Milrinone
-comes premixed from
pharmacy at 200 mcg/cc
-loading dose 50 mcg/kg over 10-20 min
-then 0.5 mcg/kg/min maintenance
-EASYCALC:
Loading Dose: BW(kg)/4= cc over 20'
Maintenance: 0.15xBW(kg) = cc/hr
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Lidocaine Drip
2gm /250 cc (8 mg/ml);1-4
mg/min (7-30 cc/hr)
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Procainamide
(Pronestyl)
Bolus:100 mg IV q 10
minutes or
Drip: 2 grams/250 ml D5W (8 mg /ml)
-run infusion at 20 mg/min
(150 cc/hr)
until:
1) QRS or PR widens >50%,
or
2) Dysrhythmia suppressed, or
3) Hypotension, or
4) Total of 17 mg/kg or 1000 mg infused
Then 2-6 mg/min (15-45
cc/hr)
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Cardizem Drip
(for free radial
artery grafts)
-mix 125 mg in 100c NaCl
bag with additional 25 cc NaCl
-run @ 2mg/hr (2cc/hr), start on patient warming
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Nitric
Oxide (inhaled)
Cam Clark 7/8/99
-therapeutic range 20-80 ppm; no increased benefit from higher
concentration
-once started, must wean gradually to avoid rebound
Toxicity of NO- Methemoglobinemia; rarely an issue clinically
- circuit: essentially a modified BAIN
-call :-Landry, Clark, Jim Smith, resp therapist on-call to help
you set it up.
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Pedi
heart, Coagulation
Platelets 1u/10kg
FFP 10-20 ml /10kg
Cryo 1u /7kg
PRBCS
1. Platelets
2. Cryo
Post-CPB bleeding can
be adequately treated with PLTs only in 40 percent.
Give CRYO after platelets.
FFP is of no benefit
1u of CRYO (10cc) contains 100%fibrinogen, 70% vWF, 40% factor XIII
of 250 cc FFP
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Pedi
heart, Extubation
1. Children with short
CPB runs and use of mild to moderate hypothermia can be extubated
early. (ASD,VSD, conduit placement). Age < 7 days=difficult.
2. Big Procedures in
neonates: keep intubated for postop hemodynamic management
3. Opioids: Fentanyl
<= 5mcg/kg /hr
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Total
Circulatory Arrest
1/13/99
- used during aortic
arch reconstruction, etc.
- Cerebral Protection:
- Solumedrol: 10-30 mg/kg
- MgSO4:
Children: 20 mg/kg
Adults: 2 grams
- Pentothal: 3-5 mg /kg
just before circulation interrupted
- Ice Bags to head
- Systemic cooling to
27 C.
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Vasopressin (Pitressin)
-for Pulseless
VT/VF
-as a Drip for Cardiac Surgery
-naturally occurring antidiuretic hormone. In high doses, vasopressin acts as a
non-adrenergic peripheral vasoconstrictor. When given during CPR, vasopressin increases coronary perfusion pressure, vital organ blood flow, ventricular fibrillation (VF) median frequency, and cerebral oxygen delivery.
Used as a Class 2b medication for pulseless VT/VF
-may be more effective than epinephrine as a pressor agent for promoting the return of spontaneous circulation in cardiac arrest.
- may be used as an alternative pressor to epinephrine in the treatment of adult shock-refractory VF
- may be useful for hemodynamic support in vasodilatory shock (e.g., septic shock). Evidence in human clinical trials is limited, but has been consistently positive. The lower adverse effects profile of vasopressin may be the major reason for use. Vasopressin is not recommended for responsive patients with coronary artery disease because the increased peripheral resistance may provoke angina pectoris. Vasopressin is administered as a single bolus dose of 40 units intravenously.
-for Pulseless VT/VF:
(ACLS
Guidelines 2002)
- a single dose/push of
vasopressin 40 IU IV (long half-life). Currently, vasopressin is only recommended to be given
once.
- after 10 to 20 minutes, if there is no clinical response to vasopressin, epinephrine 1 mg every 3 to 5 minutes can be given.
