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Anesthesia for cardiac surgery: General principles

Authors: Atilio Barbeito, MD, MPH, Eric A JohnBull, MD, MPH
Section Editor: Jonathan B Mark, MD
Deputy Editor: Nancy A Nussmeier, MD, FAHA

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Apr 2020. | This topic last updated: Mar 30, 2020.

INTRODUCTION

Anesthetic management for different types of cardiac surgical procedures such as coronary artery bypass grafting (CABG), cardiac valve
repair or replacement, surgery involving the ascending aorta, heart transplantation, and procedures for surgical repair of congenital heart
defects has many shared principles. This topic will discuss general principles for anesthetic management of adults undergoing cardiac
surgery with cardiopulmonary bypass (CPB). Similar techniques are employed for patients undergoing cardiac surgery without the aid of
CPB (eg, off-pump CABG).

Anesthetic management issues for specific types of cardiac surgical procedures are discussed in separate topics:

● (See "Anesthesia for coronary artery bypass grafting surgery" and "Anesthesia for coronary artery bypass grafting surgery", section on
'Off-pump coronary artery bypass surgery'.)
● (See "Anesthesia for cardiac valve surgery".)
● (See "Anesthesia for aortic surgery requiring deep hypothermia".)
● (See "Anesthesia for heart transplantation".)
● (See "Anesthesia for surgical repair of congenital heart defects in adults: General management" and "Anesthesia for surgical repair of
congenital heart defects in adults: Management of specific lesions and reoperation".)

For cardiac surgical procedures requiring CPB, key steps are noted in the table (table 1), and intraoperative management during and after
CPB is discussed in individual topics:

● (See "Blood management and anticoagulation for cardiopulmonary bypass".)

● (See "Initiation of cardiopulmonary bypass".)
● (See "Management of cardiopulmonary bypass".)
● (See "Weaning from cardiopulmonary bypass".)
● (See "Reversal of anticoagulation and management of bleeding after cardiopulmonary bypass".)
● (See "Intraoperative problems after cardiopulmonary bypass".)

PREANESTHETIC CONSULTATION

Preanesthetic consultation involves assessing cardiac and overall health risks to identify issues that could cause problems during and after
cardiac surgery. The anesthesiologist works with the cardiologist and cardiac surgeon to optimize medical conditions, develops an
anesthetic care plan, educates the patient and family regarding anesthetic care, and alleviates patient anxiety. These issues are discussed
in detail separately. (See "Preanesthetic consultation for cardiac surgery in adults".)

PREMEDICATION

Some cardiac surgical patients benefit from premedication with small incremental doses of a short-acting intravenous (IV) benzodiazepine
anxiolytic (eg, midazolam 1 to 2 mg) and/or opioid (eg, fentanyl 50 mcg), administered under the anesthesiologist's observation,
particularly during placement of intravascular catheters (see 'Intravascular cardiac monitors' below). Extra caution (ie, careful titration of

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smaller doses) is warranted for many cardiac surgical patients. Examples include those with critical aortic stenosis or severe ventricular
dysfunction, or those of extreme age (>80 years old).

Protocols for enhanced recovery after cardiac surgery typically emphasize minimal anxiolytic medication before or during surgery. (See
'Enhanced recovery after cardiac surgery' below.)

MONITORING

Cardiac surgery is conducted using standard American Society of Anesthesiologists (ASA) monitors (table 2) [1], as well as intra-arterial
and central venous access. We also monitor urine output, degree of neuromuscular blockade (using a peripheral nerve stimulator), and
temperature.

Furthermore, for most cardiac surgical cases, we use transesophageal echocardiography (TEE), processed electroencephalography
(EEG), and point-of-care (POC) testing of laboratory values. Additional monitoring with a pulmonary artery catheter (PAC) to monitor
pulmonary artery pressure (PAP), cardiac output, and mixed venous oximetry, or a cerebral oximetry monitor may be employed in selected
patients.

Noninvasive standard monitors

● Standard noninvasive monitors – Prior to induction, we place standard noninvasive continuous monitors, including pulse oximetry
(SaO2), electrocardiogram (ECG), and noninvasive blood pressure as a backup monitor for intra-arterial blood pressure. After
endotracheal intubation, end-tidal carbon dioxide as well as airway pressure and volume measurements are continuously monitored.

Both ECG leads II and V5 are employed, with computerized ST-segment trending to facilitate optimal detection of myocardial
ischemia, as in other patients with ischemic heart disease (see "Anesthesia for noncardiac surgery in patients with ischemic heart
disease", section on 'Monitoring for ischemia'). In high-risk patients for whom pacing, defibrillation, or cardioversion may be necessary,
defibrillator/pacing pads should be placed prior to anesthetic induction (figure 1).

A peripheral nerve stimulator is positioned along the course of the facial nerve to intermittently elicit contraction of the orbicularis oris
muscle for monitoring neuromuscular function. This ensures that appropriate muscle relaxation is maintained throughout the case.
(See "Management of cardiopulmonary bypass", section on 'Maintenance of anesthesia and neuromuscular blockade'.)

Other standard monitors

● Bladder catheter – A bladder catheter with a temperature probe is inserted after induction to measure urine output and core
temperature.

● Temperature monitors – Temperature is monitored at several sites (see "Management of cardiopulmonary bypass", section on
'Temperature'):

• A nasopharyngeal or tympanic membrane temperature probe is typically employed, particularly as a monitor of brain
temperatures during cardiopulmonary bypass (CPB) and the weaning process [2-4]. However, the oxygenator arterial outlet
temperature is the most reliable surrogate for cerebral temperature during cooling and rewarming [2-5].

• A bladder catheter with a temperature probe is used to monitor "core temperature"; a rectal temperature probe may be substituted
if no urine output is expected (eg, in a patient with end-stage kidney disease). During the cooling and rewarming phases of CPB,
bladder (or rectal) temperatures typically lag behind oxygenator, nasopharyngeal, tympanic membrane, and blood temperatures;
thus, bladder temperature poorly reflects temperatures in the highly-perfused organs (eg, brain and kidneys) [3,5].

• If a PAC is inserted, pulmonary artery blood temperature is also monitored before and after CPB [6].

● Point-of-care laboratory testing – Routine intraoperative laboratory point-of-care (POC) testing includes intermittent blood gas
analysis, hemoglobin, electrolytes, calcium, glucose, activated whole blood clotting time (ACT), and in some institutions, other
coagulation assays [7]. (See "Clinical use of coagulation tests".)

Intravascular cardiac monitors — Cardiac surgery requires continuous monitoring of the cardiovascular system because:

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● Critical cardiovascular disease (eg, coronary artery obstruction or cardiac valve lesions) necessitates close hemodynamic monitoring
to avoid and rapidly correct myocardial ischemia or dysfunction.

● Sudden and/or severe hemodynamic changes may occur due to mechanical manipulations during the surgical procedure itself.

● Effects of anesthetic and pharmacologic manipulations of the cardiovascular system must be assessed rapidly.

The following cardiovascular monitors are typically employed:

● Intra-arterial catheter – An intra-arterial catheter is inserted before anesthetic induction for continuous monitoring of blood pressure
and to facilitate intermittent blood sampling for specific POC tests during the operation. (See "Indications, interpretation, and
techniques for arterial catheterization for invasive monitoring".)

The radial artery is the most common cannulation site due to its superficial course, consistent accessibility, and redundant blood
supply of the hand via the ulnar artery. If the cardiac surgical plan includes radial artery harvest, the contralateral radial artery or ulnar
artery is also suitable. Despite concerns for hand ischemia or ulnar nerve injury (due to its proximity to the artery), complications
associated with ulnar artery cannulation rarely occur [8-11]. Other alternative sites may be selected in some patients, including
brachial, axillary, and femoral arteries. These more proximal monitoring sites have the advantage of providing better estimates of
central aortic pressure, particularly following CPB, and complications are rare [12,13]. (See "Indications, interpretation, and techniques
for arterial catheterization for invasive monitoring", section on 'Complications'.)

If an intraaortic balloon pump (IABP) is in place, intra-arterial blood pressure may be monitored at the tip of the balloon catheter in the
descending thoracic aorta to avoid any delay in beginning surgery. Insertion of a peripheral intra-arterial catheter can then be
accomplished as soon as possible after induction of anesthesia.

If surgery on the aortic arch or repair of aortic dissection is planned, it may be necessary to obtain a second upper extremity intra-
arterial catheter after induction. (See "Anesthesia for aortic surgery requiring deep hypothermia".)

● Central venous catheter – A large-bore central venous catheter (CVC) is useful given the frequent need for infusion of vasoactive
medications and the potential for high-volume administration of fluids or blood products. Typically, we cannulate the internal jugular
vein using ultrasound guidance for vein localization (movie 1 and movie 2) [14,15].

We insert an introducer sheath such as a multi-lumen access catheter or sheath introducer (eg, Cordis) that functions as a large-
caliber CVC and/or as a means to place a PAC, even if insertion of a PAC is not initially planned. Thus, if the patient becomes
hemodynamically unstable in the postbypass or postoperative period, the introducer sheath facilitates later insertion of a PAC without
interruption of vasoactive infusions. We typically insert the large-bore CVC shortly after induction of general anesthesia if there is
adequate peripheral intravenous (IV) access for use during induction. Insertion after induction avoids patient discomfort due to pain
and Trendelenburg positioning, which might result in hypertension, tachycardia, dyspnea, and myocardial ischemia in an awake
patient. However, in a patient with difficult peripheral IV access or risk factors for hemodynamic instability during induction, we may
insert the introducer sheath and/or PAC before induction of general anesthesia [16].

