Cardiac Anesthesia Events




Cardiac Laceration


Definition


A cardiac laceration is an inadvertent incision into the right atrium, right ventricle, great vessels, or vein graft(s) during sternotomy or resulting from other traumatic injury


Etiology





  • Adhesion of scar tissue and/or myocardial tissue to the sternum



  • CPR



  • Penetrating chest trauma (e.g., gunshot wound, knife injury, MVA)



Typical Situations





  • Patients who have had a previous sternotomy (“redo” sternotomy), especially those with vein grafts crossing under the sternum



  • Inexperienced surgeon



  • When the lungs are ventilated during sternotomy



  • Emergency sternotomy



  • Patients with ascending aortic aneurysms or multivessel aortic arch disease



  • Patients with an anatomic abnormality of the chest wall (kyphoscoliosis, pectus excavatum)



  • Patients who have received mediastinal radiation



  • Patients who have had CPR with rib or sternal fractures



  • Patients with penetrating injury to the chest



  • Patients following MVA



Prevention





  • Obtain preoperative lateral CXR and/or CT scan to evaluate the extent of adhesions to the heart, great vessels, and sternum



  • Stop ventilating the lungs prior to primary sternotomy; maintain ventilation at reduced tidal volumes during redo sternotomy



  • Reduce myocardial chamber size during sternotomy




    • Place the patient in reverse Trendelenburg position



    • Vasodilate the patient with an IV infusion of sodium nitroprusside or NTG




  • Consider instituting femoral artery−to−femoral vein CPB prior to sternotomy



  • Suggest that sternotomy be performed following deep hypothermia and complete circulatory arrest if an aortic aneurysm is adherent to the underside of the sternum



Manifestations





  • Large volumes of blood welling out of the surgical field or other site of injury



  • Hypotension




    • May be due to blood loss



    • Acute cardiac failure may occur if a critical vein or internal mammary artery graft to a coronary artery is lacerated




  • Tachycardia



  • Obvious signs of chest trauma—knife or bullet holes, seat belt burns



  • Hemopneumothorax



Similar Events





Management


Cardiac laceration may occur during any sternotomy or chest trauma.




  • In cardiac surgery, be prepared for major hemorrhage during sternotomy




    • Ensure adequate IV access is in place for redo sternotomy



    • If a blood salvage device is to be used during surgery, have it set up prior to sternotomy



    • Stop ventilating the lungs prior to primary sternotomy; maintain ventilation at reduced tidal volumes during redo sternotomy



    • Ensure at least two units of PRBCs are available in the OR prior to sternotomy



    • Observe the operative field carefully during sternotomy



    • Ensure rapid fluid infuser is available




  • If major hemorrhage is apparent during sternotomy




    • Stop administering volatile anesthetics and flush the anesthesia breathing circuit with 100% O 2



    • Increase FiO 2 to 100% and resume ventilation



    • Stop administering vasodilators




  • Maintain the circulating fluid volume




    • Administer IV fluid (crystalloid, colloid, blood)



    • Get help to administer volume rapidly



    • Hook up rapid fluid infuser




  • Maintain perfusion pressure




    • Administer vasopressors as required (see Event 9, Hypotension )




      • Administer phenylephrine IV, 50 to 200 μg, and escalate as needed



      • Administer epinephrine IV, 10 to 50 μg, and escalate as needed





  • Conserve the patient’s blood




    • Ensure that the blood salvage device is used by the surgeons




  • If surgical repair on CPB is necessary




    • Heparin should be administered (300 to 400 units/kg IV) by the anesthesiologist through a central line




      • Check ACT as soon as feasible



      • Administer more heparin if ACT is less than 400 seconds




    • After heparinization, blood can be salvaged by the cardiotomy suction line of the CPB pump (“sucker bypass”)



    • The femoral artery may have to be cannulated for the arterial perfusion line



    • A right ventriculotomy and the cardiotomy suction can be used as venous return for CPB




  • After CPB is initiated, anticipate and plan for problems associated with prolonged CPB time and myocardial injury (see Event 78, Low Cardiac Output State After Cardiopulmonary Bypass ; Event 75, Coagulopathy Following Cardiopulmonary Bypass ; and Event 15, Acute Coronary Syndrome )



  • Following penetrating or blunt injury to the chest or in patients who have had CPR, patients may need




