Education

Cardiac Rotation Primer

Room Set-Up

• Ambu-Bag, Anesthesia Machine Test, and Suction
• TableTop Stuff (gauze, ETOH, lubricant, oral/nasal airways, blades, ETTs)
• Standard Monitors
  • 1 large tegaderm for each EKG lead
  • OG tube x 2 and BIS monitor (suction stomach and remove OGT prior to Echo probe placement and place second OGT at end of case)
  • Triple Transducer for A-line/CVP/PAP with 500mL NS and pressure bag + manifold
  • Cardiac Output kit with 500mL NS hanging near manifold on a stylette
• A-line kit (arm board, ETOH, lidocaine, gloves, iodine, sterile gauze, catheter, end of transducer tubing with stopcock and flush syringe, suture, tegaderm, tape)
• Swan kit (central line kit – double or single lumen, swan, gloves, gown, biopatch)
• IV Lines
  • Peripheral IV → 1L plasmalyte with macro-drip tubing
  • Regular Line for Cordis → 1L plasmalyte with macro-drip tubing
  • Volume/Blood Line for cordis → 1L plasmalyte with Y-tubing + 2 stopcocks + 2 extensions
  • Infusions/Drips Line for VIP port → 1L NS with microdrip + 6 stopcocks
• Wide IV Pole with 8 Infusion Pumps (4x4) and pump tubing (special for NTG)
• Drips (get 2 4-channel pumps & set up drips on pause in anesthesia mode; note that drips are attending-specific, so be sure to discuss this the day before; the first three are almost always used)

• Levophed (Norepinephrine) 4mg in 250 NS → 16mcg/mL
• Nitroglycerine 50mg in 250ml NS → 200mcg/mL
• Ultiva (Remifentanil) 5mg in 100mL NS → 50mcg/mL
• Neosynephrine 40mg in 250mL NS → 160mcg/mL
• Epinephrine 4mg in 250mL NS → 16mcg/mL
• Primacor (Milrinone) 20mg in 100mL NS → 200mcg/mL
• Insulin 100units in 100mL NS → 1unit/mL
• Precedex (Dexmedetomidine) 200mcg in 100mL NS → 2mcg/mL
• Amikar 5 gram bolus dose and 5 grams/hr

• Syringes/Emergency Drugs
  • Succinylcholine (200mg → 10mL)
  • Lidocaine (pre-packaged syringe)
  • Calcium Chloride (100mg/mL → 10mL)
  • Heparin (1000units/mL → 20mL x 2 syringes)
  • Esmolol (10mg/mL → 10mL)
  • Levophed (16mcg/mL → take 10mL from bag)
  • Nitroglycerine (directly from bag; or dilute from bag to 20mcg/mL or to 100mcg/mL)
  • Neosynephrine (.1mg/mL → 10mL)
  • Epinephrine (16mcg/mL → take 10mL from bag)
  • Ephedrine (5mg/mL → 10mL)
• Atropine (.4mg/mL → 3mL syringe
• Induction Drugs
  • Versed (Midazolam) – 10mL syringe
  • Fentanyl – 20mL syringe / Sufentanil – 5mL syringe
  • Zemuron (Rocuronium) /Pavulon (Pancuronium) – 10mL syringe
  • Etomidate – 20mL syringe

• TEE and probe with plastic covering (found next to hanging probe in workroom); Pacemaker (check the battery)
• ABG and ACT (5mL) syringes (place patients labels on them)

• Paperwork (regular papers + TEE sheet and CT-CICU transfer form)
  

Progression

• Set-up room
• Place A-line and IV in holding/CT-ICU
• Bring pt in… set up monitors…draw ABG/ACT (then ABGs ~Q30-45min)
• Induction and Intubation
• Place BIS, OG tube (suction stomach and remove), and connect bladder temp
• give Ancef (1g if <90kg or 2g if >90kg) ~30min before incision and dose again after 4hr
• Place Swann-Ganz central line → attach and do baseline cardiac output
• Start Amikar if being used → give 1mL test dose
• Start Remifentanil +/- Dexmedetomidine Drip(s) here or possibly at the end of the case
• Hold ventilation during sternotomy
• Give heparin (300units/kg) → draw ABG & ACT ~3-5min later
• BYPASS……………
• Protamine → same volume as heparin (mL à mL) in bag over ~15min or so
• draw ABG & ACT ~3-5min later
• hold ventilation during chest closure and do cardiac output after chest is closed
• Draw final ABG/ACT and place OGT at the end before leaving the room
• transfer patient with monitors (obviously) and PACEMAKER as well as emergency drugs and blades/ETTs
• during transfer keep one line close to you ready to give any needed bolus of medication
• fill out the transfer form and then give report to the CT-ICU nurses

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