In other institutions, the sheath introducer and CVC or PAC are routinely placed before induction in order to expedite surgical care.
During large-bore CVC placement in an awake patient, small bolus doses of an anxiolytic agent (eg, midazolam 1 to 4 mg) and/or an
opioid (eg, fentanyl 50 to 150 mcg) may be judiciously administered to reduce patient discomfort.

● Pulmonary artery catheter – In selected patients, a PAC may be inserted to provide dynamic information regarding pulmonary artery
pressure (PAP), cardiac output, and mixed venous oxygen saturation (SVO2) [16-20].

We insert a PAC in patients with acute hemodynamic instability, preferably before induction of anesthesia or surgical incision [16].
Also, PAC monitoring is often employed in patients with moderate to severe pulmonary artery hypertension, reduced left ventricular
(LV) ejection fraction (<30 percent), severe coexisting pulmonary or kidney disease, planned coronary artery bypass grafting (CABG)
surgery in combination with valve repair or replacement (due to longer CPB and aortic cross-clamp times that may result in increased
potential for postbypass myocardial dysfunction), and in patients undergoing heart and/or lung transplantation. However, routine use is
avoided in many centers because of absence of evidence for mortality benefit in cardiac surgical and other patient populations, as well
as several potential risks [21-27]. (See "Pulmonary artery catheterization: Indications, contraindications, and complications in adults",
section on 'Complications'.)

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Selection of the type of PAC to be inserted is based on institution-specific availability and preferences. We prefer a continuous cardiac
output catheter with continuous mixed venous oximetry (SvO2) capabilities to facilitate management in the intensive care unit in the
highest risk patients who have a greater likelihood of continued hemodynamic instability following surgery. (See "Pulmonary artery
catheterization: Indications, contraindications, and complications in adults", section on 'Physiologic measurements' and "Evaluation of
and initial approach to the adult patient with undifferentiated hypotension and shock", section on 'Pulmonary artery catheterization'.)

Prebypass transesophageal echocardiography — Practice guidelines of the American Society of Anesthesiologists (ASA) and Society
of Cardiovascular Anesthesiologists suggest using TEE to confirm and refine preoperative diagnoses, detect new or unsuspected
cardiovascular pathology that may alter anesthetic or surgical plans, as well as guide PAC insertion and final positioning [28,29]. In the
postbypass period, TEE is used to assess results of all surgical interventions while the patient is still in the operating room [28]. (See
'Postbypass transesophageal echocardiography' below.)

We conduct an initial comprehensive prebypass TEE examination, followed by continuous use of the TEE to monitor ventricular function
and volume [30]. (See "Transesophageal echocardiography: Indications, complications, and normal views" and "Intraoperative
transesophageal echocardiography for noncardiac surgery", section on 'Components of a basic TEE examination (noncardiac surgery)'.)

Even if TEE is not used electively, rapid deployment may be needed to diagnose causes of acute, persistent, and life-threatening
hemodynamic instability (ie, "rescue" TEE). (See "Intraoperative rescue transesophageal echocardiography (TEE)".)

Initial transesophageal echocardiography examination

● Global systolic LV function is assessed and ejection fraction is evaluated using a qualitative grading system (eg, mild, moderate, or
severe global LV hypokinesia and systolic LV dysfunction) or estimated LV ejection fraction (movie 3 and movie 4). There is also some
evidence for the use strain-based indices of LV dysfunction to predict adverse postbypass and postoperative outcomes [31-33]. (See
"Intraoperative transesophageal echocardiography for noncardiac surgery", section on 'Global LV systolic function' and
"Transesophageal echocardiography in the evaluation of the left ventricle", section on 'Systolic function'.)

The presence of spontaneous echo contrast in the left atrium (LA) or aorta indicates low cardiac output.

● Global LV diastolic function is assessed using a quantitative grading system (grade 1, impaired relaxation; grade 2, pseudonormal;
grade 3 restrictive filling) (image 1). The pre-bypass evaluation of the diastolic function of the LV is most important for prognostic
reasons rather than specific therapeutic interventions. Diastolic dysfunction has been shown to be associated with major adverse
cardiac events, in-hospital mortality, and prolonged mechanical ventilation after cardiac surgery [34-37]. Details regarding a
comprehensive assessment of diastolic function are discussed elsewhere. (See "Echocardiographic evaluation of left ventricular
diastolic function".)

● It is also possible to obtain estimates of cardiac output using the LV outflow tract or aortic valve area combined with Doppler-based
methods [38]. Such estimates may be particularly useful when thermodilution measurements of cardiac output are not available in the
absence of a PAC. Details regarding calculation of hemodynamic parameters are discussed elsewhere. (See "Hemodynamics derived
from transesophageal echocardiography", section on 'Cardiac output'.)

● The LV is also assessed for regional wall motion abnormalities (RWMAs), characterized as hypokinesis, akinesis, or dyskinesis. These
may be chronic (preexisting) or may be new changes, indicative of myocardial ischemia. RWMAs indicate specific territories of
myocardium perfused by each of the major coronary arteries supplying the LV (figure 2 and figure 3) [39]. In each of the 16 segments
(17 minus the apical cap) of the LV wall, function may be graded as:

• Normal
• Hypokinetic (ie, reduced and delayed contraction)
• Akinetic (ie, absence of inward motion and thickening)
• Dyskinetic (ie, systolic thinning and outward systolic endocardial motion)

Although rigorous quantitative grading of each myocardial segment is not typically performed during cardiac operations, a qualitative
assessment of regional ventricular function is noted and recorded. Further details regarding TEE assessment of regional LV systolic
function are available elsewhere. (See "Intraoperative transesophageal echocardiography for noncardiac surgery", section on
'Regional LV systolic function' and "Transesophageal echocardiography in the evaluation of the left ventricle", section on 'Evaluation of
regional wall motion'.)

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● The LV is assessed for mural thrombus in patients who have an akinetic or dyskinetic myocardial segment, most commonly involving
the ventricular apex (image 2 and movie 5 and movie 6). (See "Left ventricular thrombus after acute myocardial infarction".)

● Right ventricular (RV) function is assessed. Myocardial ischemia or exacerbation of pulmonary hypertension may cause severe RV
dysfunction (movie 7). Some clinicians obtain strain measurements of RV dysfunction [40]. Details regarding a comprehensive
assessment of the right heart are discussed elsewhere. (See "Echocardiographic assessment of the right heart".)

● The thoracic aorta is evaluated for atheromatous disease, calcification, or dilatation. Atheromatous disease of the descending aorta
predicts stroke and death after CABG since coexisting ascending aortic disease is likely [41]. Prior to aortic manipulation, severe
atherosclerosis or calcification in the ascending aorta can usually be identified with TEE to guide the surgeon regarding selection of
sites for aortic cannulation, cardioplegia administration, aortic cross-clamping, or placement of the "side-biter" clamp to complete
proximal anastomoses during CABG (image 3). Many centers also perform epiaortic scanning prior to aortic cannulation and cross-
clamping, either selectively or routinely, as a supplemental and possibly superior technique for identifying disease in the ascending
aorta (image 3) [42-44]. This requires availability of a high-resolution (>7 MHz) ultrasound transducer, which is inserted into a sterile
sheath filled with either sterile saline or ultrasound transmission gel before placement directly on the exposed ascending aorta for
enhanced imaging of atheromas and calcification. Avoidance of surgical manipulation of aortic areas with known calcification or
atherosclerotic plaque may reduce the risk of cerebral embolism and postoperative stroke [44-48].

Identification of severe atheromatous disease or mobile plaques in the descending aorta may affect decision-making for insertion of an
intraaortic balloon pump (IABP) into the femoral artery with retrograde passage through the diseased aorta (image 4). (See "Intraaortic
balloon pump counterpulsation", section on 'Complications'.)

● Structure and function of the four cardiac valves are assessed. (See "Intraoperative transesophageal echocardiography for noncardiac
surgery", section on 'Valvular structure and function'.)

TEE can play an important role in determining the surgical plan in patients with cardiac valve disease (eg, confirming the preoperative
diagnosis, decisions to repair versus replace a valve, or whether an additional valve requires repair). One study noted that TEE
influenced cardiac surgical decisions in more than 9 percent of all patients, with the greatest observed impact in patients undergoing
combined CABG and valve procedures [49].

Identification of significant aortic regurgitation (AR) is particularly important (movie 8 and image 5 and image 6 and image 7). AR may
limit delivery of adequate antegrade cardioplegia solution into the coronary artery ostia after the ascending aorta is cross-clamped
since much of the cardioplegia solution will regurgitate through the incompetent aortic valve back into the LV. This may cause
distention of the LV as it fills. Management of patients with significant AR during CPB is addressed separately, including the possibility
of inadequate delivery of antegrade cardioplegia and alternative options (eg, retrograde cardioplegia and/or insertion of an LV vent to
maintain LV decompression) (see "Management of cardiopulmonary bypass", section on 'Aortic regurgitation'). Significant (more than
mild) AR is also a relative contraindication to the placement of an IABP, since the degree of AR may be increased with diastolic
balloon inflation during counterpulsation. (See "Intraaortic balloon pump counterpulsation", section on 'Contraindications'.)

