerve
injuries associated with supine positioning'.)
After sternotomy, placement of a sternal retractor is necessary for harvesting the internal
thoracic or internal mammary artery (see "Anesthesia for coronary artery bypass grafting
surgery", section on 'Incision, sternotomy, and harvesting of venous and arterial grafts').
Retractor positioning is closely observed since the steel post attaching it to the operating
table may compress the upper arm causing radial nerve injury and may also be associated
with brachial plexus injury [61-63]. In addition, when the retractor lifts the sternum, the
patient's head may be lifted off the supporting head cushion, particularly in an older patient
who has cervical spine arthritis. If this occurs, the retractor should be adjusted or the
patient's head should be repositioned with additional pillow support.
Antibiotic prophylaxis — Administration of antimicrobial therapy, typically a cephalosporin,

should be initiated by the anesthesiologist within 60 minutes before the surgical incision, so
that drug levels are optimal at the time of incision ( table 4). If vancomycin is selected for a
patient with a beta-lactam penicillin allergy or one who is known to be colonized with
methicillin-resistant Staphylococcus aureus (MRSA), administration should begin within 120
minutes before the incision because of the prolonged infusion time required. (See
"Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on
'Cardiac surgery'.)
MAINTENANCE OF GENERAL ANESTHESIA
Maintenance techniques
● Selection of anesthetic agents – During cardiac surgery, general anesthesia is

typically maintained with a volatile anesthetic inhalation agent (ie, isoflurane,
sevoflurane, desflurane). Use of a total intravenous anesthetic (TIVA) technique during
cardiac surgery, or combinations of volatile and intravenous agents are reasonable
alternatives to maintain adequate depth of general anesthesia and prevent movement
during surgery.
A 2020 meta-analysis (42 trials, 8197 participants) comparing maintenance of

anesthesia with volatile inhalation anesthetic agents versus TIVA techniques noted
that inhalation agents were associated with lower one-year mortality and myocardial
infarction (MI) [64]. A 2021 meta-analysis noted that volatile inhalation anesthetics were
associated with shorter durations of intensive care unit stay (16 trials; 2003
participants) and hospital stay (12 trials; 1241 participants), but no differences in
mortality or MI compared with TIVA [64,65]. Methodologic differences between these
meta-analyses may account for the conflicting results [66].
● Anesthetic depth – Anesthetic requirements vary considerably during cardiac surgical

procedures; thus, frequent adjustments of anesthetic depth are necessary. For
example, in the prebypass period, severe pain and endogenous catecholamine release
may occur during initial incision and particularly during sternotomy, necessitating
adjustments to the depth of general anesthesia in order to prevent tachycardia and
hypertension. Subsequently, during the periods of reduced surgical stimulation that
typically follow sternotomy, it is appropriate to reduce anesthetic depth to avoid
hypotension. (See "Anesthesia for coronary artery bypass grafting surgery", section on
'Incision, sternotomy, and harvesting of venous and arterial grafts'.)
Notably, hypothermia and rewarming during CPB may considerably change anesthetic
requirements [67-69]. Furthermore, some degree of hemodilution occurs with initiation
of CPB, even when limited by autologous priming. Hemodilution expands the patient's
volume of distribution for anesthetic and other drugs [70]. Thus, drugs such as
neuromuscular blocking agents (NMBAs) that are primarily distributed within the
intravascular space should be re-dosed when CPB is initiated, particularly if peripheral
nerve stimulator monitoring shows a return of neuromuscular function. During CPB,
neuromuscular function is monitored with a peripheral nerve stimulator. In contrast, re-
dosing may not be necessary for agents with a large volume of distribution (eg,
fentanyl and propofol) because of their rapid redistribution into the new larger
intravascular volume [70,71].
Prebypass ventilation strategies — We use an intraoperative lung-protective ventilation

strategy in the prebypass and postbypass period (with low tidal volume [TV], low driving
pressure, and positive end-expiratory pressure [PEEP]) to potentially reduce the incidence of
pulmonary complications. These ventilator settings are consistent with recommendations for
lung-protective ventilation for all patients undergoing anesthesia and surgery with use of
mechanical ventilation. Overdistention of the lungs should be avoided [72]. (See "Mechanical
ventilation during anesthesia in adults", section on 'Lung protective ventilation during
anesthesia'.)
In a retrospective study that included 4694 patients undergoing cardiac surgery with CPB,
10.9 percent experienced pulmonary complications in the postoperative period (pneumonia,
prolonged mechanical ventilation, need for reintubation, and/or poor oxygenation with a
ratio of arterial oxygen tension/fraction of inspired oxygen <100 mmHg within 48
postoperative hours while intubated) [73]. Fewer pulmonary complications were noted in
patients managed with lung-protective ventilation that included TV <8 mL/kg ideal body
weight, modified driving pressure (peak inspiratory pressure - PEEP) <16 cmH2O, and PEEP ≥5
cmH2O, compared with patients managed with other ventilation strategies (adjusted odds
ratio [OR] 0.56, 95% CI 0.42-0.75). A sensitivity analysis revealed that use of modified driving
pressure <16 mmHg, but not PEEP or low TV, was also independently associated with fewer
pulmonary complications (adjusted OR 0.51, 95% CI 0.39-0.66) [73]. Although elevated
driving pressure may simply be a marker (rather than a cause) of lung injury, we maintain
this pressure <16 mmHg as a component of lung-protective ventilation after CPB. A separate
retrospective study that included 9359 cardiac surgical patients has noted that lower tidal
volume (6.8 ± 1.3 mL/kg) was associated with very modest improvement in postoperative
oxygenation, compared with moderate (7.9 ± 0.3) or higher (9.5 ± 0.9) tidal volumes [74].
During the prebypass period, it may be necessary to make frequent adjustments in