-Vasopressin
Drip
1/13/99
- used to provide increased SVR
during milrinone administration
- 100 units vasopressin/100 cc
- comes from pharmacy pre-mixed
- run @ 2.4 cc/hr (0.04 units/min)
- dose is NOT weight dependent
- convert IVAC multi-channel pump to
neonatal to allow decimals in rate (More Options-> Device->Neonatal)
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CABG without CPB: Guidelines
By Saul Katz, M.D., Revised 4/02
The goal is to perform CAB with a minimum
of insult and preservation of normal physiology.
- NORMOTHERMIA
- Start heating blanket when patient
placed on OR table.
- Keep warm until patient draped.
- Bair Hugger to warm head after drapes
placed.
- SWAN GANZ CATHETER
- TEE Monitoring
- HEMODYNAMIC function should be stable
and optimal prior to the incision.
- ELEVATION & ROTATION of the heart
for exposure may require slow manipulation and sometimes IV fluid
and inotropic support to maintain blood pressure and cardiac
output.
- TRENDELENBURG POSITION may be required
during grafting of right coronary or circumflex coronary arteries.
- ROTATION OF THE TABLE to the right
may be needed for grafting the circumflex coronary artery.
- FLUID ADMINISTRATION of several liters
to restore preload and hemodynamics to allow distortion of the
heart may be required.
- PACING of the atrium for rates under
70 is useful. A-V pacing may be required if heart block occurs
during occlusion of the RCA.
- INOTROPIC SUPPORT Dopamine (2-6 mcg/kg/min)
is the drug of choice to elevate BP after adequate volume has
been administered.
- HEPARIN and protamine dosing vary from surgeon
to surgeon
- ISCHEMIA occurring after the coronary
artery is occluded and then opened can often be relieved by an intra-luminal
shunt.
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Diabetes Management, Perioperative,
for Vascular Cases
approved 2009; pdf document; see Chase Boyd for
Questions
FOR
OR Management see Page 4 of
Document
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Insulin
Drip for Cardiac Cases
Updated 11/05
See also: Insulin Drip
for Non-Cardiac Cases
- Goal: BS <140 mg%
- mix 100 units of regular Insulin in 100
ml NS
- Monitor BS at least hourly
| Measured BS |
Bolus |
Drip (units/hr) |
| <90 |
none |
none |
| 91-140 |
none |
2 |
| 141-220 |
5 |
5 |
| 221-300 |
10 |
10 |
| >300 |
20 |
15 |
Note:
1) These are only guidelines. Individual patients vary widely. Modification is often needed.
2) Insulin resistance may be pronounced during CPB. Consider increasing the insulin infusion rate at the commencement of CPB.
3) Insulin resistance will drop after CPB. Therefore, decrease the insulin infusion rate at cessation of CPB.
4)) If the post-CPB period is prolonged, continue to measure serum glucose at least once per hour.
See also: Insulin Drip
for Non-Cardiac Cases
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Methylene
Blue & CPB Vasoplegia
J Gagnon & A Christie August 2007
Indications: Methylene blue is an evolving treatment for the post CPB vasoplegia syndrome (high cardiac output, low SVR, adequate preload after CPB). The decision to administer methylene blue is made jointly by the surgeon, anesthesiologist and perfusionist on an individual patient basis.
Administration:
1. Methylene blue 2 mg/kg in 100 cc NS can be ordered from the pharmacy if time permits (about 20 minutes).
2 Alternately, a CVAT can obtain ampules
(1%, 10 cc) for you to draw up and prepare the drip yourself.
3 The dose should be administered over roughly 30 minutes as hypertension and
dysrhythmias are reported with rapid administration. Reduced doses are used in renal failure.
Inform the surgeon and perfusionist when starting the drug as it will predictably darken the arterial blood and discolor the urine. Pulse oximeters, cerebral oximeters and the Ph monitor on the pump are artifactually lowered. It can be as long as 45 minutes for the methylene blue to reach full effect.
References:
Moritoki E et al., Ann Thoracic Surg 2007:83:715-23
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Amiodarone (Cordarone®)
3/99
**for ventricular arrhythmias, and atrial
fibrillation prophylaxis;
**May cause dramatic hypotension with concurrent alpha blockade
- order the solution from the pharmacy:
-150mg /100ml parfill bag
-900mg /500 ml glass bottle (1.8mg/ml)
-multichannel pump, extension set
- BOLUS (Loading) Dose: (Bag)
150mg (100ml) over 10 minutes
- MAINTENANCE Dose: (Bottle)
33 ml/hr (60mg /hr)
- after 6 hours:
decrease rate to 17 ml/hr (30 mg/hr)
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CEA & Regional Anesthesia
-from an email by WC Boyd 12/03
1) Regional anesthesia for CEA is not going to be actively pursued as a
regular part of the anesthesia practice at MMC at this time. It will be utilized
when medical indicated or in the case of strong patient preference during
regular operating room hours Monday - Friday.