● The interatrial septum is interrogated for presence of a patent foramen ovale (PFO) or atrial septal defect [50]. This is accomplished
using two-dimensional (2D) imaging, as well as color-flow Doppler imaging. If there is equivocal evidence of a PFO, confirmation by
injection of IV agitated saline contrast (known as a "bubble study") is a maneuver used to detect right to left atrial shunting through a
PFO (movie 9). Transient atrial pressure reversal achieved with release of a sustained positive pressure breath may enhance
sensitivity of this maneuver. Although repair of an incidentally discovered PFO is not warranted unless the surgical plan includes right
atriotomy [51], its presence should be documented as useful information in case the patient suffers a future embolic stroke.

● The LA and left atrial appendage (LAA) are assessed for thrombus, particularly in patients with current or past history of atrial
fibrillation (movie 10). The finding of spontaneous echo contrast, indicative of stasis that predisposes to thrombus formation, is used to
differentiate thrombi from normal variants such as a multilobed LAA or prominent trabeculations (movie 11 and movie 12).
Identification of LA or LAA thrombus may lead to a decision to institute postoperative anticoagulation to reduce the risk of stroke. (See
"Echocardiographic evaluation of the atria and appendages", section on 'Transesophageal echocardiography'.)

Monitoring with transesophageal echocardiography — Subsequently, throughout the prebypass period, and again during the
postbypass period, we continuously monitor ventricular function and volume status. We monitor LV and RV function and filling. Goals
include rapid detection and assessment of:

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● New RWMAs (eg, hypokinesis, akinesis, or dyskinesis), which are highly suggestive of myocardial ischemia (figure 2 and figure 3)
[39]. (See "Anesthesia for coronary artery bypass grafting surgery", section on 'Avoidance and treatment of ischemia'.)

● Development of hypovolemia or hypervolemia (movie 13). (See "Intraoperative transesophageal echocardiography for noncardiac
surgery", section on 'Volume status'.)

● Development of low systemic vascular resistance as a cause of arterial hypotension. (See "Intraoperative transesophageal
echocardiography for noncardiac surgery", section on 'Systemic vascular resistance'.)

● Factors causing hypotension, including abnormalities in:

• Preload or volume status (ie, hypovolemia or hypervolemic congestive heart failure)

• Afterload or vascular resistance (ie, low systemic vascular resistance)
• Contractility or ventricular function (ie, poor LV or RV function)
• Valvular structure and function (ie, structural abnormalities or poor function)
• Other less common causes of hypotension, such as aortic dissection or cardiac tamponade

Brain monitors

● Electroencephalography – We routinely employ a raw and/or processed electroencephalography (EEG) device (eg, a bispectral
index monitor) [52]. Although such monitoring may help detect "light" anesthesia or awareness, EEG indices cannot reliably confirm
that a patient is adequately anesthetized [53]. (See "Awareness with recall following general anesthesia" and "Management of
cardiopulmonary bypass", section on 'Maintenance of anesthesia and neuromuscular blockade'.)

● Cerebral oximetry – Near-infrared spectroscopy cerebral oximetry monitoring and maintenance of regional cerebral oxygen
saturation (rSO2) within 20 percent of baseline is occasionally employed in a patient with significant cerebrovascular disease or other
risk factors for neurologic or renal complications, and in patients who are undergoing a concomitant procedure on the ascending aorta
or arch. (See "Management of cardiopulmonary bypass", section on 'Cerebrovascular disease' and "Anesthesia for aortic surgery
requiring deep hypothermia", section on 'Cerebral oximetry'.)

INDUCTION OF GENERAL ANESTHESIA

Induction techniques — The goals of general anesthetic induction are to produce and maintain unconsciousness, attenuate the
hemodynamic responses to endotracheal intubation and surgical stimulation, and prevent or treat hemodynamic changes that lead to
myocardial oxygen imbalance and ischemia. Specific hemodynamic and physiologic goals for different types of cardiac disease (eg,
coronary artery disease, cardiac valve lesions) are discussed in individual topics.

Regardless of the induction technique employed, hypotension may occur post-induction when a volatile inhalation anesthetic agent is
administered to increase anesthetic depth in anticipation of the surgical incision. Hypotension occurs because of the long context-sensitive
half time for high doses of an opioid such as fentanyl [54], and synergistic interaction of opioids with volatile agents (see "Maintenance of
general anesthesia: Overview", section on 'Analgesic component: Opioid agents'). Significant hypotension is avoided by reducing the dose
of volatile agent, or treated by administering a vasopressor in small bolus doses (eg, phenylephrine) or as a low-dose infusion (table 3).

Balanced technique — The most common anesthetic induction techniques for cardiac surgical patients includes use of a low dose of a
sedative-hypnotic agent combined with a low dose of opioid and volatile anesthetic agent ("balanced technique"). For example, a small
dose of propofol (eg, 0.5 to 1.5 mg/kg) may be administered in combination with a moderate dose of fentanyl 2 to 4 mcg/kg and a
neuromuscular blocking agent. Since a bolus injection of propofol typically produces dose-dependent hypotension due to venous and
arterial dilation as well as decreased myocardial contractility, administration of a vasopressor such as phenylephrine is often necessary.
(See "General anesthesia: Intravenous induction agents", section on 'Propofol'.)

Owing to its minimal hemodynamic side effects, etomidate may be selected as the anesthetic induction agent for patients with cardiogenic
shock, hemodynamic instability, critical left main coronary disease, severe aortic stenosis, or severe cardiomyopathy. A possible concern
with the use of etomidate is that it inhibits the biosynthesis of cortisol, an effect that lasts <24 hours following a single dose. Although this
finding may not be clinically significant [55], etomidate is not routinely administered. (See "General anesthesia: Intravenous induction
agents", section on 'Etomidate'.)

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A neuromuscular blocking agent is also administered during induction. During the few minutes required for adequate relaxation for
endotracheal intubation, a volatile inhaled anesthetic is typically titrated to its effect on anesthetic depth. Anesthetic depth should be
sufficient to assure unconsciousness and attenuate the sympathetic response to laryngoscopy and intubation. Lidocaine 1 mg/kg
intravenous (IV) is often included in the induction sequence to further blunt this sympathetic response. (See "General anesthesia:
Intravenous induction agents", section on 'Lidocaine' and "Anesthesia for noncardiac surgery in patients with ischemic heart disease",
section on 'Induction'.)

Higher-dose opioid technique — An alternative induction technique that is used less commonly includes administration of a higher
dose of a synthetic opioid (eg, fentanyl 10 to 25 mcg/kg) for patients who will remain intubated with controlled ventilation for several
postoperative hours. This technique results in minimal direct myocardial depressant effect and only a small decrease in blood pressure.
One important adverse side effect of high-dose opioid administration is chest wall rigidity, which may make ventilation difficult [56]. (See
"Perioperative uses of intravenous opioids in adults", section on 'High-dose opioid induction technique'.)

Patient positioning — Patients are typically in the supine position during cardiac surgery. The arms may either be tucked at the patient's
side, or, less commonly, in an abducted position. A shoulder roll is typically placed under the scapulae to extend the neck. (See "Patient
positioning for surgery and anesthesia in adults", section on 'Supine' and "Patient positioning for surgery and anesthesia in adults", section
on 'Particular concerns with the supine position'.)

Patients are susceptible to positioning injuries during CABG surgery due to a prolonged duration in an unchanging position [57].
Theoretically, nonpulsatile flow and induced hypothermia during cardiopulmonary bypass (CPB), as well as intermittent hypotension during
the prebypass and postbypass periods, may exacerbate nerve, skin, and other positioning injuries. Although there is no definitive evidence
for the roles of these potential risk factors, extra precautions are taken to prevent such injuries. For example, the head is initially positioned
on a cushioned pillow or "donut" pad, with frequent repositioning to prevent scalp ischemia and resultant occipital alopecia. If arms are
tucked, the olecranon groove and fingers should be padded and protected from the metallic edge of the operating table to avoid pressure
injuries. If arms are abducted, overextension beyond 90 degrees is avoided to prevent excessive tension on the pectoralis major muscle
and brachial plexus injury [57]. (See "Patient positioning for surgery and anesthesia in adults", section on 'Nerve injuries associated with
supine positioning'.)

After sternotomy, placement of a sternal retractor is necessary for harvesting the internal thoracic or internal mammary artery (see
"Anesthesia for coronary artery bypass grafting surgery", section on 'Incision, sternotomy, and harvesting of venous and arterial grafts').
Retractor positioning is closely observed since the steel post attaching it to the operating table may compress the upper arm causing radial
nerve injury, and may also be associated with brachial plexus injury [57-59]. In addition, when the retractor lifts the sternum, the patient's
head may be lifted off the supporting head cushion, particularly in an older patient who has cervical spine arthritis. If this occurs, the
retractor should be adjusted or the patient's head should be repositioned with additional pillow support.

Antibiotic prophylaxis — Administration of antimicrobial therapy, typically a cephalosporin, should be initiated by the anesthesiologist
within 60 minutes before the surgical incision, so that drug levels are optimal at the time of incision (table 4). If vancomycin is selected for a
patient with a beta-lactam penicillin allergy or one who is known to be colonized with methicillin-resistant Staphylococcus aureus (MRSA),
administration should begin within 120 minutes before the incision because of the prolonged infusion time required. (See "Antimicrobial
prophylaxis for prevention of surgical site infection in adults", section on 'Cardiac surgery'.)