ventilation to accommodate changing surgical conditions. Notably, during sternotomy
ventilation is briefly interrupted to prevent lung injury from the sternal saw. During
subsequent internal mammary artery harvest, some surgeons request reduction in the tidal
volume (TV) to avoid suboptimal surgical exposure due to interference from the lungs during
inspiration. In these instances, respiratory rate is increased to maintain adequate alveolar
ventilation.
Prebypass fluid management — Prior to CPB, fluid administration (usually with a balanced
crystalloid solution rather than a colloid solution) is typically restricted to the small volumes
necessary to administer IV medications because initiation of CPB results in significant
hemodilution as the CPB circuit prime (up to 1.5 liters of crystalloid) mixes with the patient's
blood volume. However, judicious IV volume expansion, or administration of a vasopressor
infusion, may be necessary to maintain hemodynamic stability in response to blood loss or
hypovolemia in the prebypass period. Excessive hemodilution is avoided during cardiac
surgery with or without CPB due to risks for postoperative weight gain, increased use of
blood products, delirium, and longer durations of controlled mechanical ventilation and
hospital stay [75,76]. (See "Blood management and anticoagulation for cardiopulmonary
bypass", section on 'Avoiding excessive fluid administration' and "Anesthesia for coronary
artery bypass grafting surgery", section on 'Off-pump coronary artery bypass surgery'.)
Hydroxyethyl starch (HES) colloid solutions are avoided due to concerns regarding
impairment of hemostasis and acute kidney injury (AKI) [77-82]. In a 2012 meta-analysis of
randomized trials in cardiac surgical patients receiving HES solutions, risk of reoperation for
bleeding was more than doubled (relative risk [RR] 2.24, 95% CI 1.14-4.40) compared with
albumin [80]. In that meta-analysis, postoperative blood loss and transfusions of red cells,
fresh frozen plasma, and platelets were all increased in patients receiving HES. One
retrospective study in cardiac surgical patients noted that patients receiving a HES 130/0.4
solution for intraoperative fluid therapy, including use in the CPB pump prime, were twice as
likely to develop AKI compared with those receiving a balanced crystalloid solution [77].
However, data are not consistent, and some studies in other surgical populations have noted
no differences in risk for AKI or other serious postoperative complications in patients
receiving HES solution compared with other types of fluids [83-88]. (See "Intraoperative fluid
management", section on 'Hydroxyethyl starches'.)
Transfusion of red blood cells is uncommon prior to CPB but may be necessary in response
to sudden blood loss, or while preparing for initiation of CPB in patients with severe anemia.
Urine output is measured before CPB, confirming proper placement of the Foley catheter
and adequate bladder drainage, and subsequently as a gross indicator of renal perfusion
and function. Effects of anesthesia and surgery typically reduce glomerular filtration and
tubular function and may reduce urine output in the prebypass period [89]. Urine output is
also monitored during CPB as a surrogate for end-organ perfusion.
Remote ischemic preconditioning (RIPC), the application of repeated cycles of blood flow
restriction typically in an upper extremity, has shown some association with reduced
incidence of AKI, particularly with concurrent volatile anesthesia use [90,91].
PREPARATIONS FOR CARDIOPULMONARY BYPASS
Prior to initiating cardiopulmonary bypass (CPB), several key steps must be completed, as
noted in separate topics ( table 1).
● Systemic anticoagulation – Systemic anticoagulation is necessary before aortic

cannulation and subsequent initiation of CPB. Typically, this is accomplished with an
intravenous (IV) dose of heparin 300 to 400 units/kg, with confirmation of adequacy of
systemic anticoagulation to prevent clot formation in the CPB circuit. Details regarding
heparin administration and monitoring are available in a separate topic. (See "Blood
management and anticoagulation for cardiopulmonary bypass", section on 'Systemic

anticoagulation'.)
● Antifibrinolytic administration – Prophylactic antifibrinolytic therapy using a lysine

analog (eg, epsilon-aminocaproic acid [EACA] or tranexamic acid [TXA]) is typically
administered shortly after systemic heparinization to decrease microvascular bleeding
in the postbypass period. Details are available in a separate topic. (See "Blood
management and anticoagulation for cardiopulmonary bypass", section on
'Antifibrinolytic administration'.)
● Cannulation of the great vessels – To initiate CPB, aortic and venous cannulation are
necessary to divert the patient's blood from the heart and lungs, with rerouting to the
extracorporeal circuit. (See "Initiation of cardiopulmonary bypass", section on 'Aortic,
venous, and coronary sinus cannulation'.)
MANAGEMENT OF CARDIOPULMONARY BYPASS
Initiation of cardiopulmonary bypass (CPB), management during CPB, and weaning from CPB
are discussed in separate topics ( table 1):
● (See "Initiation of cardiopulmonary bypass".)
● (See "Management of cardiopulmonary bypass".)
● (See "Weaning from cardiopulmonary bypass".)
MANAGEMENT DURING THE POSTBYPASS PERIOD
Key steps for any cardiac surgical procedure in the period immediately after
cardiopulmonary bypass (CPB) include venous and arterial decannulation and reversal of
anticoagulation with protamine administration ( table 1) (see "Achieving hemostasis after
cardiac surgery with cardiopulmonary bypass", section on 'Reversal of anticoagulation
activity'). Residual pump blood is reinfused, and temporary or backup epicardial pacing wires
are inserted.
Management of cardiovascular problems — Cardiovascular problems that result in

hemodynamic instability are identified and treated ( table 5 and table 3). (See
"Intraoperative problems after cardiopulmonary bypass", section on 'Cardiovascular
problems'.)
Similar cardiovascular problems may be encountered after cardiac surgical repairs

accomplished without the aid of CPB (eg, off-pump coronary artery bypass grafting [CABG]
surgery). (See "Anesthesia for coronary artery bypass grafting surgery", section on 'Off-pump
coronary artery bypass surgery'.)
Postbypass management of fluids and blood products — After weaning from CPB,
intravascular volume status is reevaluated with transesophageal echocardiography (TEE)
assessments (see 'Postbypass transesophageal echocardiography' below), with consideration
of hemodynamic parameters such as blood pressure, central venous pressure (CVP),
pulmonary artery pressure (PAP), cardiac output, and mixed venous oxygen saturation
(SvO2). Serial lactate and/or base deficit values on arterial blood gases can also be useful to
guide fluid therapy. Fluid administration may be necessary due to treat hypovolemia, or
transfusion of red blood cells may be necessary due to persistent surgical bleeding.
Decisions regarding transfusion are individualized, but hemoglobin is typically maintained
≥7.5 g/dL [92-96]. (See "Achieving hemostasis after cardiac surgery with cardiopulmonary
bypass", section on 'Transfusion of red blood cells'.)
Management of other systemic problems — Other systemic complications (eg, pulmonary,

metabolic, renal) are frequently encountered immediately after weaning from CPB while the
patient is still in the operating room. These problems are often predictable based on patient-
specific and cardiac surgical procedure-specific factors. However, some patients experience
unpredictable, sudden, or severe complications that require immediate intervention and/or
urgent reinstitution of CPB. Management of these problems is discussed separately. (See
"Intraoperative problems after cardiopulmonary bypass".)
Postbypass transesophageal echocardiography — TEE examination immediately after

cardiac surgery emphasizes the following aspects [39]:
● Adequacy of any surgical repair (eg, repair or replacement of a cardiac valve) is

assessed.
● Global left ventricular (LV) and right ventricular (RV) function are evaluated.
● LV and RV chamber sizes are assessed to determine intravascular volume status