    • Chest tube placement



    • Fluid resuscitation



    • Sternotomy/thoracotomy to control bleeding and/or cross-clamping of the descending aorta



    • Transfer to the OR for definitive surgery




Complications





  • Failure to wean from CPB



  • Acute myocardial failure



  • Myocardial ischemia



  • Arrhythmias



  • Cardiac arrest



  • ARDS



  • Hypothermia



  • Systemic air embolism



Suggested Reading


  • 1. Mehta A.R., Romanoff M.E., Licina M.G.: Anesthetic management in the precardiopulmonary bypass period. Hensley F.A. Martin D.E. Gravlee G.P. The practical approach to cardiac anesthesia . 2008. Lippincott Williams & Wilkins Philadelphia: pp. 182-183.
  • 2. Despotis G., Avidan M., Eby C., et. al.: Prediction and management of bleeding in cardiac surgery. J Thromb Haemost 2009; 7: pp. 111-117.
  • 3. Misao T., Yoshikawa T., Aoe M., et. al.: Bronchial and cardiac ruptures due to blunt trauma. Gen Thorac Cardiovasc Surg 2011; 59: pp. 216-219.
  • 4. Nyawo B., Botha P., Pillay T., et. al.: Clinical experience with assisted venous drainage cardiopulmonary bypass in elective cardiac reoperations. Heart Surg Forum 2008; 11: pp. E21-E23.
  • 5. Hellevuo H., Sainio M., Nevalainen R., et. al.: Deeper chest compression: more complications for cardiac arrest patients?. Resuscitation 2013; 84: pp. 760-765.



  • Coagulopathy Following Cardiopulmonary Bypass


    Definition


    Coagulopathy following CPB as a result of deficiency or dysfunction of platelets or of the coagulation cascade


    Etiology





    • Circulating anticoagulant




      • Inadequate heparin neutralization



      • Heparin rebound



      • Protamine overdose




    • Thrombocytopenia



    • Impaired platelet function



    • Low plasma concentrations of coagulation factors



    • DIC



    • Primary fibrinolysis



    • Preexisting congenital or acquired coagulopathy



    Typical Situations





    • Postoperative cardiac surgery patients



    • Prolonged time on CPB




      • Increased platelet activation



      • Thrombocytopenia



      • Consumption of coagulation factors




    • Massive hemorrhage or transfusion



    • Vigorous cardiotomy suction



    • Patients requiring a circulatory assist device



    • Patients undergoing deep hypothermia (core temperature below 20° C)



    • Preexisting coagulopathy




      • Drug therapy inhibiting platelet function (aspirin, dipyridamole, clopidogrel)



      • Anticoagulant therapy



      • Thrombolytic therapy (streptokinase or similar agents)



      • Hepatic dysfunction



      • Chronic renal failure



      • Myeloproliferative disorders




    Prevention





    • Identify patients with preexisting clinical, subclinical, or pharmacologically induced coagulation disorders




      • Obtain preoperative laboratory studies of coagulation function




        • PT, PTT



        • Platelet count



        • Thromboelastogram, if available





    • Keep CPB time as short as possible



    • Minimize the negative pressure applied to the cardiotomy suction to reduce platelet trauma



    • Administer heparin and protamine in appropriate doses




      • Monitor coagulation during and immediately after CPB



      • Maintain adequate anticoagulation during CPB (ACT > 400 seconds)




    • Consider the use of acute normovolemic hemodilution (remove whole blood pre-CPB for retransfusion post-CPB)



    • Coordinate the discontinuation of preoperative medications known to cause platelet dysfunction with the surgical team



    • Consider administering pharmacologic therapy in high-risk cases




      • ε-Aminocaproic acid



      • Tranexamic acid




    • Have blood products available at the end of CPB for patients at high risk of a coagulopathy




      • Patients who have had previous cardiac surgery



      • Duration of CPB longer than 3 hours




    Manifestations





    • Bleeding into the surgical field from multiple sites and from wound edges after administration of an adequate dose of protamine



    • Increased mediastinal chest tube output after the chest has been closed



    • Bleeding from IV insertion sites, wounds, or mucous membranes



    • Abnormalities in laboratory tests of coagulation function




      • Prolonged ACT that does not correct with additional protamine



      • Thrombocytopenia



      • Prolonged PT and PTT



      • Decreased fibrinogen level



      • Increased levels of fibrin split products



      • Abnormal thromboelastogram




    • Hypotension, tachycardia



    • Cardiac tamponade



    Similar Events





    Management





    • Surgical exploration is indicated if




      • The mediastinal chest tube drainage exceeds 300 to 400 mL in 1 hour, drainage is continuing, and laboratory tests of coagulation are normal