MAINTENANCE OF GENERAL ANESTHESIA

Maintenance techniques — General anesthesia may be maintained with a volatile anesthetic agent, a total intravenous anesthetic (TIVA)
technique, or a combination of volatile and intravenous (IV) agents.

In a large randomized 2019 trial, 5400 patients undergoing elective coronary artery bypass grafting (CABG) surgery received either a
volatile anesthetic agent (ie, sevoflurane, desflurane, isoflurane) or a TIVA technique that included only IV agents administered before,
during, and after the period on cardiopulmonary bypass (CPB) [60]. Anesthetic technique was not associated with the primary outcome
(death at one postoperative year), or any secondary outcomes including death or nonfatal myocardial infarction (MI) at 30 days, duration of
stay in the intensive care unit or hospital, or hospital readmission at any time during the first postoperative year. However, a 2020 meta-
analysis that included 8197 cardiac surgical patients in 42 studies noted lower one-year mortality associated with volatile anesthetics
compared with TIVA with propofol (5.5 versus 6.8 percent; odds ratio [OR] 0.76, 95% CI 0.60-0.96), but no differences in short-term

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mortality [61]. Other outcomes in this meta-analysis included lower incidences of MI (OR 0.60, 95% CI 0.39-0.92) and need for inotropic
medications (OR 0.40, 95% CI, 0.24-0.67). Limitations of the meta-analysis included a small number of outcome events with one-year
mortality differences noted in only two studies, and marked heterogeneity among the 42 included studies [61]. Other studies and
investigations have suggested that a TIVA technique with propofol may also have cardioprotective effects in certain subgroups of cardiac
surgical patients [62-64]. (See "Management of cardiopulmonary bypass", section on 'Anesthetic agents'.)

Anesthetic requirements vary considerably during cardiac surgical procedures; thus, frequent adjustments of anesthetic depth are
necessary. For example, in the prebypass period, severe pain and endogenous catecholamine release may occur during initial incision and
particularly during sternotomy, necessitating adjustments to the depth of general anesthesia in order to prevent tachycardia and
hypertension. Subsequently, during the periods of reduced surgical stimulation that typically follow sternotomy, it is appropriate to reduce
anesthetic depth to avoid hypotension. (See "Anesthesia for coronary artery bypass grafting surgery", section on 'Incision, sternotomy, and
harvesting of venous and arterial grafts'.)

Prebypass ventilation strategies — Similar to all patients who require mechanical ventilation during general anesthesia, we use a lung-
protective ventilation strategy during cardiac surgical procedures (See 'Use of lung-protective ventilation' below and "Mechanical ventilation
during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)

During the prebypass period, it may be necessary to make frequent adjustments in ventilation to accommodate changing surgical
conditions. Notably, during sternotomy ventilation is briefly interrupted to prevent lung injury from the sternal saw. During subsequent
internal mammary artery harvest, some surgeons request reduction in the tidal volume (TV) to avoid suboptimal surgical exposure due to
interference from the lungs during inspiration. In these instances, respiratory rate is increased to maintain adequate alveolar ventilation.

Prebypass fluid management — Prior to CPB, fluid administration (usually with a balanced crystalloid solution rather than a colloid
solution) is typically restricted to the small volumes necessary to administer IV medications because initiation of CPB results in significant
hemodilution as the CPB circuit prime (up to 1.5 liters of crystalloid) mixes with the patient's blood volume. However, judicious IV volume
expansion, or administration of a vasopressor infusion, may be necessary to maintain hemodynamic stability in response to blood loss or
hypovolemia in the prebypass period. Excessive hemodilution is avoided during cardiac surgery with or without CPB due to risks for
postoperative weight gain, increased use of blood products, delirium, and longer durations of controlled mechanical ventilation and hospital
stay [65,66]. (See "Blood management and anticoagulation for cardiopulmonary bypass", section on 'Avoiding excessive fluid
administration' and "Anesthesia for coronary artery bypass grafting surgery", section on 'Off-pump coronary artery bypass surgery'.)

Hydroxyethyl starch (HES) colloid solutions are avoided due to concerns regarding impairment of hemostasis and acute kidney injury (AKI)
[67-72]. In a 2012 meta-analysis of randomized trials in cardiac surgical patients receiving HES solutions, risk of reoperation for bleeding
was more than doubled (relative risk [RR] 2.24, 95% CI 1.14-4.40) compared with albumin [70]. In that meta-analysis, postoperative blood
loss and transfusions of red cells, fresh frozen plasma, and platelets were all increased in patients receiving HES. One retrospective study
in cardiac surgical patients noted that patients receiving a HES 130/0.4 solution for intraoperative fluid therapy, including use in the CPB
pump prime, were twice as likely to develop AKI compared with those receiving a balanced crystalloid solution [67]. However, data are not
consistent, and some studies in other surgical populations have noted no differences in risk for AKI or other serious postoperative
complications in patients receiving HES solution compared with other types of fluids [73-77]. (See "Intraoperative fluid management",
section on 'Hydroxyethyl starches'.)

Transfusion of red blood cells is uncommon prior to CPB but may be necessary in response to sudden blood loss, or while preparing for
initiation of CPB in patients with severe anemia.

Urine output is measured before CPB, confirming proper placement of the Foley catheter and adequate bladder drainage, and
subsequently as a gross indicator of renal perfusion and function. Effects of anesthesia and surgery typically reduce glomerular filtration
and tubular function and may reduce urine output in the prebypass period [78]. Urine output is also monitored during CPB as a surrogate
for end-organ perfusion.

PREPARATIONS FOR CARDIOPULMONARY BYPASS

Prior to initiating cardiopulmonary bypass (CPB), several key steps must be completed, as noted in separate topics (table 1):

● Systemic anticoagulation – Systemic anticoagulation is necessary before aortic cannulation and subsequent initiation of CPB.

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Typically, this is accomplished with an intravenous (IV) dose of heparin 300 to 400 units/kg, with confirmation of adequacy of systemic
anticoagulation to prevent clot formation in the CPB circuit. Details regarding heparin administration and monitoring are available in a
separate topic. (See "Blood management and anticoagulation for cardiopulmonary bypass", section on 'Systemic anticoagulation'.)

● Antifibrinolytic administration – Prophylactic antifibrinolytic therapy using a lysine analog (eg, epsilon-aminocaproic acid [EACA] or
tranexamic acid [TXA]) is typically administered shortly after systemic heparinization to decrease microvascular bleeding in the
postbypass period. Details are available in a separate topic. (See "Blood management and anticoagulation for cardiopulmonary
bypass", section on 'Antifibrinolytic administration'.)

● Cannulation of the great vessels – To initiate CPB, aortic and venous cannulation are necessary to divert the patient's blood from
the heart and lungs, with rerouting to the extracorporeal circuit. (See "Initiation of cardiopulmonary bypass", section on 'Aortic, venous,
and coronary sinus cannulation'.)

MANAGEMENT OF CARDIOPULMONARY BYPASS

Initiation of cardiopulmonary bypass (CPB), management during CPB, and weaning from CPB are discussed in separate topics (table 1):

● (See "Initiation of cardiopulmonary bypass".)

● (See "Management of cardiopulmonary bypass".)
● (See "Weaning from cardiopulmonary bypass".)

MANAGEMENT DURING THE POSTBYPASS PERIOD

Key steps for any cardiac surgical procedure in the period immediately after cardiopulmonary bypass (CPB) include venous and arterial
decannulation and reversal of anticoagulation with protamine administration (table 1) (see "Reversal of anticoagulation and management
of bleeding after cardiopulmonary bypass", section on 'Reversal of anticoagulation'). Residual pump blood is reinfused, and temporary or
backup epicardial pacing wires are inserted.

Management of cardiovascular problems — Cardiovascular problems that result in hemodynamic instability are identified and treated
(table 5 and table 3). (See "Intraoperative problems after cardiopulmonary bypass", section on 'Cardiovascular problems'.)

Similar cardiovascular problems may be encountered after cardiac surgical repairs accomplished without the aid of CPB (eg, off-pump
coronary artery bypass grafting [CABG] surgery). (See "Anesthesia for coronary artery bypass grafting surgery", section on 'Off-pump
coronary artery bypass surgery'.)

Postbypass management of fluids and blood products — After weaning from CPB, intravascular volume status is reevaluated with
transesophageal echocardiography (TEE) assessments (see 'Postbypass transesophageal echocardiography' below), with consideration
of hemodynamic parameters such as blood pressure, central venous pressure (CVP), pulmonary artery pressure (PAP), cardiac output,
and mixed venous oxygen saturation (SvO2). Serial lactate and/or base deficit values on arterial blood gases can also be useful to guide
fluid therapy. Fluid administration may be necessary due to treat hypovolemia, or transfusion of red blood cells may be necessary due to
persistent surgical bleeding. Decisions regarding transfusion are individualized, but hemoglobin is typically maintained ≥7.5 g/dL [79-83].
(See "Reversal of anticoagulation and management of bleeding after cardiopulmonary bypass", section on 'Transfusion of blood products'.)