( movie 13). This is important because CVP and PAP measurements are poor
predictors of intravascular volume and fluid responsiveness [97]. (See "Intraoperative
transesophageal echocardiography for noncardiac surgery", section on 'Volume
status'.)
● LV regional wall motion abnormalities (RWMAs) are documented as part of the overall
assessment of the adequacy of revascularization in territories of myocardium perfused
by each of the major coronary arteries supplying the LV ( figure 2 and figure 3).
(See "Anesthesia for coronary artery bypass grafting surgery", section on 'Postbypass
transesophageal echocardiography'.)
Previously ischemic or hibernating myocardium may show improved function in the

early postbypass period. However, myocardial stunning is common and consequently,
myocardial segments that had abnormal contraction in the prebypass period may
remain impaired even after adequate coronary blood flow has been restored.
Significant deterioration of regional wall motion in previously normal myocardial

segments may indicate a technical problem with a coronary graft (eg, poor quality of a
bypass graft anastomosis, kinking, vasospasm, or embolization of air or
microparticulate debris into the graft) ( movie 14). Poor graft flow can be confirmed
by a Doppler flow probe applied to the graft. ST-segment changes on the
electrocardiogram (ECG) or hypotension with low cardiac output may also be noted.
Detection of such problems allows surgical correction prior to leaving the operating
room. (See "Intraoperative problems after cardiopulmonary bypass", section on
'Surgical or technical problems'.)
In patients who require ventricular pacing after CPB, a distinct septal motion
abnormality termed "septal bounce" is often observed; this occurs due to the abnormal
pattern of ventricular depolarization that accompanies RV epicardial pacing
( movie 15). Septal bounce can be distinguished from a true RWMA because septal
thickening persists during ventricular pacing but is absent when the septum is
ischemic. If this is difficult to discern visually, a brief pause in ventricular pacing may be
helpful.
New or worsening mitral regurgitation (MR) in the postbypass period should prompt a
thorough evaluation for LV RWMAs indicating an ischemic cause of the MR.
● Hypotension after cardiac surgical procedures may occasionally be caused by dynamic

LV outflow tract obstruction with systolic anterior motion of the mitral leaflets [98].
● If aortic dissection is suspected following decannulation (eg, in a patient with a calcific

or diffusely atheromatous ascending aorta, or one who develops postbypass
hypotension that is unresponsive to treatment), the ascending aorta is evaluated to
identify this potentially fatal complication ( image 7).
TEE is also used for continuous monitoring throughout the postbypass period to assess
ventricular volume and function, and to aid diagnosis of hypotension. The TEE probe is left in
place until the patient is ready for transport to the intensive care unit.
Postbypass ventilation — As noted above, we use an intraoperative lung-protective

ventilation strategy in the prebypass and postbypass period (with low tidal volume [TV], low
driving pressure, and positive end-expiratory pressure [PEEP]) to potentially reduce the
incidence of pulmonary complications [73,74]. (See 'Prebypass ventilation strategies' above
and "Mechanical ventilation during anesthesia in adults", section on 'Lung protective

ventilation during anesthesia'.)
Sternotomy closure — Hemostasis must be achieved prior to closure of the sternotomy

wound. Management of bleeding and coagulopathy in the postbypass period can be
challenging, as discussed in detail separately. (See "Achieving hemostasis after cardiac
surgery with cardiopulmonary bypass", section on 'Achieving hemostasis and management
of bleeding'.)
With chest closure, it is common to see minor decreases in arterial blood pressure with
concomitant increases in CVP and/or PAP. This occurs due to cardiac chamber compression
as the sternum is reapproximated. TEE is employed to verify that hypotension is not the
result of new RWMAs that may result from kinking or occlusion of a newly placed bypass
graft.
In rare cases, sternal closure is not possible due to persistent bleeding, hemodynamic
instability caused by compression of the right atrium and ventricle, or other technical
problems. In these instances, an Esmarch bandage is sutured to the open sternal edges to
"close" the wound prior to leaving the operating room. (See "Intraoperative problems after
cardiopulmonary bypass", section on 'Inability to close the sternum'.)
Transport and handoff in the intensive care unit
Preparation for transport — Optimal patient condition for transport to the intensive care
unit (ICU) is ensured as surgery concludes (eg, hemodynamic stability, control of bleeding
and coagulopathy, adequate oxygenation and ventilation). A final arterial blood gas is
obtained to assess PaO2 and base deficit, and point-of-care tests are obtained to check
hemoglobin (Hgb), potassium, and calcium levels. A final transesophageal echocardiography
(TEE) evaluation of ventricular function and volume status is performed, and appropriate
adjustments in inotropic, vasodilator, or fluid therapy are made.
If there is clinical evidence for ongoing hemodynamic instability evidenced by refractory

hypotension, low measured cardiac index, metabolic acidosis, persistent electrocardiogram
(ECG) changes (particularly ST-segment elevation), or significant deterioration in regional or
global left ventricular (LV) or right ventricular (RV) function noted with TEE, then we often
insert a pulmonary artery catheter (PAC) before the patient leaves the operating room. The
continuous hemodynamic data provided by a PAC may be useful for ongoing resuscitation in
the ICU since continuous TEE monitoring will no longer be available in the postoperative
period. PAC placement under controlled conditions in the operating room is preferred to
urgent or emergency placement in an unstable patient after transport to the ICU. Risks
during insertion include inducing ventricular fibrillation, particularly in patients with active
RV ischemia [99].
Continuous infusion of an intravenous (IV) sedative such as propofol or dexmedetomidine is

initiated before discontinuing the volatile inhalation anesthetic. Adequate time for the
selected IV agent to reach steady plasma concentrations should be allowed in the final
minutes before leaving the operating room so that the patient remains adequately sedated
during transport. (See "Monitored anesthesia care in adults", section on 'Propofol' and
"Monitored anesthesia care in adults", section on 'Dexmedetomidine'.)
Transport to the intensive care unit — Details regarding transport to the intensive care
unit are discussed separately. (See "Transport of surgical patients" and "Transport of surgical
patients", section on 'Considerations for critically ill patients'.)
In rare cases, direct transport to a cardiac catheterization suite for emergency coronary
angiography may be necessary after cardiac surgery (eg, if acute coronary ischemia is
suspected or if hemodynamic instability of unclear etiology persists) [100].
Handoff in the intensive care unit — Upon arrival in the ICU, patient information is
communicated from the surgical team to the ICU team using a formal process that is termed
a "handoff," or "handover." The table outlines one suggested handover protocol ( table 6)
[101-103]. In all cases, the anesthesiologist should remain with the patient until
hemodynamic and overall stability are ensured. (See "Handoffs of surgical patients", section
on 'Operating room to intensive care unit'.)
In a 2018 literature review of 21 studies (4568 patients), a structured interdisciplinary

