Anesthesia For Cardiac Surgery - General Principles - UpToDate

22/9/22, 18:06 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: Aug 2022. | This topic last updated: Sep 19, 2022.
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 requiring deep hypothermia".)
● (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:
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:
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● (See "Blood management and anticoagulation for cardiopulmonary bypass".)

● (See "Initiation of cardiopulmonary bypass".)
● (See "Management of cardiopulmonary bypass".)
● (See "Weaning from cardiopulmonary bypass".)
● (See "Reversal of anticoagulation and management of bleeding after 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 requiring deep hypothermia".)
● 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 after
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
requiring deep hypothermia", 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 in
selected patients (eg, those with significant cerebrovascular disease or other risk factors
for neurologic or renal complications, and in patients who are undergoing a concomitant
procedure on the ascending aorta or arch) [31,32]. (See "Management of cardiopulmonary
bypass", section on 'Neuromonitoring modalities' and "Anesthesia for aortic surgery
requiring deep hypothermia", 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 [33,34]. 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 [35,36]. 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 [37]. (See "Anesthesia for cardiac valve surgery", section
on 'Transesophageal echocardiography: General considerations' and "Anesthesia for aortic
surgery requiring deep hypothermia", 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 [33]. (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 [38]. (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 [39-41]. (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 [42-45]. 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 [46]. 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) [47]. 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 [48]. 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
[49].
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 [50]. 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 [51], 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 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.
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(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) [47]. (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 [52-56]. (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 [53]. Examples of procedures for which TEE is usually warranted
include:
● Type A aortic dissection.
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● 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 [55], 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 [52-54,56]. 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 "COVID-19: Perioperative risk
assessment and anesthetic considerations, including airway management and infection
control", section on 'PPE during airway management or 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 [57], 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 [58], 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 [59]. (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 [60]. 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 [60]. (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 [60-62]. 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.
Meta-analyses comparing maintenance of anesthesia with volatile inhalation anesthetic

agents versus TIVA anesthetic techniques have noted inconsistent results with respect to
one-year mortality, myocardial infarction, and other adverse outcomes [63,64].
Methodologic differences between these meta-analyses may account for the conflicting
results [65]. Notably, shorter durations of mechanical ventilation and intensive care unit
(ICU) and hospital stays were noted in both meta-analyses [63,64].
● 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 [66-68]. 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 [69]. 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 [69,70].
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 [71]. (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) [72]. 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) [72]. 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 [73].
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
[74,75]. (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) [76-81]. 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 [79]. 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 [76]. 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 [82-87]. (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 [88]. 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 [89,90].
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 "Reversal of anticoagulation and management of

bleeding after cardiopulmonary bypass", section on 'Reversal of anticoagulation'). 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 [91-95]. (See "Reversal of
anticoagulation and management of bleeding after cardiopulmonary bypass", section on
'Transfusion of blood products'.)
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 [38] :
● 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 [96]. (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 [97].
● 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 [72,73]. (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 "Reversal of anticoagulation and
management of bleeding after cardiopulmonary bypass", section on '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 [98].
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) [99].
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) [100-
102]. 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 [103].

EMERGENCY CARDIAC SURGICAL PROCEDURES
Patients requiring emergency surgery have a high risk for morbidity and mortality [16,104-107].
(See "Preoperative evaluation for anesthesia for cardiac surgery", section on 'Emergency
surgery' and "Anesthesia for aortic surgery requiring deep hypothermia", section on
'Preanesthetic consultation 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 "Reversal of anticoagulation and management of bleeding after 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.)
Use of UpToDate is subject to the Terms of Use.
Topic 126473 Version 14.0

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

management causes significant hemodilution
Prebypass TEE Assess regional LV wall motion abnormalities

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

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

internal
mammary artery
Anticoagulation Administer heparin and ensure adequate

for CPB anticoagulation (confirm with ACT)
Antifibrinolytic Administer antifibrinolytic agent to minimize

administration microvascular bleeding
Perfusionist Confer with perfusionist if indicated

completes CPB
circuit setup,
priming, testing
of alarms and

circuit, adherence
to checklist
Aortic Reduce systolic BP to <100 mmHg to reduce risk of

cannulation 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
awareness
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

monitoring of for 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

decannulation venous 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

decannulation aortic dissection
Pacemaker Ensure optimal pacemaker settings

management
Postbypass TEE Assess regional LV wall motion abnormalities

examination Assess global LV function
Assess global RV function
Monitor LV and RV chamber sizes to assess intravascular
volume status
Evaluate the ascending aorta to rule out dissection
Hemostasis Ensure absence of residual heparin

Check point-of-care and laboratory tests of coagulation
if bleeding persists
Manage anemia, thrombocytopenia, and coagulopathy
if necessary
y
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 functio
targeted
Oxygenation Inspired gas O2 analyzer Paramagnetic Inspired/expired A low-level al