Management of other systemic problems — Other systemic complications (eg, pulmonary, metabolic, renal) are frequently encountered
immediately after weaning from CPB while the patient is still in the operating room. These problems are often predictable based on patient-
specific and cardiac surgical procedure-specific factors. However, some patients experience unpredictable, sudden, or severe
complications that require immediate intervention and/or urgent reinstitution of CPB. Management of these problems is discussed
separately. (See "Intraoperative problems after cardiopulmonary bypass".)

Postbypass transesophageal echocardiography — TEE examination immediately after cardiac surgery emphasizes the following
aspects [30] :

● Adequacy of any surgical repair (eg, repair or replacement of a cardiac valve) is assessed.

● Global left ventricular (LV) and right ventricular (RV) function are evaluated.

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● LV and RV chamber sizes are assessed to determine intravascular volume status (movie 13). This is important because CVP and PAP
measurements are poor predictors of intravascular volume and fluid responsiveness [84]. (See "Intraoperative transesophageal
echocardiography for noncardiac surgery", section on 'Volume status'.)

● LV regional wall motion abnormalities (RWMAs) are documented as part of the overall assessment of the adequacy of
revascularization in territories of myocardium perfused by each of the major coronary arteries supplying the LV (figure 2 and figure 3).
(See "Anesthesia for coronary artery bypass grafting surgery", section on 'Postbypass transesophageal echocardiography'.)

Previously ischemic or hibernating myocardium may show improved function in the early postbypass period. However, myocardial
stunning is common and consequently, myocardial segments that had abnormal contraction in the prebypass period may remain
impaired even after adequate coronary blood flow has been restored.

Significant deterioration of regional wall motion in previously normal myocardial segments may indicate a technical problem with a
coronary graft (eg, poor quality of a bypass graft anastomosis, kinking, vasospasm, or embolization of air or microparticulate debris
into the graft) (movie 14). Poor graft flow can be confirmed by a Doppler flow probe applied to the graft. ST-segment changes on the
electrocardiogram (ECG) or hypotension with low cardiac output may also be noted. Detection of such problems allows surgical
correction prior to leaving the operating room. (See "Intraoperative problems after cardiopulmonary bypass", section on 'Surgical or
technical problems'.)

In patients who require ventricular pacing after CPB, a distinct septal motion abnormality termed "septal bounce" is often observed;
this occurs due to the abnormal pattern of ventricular depolarization that accompanies RV epicardial pacing (movie 15). Septal bounce
can be distinguished from a true RWMA because septal thickening persists during ventricular pacing but is absent when the septum is
ischemic. If this is difficult to discern visually, a brief pause in ventricular pacing may be helpful.

New or worsening mitral regurgitation (MR) in the postbypass period should prompt a thorough evaluation for LV RWMAs indicating an
ischemic cause of the MR.

● Hypotension after cardiac surgical procedures may occasionally be caused by dynamic LV outflow tract obstruction with systolic
anterior motion of the mitral leaflets [85].

● If aortic dissection is suspected following decannulation (eg, in a patient with a calcific or diffusely atheromatous ascending aorta, or
one who develops postbypass hypotension that is unresponsive to treatment), the ascending aorta is evaluated to identify this
potentially fatal complication (image 8).

TEE is also used for continuous monitoring throughout the postbypass period to assess ventricular volume and function, and to aid
diagnosis of hypotension. The TEE probe is left in place until the patient is ready for transport to the intensive care unit.

Use of lung-protective ventilation — We use a lung-protective ventilation strategy in the postbypass period (with low tidal volume [TV],
low driving pressure, and positive end-expiratory pressure [PEEP]) to potentially reduce the incidence of pulmonary complications. In a
retrospective study that included 4694 patients undergoing cardiac surgery with CPB, 10.9 percent experienced pulmonary complications
in the postoperative period (pneumonia, prolonged mechanical ventilation, need for reintubation, and/or poor oxygenation with a ratio of
arterial oxygen tension/fraction of inspired oxygen <100 mmHg within 48 postoperative hours while intubated) [86]. Fewer pulmonary
complications were noted in patients managed with lung-protective ventilation that included TV <8 mL/kg ideal body weight, modified
driving pressure (peak inspiratory pressure - PEEP) <16 cmH2O, and PEEP ≥5 cmH2O, compared with patients managed with other
ventilation strategies (adjusted odds ratio [OR] 0.56, 95% CI 0.42-0.75). A sensitivity analysis revealed that use of modified driving
pressure <16 mmHg, but not PEEP or low TV, was also independently associated with fewer pulmonary complications (adjusted OR 0.51,
95% CI 0.39-0.66) [86]. Although elevated driving pressure may simply be a marker (rather than a cause) of lung injury, we maintain this
pressure <16 mmHg as a component of lung-protective ventilation after CPB.

These ventilator settings are consistent with recommendations for lung-protective ventilation for all patients undergoing anesthesia and
surgery with use of mechanical ventilation. (See "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation
during anesthesia'.)

Sternotomy closure — Hemostasis must be achieved prior to closure of the sternotomy wound. Management of bleeding and
coagulopathy in the postbypass period can be challenging, as discussed in detail separately. (See "Reversal of anticoagulation and
management of bleeding after cardiopulmonary bypass", section on 'Management of bleeding'.)

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With chest closure, it is common to see minor decreases in arterial blood pressure with concomitant increases in CVP and/or PAP. This
occurs due to cardiac chamber compression as the sternum is reapproximated. TEE is employed to verify that hypotension is not the result
of new RWMAs that may result from kinking or occlusion of a newly placed bypass graft.

In rare cases, sternal closure is not possible due to persistent bleeding, hemodynamic instability caused by compression of the right atrium
and ventricle, or other technical problems. In these instances, an Esmarch bandage is sutured to the open sternal edges to "close" the
wound prior to leaving the operating room. (See "Intraoperative problems after cardiopulmonary bypass", section on 'Inability to close the
sternum'.)

Transport and handoff in the intensive care unit — Preparations, transport, and handoff in the intensive care unit are addressed
separately. (See "Intraoperative problems after cardiopulmonary bypass", section on 'Transport and handoff in the intensive care unit' and
"Handoffs of surgical patients", section on 'Operating room to intensive care unit'.)

EMERGENCY CARDIAC SURGICAL PROCEDURES

Patients requiring emergency surgery have a high risk for morbidity and mortality [16,87-90]. (See "Preanesthetic consultation for cardiac
surgery in adults", section on 'Emergency surgery' and "Anesthesia for aortic surgery requiring deep hypothermia", section on
'Preanesthetic consultation and planning'.)

Considerations for emergency or high-risk cases include:

● Patients with actual or potential hemodynamic instability may present to the operating room with an intraaortic balloon pump (IABP) in
place, or the surgeon may plan to insert an IABP after induction of general anesthesia or before termination of cardiopulmonary
bypass (CPB). Notably, an IABP is contraindicated if the patient has significant aortic regurgitation (AR). (See "Anesthesia for cardiac
valve surgery", section on 'Prebypass TEE assessment' and "Intraaortic balloon pump counterpulsation".)

● All monitoring should be established before (rather than after) anesthetic induction if possible, including insertion of the intra-arterial
catheter and placement of a central venous catheter (CVC).

● External defibrillator pads should be placed on the patient prior to induction, and a functioning pacemaker/defibrillator should be ready
at the bedside. If atrial or ventricular fibrillation occur, appropriate and immediate cardioversion or defibrillation is typically necessary
unless the surgical team can rapidly insert arterial and venous cannulae to initiate CPB.

● In some cases, prepping and draping in preparation for surgery should be completed while the patient is still awake, with the entire
operating room team present and ready to urgently establish CPB if cardiac arrest occurs during anesthetic induction.

● Inotropic and vasopressor infusions should be connected in the CVC ports, ready to infuse.

● Induction of anesthesia is performed with agents that cause minimal change in hemodynamics. Examples include etomidate 0.3
mg/kg or fentanyl 5 to 10 mcg/kg combined with midazolam 0.05 to 0.1 mg/kg. Anesthesia is subsequently maintained during the
prebypass period with appropriate doses of volatile inhalation anesthetic.

● Hemodynamic stability is carefully maintained during the prebypass period. Typically, vasoactive drug infusions are required to
maintain adequate blood pressure and cardiac output (table 3). Atrial pacing may be necessary to establish optimum heart rate, or
atrioventricular (AV) pacing may be necessary if heart block is present.

● CPB is established as quickly as possible. (See "Initiation of cardiopulmonary bypass".)

● Postbypass problems should be anticipated, as noted below after surgery for each lesion. (See "Intraoperative problems after
cardiopulmonary bypass" and "Anesthesia for cardiac valve surgery", section on 'Postbypass management' and "Anesthesia for
cardiac valve surgery", section on 'Postbypass management' and "Anesthesia for cardiac valve surgery", section on 'Postbypass
management' and "Anesthesia for cardiac valve surgery", section on 'Postbypass management'.)

ENHANCED RECOVERY AFTER CARDIAC SURGERY

Initially designed to improve recovery following colorectal surgery, enhanced recovery after surgery (ERAS) programs are increasingly

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applied to all major surgical procedures including cardiac surgery [91-93]. (See "Enhanced recovery after colorectal surgery" and
"Anesthetic management for enhanced recovery after major surgery (ERAS) in adults".)

Enhanced recovery after cardiac surgery programs leverage the expertise of a multidisciplinary approach to perioperative care and
evidence-based protocols aimed at reducing complications, duration of hospital stay, and improving clinical outcomes [91-96]. Certain
components of anesthetic care for ERAS patients require preoperative planning (eg, multimodal postoperative analgesia strategies, early
extubation).