handover from the operating room to the ICU after cardiac surgery was associated with
prevention of adverse events (seven studies), as well as with improved provider satisfaction
(13 studies), handoff completeness (18 studies), and compliance with process measures such
as efficiency in transfer of equipment and technology and handoff of critical information,
compared with unstructured handoffs [104].
EMERGENCY CARDIAC SURGICAL PROCEDURES
Patients requiring emergency surgery have a high risk for morbidity and mortality [16,105-
108]. (See "Preoperative evaluation for anesthesia for cardiac surgery", section on
'Emergency surgery' and "Anesthesia for aortic surgery with hypothermia and elective
circulatory arrest in adult patients", section on 'Preanesthetic assessment and planning'.)
Considerations for emergency or high-risk cases include:
● Patients with actual or potential hemodynamic instability may present to the operating
room with an intraaortic balloon pump (IABP) in place, or the surgeon may plan to
insert an IABP after induction of general anesthesia or before termination of
cardiopulmonary bypass (CPB). Notably, an IABP is contraindicated if the patient has
significant aortic regurgitation (AR). (See "Anesthesia for cardiac valve surgery", section
on 'Prebypass TEE assessment' and "Intraaortic balloon pump counterpulsation".)
● All monitoring should be established before (rather than after) anesthetic induction if
possible, including insertion of the intra-arterial catheter and placement of a central
venous catheter (CVC).
● External defibrillator pads should be placed on the patient prior to induction, and a
functioning pacemaker/defibrillator should be ready at the bedside. If atrial or
ventricular fibrillation occur, appropriate and immediate cardioversion or defibrillation
is typically necessary unless the surgical team can rapidly insert arterial and venous
cannulae to initiate CPB.
● In some cases, prepping and draping in preparation for surgery should be completed
while the patient is still awake, with the entire operating room team present and ready
to urgently establish CPB if cardiac arrest occurs during anesthetic induction.
● Inotropic and vasopressor infusions should be connected in the CVC ports, ready to
infuse.
● Induction of anesthesia is performed with agents that cause minimal change in

hemodynamics. Examples include etomidate 0.3 mg/kg or fentanyl 5 to 10 mcg/kg
combined with midazolam 0.05 to 0.1 mg/kg. Anesthesia is subsequently maintained
during the prebypass period with appropriate doses of volatile inhalation anesthetic.
● Hemodynamic stability is carefully maintained during the prebypass period. Typically,

vasoactive drug infusions are required to maintain adequate blood pressure and
cardiac output ( table 3). Atrial pacing may be necessary to establish optimum heart
rate, or atrioventricular (AV) pacing may be necessary if heart block is present.
● CPB is established as quickly as possible. (See "Initiation of cardiopulmonary bypass".)
● Postbypass problems should be anticipated, as noted below after surgery for each
lesion. (See "Intraoperative problems after cardiopulmonary bypass" and "Anesthesia
for cardiac valve surgery", section on 'Postbypass management' and "Anesthesia for
cardiac valve surgery", section on 'Postbypass management' and "Anesthesia for
cardiac valve surgery", section on 'Postbypass management' and "Anesthesia for
cardiac valve surgery", section on 'Postbypass management'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Management of
cardiopulmonary bypass".)
SUMMARY AND RECOMMENDATIONS
● Premedication – Some cardiac surgical patients benefit from premedication with small
incremental doses of a short-acting intravenous (IV) benzodiazepine (eg, midazolam 1
to 2 mg) and/or opioid (eg, fentanyl 50 mcg), administered under the anesthesiologist's
observation. However, titration of smaller doses is warranted in older patients with
critical cardiac lesions.
● Monitoring – Cardiac surgery is conducted using standard American Society of

Anesthesiologists (ASA) monitors ( table 2), as well as intra-arterial and central
venous access. We also monitor urine output, degree of neuromuscular blockade
(using a peripheral nerve stimulator), and temperature. Furthermore, for most cardiac
surgical cases, we use transesophageal echocardiography (TEE), processed
electroencephalography (EEG), and point-of-care (POC) testing of laboratory values.
Additional monitoring with a pulmonary artery catheter (PAC) or a cerebral oximetry
monitor may be employed in selected patients. (See 'Monitoring' above.)
● TEE considerations – Intraoperative TEE is often used during cardiac surgery to

confirm and refine preoperative diagnoses, detect new or unsuspected cardiovascular
pathology that may alter anesthetic or surgical plans, and guide PAC positioning. We
conduct an initial comprehensive prebypass TEE examination, followed by continuous
use of the TEE to monitor ventricular function and volume. In the postbypass period,
TEE is used to assess results of all surgical interventions while the patient is still in the
operating room. Even if TEE is not used electively, rapid deployment may be needed to
diagnose causes of acute, persistent, and life-threatening hemodynamic instability (ie,
"rescue" TEE). (See 'Prebypass transesophageal echocardiography' above and
'Postbypass transesophageal echocardiography' above.)
● Induction of anesthesia – The most common anesthetic induction technique includes

use of a low dose of a sedative-hypnotic agent combined with a low dose of opioid and
volatile anesthetic agent ("balanced technique"). Administration of higher doses of a
synthetic opioid is avoided in patients participating in enhanced recovery after cardiac
surgery (ERACS) protocols to avoid prolonged respiratory depression and need for
mechanical ventilation. (See 'Induction techniques' above and "Anesthetic management
for enhanced recovery after cardiac surgery (ERACS)".)
● Maintenance of anesthesia – We suggest maintenance of general anesthesia with a

volatile anesthetic agent (Grade 2C). Use of a total intravenous anesthetic (TIVA)
technique or combinations of volatile and intravenous agents are reasonable
alternatives to maintain adequate anesthetic depth and prevent movement during

surgery. Neuromuscular function is monitored with a peripheral nerve stimulator
during CPB. (See 'Maintenance techniques' above.)
● Lung-protective ventilation – We use a lung-protective ventilation strategy before and

after cardiopulmonary bypass (CPB) with low tidal volume [TV], low driving pressure,
and positive end-expiratory pressure [PEEP]) to potentially reduce the incidence of
pulmonary complications. (See 'Prebypass ventilation strategies' above and 'Postbypass
ventilation' above.)
● Fluid management – Judicious fluid administration (usually with a balanced crystalloid

solution rather than a colloid solution) prior to CPB is typically restricted to small
volumes because initiation of CPB results in significant hemodilution as the CPB circuit
prime mixes with the patient's blood volume. We suggest avoiding hydroxyethyl starch
(HES) colloid solutions (Grade 1B), due to concerns regarding increased risk of bleeding
and transfusion, and possibly acute kidney injury (AKI). After weaning from CPB and
return of reservoir pump blood, intravascular volume status is reevaluated and treated.
Decisions regarding transfusion of blood products are individualized, but hemoglobin is
typically maintained ≥7.5 g/dL. (See "Intraoperative fluid management", section on
'Choosing fluid: Crystalloid, colloid, or blood' and 'Prebypass fluid management' above
and 'Postbypass management of fluids and blood products' above.)
● Management during CPB – Key steps for intraoperative management of CPB are
noted in the table ( table 1), and are discussed in detail in separate topics:
• (See "Blood management and anticoagulation for cardiopulmonary bypass".)
• (See "Initiation of cardiopulmonary bypass".)
• (See "Management of cardiopulmonary bypass".)
• (See "Weaning from cardiopulmonary bypass".)
• (See "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass".)
● Management after CPB – Key steps for the period immediately after CPB are noted in
the ( table 1). Cardiovascular and other systemic problems in the postbypass period
are identified and treated ( table 5). (See 'Management during the postbypass period'
above and "Intraoperative problems after cardiopulmonary bypass".)
● Emergency or high-risk procedures – Considerations for emergency or high-risk

cardiac surgical procedures are discussed above. (See 'Emergency cardiac surgical
procedures' above.)
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Topic 126473 Version 17.0
GRAPHICS
Key periods during cardiac surgery
Period Anesthetic goals

