| Period | Anesthetic goals |
| Prebypass period | Induction and maintenance of anesthesia | - Maintain optimal myocardial O2 supply and minimize demand to prevent or treat ischemia
|
| Antibiotic prophylaxis | - Timely administration of selected antibiotics
|
| Positioning | - Careful arm, hand, and head positioning to avoid injuries
|
| Fluid management | - Restrict fluid administration since initiation of CPB causes significant hemodilution
|
| Prebypass TEE examination | - Assess regional LV wall motion abnormalities
- 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 sternotomy | - Treat hypertension and tachycardia due to painful stimuli
- Briefly interrupt ventilation during sternotomy to avoid lung injury
|
| Harvesting of the internal mammary artery | |
| Anticoagulation for CPB | - Administer heparin and ensure adequate anticoagulation (confirm with ACT)
|
| Antifibrinolytic administration | - Administer antifibrinolytic agent to minimize microvascular bleeding
|
| Perfusionist completes CPB circuit setup, priming, testing of alarms and circuit, adherence to checklist | - Confer with perfusionist if indicated
|
| Aortic cannulation | - Reduce systolic BP to <100 mmHg to reduce risk of aortic dissection
|
| Venous cannulation | - Treat hypotension or initiate CPB for malignant arrhythmias
|
| Initiation of CPB | Retrograde autologous priming | - Gradual onset of CPB to reduce hemodilution from crystalloid prime
|
| Control of O2 delivery, CO2 removal, and pump flow assumed by perfusionist | - Discontinue controlled ventilation and anesthetic administration via the anesthesia machine
- Discontinue cardiac support (eg, inotropic agents, IABP)
|
| Anesthetic administration | - Initiate volatile anesthetic administration via vaporizer attached to CPB circuit, or use TIVA technique
- Monitor raw and/or processed EEG and expired anesthetic gas from the oxygenator to prevent awareness
- Monitor neuromuscular function; administer NMBAs to prevent movement or shivering
|
| Placement of aortic crossclamp and administration of cardioplegia | - Ensure complete myocardial arrest (absence of ECG electrical activity)
- TEE monitoring for aortic insufficiency and LV distension during antegrade cardioplegia delivery
|
| Placement and monitoring of coronary sinus catheter and LV vent | - TEE assessment of coronary sinus catheter placement for retrograde cardioplegia delivery
- Monitor coronary sinus pressure
- TEE assessment of correct LV vent placement and effective LV decompression
|
| Maintenance of CPB | Cooling | - Maintain temperature gradient between venous inflow and arterial outlet <10°C
|
| Maintenance | - Maintain MAP ≥65 mmHg (or ≥75 mmHg for patients with cerebrovascular disease or severe aortic atherosclerosis)
- Monitor temperature at oxygenator arterial outlet temperature (surrogate for cerebral temperature) and other sites (eg, nasopharyngeal, bladder, blood)
- Maintain Hgb ≥7.5 g/dL (Hct ≥22%); suggest hemoconcentration if Hgb <7.5 g/dL, then transfuse PRBC if necessary
- Maintain SvO2 ≥75%; suggest increase in pump flow if SvO2 <75%
|
| Rewarming | - Slow rewarming ≤0.5°C/minute, with temperature gradient between venous inflow and arterial outlet ≤4°C
- Avoid hyperthermia; target temperature is 37°C at nasopharyngeal site and 35.5°C at bladder site
- Monitor for awareness or return of neuromuscular function
|
| Removal of aortic crossclamp | - Defibrillate and administer antiarrhythmic agents if necessary to treat ventricular fibrillation
|
| Weaning from CPB | | - Refer to UpToDate topic on weaning from cardiopulmonary bypass (CPB)
|
| Post-bypass | Venous decannulation | - Ensure initial reinfusion of blood drained from the venous tubing into the pump reservoir in 50- to 100-mL aliquots
- TEE assessment for adequate ventricular filling
|
| Anticoagulation reversal, pump suckers turned off, intravascular vents removed | - Administer protamine slowly, treat protamine reactions
- Ensure complete reversal of anticoagulation
|
| Aortic decannulation | - Reduce systolic BP to <100 mmHg to reduce risk of aortic dissection
|
| Pacemaker management | - Ensure optimal pacemaker settings
|
| Postbypass TEE examination | - Assess regional LV wall motion abnormalities
- Assess global LV function
- Assess global RV function
- Monitor LV and RV chamber sizes to assess intravascular volume status
- Evaluate the ascending aorta to rule out dissection
|
| Hemostasis | - Ensure absence of residual heparin
- Check point-of-care and laboratory tests of coagulation if bleeding persists
- Manage anemia, thrombocytopenia, and coagulopathy if necessary
|
| Chest closure | - Observe for RV compression and dysfunction, coronary graft compromise, pacing wire displacement, or lung compression
|
| Transport to ICU and handover | | - Ensure optimal patient condition prior to transport
- 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
|