● Multimodal analgesic techniques – High-dose opioid techniques are avoided as these may lead to prolonged respiratory depression
and need for mechanical ventilation, increased intensive care unit stays, delayed recovery, and potential for postoperative
complications [97]. Various multimodal opioid-sparing analgesic techniques have been employed in cardiac surgical patients, including
[91,92,95,98]:

• Regional analgesic techniques

- Epidural analgesia – In a 2019 meta-analysis of 69 randomized controlled trials in 2404 patients undergoing cardiac surgery
with or without cardiopulmonary bypass (CPB), use of epidural analgesia was associated with reduced risk of myocardial
infarction, respiratory depression, and atrial fibrillation or flutter, as well as reduced pain at rest and with movement,
compared with other analgesic techniques (eg, systemic analgesia, peripheral nerve block, intrapleural analgesia, wound
infiltration) [99]. No epidural hematomas were reported in any of the trials, but there was an increased risk of hypotension in
this meta-analysis. Notably, only four of the trials were conducted in North America. (See "Epidural and combined spinal-
epidural anesthesia: Techniques".)

- Thoracic erector spinae plane block – Small nonrandomized studies of the use of continuous bilateral thoracic erector spinae
plane blocks have reported decreased intraoperative and postoperative opioid consumption [100,101]. (See "Thoracic nerve
block techniques", section on 'Erector spinae plane block'.)

- Other regional anesthetic techniques – Other techniques that have been studied include serratus anterior plane blocks,
pectoral fascial plane blocks, transverse thoracic plane blocks, and intrathecal morphine [92,95,102-104]. Regional
techniques may be particularly helpful in minimally invasive cardiac surgery. (See "Thoracic nerve block techniques", section
on 'Interfascial plane blocks of the chest wall' and "Minimally invasive aortic and mitral valve surgery".)

• Nonopioid systemic analgesic agents – Nonopioid analgesics may be used during and after cardiac surgical procedures
including dexmedetomidine, gabapentinoids, ketamine, lidocaine, and acetaminophen [91,92,94,95,105]. In a small randomized
trial in older adults having cardiac surgery, postoperative scheduled intravenous (IV) acetaminophen combined with IV propofol or
IV dexmedetomidine reduced the incidence of in-hospital delirium compared with placebo (10 versus 28 percent; hazard ratio
[HR] 2.8, 95% CI 1.1-7.8; 121 patients), and reduced opioid use during the first 48 postoperative hours (median morphine
equivalents 323 versus 405 mcg) [106]. Another small randomized study demonstrated a reduced incidence of persistent pain
three and six months after cardiac surgery in patients who received pregabalin 150 mg in the preoperative period then twice daily
for 14 postoperative days (with or without ketamine infused for 48 postoperative hours), compared with patients receiving placebo
[105].

● Early extubation – Routine early extubation (eg, within approximately six postoperative hours) and overnight extubation protocols
have been successfully implemented in elective cardiac surgical patients without increased risk of adverse outcomes [94,107-109].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See
"Society guideline links: Management of cardiopulmonary bypass".)

SUMMARY AND RECOMMENDATIONS

● Cardiac surgery is conducted using standard American Society of Anesthesiologists (ASA) monitors (table 2), as well as intra-arterial
and central venous access. We also monitor urine output, degree of neuromuscular blockade (using a peripheral nerve stimulator),

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and temperature. Furthermore, for most cardiac surgical cases, we use transesophageal echocardiography (TEE), processed
electroencephalography (EEG), and point-of-care (POC) testing of laboratory values. Additional monitoring with a pulmonary artery
catheter (PAC) or a cerebral oximetry monitor may be employed in selected patients. (See 'Monitoring' above.)

● Intraoperative TEE is often used during cardiac surgery to confirm and refine preoperative diagnoses, detect new or unsuspected
cardiovascular pathology that may alter anesthetic or surgical plans, and guide PAC positioning. We conduct an initial comprehensive
prebypass TEE examination, followed by continuous use of the TEE to monitor ventricular function and volume. In the postbypass
period, TEE is used to assess results of all surgical interventions while the patient is still in the operating room. Even if TEE is not
used electively, rapid deployment may be needed to diagnose causes of acute, persistent, and life-threatening hemodynamic
instability (ie, "rescue" TEE). (See 'Prebypass transesophageal echocardiography' above and 'Postbypass transesophageal
echocardiography' above.)

● The most common anesthetic induction technique includes use of a low dose of a sedative-hypnotic agent combined with a low dose
of opioid and volatile anesthetic agent ("balanced technique"). For example, a small dose of propofol (eg, 0.5 to 1 mg/kg) may be
administered in combination with a moderate dose of fentanyl 2 to 4 mcg/kg and a neuromuscular blocking agent. An alternative
induction technique that is used less commonly includes administration of a higher dose of a synthetic opioid. High-dose opioid
techniques are avoided in patient participating in enhanced recovery after cardiac surgery protocols, as these may lead to prolonged
respiratory depression and need for mechanical ventilation, increased intensive care unit stays, delayed recovery, and potential for
postoperative complications. (See 'Induction techniques' above and 'Enhanced recovery after cardiac surgery' above.)

● General anesthesia may be maintained with a volatile anesthetic agent, a total intravenous anesthetic (TIVA) technique, or a
combination of volatile and intravenous (IV) agents. (See 'Maintenance techniques' above.)

● We use a lung-protective ventilation strategy before and after cardiopulmonary bypass (CPB; with low tidal volume [TV], low driving
pressure, and positive end-expiratory pressure [PEEP]) to potentially reduce the incidence of pulmonary complications. (See
'Prebypass ventilation strategies' above and 'Use of lung-protective ventilation' above.)

● Judicious fluid administration (usually with a balanced crystalloid solution rather than a colloid solution) prior to CPB is typically
restricted to small volumes because initiation of CPB results in significant hemodilution as the CPB circuit prime mixes with the
patient's blood volume. We suggest avoiding hydroxyethyl starch (HES) colloid solutions (Grade 1B), due to concerns regarding
increased risk of bleeding and transfusion, and possibly acute kidney injury (AKI). After weaning from CPB and return of reservoir
pump blood, intravascular volume status is reevaluated and treated. Decisions regarding transfusion of blood products are
individualized, but hemoglobin is typically maintained ≥7.5 g/dL. (See "Intraoperative fluid management", section on 'Choosing fluid:
Crystalloid, colloid, or blood' and 'Prebypass fluid management' above and 'Postbypass management of fluids and blood products'
above.)

● Key steps for intraoperative management of CPB are noted in the table (table 1), and are discussed in detail in separate topics:

• (See "Blood management and anticoagulation for cardiopulmonary bypass".)

• (See "Initiation of cardiopulmonary bypass".)
• (See "Management of cardiopulmonary bypass".)
• (See "Weaning from cardiopulmonary bypass".)
• (See "Reversal of anticoagulation and management of bleeding after cardiopulmonary bypass".)

● Key steps for the period immediately after CPB are noted in the (table 1). Cardiovascular and other systemic problems in the
postbypass period are identified and treated. (See 'Management during the postbypass period' above and "Intraoperative problems
after cardiopulmonary bypass".)

● Considerations for emergency or high-risk cardiac surgical procedures are discussed above. (See 'Emergency cardiac surgical
procedures' above.)

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GRAPHICS

Key periods during cardiac surgery

Period Anesthetic goals

Prebypass period Induction and maintenance of Maintain optimal myocardial O 2 supply and minimize demand to prevent or treat ischemia
anesthesia

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 Reduce tidal volume

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 Confer with perfusionist if indicated

circuit setup, priming, testing
of alarms and circuit,
adherence to checklist

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 O 2 delivery, CO 2 Discontinue controlled ventilation and anesthetic administration via the anesthesia machine
removal, and pump flow Discontinue cardiac support (eg, inotropic agents, IABP)
assumed by perfusionist

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 Ensure complete myocardial arrest (absence of ECG electrical activity)
and administration of TEE monitoring for aortic insufficiency and LV distension during antegrade cardioplegia delivery
cardioplegia

Placement and monitoring of TEE assessment of coronary sinus catheter placement for retrograde cardioplegia delivery
coronary sinus catheter and LV Monitor coronary sinus pressure
vent 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 SvO 2 ≥75%; suggest increase in pump flow if SvO 2 <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

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Anticoagulation reversal, pump Administer protamine slowly, treat protamine reactions

suckers turned off, Ensure complete reversal of anticoagulation
intravascular vents removed

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, SpO 2 , and intraarterial BP during transport
Use of a formal protocol for communication and transfer of technology during handover to the
ICU team

O 2 : oxygen; CPB: cardiopulmonary bypass; TEE: transesophageal echocardiography; LV: left ventricular; RV: right ventricular; SVR: systemic vascular resistance; ACT:
activated clotting time; BP: blood pressure; CO 2 : carbon dioxide; IABP: intraaortic balloon pump; TIVA: total intravenous anesthesia; EEG: electroencephalography; MAP:
mean arterial pressure; Hgb: hemoglobin; Hct: hematocrit; SVO 2 : mixed venous oxygen saturation; ECG: electrocardiogram; SpO 2 : peripheral oxygen saturation; ICU:
intensive care unit.