Prebypass period Induction and Maintain optimal myocardial O2 supply and minimize
maintenance of demand to prevent or treat ischemia
anesthesia
Antibiotic Timely administration of selected antibiotics

prophylaxis
Positioning Careful arm, hand, and head positioning to avoid injuries
Fluid Restrict fluid administration since initiation of CPB causes

management 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 painful stimuli

sternotomy Briefly interrupt ventilation during sternotomy to avoid
lung injury
Harvesting of the Reduce tidal volume

internal
mammary artery
Anticoagulation Administer heparin and ensure adequate anticoagulation

for CPB (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 cannulation Reduce systolic BP to <100 mmHg to reduce risk of aortic

dissection
Venous Treat hypotension or initiate CPB for malignant

cannulation arrhythmias
Initiation of CPB Retrograde Gradual onset of CPB to reduce hemodilution from

autologous crystalloid prime
priming
Control of O2 Discontinue controlled ventilation and anesthetic

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

administration attached to CPB circuit, or use TIVA technique
Monitor raw and/or processed EEG and expired
anesthetic gas from the oxygenator to prevent awarenes
Monitor neuromuscular function; administer NMBAs to
prevent movement or shivering
Placement of Ensure complete myocardial arrest (absence of ECG

aortic crossclamp electrical activity)
and TEE monitoring for aortic insufficiency and LV distension
administration of during antegrade cardioplegia delivery
cardioplegia
Placement and TEE assessment of coronary sinus catheter placement for

monitoring of retrograde cardioplegia delivery
coronary sinus Monitor coronary sinus pressure
catheter and LV
TEE assessment of correct LV vent placement and
vent
effective LV decompression
Maintenance of Cooling Maintain temperature gradient between venous inflow

CPB 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 aortic Defibrillate and administer antiarrhythmic agents if

crossclamp necessary to treat ventricular fibrillation
Weaning from Refer to UpToDate topic on weaning from

CPB cardiopulmonary bypass (CPB)
Post-bypass Venous Ensure initial reinfusion of blood drained from the venou
decannulation tubing into the pump reservoir in 50- to 100-mL aliquots
TEE assessment for adequate ventricular filling
Anticoagulation Administer protamine slowly, treat protamine reactions

reversal, pump Ensure complete reversal of anticoagulation
suckers turned
off, intravascular
vents removed
Aortic Reduce systolic BP to <100 mmHg to reduce risk of aortic

decannulation 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 ICU Ensure optimal patient condition prior to transport

and 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.
Graphic 108173 Version 2.0
Basic monitoring during anesthesia
Primary physiologic
Monitoring Derived Additio
process/parameter Principle
equipment information functi
targeted
Oxygenation Inspired gas O2 analyzer Paramagnetic Inspired/expired A low-level a

O2 content (with a low- sensor, fuel O2 concentration automaticall
limit alarm in (galvanic) cell, when placed activated by
use) polarographic downstream on the anest
(Clark) electrode, from fresh flow machine
mass control valves
spectroscopy, or
Raman scattering.
Blood Pulse The Beer-Lambert Hemoglobin Continuous

oxygenation oximeter law applied to saturation, pulse evaluation of
tissues and rate, relative circulation, v
pulsatile blood pulse amplitude pitch pulse t
flow. The relative displayed on and audible
absorbency at plethysmography threshold ala
wavelengths of waveform
660 and 940 nm is
used to estimate
saturation, which
is derived from
the ratio of
oxyhemoglobin to
the sum of
oxyhemoglobin
plus
deoxyhemoglobin.
Ventilation Exhaled CO2 Capnograph CO2 molecules ETCO2, inspired Instantaneou

absorb infrared CO2, diagnostic information
radiation at 4.26 waveforms, Perfusi
micrometers, respiratory rate, effectiv
proportionate to apnea detection is being
the CO2 transpo
concentration throug
present in the vascula
breath sample. system
Metabo
(how ef
CO2 is b
produc
cellular
metabo
Confirm
of trach
tube
placem
after
intubat
Integrity of Disconnection Detects the Alarms if a Alarms if hig

ventilation alarm cyclical changes in significant pressures ar
system airway pressure in decrease in rate sensed
during the normal range. or pressure
mechanical occurs
ventilation
Pulmonary Pulmonary Volume of gas Inspired and Pressure vol

mechanics flow and proportional to a expired volume, and flow volu
(volume, pressure drum movement, flow, and airway loops
flow, sensors changes in pressure
pressure) differential
pressure (near the
Y-connector) or in
electrical
resistance (hot
wire housed in a
monitor or
ventilator).
Circulation Cardiac ECG The ECG monitor Heart rate and ST segment
activity detects, amplifies, rhythm depression/e
displays, and and trend ov
records the ECG with an audi
signal. alarm warnin
significant
arrhythmias
asystole
Arterial BP Noninvasive Oscillometric Arterial BP Indicator of o

BP monitor devices perfusion
automatically
inflate and deflate
the cuff, and have
electronic
pressure sensors
that record the
pressure
oscillations of the
arteries. The
pressure at which
maximal
oscillations occur
as the cuff is
deflated
corresponds with
MAP. Proprietary
algorithms are
used to calculate
systolic and
diastolic BP.
Temperature Temperature Devices with a Core or A greater tha

monitor semiconductor, peripheral core-to-perip
electrical temperature temperature
resistance gradient is in
decreases as of low cardia
temperature output
decreases.
BP: blood pressure; CO2: carbon dioxide; ECG: electrocardiogram; ETCO2: end-tidal carbon dioxide;
MAP: mean arterial pressure; O2: oxygen.
Placement of transcutaneous pacemaker/defibrillator pads for sternotomy

incision
Pads are placed to ensure that the heart is between the two pads, but that neither pad will be in the
sterile surgical field.
Treatment algorithm for regional cerebral oxygen desaturation during

