7 Cardiovascular Case Checklist

Preop – prepare before bringing patient to OR

Airway

• Backup AMBU bag on machine
• Face mask
• Suction
• Cuffed ETT
• Syringe for cuff
• Stylet for ETT < 3.5 (unopened but available otherwise)
• Blade/handle – check light
• Oral airway
• Tape

Anesthesia Machine

• Check machine
• Humidifier – electric for < 6mo, HME otherwise

Medications

• Order drips the night before (antifibrinolytic, sedation, Epi only; other meds are in Pyxis)
• Cardiac pack from OR pharmacy with bolus emergency drugs
• Flush syringes
• 5% albumin available
• Induction drugs – discuss with attending
• Antibiotics – usually cefazolin 30 mg/kg IV
• Hotline
• Blood tubing

Infusion Towers

#1 – small tower on R side of bed with 3 syringe pumps and 1 regular channel

• Narcotic – usually fentanyl
• Ketamine or dexmedetomidine (depends on attending)
• Cisatracurium
• Amicar or TXA (whichever is available)

#2 – main tower on R side of bed with 2 Alaris brains – goes with patient to CVICU

• Dopamine
• Milrinone
• Nitroglycerin
• Epinephrine: for stat category 4-5
• Dexmedetomidine (if used)
• Amicar or TXA (whichever is available)
• IV carrier x3 (D5LR for age < 6 months at maintenance rate on the line with infusions)

All infusions on snake to CVL if available; if proceeding without CVL at beginning, sedation drips on IV with tri-flow, vasoactive medications on snake, primed and ready to pass onto RA line

#3 – accessory tower on L side of bed with 1 Alaris brain (as needed)

Other Items

• Bair hugger
• 2 transducers, with 3 stopcocks flushed on CVP extension
• Confirm all lines are de-bubbled
• ECHO machine
• ECHO probe
• Ultrasound
• Stethoscope
• iNO in room if needed (call RT)
• Check blood availability, especially if redo
• Confirm choice, site of CVL
• Turrentine – confirm if Edwards line needed
• Brown, Rodefeld, Hermann – typically no CVL unless inadequate PIVs
• NIRS
  • #1 (top number) = head
  • #2 (bottom number) = flank

Intraoperative

Induction

• Monitors
• Confirm which extremities for BP and AL
• 2 pulse oximeters
• Try to have something on every extremity
• Label location of each
• Confirm FiO2 to be used for induction

Maintenance Prior to Incision

• Vital signs
• Ventilation
• Adequate anesthesia and paralysis
• Check lines, start infusions
• Check positioning and padding
• ABG/ACT baselines
• Antibiotics after surgeon arrives, within 60 min of incision
• Confirm antifibrinolytic/FFP
• Place TEE probe
• NIRS – set baselines

Maintenance on CPB

Going on CPB

• ACT within 2 minutes of heparin administration
• Heparin may be given directly by surgeon, or handed off to you by scrub tech. If handed to you, confirm dose (~400 Units/kg) and give centrally when possible
• Turn off ventilator and APL valve all the way open when up to full CPB flow – confirm with perfusion
• Monitor in CPB mode
• Turn off humidifier and Masimo
• Mark event on NIRS
• Record urine output at time of CPB initiation
• Start nitroglycerin at 0.25 mcg/kg/min

During CPB

• Discuss what to do with PGE – usually stop on CPB
• Discuss/set up appropriate inotropes
• Discuss goal Hct, blood products needed after separation from CPB, and where they will be administered
• Discuss suitability of extubation – see exclusion criteria protocol
• Prepare blood tubing for all blood products
• Prepare appropriately sized suction catheter and saline
• 6Fr for 3.0, 8Fr for 3.5, 10Fr > 4.0
• Confirm availability of pacemaker box, check battery
• Catch up chart, STS form, start handoff forms
• Notify RT if iNO needed

During Rewarming

• Notify attending
• Bair hugger on warm (after cross-clamp release)
• Monitor out of CPB mode
• Record urine output during CPB
• Suction ETT when okay with surgeon, prior to ventilating
• 2-3 Valsalva breaths to pressure 20cm, to open up lungs prior to placing on ventilator, at FiO2 100%
• Start inotropes – discuss with attending/surgeon

Weaning Off CPB

• Consider drawing TEG prior to protamine administration
• Protamine – drawn up by perfusion and handed to you
  • Confirm dose prior to administration – 1mg per 100 units of heparin
  • Administer peripherally due to risk of PH
  • Administer over several minutes. Communicate with surgeon and perfusion when first-half given. Confirm with surgeon prior to administering second-half.
• Start “yellow” products (platelets, cryo) after protamine administration
• ACT/ABG 5 minutes after protamine administration
• Additional ABGs q30min, or as needed
• Consider ABG on 50% O2 to assess PO2/suitability for extubation
• Update handoff sheets

Emergence

If Extubating

• Confirm suitability with Extubation Exclusion Criteria Protocol
• Stop sedation/paralytic infusions
• Start dexmedetomidine prior to chest closure if not already running – unless contraindicated
• Have long-acting narcotic available
• Wean ventilator after sternum closure

Transport to CVICU

• Maintain vigilance with watching patient and VS
• Discuss which IVs/lumens to cap
• Call RT for transport/ETT re-taping
• Confirm full O2 tank
• Confirm appropriate FiO2
• Confirm appropriate infusions running
• Bring emergency drugs, extra sedation, volume for bolus just in case
• Working transport monitor
• Suspend anesthesia record

2019 R. Abbasi