      • Signs of cardiac tamponade are occurring (see Event 18, Cardiac Tamponade )




        • Equilibration of filling pressures



        • TEE/TTE examination is suggestive of cardiac tamponade




      • Provide supportive therapy until bleeding is controlled



      • Maintain the circulating fluid volume




        • Infuse crystalloid, colloid, and blood products as necessary to maintain perfusion pressure




      • Administer vasopressors as required to maintain perfusion pressure (see Event 9, Hypotension )




        • Phenylephrine IV, 50 to 100 μg, and escalate as needed



        • Epinephrine IV, 10 to 50 μg, and escalate as needed




      • Maintain normothermia (see Event 44, Hypothermia )




        • Use heating blankets and/or a forced-air warming device



        • Warm all IV fluids




      • Prevent hypertension




        • Maintain adequate sedation



        • Administer vasodilator agents as needed




      • Consider PEEP to decrease the amount of venous mediastinal bleeding following chest closure




    • Assess laboratory tests of coagulation function




      • Check the ACT




        • Administer additional protamine until the ACT returns to control or until there is no further reduction in the ACT




      • Send samples to the clinical laboratory for




        • Platelet count



        • PT



        • PTT



        • Fibrinogen



        • Fibrin split products




      • Check thromboelastogram




    • Begin empirical therapy while waiting for laboratory results if bleeding is severe (see Event 1, Acute Hemorrhage )




      • Restore platelet numbers and function




        • Reinfuse any fresh whole blood removed from the patient prior to CPB after administration of protamine



        • Administer platelets (one apheresis unit should increase platelet count by 50,000 to 80,000/μL)



        • Consider desmopressin (DDAVP) IV by slow infusion, 0.3 μg/kg. Can cause hypotension if given too quickly




      • Infuse 2 to 4 units of fresh frozen plasma (adults)



      • Further use of blood products should be guided by laboratory results if practical



      • Consult a hematologist for further management of a coagulopathy that does not resolve



      • Consider recombinant factor VIIa IV, 15 to 180 μg/kg (dosage for the treatment of uncontrolled hemorrhage in nonhemophiliac patients vary; consult a hematologist)




    • If primary fibrinolysis is thought to be the cause of bleeding




      • Administer ε-aminocaproic acid IV, 5 g bolus infusion followed by 1 g/hr for 6 hours




    Complications





    • Transfusion reaction



    • Hypovolemia



    • Hypervolemia



    • DIC



    • Hypercoagulable states



    • Renal failure



    • Mediastinitis following reexploration



    • Bloodborne virus infection



    • Death



    Suggested Reading


  • 1. Avery E.G.: Massive bleeding post bypass: rational approach to management. ASA refresher course lectures . 2012. American Society of Anesthesiologists Park Ridge, Ill: pp. 214.
  • 2. Mazer C.D.: Update on strategies for blood conservation and hemostasis in cardiac surgery. ASA refresher course lectures . 2012. American Society of Anesthesiologists Park Ridge, Ill: p. 424
  • 3. Romanoff M.E., Royster R.L.: The postcardiopulmonary bypass period: weaning to ICU transport. Hensley F.A. Martin D.E. Gravlee G.P. The practical approach to cardiac anesthesia . 2008. Lippincott Williams & Wilkins Philadelphia: p. 233
  • 4. DiNardo J.A.: Management of cardiopulmonary bypass. DiNardo J.A. Zvara D.A. Anesthesia for cardiac surgery . 2008. Blackwell Malden, Mass: pp. 369.
  • 5. Speiss B.D., Horrow J., Kaplan J.A.: Transfusion medicine and coagulation disorders. Kaplan J.A. Kaplan’s cardiac anesthesia . 2006. Saunders Philadelphia: pp. 972.
  • 6. Lam M.S., Sims-McCallum R.P.: Recombinant factor VIIa in the treatment of nonhemophiliac bleeding. Ann Pharmacother 2005; 39: pp. 885-891.