cardiopulmonary bypass*
rSO2: regional oxygen saturation index; CVP: central venous pressure; CPB: cardiopulmonary bypass;
MAP: mean arterial pressure; SaO2: oxygen saturation of arterial blood; FiO2: fraction of inspired
oxygen; PaCO2: partial pressure of carbon dioxide; Hgb: hemoglobin; RBC: red blood cells; O2: oxygen.
* When using this algorithm to treat cerebral oxygen desaturation, it is important to verify the
accuracy of the monitoring equipment, particularly if unexpected values are encountered or sensor
signal levels are inconsistent (suggesting a technical measurement problem).
¶ If rSO2 has not returned to baseline, continue assessments and treat abnormalities, as noted in the
algorithm.
Δ When low MAP is identified, always verify adequate CPB pump flow before administering
pharmacologic treatment (ie, vasopressors).
◊ Administering 100% O2, even if the SaO2 is within normal limits, may improve O2 delivery by
increasing the O2 content dissolved in arterial blood.
Adapted from:
1. Subramanian B, Nyman C, Fritock M, et al. A multicenter pilot study assessing regional cerebral oxygen desaturation
frequency during cardiopulmonary bypass and responsiveness to an intervention algorithm. Anesth Analg 2016;
122:1786.
2. Denault A, Deschamps A, Murkin JM. A proposed algorithm for the intraoperative use of cerebral near-infrared
spectroscopy. Semin Cardiothorac Vasc Anesth 2007; 11:274.
3. Kara I, Erkin A, Sach H, et al. The effects of near-infrared spectroscopy on the neurocognitive functions in patients
undergoing coronary artery bypass grafting with asymptomatic carotic artery disease: A randomized prospective study.
Ann Thorac Cardiovasc Surg 2015; 21:544.
TEE assessment of LV diastolic dysfunction using pulsed wave tissue Doppler

of the mitral annulus (center panels) and pulsed wave Doppler of the mitral
inflow (right panels)
Accurate identification of each Doppler spectral peak requires an accompanying electrocardiographic

tracing. Conditions such as atrial fibrillation, mitral annular calcification, mitral valve surgery, or
extracorporeal circulatory support generally preclude using these Doppler techniques.
A: late mitral inflow velocity resulting from atrial contraction; E: early mitral inflow velocity; e′: early
mitral annular velocity recorded from the lateral mitral annulus.
From: Maxwell C, Konoske R, Mark J. Emerging concepts in transesophageal echocardiography. F1000Research 2016; 5:340.
DOI: 10.12688/f1000research.7169.1. Reproduced under the terms of the Creative Commons Attribution License.
LV perfusion territories
The regional distribution of LV segmental wall motion abnormalities detected by TEE can be used to
help determine the location of disease within the coronary arteries. The diagram displays the typical
territories of myocardium perfused by each of the major coronary arteries supplying the LV in the TEE
mid-esophageal four-chamber view, TEE mid-esophageal two-chamber view, TEE mid-esophageal
long-axis view, and TEE transgastric LV short-axis view. Anatomic variations and coronary collateral
flow may produce different patterns of coronary perfusion in individual patients.
LV: left ventricle/left ventricular; TEE: transesophageal echocardiography; LAD: left anterior
descending; Cx: circumflex; RCA: right coronary artery.
Modified from: Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative
multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography
Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in
Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr 1999; 12:884.
LV segmental anatomy
The regional distribution of myocardial ischemia can be detected as segmental LV wall motion
abnormalities by TEE. The entire LV in the 17-segment model can be imaged in long-axis using a
combination of the TEE mid-esophageal four-chamber view (a), TEE mid-esophageal two-chamber
view (b), and TEE mid-esophageal long-axis view (c). Alternatively, all 17 LV wall segments can be
imaged using the TEE transgastric LV short-axis views at the levels of the LV base (d), papillary muscles
(e), and apex (not shown). Alternatively, an earlier version of a 16-segment LV model that excludes the
apical cap is often used for TEE studies.
LV: left ventricle/left ventricular; TEE: transesophageal echocardiography.
Modified from: Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a comprehensive intraoperative
multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography
Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in
Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr 1999; 12:884.
Midesophageal 2-chamber TEE image of left ventricular thrombus
This midesophageal 2-chamber TEE image demonstrates a large (18 mm x 53 mm) anterior-apical left
ventricular thrombus.
TEE: transesophageal echocardiography.
TEE in the mid-esophageal long axis imaging plane and epiaortic scan
A TEE still in the mid-esophageal long axis imaging plane (A) demonstrates heavy calcification of the
root, sinotubular junction, and tubular ascending aorta. There is a particularly heavy calcium burden
on the posterior wall (nearest to the TEE probe). An epiaortic scan (B) of the same patient
demonstrates a significant circumferential atheroma, which would preclude cannulation or cross-
clamping at this site.
Color flow Doppler of severe aortic regurgitation
Color flow Doppler mid-esophageal five-chamber view from a transesophageal echocardiogram. The
outflow tract is completely occupied by the aortic regurgitant color flow jet (AR jet); when the jet
exceeds 65% of the left ventricular outflow tract (LVOT) width, the regurgitation is judged severe.
Ao: aorta; LV: left ventricle.
Vena contracta measurement in aortic insufficiency
From the mid-esophageal aortic valve long-axis view, a color-flow video loop of the regurgitant jet
through the aortic valve should be captured in diastole. The video should be cycled through until the
peak diastolic flow is observed in a still frame (shown here). To make a valid measurement, the frame
must contain the hemisphere of flow acceleration on the aortic valve side of the outflow tract, a clear
image of the narrowest neck of the jet, and the jet itself in the left ventricular outflow tract. Aliasing
velocities should be between 40 and 60 cm/s, and the focus should be at the level of the valve. The
vena contracta is measured at the narrowest neck of the jet (illustrated in the image on the right). This
measurement is reproducible and relatively independent of load, making it an attractive tool for
quantifying the severity of aortic regurgitation using intraoperative TEE.
Holodiastolic flow reversal AI
Holodiastolic flow reversal seen in the descending aorta, suggesting severe aortic regurgitation. Note
the presence of the ECG, which can be used to time systole and diastole.
AI: aortic insufficiency; ECG: electrocardiogram.
Vasopressors and inotropic agents used in the operating room: Adult

dosing* ¶
Functional class
Bolus
Drug (predominant receptor or Infusion dose Com
dose
mechanism of action)
Ephedrine Inotrope/chronotrope/vasopressor 5 to 10 mg N/A Tachy

(alpha1-adrenergic receptor boluses occur
agonist; beta1- and beta2- repea
adrenergic receptor agonist) to ind
postsy
releas
norep
Cardio
effect
by dru
ephed
into a
nerve
or tho
deple
norep
reserv
reserp
Admin
extrem
(eg, in
increm
of 2.5
patien
mono
oxida
inhibi
metha
since
hyper
respo
threat
dysrh
occur
Phenylephrine Vasopressor (alpha1-adrenergic 50 to 100 10 to 100 Often

receptor agonist) mcg mcg/minute treat
boluses norm
or
(may begin HR is
infusion if 0.1 to 1
Genet
repeated mcg/kg/minute
polym
bolus lead t
doses are indivi
necessary) respo
Norepinephrine Inotrope/vasopressor (alpha1- and 4 to 8 mcg 1 to 20 mcg/minute Often

beta1-adrenergic receptor agonist) (may begin first-li
or
infusion if durin
repeated 0.01 to 0.3
surge
bolus mcg/kg/minute
for tre
doses are most
necessary) Norep
mcg i
appro
equiv
poten
pheny
mcg
Periph
extrav
high c
may c
dama
Epinephrine Inotrope/chronotrope/vasopressor 4 to 10 1 to 100 First-l

