Considerations: CABG On-Pump

I have had the opportunity to work with a couple of MDAs on a few CABG cases. Here are some of the things they thought were good to know when doing such cases. These are just somethings I wrote down during the case. Please let me know if you have something to add or correct.







Preoperative

• Be sure to give assessment of patient's respiratory status just as much as his cardiac status. A patient with severe CAD is generally going to be a smoker or have significant history of it. There decreased FRC may be enough to cause issues while intubation and result in a very bad situation.
• Include there activity level. They generally won't be able to climb a flight of stairs without getting short of breath. That again will help direct your decision on how you want to induce the patient.
• Diabetes. If they have history of diabetes, if may be that they have never had chest pain. So thoroughly assess the EKG.

Induction

• First thing to do when the patient comes to the OR table is start Preoxygenating! It is literally going to be the factor that can determine if patient survives the induction
• Give appropriate dose of versed. If can help keep the patient calm and is good because it is not a respiratory depressant.
• Start a radial arterial line. Use lidocaine infiltration to limit stress on patient.
• Induce with Etomidate, Lidocaine, Succinylcholine and most importantly Fentanyl (or other rapid onset opioids)
• Make the first view the best view! 
• Direct laryngoscopy is highly stimulation and repeated attempts can be detrimental. So, if you think you might need a glidescope...use it the first time!
• A BIS monitor is also helpful to have on before induction, and when you push the induction meds wait for it to go to the appropriate range (40-60) before DL.

Management

• Monitors: Central line, a femoral arterial line, PA catheter
• Drips:
• Amicar: 1g/hr=50ml/hr after 5g bolus
• Propofol (if TIVA)
• Nitroglycerin: 200mcg/ml concentration
• Levophed: 8mg/250ml concentration
• Epinephrine: 2mg/250ml concentration
• One of the most stimulating time period during surgery is during STERNOTOMY!
• So, plan ahead and give Fentanyl (large doses)
• Another thing before sternotomy is that you will need to drop the lungs to avoid puncture.
• Bypass
• Before bypass, you need to make sure the ACT is above 400. Heparin dose is usually 300 units/kg. Cardiac perfusionists may give additional doses if needed to keep ACT >400
• We gave solumedrol 1g immediately before going on bypass to help limit the inflammatory process
• During aortic cannulation, it is very important to ensure that the BP is low, or dissection of the aorta can occur.
• The perfusionists will generally check ACTs every 30 minutes
• Also mannitol to scavenge oxygen free radicals
• Lidocaine dose before cross clamp is off
• If hyperkalemia is seen, calcium chloride may also be given.
• After bypass, blood glucose are usually elevated because insulin is not as effective in cold temperatures
• Some patients may also need platelets, FFPs, and cryos. Consumptive coagulopathy may occur (generally is seen after surgery is over)
• Protamine: ONLY given AFTER patient is off bypass. If you give it before, all of patient's blood in the pump will clot and patient will not make it.
• Give it slow and watch for protamine reaction (increased PA pressure, decreased BP)
• If platelets are used. Do not infuse them through the fluid warmer as they may clump.

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