O2 content (with a low- sensor, fuel O2 concentration automatically
limit alarm in (galvanic) cell, when placed activated by t
use) polarographic downstream from on the anesth
(Clark) electrode, fresh flow control machine
mass 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 pulse circulation, va
pulsatile blood amplitude pitch pulse to
flow. The relative displayed on audible low-
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 Capnograph CO2 molecules ETCO2, inspired Instantaneou

CO2 absorb infrared CO2, diagnostic information a
radiation at 4.26 waveforms, Perfusion
micrometers, respiratory rate, effectively
proportionate to apnea detection being
the CO2 transporte
concentration through t
present in the vascular s
breath sample Metabolis
effectively
being pro
by cellular
metabolis

Confirmat
tracheal t
placemen
intubation
Integrity of Disconnection Detects the Alarms if a Alarms if hig

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

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 audib
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 peripheral A greater tha

monitor semiconductor, temperature core-to-perip
electrical temperature
resistance gradient is in
decreases as of low cardia
temperature output.
decreases
Temperature monitoring is conditional and can be waived according to the ASA document.
O2: oxygen; CO2: carbon dioxide; ETCO2: end-tidal carbon dioxide; ECG: electrocardiogram; BP:
blood pressure; MAP: mean arterial pressure.

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.

TEE assessment of LV diastolic dysfunction using pulsed wave tissue Doppler of

panels) and pulsed wave Doppler of the mitral inflow (right panels)


Accurate identification of each Doppler spectral peak requires an accompanying electrocardiographic tracin
fibrillation, mitral annular calcification, mitral valve surgery, or extracorporeal circulatory support generally
techniques.
A: late mitral inflow velocity resulting from atrial contraction; E: early mitral inflow velocity; e′: early mitral an
lateral mitral annulus.
From: Maxwell C, Konoske R, Mark J. Emerging concepts in transesophageal echocardiography. F1000Research 2016; 5:340. DOI: 10.1
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 ventr
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 percent 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 t
be captured in diastole. The video should be cycled through until the peak diastolic flow is observed in a stil
To make a valid measurement, the frame must contain the hemisphere of flow acceleration on the aortic va
tract, a clear image of the narrowest neck of the jet, and the jet itself in the left ventricular outflow tract. Alia
be between 40 and 60 cm/s, and the focus should be at the level of the valve. The vena contracta is measure
neck of the jet (illustrated in the image on the right). This measurement is reproducible and relatively indepe
it an attractive tool for quantifying the severity of aortic regurgitation using intraoperative TEE.
TEE: transesophageal echocardiography.

Holodiastolic flow reversal AI
Holodiastolic flow reversal seen in the descending aorta, suggesting severe aortic regurgitation. Note the pr
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 Tachyph

(alpha1-adrenergic receptor boluses occur w
agonist; beta1- and beta2- repeate
adrenergic receptor agonist) to indir
postsyn
of nore
Cardiov
effects
by drug
ephedr
into adr
nerves
or those
deplete
norepin
reserve
reserpin
Adminis
extreme
(eg, in s
increme
of 2.5 m
patients
monoa
(MAO) i
metham
since ex
hyperte
respons
threate
dysrhyt
occur
Phenylephrine Vasopressor (alpha1-adrenergic 50 to 100 10 to 100 Often s

receptor agonist) mcg mcg/minute treat hy
boluses normal
or
(may begin HR is pr
infusion if

repeated 0.1 to 1 Genetic

bolus mcg/kg/minute polymo
doses are to varia
necessary) individu
respons
Norepinephrine Inotrope/vasopressor (alpha1- and 4 to 8 mcg 1 to 20 mcg/minute Often s

beta1-adrenergic receptor agonist) (may begin first-line
or
infusion if during
repeated 0.01 to 0.3 surgery
bolus mcg/kg/minute for trea
doses are most ty
necessary) Norepin
mcg is
approxi
equival
potency
phenyle
mcg
Periphe
extrava
high co
may cau
damage
Epinephrine Inotrope/chronotrope/vasopressor 4 to 10 1 to 100 mcg/minute First-lin

(alpha1-adrenergic receptor mcg for card
or
agonist; beta1- and beta2- initially; up and for
adrenergic receptor agonist) to 100 mcg 0.01 to 1
May be
boluses mcg/kg/minute
adminis
may be or via a
used when endotra
Note changing
initial in emer
effects across dose
response is
range: Low do
inadequate
Low doses broncho
have primarily effects
beta2- cause a
adrenergic vasodila
effects at 1 to 2 decreas
mcg/minute or Interme
0.01 to 0.02 cause in
mcg/kg/minute HR and
Intermediate High do
doses have vasocon
primarily with po
beta1- and hyperte

beta2- adverse
adrenergic effects
effects at 2 to Individu
10 mcg/minute respons
or 0.02 to 0.1 related
mcg/kg/minute variable
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 Effectiv