(alpha1-adrenergic receptor mcg mcg/minute for ca
agonist; beta1- and beta2- initially; up and fo
or
adrenergic receptor agonist) to 100 mcg May b
boluses 0.01 to 1
admin
may be mcg/kg/minute
or via
used when endot
initial in em
Note changing
response is
effects across dose Low d
inadequate
range: bronc
Low doses effect
have primarily cause
beta2- vasod
adrenergic decre
effects at 1 to 2 Interm
mcg/minute or cause
0.01 to 0.02 HR an
mcg/kg/minute High d
Intermediate vasoc
doses have with p
primarily hyper
beta1- and adver
beta2- effect
adrenergic Indivi
effects at 2 to respo
10 mcg/minute
or 0.02 to 0.1 relate

mcg/kg/minute variab
High doses
have primarily
alpha1-
adrenergic
effects at 10 to
100
mcg/minute or
0.1 to 1
mcg/kg/minute
Vasopressin Vasopressor (vasopressin1 and 1 to 4 units 0.01 to 0.04 Effect

vasopressin2 receptor agonist) units/minute treatm
hypot
refrac
Doses >0.04
admin
units/minute up to
catech
0.1 units/minute are
symp
reserved for salvage
such a
therapy (ie, failure to
pheny
achieve adequate BP
norep
goals with other
No di
vasopressor
HR
agents) ¶
Little
can ca
splan
vasoc
Indivi
respo
relate
variab
Periph
extrav
cause
Dopamine Inotrope/vasopressor/dose- N/A 2 to 20 Low d

dependent chronotropy mcg/kg/minute exace
(dopaminergic, beta1-, beta2-, and hypot
alpha1-adrenergic receptor beta2
agonist) Note changing
High d
effects across dose
cause
range:
vasoc
Low doses
adver
have primarily
effect
dopaminergic
arrhyt
effects at <3
mcg/kg/minute
Intermediate
doses have
primarily
beta1- and
beta2-
adrenergic
effects at 3 to
10
mcg/kg/minute
High doses
have primarily
alpha1-
adrenergic
effects >10
mcg/kg/minute
Dobutamine Inotrope/vasodilator/dose- N/A 1 to 20 Exace

dependent chronotropy (beta1- mcg/kg/minute hypot
and beta2-adrenergic receptor possib
agonist) dose-
vasod
beta2
concu
admin
poten
vasoc
such a
norep
vasop
neces
Milrinone Inotrope/vasodilator N/A 0.375 to 0.75 Exace

(phosphodiesterase inhibitor) mcg/kg/minute (a hypot
(decreases rate of cyclic adenosine loading dose of 50 due to
monophosphate [cAMP] mcg/kg over ≥10 (via
degradation) minutes may be phosp
administered, but inhibi
may be omitted to concu
avoid hypotension) admin
poten
vasoc
such a
norep
vasop
neces
Isoproterenol Inotrope/chronotrope/vasodilator N/A 5 to 20 mcg/minute Exace

(beta1- and beta2-adrenergic hypot
or
receptor agonist) due to
0.05 to 0.2
depen
mcg/kg/minute
vasod
beta2
May c
arrhyt
Not av
most
N/A: not applicable; HR: heart rate; IV: intravenous; IM: intramuscular; BP: blood pressure; PVR:
pulmonary vascular resistance.
* Dose ranges are based on adult patients of average size.
¶ Refer to related UpToDate content on hemodynamic management during anesthesia and surgery.
Antimicrobial prophylaxis for cardiac surgery in adults
Usual
Nature of Recommended Redose
Common pathogens adult
operation antimicrobials interval ¶
dose*
Cardiac Staphylococcus Cefazolin Δ <120 kg: 2 4 hours

procedures: aureus, Staphylococcus epidermidis g IV
coronary artery
≥120 kg: 3
bypass, cardiac
g IV
device
insertion
OR cefuroxime 1.5 g IV 4 hours ◊
procedures
(eg, pacemaker OR vancomycin § 15 mg/kg N/A
implantation), IV (max 2
placement of g)
ventricular
assist devices OR clindamycin 900 mg IV 6 hours
IV: intravenous.
* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes
before the procedure. If vancomycin is used, the infusion should be started within 60 to 120 minutes
before the initial incision to have adequate tissue levels at the time of incision and to minimize the
possibility of an infusion reaction close to the time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive
burns, additional intraoperative doses should be given at intervals 1 to 2 times the half-life of the drug
for the duration of the procedure in patients with normal renal function.
Δ Cefazolin is preferred over cefuroxime, given increasing resistance to second-generation

cephalosporins. Indications for vancomycin are summarized in footnote §. Clindamycin may be used
for patients unable to tolerate the other agents listed.
◊ Some experts recommend an additional dose when patients are removed from bypass during
open-heart surgery.
§ Use of vancomycin is appropriate in hospitals in which methicillin-resistant S. aureus (MRSA) and S.

epidermidis are a frequent cause of postoperative wound infection, in patients previously colonized
with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may
cause hypotension, which could be especially dangerous during induction of anesthesia. Even when
the drug is given over 60 minutes, hypotension may occur; treatment with diphenhydramine and
further slowing of the infusion rate may be helpful. For procedures in which enteric gram-negative
bacilli are common pathogens, many experts would add another drug such as an aminoglycoside
(gentamicin 5 mg/kg IV), aztreonam (2 g IV), or a fluoroquinolone (ciprofloxacin 400 mg IV or
levofloxacin 500 mg IV).
Adapted from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg
Infect (Larchmt) 2013; 14:73.
Hemodynamic management of hypotension during and after weaning from