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Basic monitoring during anesthesia

Primary physiologic
Monitoring
process/parameter Principle Derived information Additional function
equipment
targeted

Oxygenation Inspired gas O 2 analyzer Paramagnetic sensor, fuel (galvanic) cell, Inspired/expired O 2 A low-level alarm is
O 2 content (with a low- polarographic (Clark) electrode, mass concentration when placed automatically activated by
limit alarm in spectroscopy, or Raman scattering downstream from fresh flow turning on the anesthesia
use) control valves machine

Blood Pulse oximeter The Beer-Lambert law applied to tissues and Hemoglobin saturation, pulse Continuous evaluation of
oxygenation pulsatile blood flow. The relative absorbency at rate, relative pulse amplitude circulation, variable pitch pulse
wavelengths of 660 and 940 nm is used to displayed on plethysmography tone, and audible low-threshold
estimate saturation, which is derived from the waveform alarm
ratio of oxyhemoglobin to the sum of
oxyhemoglobin plus deoxyhemoglobin.

Ventilation Exhaled CO 2 Capnograph CO 2 molecules absorb infrared radiation at 4.26 ETCO 2 , inspired CO 2 , Instantaneous information
micrometers, proportionate to the CO 2 diagnostic waveforms, about:
concentration present in the breath sample respiratory rate, apnea Perfusion (how effectively
detection CO 2 is being transported
through the vascular
system)
Metabolism (how effectively
CO 2 is being produced by
cellular metabolism)
Confirmation of tracheal
tube placement after
intubation

Integrity of Disconnection Detects the cyclical changes in airway pressure Alarms if a significant decrease Alarms if high pressures are
ventilation alarm in the normal range in rate or pressure occurs sensed
system during
mechanical
ventilation

Pulmonary Pulmonary Volume of gas proportional to a drum Inspired and expired volume, Pressure volume and flow
mechanics flow and movement, changes in differential pressure flow, and airway pressure volume loops
(volume, flow, pressure (near the Y-connector) or in electrical resistance
pressure) sensors (hot wire housed in a monitor or ventilator)

Circulation Cardiac ECG The ECG monitor detects, amplifies, displays, Heart rate and rhythm ST segment
activity and records the ECG signal. depression/elevation and trend
over time, with an audible
alarm warning of significant
arrhythmias or asystole

Arterial BP Noninvasive Oscillometric devices automatically inflate and Arterial BP Indicator of organ perfusion
BP monitor deflate the cuff, and have electronic pressure
sensors that record the pressure oscillations of
the arteries. The pressure at which maximal
oscillations occur as the cuff is deflated
corresponds with MAP. Proprietary algorithms
are used to calculate systolic and diastolic BP.

Temperature Temperature Devices with a semiconductor, electrical Core or peripheral temperature A greater than 2°C core-to-
monitor resistance decreases as temperature decreases periphery temperature gradient
is indicative of low cardiac
output.

O 2 : oxygen; CO 2 : carbon dioxide; ETCO 2 : end-tidal carbon dioxide; ECG: electrocardiogram; BP: blood pressure; MAP: mean arterial pressure.

Graphic 110080 Version 3.0

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Placement of transcutaneous pacemaker/defibrillator pads for

sternotomy incision

Pads are placed to ensure that the heart is between the two pads, but that neither pad will be
in the sterile surgical field.

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TEE assessment of LV diastolic dysfunction using pulsed wave tissue Doppler of the mitral annulus (center panels) and
pulsed wave Doppler of the mitral inflow (right panels)

Accurate identification of each Doppler spectral peak requires an accompanying electrocardiographic tracing. Conditions such as atrial fibrillation, mitral annular
calcification, mitral valve surgery, or extracorporeal circulatory support generally preclude using these Doppler techniques.

A: late mitral inflow velocity resulting from atrial contraction; E: early mitral inflow velocity; e′: early mitral annular velocity recorded from the lateral mitral annulus.

From: Maxwell C, Konoske R, Mark J. Emerging concepts in transesophageal echocardiography. F1000Research 2016; 5:340. DOI: 10.12688/f1000research.7169.1. Reproduced
under the terms of the Creative Commons Attribution License.

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LV perfusion territories

The regional distribution of LV segmental wall motion abnormalities detected by TEE can be
used to help determine the location of disease within the coronary arteries. The diagram
displays the typical territories of myocardium perfused by each of the major coronary
arteries supplying the LV in the TEE mid-esophageal four-chamber view, TEE mid-
esophageal two-chamber view, TEE mid-esophageal long-axis view, and TEE transgastric LV
short-axis view. Anatomic variations and coronary collateral flow may produce different
patterns of coronary perfusion in individual patients.

LV: left ventricle/left ventricular; TEE: transesophageal echocardiography; LAD: left anterior
descending; Cx: circumflex; RCA: right coronary artery.

Modified from: Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a
comprehensive intraoperative multiplane transesophageal echocardiography examination:
recommendations of the American Society of Echocardiography Council for Intraoperative
Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification
in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr 1999; 12:884.

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LV segmental anatomy

The regional distribution of myocardial ischemia can be detected as segmental LV wall

motion abnormalities by TEE. The entire LV in the 17-segment model can be imaged in
long-axis using a combination of the TEE mid-esophageal four-chamber view (a), TEE mid-
esophageal two-chamber view (b), and TEE mid-esophageal long-axis view (c).
Alternatively, all 17 LV wall segments can be imaged using the TEE transgastric LV short-
axis views at the levels of the LV base (d), papillary muscles (e), and apex (not shown).
Alternatively, an earlier version of a 16-segment LV model that excludes the apical cap is
often used for TEE studies.

LV: left ventricle/left ventricular; TEE: transesophageal echocardiography.

Modified from: Shanewise JS, Cheung AT, Aronson S, et al. ASE/SCA guidelines for performing a
comprehensive intraoperative multiplane transesophageal echocardiography examination:
recommendations of the American Society of Echocardiography Council for Intraoperative
Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification
in Perioperative Transesophageal Echocardiography. J Am Soc Echocardiogr 1999; 12:884.

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Midesophageal 2-chamber TEE image of left ventricular thrombus

This midesophageal 2-chamber TEE image demonstrates a large (18 mm x 53 mm) anterior-apical left ventricular thrombus.

TEE: transesophageal echocardiography.

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TEE in the mid-esophageal long axis imaging plane and epiaortic

scan

A TEE still in the mid-esophageal long axis imaging plane (A) demonstrates heavy
calcification of the root, sinotubular junction, and tubular ascending aorta. There is a
particularly heavy calcium burden on the posterior wall (nearest to the TEE probe). An
epiaortic scan (B) of the same patient demonstrates a significant circumferential atheroma
which would preclude cannulation or cross-clamping at this site.

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TEE proximal descending thoracic aorta

A TEE image of the proximal descending thoracic aorta. Large atheromatous plaques such as these should be communicated to the
surgeon in case the use of an intra-aortic balloon pump is being considered.

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Color flow Doppler of severe aortic regurgitation

Color-flow Doppler mid-esophageal five-chamber view from a transesophageal

echocardiogram. The outflow tract is completely occupied by the aortic
regurgitant color flow jet (AR jet); when the jet exceeds 65 percent of the left
ventricular outflow tract (LVOT) width, the regurgitation is judged severe.

Ao: aorta; LV: left ventricle.

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Vena contracta measurement in aortic insufficiency

From the mid-esophageal aortic valve long-axis view, a color-flow video loop of the regurgitant jet through the aortic valve should be captured in
diastole. The video should be cycled through until the peak diastolic flow is observed in a still frame (shown here). To make a valid measurement, the
frame must contain the hemisphere of flow acceleration on the aortic valve side of the outflow tract, a clear image of the narrowest neck of the jet, and
the jet itself in the left ventricular outflow tract. Aliasing velocities should be between 40 and 60 cm/s, and the focus should be at the level of the valve.
The vena contracta is measured at the narrowest neck of the jet (illustrated in the image on the right). This measurement is reproducible and relatively
independent of load, making it an attractive tool for quantifying the severity of aortic regurgitation using intraoperative TEE.

TEE: transesophageal echocardiography.

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Holodiastolic flow reversal AI

Holodiastolic flow reversal seen in the descending aorta, suggesting severe aortic regurgitation. Note the presence of the ECG, which can be
used to time systole and diastole.

AI: aortic insufficiency; ECG: electrocardiogram.