vasopressin2 receptor agonist) units/minute treatme
hypoten

refracto
Doses >0.04 adminis
units/minute up to catecho
0.1 units/minute are sympat
reserved for salvage such as
therapy (ie, failure to phenyle
achieve adequate BP norepin
goals with other
No dire
vasopressor agents)¶
HR
Little ef
can cau
splanch
vasocon
Individu
respons
related
variable
Periphe
extrava
cause s
Dopamine Inotrope/vasopressor/dose- N/A 2 to 20 Low do

dependent chronotropy mcg/kg/minute exacerb
(dopaminergic, beta1-, beta2-, and hypoten

alpha1-adrenergic receptor beta2 st
agonist) Note changing
High do
effects across dose
cause

range: vasocon
Low doses adverse
have primarily effects,
dopaminergic arrhyth
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 Exacerb

dependent chronotropy (beta1- mcg/kg/minute hypoten
and beta2-adrenergic receptor possible
agonist) dose-de
vasodila
beta2 st
concurr
adminis
potent
vasocon
such as
norepin
vasopre
necessa
Milrinone Inotrope/vasodilator N/A 0.375 to 0.75 Exacerb

(phosphodiesterase inhibitor) mcg/kg/minute (a hypoten
(decreases rate of cyclic adenosine loading dose of 50 due to v
monophosphate [cAMP] mcg/kg over ≥10 (via
degradation) minutes may be phosph
administered, but inhibitio
may be omitted to concurr
avoid hypotension) adminis
potent

vasocon
such as
norepin
vasopre
necessa
Isoproterenol Inotrope/chronotrope/vasodilator N/A 5 to 20 mcg/minute Exacerb

(beta1- and beta2-adrenergic hypoten
or
receptor agonist) due to d
0.05 to 0.2 depend
mcg/kg/minute vasodila
beta2 st
May cau
arrhyth
Not ava
most se
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 normal 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 CefazolinΔ <120 kg: 2 4 hours

procedures: aureus, Staphylococcus epidermidis g IV
coronary
≥120 kg:
artery bypass,
3 g IV
cardiac device
insertion
procedures OR cefuroxime 1.5 g IV 4 hours◊
(eg,
OR vancomycin§ 15 mg/kg N/A
pacemaker
IV (max 2
implantation),
g)
placement of
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 Diagno
output pressure by TEE by TEE
PAWP*
Low Low Low Low Low Normal or Normal or Hypovole

hyperdynamic hyperdynamic
Low or Low or Low or High Low Normal or Normal or Vasopleg

normal normal normal hyperdynamic hyperdynamic
High or High Low or High Low Normal Normal or Pulmonar

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

or low or high¶ often dilated ventricula
dysfuncti
Normal Normal High Low Low Hypocontractile, Normal Left

or high or high often dilated ventricula
dysfuncti
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
ICU: intensive care unit.


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22/9/22, 18:06 Anesthesia for cardiac surgery: General principles - UpToDate

Official reprint from UpToDate®

Anesthesia for cardiac surgery: General principles

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

Multidisciplinary approaches including standardized preoperative, intraoperative and

https://www.uptodate.com/contents/anesthesia-for-cardiac-surgery-general-principles/print?search=evaluacion preanestesica para cirugia cardiaca&s… 2/58

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

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

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

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

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

● Point-of-care laboratory testing – Routine intraoperative laboratory point-of-care (POC)

Intravascular cardiac monitors — Cardiac surgery requires continuous monitoring of the

● Effects of anesthetic and pharmacologic manipulations of the cardiovascular system must

The following cardiovascular monitors are typically employed:

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

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

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

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● 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 and

● 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 Society

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

Initial transesophageal echocardiography examination

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

https://www.uptodate.com/contents/anesthesia-for-cardiac-surgery-general-principles/print?search=evaluacion preanestesica para cirugia cardiaca&s… 8/58

Although rigorous quantitative grading of each myocardial segment is not typically

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

Identification of significant aortic regurgitation (AR) is particularly important ( movie 8

(See "Echocardiographic evaluation of the atria and appendages", section on

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. (See

● 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.

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

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

INDUCTION OF GENERAL ANESTHESIA

Induction techniques — The goals of general anesthetic induction are to produce and

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Balanced technique — The most common anesthetic induction techniques for cardiac

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

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"Perioperative uses of intravenous opioids in adults: General considerations", section on 'High-

Antibiotic prophylaxis — Administration of antimicrobial therapy, typically a cephalosporin,

MAINTENANCE OF GENERAL ANESTHESIA

● Selection of anesthetic agents – During cardiac surgery, general anesthesia is typically

Meta-analyses comparing maintenance of anesthesia with volatile inhalation anesthetic

● Anesthetic depth – Anesthetic requirements vary considerably during cardiac surgical

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Prebypass ventilation strategies — We use an intraoperative lung-protective ventilation