CPB
PADP
Cardiac Blood LV function RV function
CVP PAP or Diagn
output pressure by TEE by TEE
PAWP*
Low Low Low Low Low Normal or Normal or Hypovo

hyperdynamic hyperdynamic
Low or Low or Low or High Low Normal or Normal or Vasople

normal normal normal hyperdynamic hyperdynamic
High or High Low or High Low Normal Normal or Pulmon

normal normal ¶ hypocontractile hyperte
High Normal Normal Low Low Normal Hypocontractile, Right

or low or high ¶ often dilated ventric
dysfun
Normal Normal High Low Low Hypocontractile, Normal Left

or high or high often dilated ventric
dysfun
CPB: cardiopulmonary bypass; CVP: central venous pressure; PAP: pulmonary artery pressure; PADP:
pulmonary artery diastolic pressure; PAWP: pulmonary artery wedge pressure; LV: left ventricular; TEE:
transesophageal echocardiography; RV: right ventricular.
* PAWP should not be measured prior to neutralizing heparin following CPB. Initially, PADP is
measured, the PADP may overestimate PAWP when patients have elevated pulmonary vascular
resistance (eg, pulmonary hypertension).
¶ PADP or PAWP are indirect measures of LV filling pressure. With RV dysfunction and dilation,
ventricular septal shift may increase LV filling pressure despite low or normal LV filling volume.
Type A aortic dissection with aortic insufficiency
Intraoperative TEE image of the aortic valve, aortic root, and proximal ascending aorta in a long-axis
view, with color-flow Doppler imaging in diastole demonstrating severe aortic regurgitation with an
acute aortic dissection. The presence of an intimal flap in the aortic root (arrowheads) is diagnostic for
Stanford type A aortic dissection. Severe aortic regurgitation is present as a mosaic regurgitant jet in
the LVOT caused by acute enlargement of the aortic root due to the dissection.
LVOT: left ventricular outflow tract; Ao: ascending aorta; TEE: transesophageal echocardiography.
Protocol for "handoff" in the intensive care unit
Phase 1: Equipment and technology handoff
Monitoring transferred to ICU equipment

Ventilator function initiated
Infusions and fluids checked
Chest drains secured and on suction
Vital signs confirmed to be stable, ventilator functioning well, infusions running appropriately
Anesthesiologist, nurse, surgeon, and intensivist confirm that they are ready for information
transfer
Phase 2: Information handoff

Anesthesiologist presents:
Patient-specific information (age, weight, medical and surgical history, allergy status, baseline
vital signs, pertinent laboratory results, diagnosis, current condition and vital signs)
Anesthetic information (intraoperative course and any complications, lines present, blood
transfusion and fluid totals, doses of paralytic and opioids, antibiotics, current infusions, vital
sign parameters and limits, pain relief plan, laboratory values)
Surgeon presents:
Surgical course (diagnosis, operation performed, surgical findings, complications, blood loss,
drains)
If no intensivist present or if surgeon provides ICU care: further plans (antibiotic plan, deep
vein thrombosis [DVT] prophylaxis medication plan, tests to be done, nutrition, key goals for
the next 6 to 12 hours)
Intensivist presents:
Further plans (antibiotic plan, deep vein thrombosis [DVT] prophylaxis medication plan, tests to
be done, nutrition, key goals for the next 6 to 12 hours)
Phase 3: Questions and discussion
Ask ICU team if there are any questions or other points of clarification at the end of handoff
ICU: intensive care unit.

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23/2/24, 14:02 Anesthesia for cardiac surgery: General principles - UpToDate

Official reprint from UpToDate®

Anesthesia for cardiac surgery: General principles

Literature review current through: Jan 2024.

● (See "Anesthesia for cardiac valve surgery".)

● (See "Anesthesia for heart transplantation".)

Management of specific lesions and reoperation".)

● (See "Blood management and anticoagulation for cardiopulmonary bypass".)

● (See "Initiation of cardiopulmonary bypass".)

● (See "Management of cardiopulmonary bypass".)

● (See "Weaning from cardiopulmonary bypass".)

● (See "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass".)

● (See "Intraoperative problems after cardiopulmonary bypass".)

Multidisciplinary approaches including standardized preoperative, intraoperative and

after cardiac surgery (ERACS)".)

Cardiac surgery is conducted using standard American Society of Anesthesiologists (ASA)

Furthermore, for most cardiac surgical cases, we use transesophageal echocardiography

Noninvasive standard monitors

● Standard noninvasive monitors – Prior to induction, we place standard noninvasive

Other standard monitors

● Bladder catheter – A bladder catheter with a temperature probe is inserted after

● Temperature monitors – Temperature is monitored at several sites (see "Management

• A nasopharyngeal or tympanic membrane temperature probe is typically employed,

• A bladder catheter with a temperature probe is used to monitor "core temperature";

• If a PAC is inserted, pulmonary artery blood temperature is also monitored before

● Point-of-care laboratory testing – Routine intraoperative laboratory point-of-care

Intravascular cardiac monitors — Cardiac surgery requires continuous monitoring of the

● Sudden and/or severe hemodynamic changes may occur due to mechanical

● Effects of anesthetic and pharmacologic manipulations of the cardiovascular system

The following cardiovascular monitors are typically employed:

● Intra-arterial catheter – An intra-arterial catheter is inserted before anesthetic

If an intraaortic balloon pump (IABP) is in place, intra-arterial blood pressure may be

If surgery on the aortic arch or repair of aortic dissection is planned, it may be

We insert an introducer sheath such as a multi-lumen access catheter or sheath

● Pulmonary artery catheter – In selected patients, a PAC may be inserted to provide

We insert a PAC in patients with acute hemodynamic instability, preferably before

Selection of the type of PAC to be inserted is based on institution-specific availability

● Electroencephalography – We routinely employ a raw and/or processed

● Cerebral oximetry – NIRS cerebral oximetry monitoring and maintenance of regional

Prebypass transesophageal echocardiography — Practice guidelines of the American

We conduct an initial comprehensive prebypass TEE examination, followed by continuous

Initial transesophageal echocardiography examination

● Global systolic LV function is assessed and ejection fraction is evaluated using a

● Global LV diastolic function is assessed using a quantitative grading system (grade 1,

available in the absence of a PAC. Details regarding calculation of hemodynamic

Although rigorous quantitative grading of each myocardial segment is not typically

● RV function is assessed. Myocardial ischemia or exacerbation of pulmonary

● The thoracic aorta is evaluated for atheromatous disease, calcification, or dilatation

Identification of significant aortic regurgitation (AR) is particularly important

LAA or prominent trabeculations ( movie 11 and movie 12). Identification of LA or

Monitoring with transesophageal echocardiography — Subsequently, throughout the

● Development of hypovolemia or hypervolemia ( movie 13). (See "Intraoperative

● Development of low systemic vascular resistance as a cause of arterial hypotension.

● Factors causing hypotension, including abnormalities in:

• Preload or volume status (ie, hypovolemia or hypervolemic congestive heart failure)

Transesophageal echocardiography considerations for patients with COVID-19 — Since

● Type A aortic dissection.

● Myocardial infarction with anatomical complications (eg, papillary muscle rupture,

In some cases, alternative echocardiographic imaging modalities (eg, transthoracic

INDUCTION OF GENERAL ANESTHESIA

Regardless of the induction technique employed, hypotension may occur post-induction

avoided by reducing the dose of volatile agent, or treated by administering a vasopressor in

Higher-dose opioid technique — An alternative induction technique that is used less