  • Emergent “Crash” onto Cardiopulmonary Bypass


    Definition


    Emergent initiation of CPB


    Etiology





    • Cardiac surgery




      • Perioperative cardiac arrest, myocardial ischemia, hypotension, or massive hemorrhage




    • Airway catastrophe




      • Inability to establish an airway by routine methods (e.g., anterior mediastinal mass with tracheomalacia)




    • LAST requiring prolonged CPR



    Typical Situations





    • Acute coronary graft occlusion



    • Failure of PCI



    • Severe valvular dysfunction




      • Failure of valve (e.g., ruptured chordae), valve repair or replacement



      • Endocarditis with acute severe valvular incompetence




    • Acute severe myocardial dysfunction




      • Severe hypotension



      • Severe protamine reaction




    • Massive perioperative hemorrhage



    • Massive PE



    • Obstetrical catastrophes (e.g., LAST, AFE, and cardiac arrest in the parturient)



    Prevention





    • Wean from CPB with all necessary inotropic and mechanical myocardial support



    • Verify protamine reversal and obtain good hemostasis prior to chest closure



    • Perform a post-CPB TEE examination to evaluate ventricular and valvular function



    Manifestations





    • Signs of global or regional myocardial dysfunction




      • Visible cardiac distention and poor myocardial contractility



      • Systemic hypotension with increased filling pressures



      • Wall motion abnormalities on TEE (global or regional)



      • Abnormalities of ECG morphology or rhythm




        • ST elevation, often on the inferior leads II, III, AVF



        • Heart block



        • Ventricular arrhythmias (VT, VF)



        • Asystole





    • Severe hemorrhage



    • EEG activity may slow or become quiescent



    • Cardiac arrest



    Management





    • Alert cardiac surgeon, perfusionist, and nursing team of the situation




      • Emergent CPB usually takes some time to organize for heparinization, CPB circuit preparation, and placement of arterial and venous cannulae (not in the context of ongoing cardiac surgery)




    • Resuscitate the patient




      • Check that the patient is being oxygenated (deliver 100% O 2 ) and ventilated and that infusions of vasopressors are running; adjust ventilation and infusion rates as necessary



      • Administer boluses of vasopressors IV as necessary (see Event 9, Hypotension )




        • Phenylephrine IV, 100 to 200 μg, and escalate as necessary



        • Ephedrine IV, 10 to 20 mg



        • Epinephrine IV, 10 to 50 μg, and escalate as necessary




      • Administer IV fluids




        • Crystalloid bolus IV, 500 mL, and additional boluses as needed



        • Colloid bolus IV




          • Hetastarch 500 mL



          • 5% albumin 250 to 500 mL



          • RBCs—if massive hemorrhage, inform blood bank of the ongoing need for blood products; initiate your facility’s MTP






    • Once the decision has been made to go on CPB stat, ANTICOAGULATE THE PATIENT




      • Administer heparin through a central line or surgeons may choose to administer heparin intra-atrially



      • Heparin dose will depend on the current level of anticoagulation and whether the patient has received protamine.




        • Aim for ACT > 400 seconds




      • Initial heparin dose should be at least 300 units/kg




    • Perfusionist should immediately prime the oxygenator and CPB pump circuit




      • If there is any question about the circulation of heparin, have an additional 15,000 units of heparin added to the pump prime



      • Volume can be delivered to the patient via arterial cannula once it is in place




    • Cardiac surgeon should cannulate the arterial system (aorta or femoral artery) first, then the venous system (right atrium or femoral vein)




      • If there is massive hemorrhage, the cardiotomy suction cannulae can be used as the source of venous drainage (MUST heparinize before doing this)




    • Anesthesiologist should consider administering additional anesthetic agents if the case is prolonged once the patient is stable



    • Check an ABG; correct acidosis if present



    Complications





    • Difficulty in separation from CPB



    • Myocardial ischemia or infarction



    • Coagulopathy



    • Stroke



    • Arrhythmias



    • Cardiac arrest



    • Death



    Suggested Reading


  • 1. Mora-Mangano C.T., Chow J.L., Kanevsky M.: Cardiopulmonary bypass and the anesthesiologist. Kaplan J.A. Kaplan’s cardiac anesthesia . 2006. Saunders Philadelphia: pp. 908.
  • 2. Birdi I., Chaudhuri N., Lenthall K., Reddy S., Nashef S.A.: Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: outcome justifies the cost. Eur J Cardiothorac Surg 2000; 17: pp. 743-746.
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    Feb 22, 2019 | Posted by in ANESTHESIA | Comments Off on Cardiac Anesthesia Events

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