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Vasopressors and inotropic agents used in the operating room: Adult dosing* ¶

Functional class
(predominant
Drug receptor or Bolus dose Infusion dose Comments
mechanism of
action)

Ephedrine Inotrope/chronotrope 5 to 10 mg boluses N/A Tachyphylaxis may occur with multiple

/vasopressor (alpha 1 repeated doses due to indirect postsynaptic
-adrenergic receptor release of norepinephrine
agonist; beta 1 - and Cardiovascular effects attenuated by drugs
beta 2 -adrenergic that block ephedrine uptake into adrenergic
receptor agonist) nerves (eg, cocaine) or those that deplete
norepinephrine reserves (eg, reserpine)
Administered with extreme caution (eg, in
small incremental doses of 2.5 mg) to
patients using monoamine oxidase (MAO)
inhibitors or methamphetamines since
exaggerated hypertensive responses or life-
threatening dysrhythmias may occur

Phenylephrine Vasopressor (alpha 1 - 50 to 100 mcg boluses 10 to 100 mcg/minute Often selected to treat hypotension if normal
adrenergic receptor (may begin infusion if or or elevated HR is present
agonist) repeated bolus doses Genetic polymorphisms lead to variable
0.1 to 1 mcg/kg/minute
are necessary) individual responses

Norepinephrine Inotrope/vasopressor 4 to 8 mcg (may begin 1 to 20 mcg/minute Often selected as a first-line agent during
(alpha 1 - and beta 1 - infusion if repeated or noncardiac surgery, particularly for treatment
adrenergic receptor bolus doses are of most types of shock
0.01 to 0.3 mcg/kg/minute
agonist) necessary) Norepinephrine 8 mcg is approximately
equivalent in potency to phenylephrine 100
mcg
Peripheral extravasation of a high
concentration may cause tissue damage

Epinephrine Inotrope/chronotrope 4 to 10 mcg initially; 1 to 100 mcg/minute First-line treatment for cardiac arrest and for
/vasopressor (alpha 1 - up to 100 mcg boluses or anaphylaxis
adrenergic receptor may be used when May be administered IV, IM, or via an
0.01 to 1 mcg/kg/minute
agonist; beta 1 - and initial response is endotracheal tube in emergencies
beta 2 -adrenergic inadequate Low doses cause bronchodilatory effects and
receptor agonist) Note changing effects across dose range: may cause arterial vasodilation and
Low doses have primarily beta 2 - decreased BP
adrenergic effects at 1 to 2 mcg/minute or Intermediate doses cause increases in HR
0.01 to 0.02 mcg/kg/minute and BP
Intermediate doses have primarily beta 1 - High doses cause vasoconstriction, with
and beta 2 -adrenergic effects at 2 to 10 possible severe hypertension and adverse
mcg/minute or 0.02 to 0.1 mcg/kg/minute metabolic effects
High doses have primarily alpha 1 - Individual responses to dose-related effect
adrenergic effects at 10 to 100 are variable
mcg/minute or 0.1 to 1 mcg/kg/minute

Vasopressin Vasopressor 1 to 4 units 0.01 to 0.04 units/minute Effective for treatment of hypotension
(vasopressin 1 and refractory to administration of
vasopressin 2 receptor catecholamines or sympathomimetics such as
Doses >0.04 units/minute up to 0.1
agonist) ephedrine, phenylephrine, or norepinephrine
units/minute are reserved for salvage therapy
No direct effect on HR
(ie, failure to achieve adequate BP goals with
Little effect on PVR; can cause splanchnic
other vasopressor agents) ¶
vasoconstriction
Individual responses to dose-related effects
are variable
Peripheral extravasation may cause skin
necrosis

Dopamine Inotrope/vasopressor N/A 2 to 20 mcg/kg/minute Low doses may exacerbate hypotension via
/dose-dependent beta 2 stimulation
chronotropy High doses may cause vasoconstriction,
Note changing effects across dose range:
(dopaminergic, adverse metabolic effects, and arrhythmias
beta 1 -, beta 2 -, and Low doses have primarily dopaminergic
alpha 1 -adrenergic effects at <3 mcg/kg/minute
receptor agonist) Intermediate doses have primarily beta 1 -
and beta 2 -adrenergic effects at 3 to 10
mcg/kg/minute
High doses have primarily alpha 1 -
adrenergic effects >10 mcg/kg/minute

Dobutamine Inotrope/vasodilator N/A 1 to 20 mcg/kg/minute Exacerbation of hypotension is possible due

/dose-dependent to dose-dependent vasodilation (via beta 2
chronotropy (beta 1 - stimulation); concurrent administration of a
and beta 2 -adrenergic potent vasoconstrictor such as
receptor agonist) norepinephrine or vasopressin may be

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necessary

Milrinone Inotrope/vasodilator N/A 0.375 to 0.75 mcg/kg/minute (a loading dose of Exacerbation of hypotension is likely due to
(phosphodiesterase 50 mcg/kg over ≥10 minutes may be vasodilation (via phosphodiesterase
inhibitor) (decreases administered, but is often omitted) inhibition); concurrent administration of a
rate of cyclic potent vasoconstrictor such as
adenosine norepinephrine or vasopressin may be
monophosphate necessary
[cAMP] degradation)

Isoproterenol Inotrope/chronotrope N/A 5 to 20 mcg/minute Exacerbation of hypotension is likely due to

/vasodilator (beta 1 - or dose-dependent vasodilation (via beta 2
and beta 2 -adrenergic stimulation)
0.05 to 0.2 mcg/kg/minute
receptor agonist) May cause arrhythmias
Not available in most settings

N/A: not applicable; HR: heart rate; IV: intravenous; IM: intramuscular; BP: blood pressure; PVR: pulmonary vascular resistance.
* Dose ranges are based on adult patients of normal size.
¶ Refer to related UpToDate content on hemodynamic management during anesthesia and surgery.

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Antimicrobial prophylaxis for cardiac surgery in adults

Recommended
Nature of operation Common pathogens Usual adult dose* Redose interval ¶
antimicrobials

Cardiac procedures: coronary Staphylococcus Cefazolin Δ <120 kg: 2 g IV 4 hours

artery bypass, cardiac device aureus, Staphylococcus epidermidis ≥120 kg: 3 g IV
insertion procedures (eg,
pacemaker implantation), OR cefuroxime 1.5 g IV 4 hours ◊
placement of ventricular assist OR vancomycin § 15 mg/kg IV (max 2 g) N/A
devices
OR clindamycin 900 mg IV 6 hours

IV: intravenous.

* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If vancomycin is used, the infusion should be started
within 60 to 120 minutes before the initial incision to have adequate tissue levels at the time of incision and to minimize the possibility of an infusion reaction close to the
time of induction of anesthesia.
¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns, additional intraoperative doses should be given at intervals 1 to 2
times the half-life of the drug for the duration of the procedure in patients with normal renal function.
Δ Cefazolin is preferred over cefuroxime, given increasing resistance to second-generation cephalosporins. Indications for vancomycin are summarized in footnote §.
Clindamycin may be used for patients unable to tolerate the other agents listed.
◊ Some experts recommend an additional dose when patients are removed from bypass during open-heart surgery.
§ Use of vancomycin is appropriate in hospitals in which methicillin-resistant S. aureus (MRSA) and S. epidermidis are a frequent cause of postoperative wound infection, in
patients previously colonized with MRSA, or for those who are allergic to penicillins or cephalosporins. Rapid IV administration may cause hypotension, which could be
especially dangerous during induction of anesthesia. Even when the drug is given over 60 minutes, hypotension may occur; treatment with diphenhydramine and further
slowing of the infusion rate may be helpful. For procedures in which enteric gram-negative bacilli are common pathogens, many experts would add another drug such as an
aminoglycoside (gentamicin 5 mg/kg IV), aztreonam (2 g IV), or a fluoroquinolone (ciprofloxacin 400 mg IV or levofloxacin 500 mg IV).

Adapted from:
1. Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013; 14:73.

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Hemodynamic management of hypotension during and after weaning from CPB

PADP or Cardiac Blood LV function RV function

CVP PAP Diagnosis Response
PAWP* output pressure by TEE by TEE

Low Low Low Low Low Normal or Normal or Hypovolemia Administer

hyperdynamic hyperdynamic volume

Low or normal Low or normal Low or normal High Low Normal or Normal or Vasoplegia Administer
hyperdynamic hyperdynamic vasopressor

High or normal High Low or normal ¶ High Low Normal Normal or Pulmonary Administer
hypocontractile hypertension pulmonary
vasodilator

High Normal or low Normal or high ¶ Low Low Normal Hypocontractile, Right Administer
often dilated ventricular inotropic
dysfunction agent
Administer
pulmonary
vasodilator

Normal or high Normal or high High Low Low Hypocontractile, Normal Left Administer
often dilated ventricular inotropic
dysfunction agent

CPB: cardiopulmonary bypass; CVP: central venous pressure; PAP: positive airway pressure; PADP: pulmonary artery diastolic pressure; PAWP: pulmonary artery wedge
pressure; LV: left ventricular; TEE: transesophageal echocardiography; RV: right ventricular.
* PAWP should not be measured prior to neutralizing heparin following CPB. Initially, PADP is measured, the PADP may overestimate PAWP when patients have elevated
pulmonary vascular resistance (eg, pulmonary hypertension).
¶ PADP or PAWP are indirect measures of LV filling pressure. With RV dysfunction and dilation, ventricular septal shift may increase LV filling pressure despite low or normal
LV filling volume.

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Type A aortic dissection with aortic insufficiency

Intraoperative TEE image of the aortic valve, aortic root, and proximal ascending aorta in a long-axis view, with color-flow
Doppler imaging in diastole demonstrating severe aortic regurgitation with an acute aortic dissection. The presence of an intimal
flap in the aortic root (arrowheads) is diagnostic for Stanford type A aortic dissection. Severe aortic regurgitation is present as a
mosaic regurgitant jet in the LVOT caused by acute enlargement of the aortic root due to the dissection.

LVOT: left ventricular outflow tract; Ao: ascending aorta; TEE: transesophageal echocardiography.

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Contributor Disclosures
Atilio Barbeito, MD, MPH Nothing to disclose Eric A JohnBull, MD, MPH Nothing to disclose Jonathan B Mark, MD Nothing to disclose Nancy A
Nussmeier, MD, FAHA Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level
review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors
and must conform to UpToDate standards of evidence.

Conflict of interest policy

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