2) If the surgeon finds that a carotid should be done under regional anesthesia,
the surgeon's secretary will contact the anesthesia secretary and anesthesia
coverage will be provided.
3) If regional anesthesia is the decision reached at the preanesthesia visit,
the anesthesiologist must make sure that the surgeon is aware of this decision,
they must contact the anesthesia secretary to arrange coverage, and they must
make sure EEG is cancelled.
4) EEG is available during the weekend and at night if required.
5) In part because regional anesthesia is not actively pursued for CEA, it is
not an expectation of anesthesia coverage for weekends and nights.
In conjunction with this agreement we are soliciting individuals interested in
being on the list as providers of regional anesthesia for CEA.
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nice summary of drugs to anticoagulate,
and tests to monitor anticoagulation, during cardiac surgery.
Click on link to open.
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Cardiac Transplant Patient: Non-Cardiac
Surgery Considerations
ASA ACE Program, 2009
Patients after cardiac transplantation have the following characteristics:
• lack of cardiac innervation
• risk for allograft rejection
• accelerated coronary artery disease
• increased risk for malignancy
• chronic use of corticosteroids and other immunosuppressive agents
After heart transplantation, the donor heart is denervated. Lack of this innervation restricts the ability of the new heart to increase heart rate in response to sympathetic stimulation, as occurs with hypotension or hypovolemia. A patient with a transplanted heart is considered to be preload dependent. A perioperative goal would be to maintain normovolemia and not restrict intravenous fluids.
A patient with a transplanted heart may regenerate cardiac innervation after approximately one
year. These patients will then experience tachycardia in response to conditions such as hypovolemia, hypotension, myocardial ischemia, and hypoglycemia.
Premedication with atropine is not routinely required. In the absence of regenerated cardiac innervation, the administration of an indirect-acting anticholinergic such as atropine or glycopyrrolate will not be effective (ie, produce tachycardia). If a medication is required for increasing heart rate, administration of a direct-acting agent (e.g., epinephrine, isoproterenol) is recommended.
Corticosteroids are commonly administered chronically to patients after cardiac transplantation. Strong consideration should be given to providing a stress dose of corticosteroids for patients who continue to receive steroids for immunosuppression. Many patients will have the side effects associated with long-term administration including hypertension and diabetes mellitus.
Patients with a transplanted heart are at increased risk for accelerated coronary artery disease (CAD), thereby warranting
use of ST segment monitoring even in children or adolescents. The detection of myocardial ischemia can be challenging if the patient is unable to sense the chest pain from myocardial ischemia. The detection of CAD in patients after cardiac transplantation is typically determined by cardiac angiography. The presence of CAD in patients with transplanted hearts generally increases proportionally from the time of cardiac transplantation. A recent study reports that approximately half of patients are free of angiographic evidence of CAD nine years after cardiac transplantation.
REFERENCES
1. Williams GD, Ramamoorthy C. Anesthesia considerations for pediatric thoracic solid organ transplant. Anesthesiol C/in North America. 2005;
23:709-731.
2. Miller RD. Millers Anesthesia. 6th ed. Philadelphia: Elsevier Churchill Livingstone;
2005:2253 - 2263.
3. Motoyama EK, Davis PJ. Smith's Anesthesia for Infants and Children. 7th ed. Philadelphia:
Elsevier Mosby; 2006:910-915.
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Thoracotomies & Epidurals
Boyd August 2004
Place epidural pre-op for post-op pain management
at mid- to high thoracic level.
If possible, confirm satisfactory placement with adequate dose of local
anesthetic before induction of GA.
Post-op Orders for APMS:
PCEA 0.0625% bupivicaine with dilaudid 10 mcg /
cc
Continuous rate = 4-6cc/hr
On Demand= 2 cc
Lockout Interval= 20 minutes
4 hour limit= 20 cc
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