Fentanil 5-35 mcg/kg or Sufentanil 1-8 mcg/kg plus
Sedative-Hypnotic
Pentothal
Etomidate
Valium or Versed
Propofol
Maintenance
Narcotic PLUS
Propofol, Benzodiazepine, or low dose inhalation drug (Ethrane, Forane, Deslurane, Halothane, Sevoflurane)
"Fast Track" Anesthesia
3. Pediatric Anesthetic Agents
Induction is usually not intravenous
Induction
Ketamine 5 mg/kg intramuscular
Inhalation using Halothane or Sevoflurane
"Halothane sensitizes myocardium to arrhythmogenic influence of catacholamines"
IV established after induction
Maintenance
Narcotic PLUS
Hypnotic or Inhalation
4. Anesthetic Management of Ischemic Heart Disease
Goal: prevent myocardial damage
Optimum myocardial oxygen demand : supply ration
MVO2 is directly related to
Heart rate
Contractility
Oxygen supply is directly related to
Coronary blood flow
LV wall tension
5. Minimize Ischemia
Avoid tachycardia
Increased heart rates are correlated with post-operative MI
Maintain resting (ischemia-free) hemodynamics
Slow: maximize diastolic time
Small: minimize wall tension
Well Perfused: Adequate coronary pressure
6. Valvular Heart Disease
Aortic Stenosis
LVH
May have coronary artery disease
Requires high filling pressures
Anesthetic goals
Normal heart rate (avoid tachycardia)
Atrial "kick" crucial for adequate preloading of LV
Aortic Insufficiency
CHF common in acute AI
Anesthetic goals:
Decreased afterload
high-normal heart rate (avoid bradycardia)
Mitral Stenosis
High LA pressure and volume needed to fill LV
Anesthetic goals:
Adequate preload
Maintain diastolic filling time (avoid tachycardia)
Mitral Regurgitation
Volume overload leads to CHF and pulmonary hyptertension
Anesthetic goals:
Vasodilation improve forward flow
Normal to increased heart rate (avoid bradycardia)
7. Weaning from Bypass
Establish rhythm
Defrbrillate
AV pacing
Control rate
SVR (normal to low-normal)
SVR= (BP-CVP/CO) x 80
On pump: BP-CVP = mean BP; CO = Pump flow (L/min)
Normalize cardiac output
Visual
Blood pressure
Measured CO
Adjust preload
Post-bypass heart is stiff and volume dependent
8. Heparin Reversal
Use calculated dose of Protamine
Excess Protamine will cause a prolongation of A.C.T. and coagulopathy
9. One Lung Ventilation
To facilitate surgery on the lung or thoracic aorta
Absolute indications-
Lung abcess
HeartPort
Useful in-
Pulmonary hemorrhage
V.A.T.
Hypoxemia- commonly due to increased shunt
Minimize hypoxemia by-
100% FiO2
Decrease volatile agents to < 1%
Increase ventilation to the dependent lung (non-operative)
PEEP the dependent lung
CPAP on the operative lung
Occlude the pulmonary artery of the operative lung
9. Pericardial Tamponade
Acute drop in BP on induction
Decreased venous return with controlled ventilation
Decreased sympathetic tone due to anesthetic state
Management
Prep awake with spontaneous ventilation
Ketamine induction
Sympathomimetic
Spontaneous ventilation possible
10. Anterior Mediastinal Mass
Sudden inability to ventilate
Obstruction of major airways with
Supine position
Controlled ventilation
Depressed ventilation
Management
Radiation therapy pre-op
Awake fiberoptic intubation (sitting)
Spontaneous ventilation
Standby cardiopulmonary bypass
