>> session 1 cmc anesthesia protocolcmcapm.bjsolution.co.kr/register/201601/file/p1.s1.pdf-...

Program 1 ANESTHESIA

(Room 2층 대강당)

제5회 가톨릭대학교 의과대학

마취통증의학교실 심포지엄

>> Session 1 CMC Anesthesia Protocol

Anesthetic protocol for liver transplantation 인천성모병원 김달아

Anesthetic protocol for adult cardiac surgery 성빈센트병원 서권휘

Anesthetic protocol for pediatric cardiac surgery 서울성모병원 김미현

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Anesthetic protocol for liver transplantation

김달아

인천성모병원



4 제5회 가톨릭대학교 의과대학 마취통증의학교실 심포지엄

Anesthetic protocol for adult cardiac surgery

서권휘

가톨릭대학교 성빈센트병원

Preparation of anesthetic management Monitoring• Basic monitoring: ECG (≥ 2 leads (II and V5)), pulse oximetry, automatic blood pr. cuff• CNS monitoring: cerebral oximetry, transcranial Doppler (detection of cerebral blood flow and emboli), BIS, TEE (severity

of atheromatous disease: a strong predictor of death and stroke after CABG)

Venous Access• Large-bore peripheral IV catheters• One or two central venous line (usually IJV): measurement of CVP• PA-catheters: preload, C.O, mixed venous oxygen saturation, PCWP, core temperature, cardiac pacing

Indication Contraindication

• Major procedures involving large fluid shifts or blood loss in patients with Rt. heart failure, pulmonary HTN

• Severe Lt. heart failure not responsive to therapy• Cardiogenic/septic shock or multiple organ failure• Hemodynamic instability requiring inotropes or intraaortic

balloon counterpulsation• Surgery of the aorta requiring suprarenal cross-clamping• Orthotopic heart transplantation

Absolute• tricuspid or pulmonic valvular stenosis • RA or RV masses • tetralogy of Fallot.Relative• severe arrhythmias• newly inserted pacemaker wires (which may be

dislodged by the catheter during insertion).

Arterial cannulation• Insert before induction of anesthesia• Non-dominant hand (if harvesting: dominant hand)

OthersIndwelling urinary catheter, temperature probes (esophageal, nasopharyngeal, bladder, blood), TEE

Anesthetic management of pre-bypass periodInduction of anesthesia• Goal: Hemodynamic & metabolic stability, early extubation (1-6 h postop.), fast track?• Immediately available drugs preparation: vasopressors (phenylephrine, ephedrine, calcium chloride, vasopressin), inotropes

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(ephedrine, epinephrine, norepinephrine, dopamine, dobutamine), vasodilators (nitroglycerin, nitroprusside, nicardipine), an anticholinergic drug (atropine), antiarrhythmic drugs (lidocaine, esmolol, magnesium, amiodarone, adenosine), and heparin

- Vasopressor if blood pressure falls >20%

Choice of anesthetic agents• TIVA with short acting agents, covers whole procedure- propofol 0.5-1.5 mg/kg followed by 25-100 μg/kg/min or TCI: 1.5-2 μg/mL- modest doses of fentanyl (5-7 μg/kg) or remifentanil 0-1μg/kg followed by 0.25-1 μg/kg/min• Mixed intravenous/Inhalation anesthesia- induction: propofol 0.5-1.5 mg/kg or etomidate 0.1-0.3 mg/kg- Volatile anesthetic agents (Cardioprotection, Difficult to use during CPB) with opioids• Avoid N2O (expansion of intravascular air bubbles, pneumothorax)• Muscle relaxants- rocuronium, vecuronium and cisatracurium are commonly used- vecuronium has been reported to markedly enhance bradycardia associated with large dose of opioids (sufentanil).- pancuronium has vagolytic effects, may be beneficial in patients with marked bradycardia.

<typical hemodynamic responses to surgical stimulation before CPB>

Preparations for CPB• Prebypass checklist: anticoagulation, anesthesia (adequate?), cannulation (proper and patent), infusions (turn off),

monitoring (pressure transducers, temperature, urine catheter), pupil• Anticoagulation: heparin 300-400 units/kg- Monitoring of anticoagulation: ACT >400 sec




<heparin dose-response curve>- prolongs ACT: hemodilution, hypothermia, thrombocytopenia, platelet inhibitors, aprotinin (only ↑ celite ACT)- shortens ACT: platelet lysis, surgical stress• Heparin resistance (Antithrombin III (AT) deficiency): inability to raise the ACT to therapeutic levels after administration

of the recommended doses of unfractionated heparin.- etiology: congenital deficiency or abnormality of AT, acquired AT deficiency, increased levels of heparin-binding proteins,

activated platelets, sepsis, or other conditions.- risk factors for altered heparin responsiveness: AT levels < 60% of normal, preoperative heparin therapy, and a platelet count

> 300,000/μL- treatment: altered heparin responsiveness → supplemental heparin refractory cases → AT concentrate, recombinant AT• Heparin-induced thrombocytopenia (HIT): <100,000/µL or < 50% of baseline count in pt exposed to heparin previously- etiology: Antibodies form against the protein platelet factor 4(PF4) when PF4 has formed a complex with heparin - assessment of risk to benefit analysis, delay operation or alternative anticoagulants: primary factor Xa inhibitors (LMWH,

fondaparinux), direct thrombin inhibitors (hirudin, bivaludine, agatroban), direct finrinogen blocker (ancrod)- HIT History (+) and Ab (-): heparin and reverse with sufficient dose of protamin

Anesthetic management during CPBGoing on-pump• Aortic cannulation: Reduce systemic arterial pressure (to 90-100 mm Hg systolic)- Complications: arterial dissection, hemorrhage & resultant hypotension, inadvertent cannulation of the aortic arch vessels,

embolic phenomena caused by dislodged atherosclerotic plaque or by air introduced into or entrained around the aortic cannula.

• Venous cannulation- Complications: hypotension from blood loss, dysrhythmias, and surgical mechanical compression of the heart or great

vessels.

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Initial bypass checklist

Face: Examine for color, temperature, plethora, edema, and symmetryEyes: Examine pupils for size and symmetry and conjunctiva for chemosis (edema) and injection Pump lines: Arteriovenous color difference should be visibleArterial blood pressure: Normally 30-60 mm Hg initiallyPA pressure: If monitored, should be <15 mm Hg meanCentral venous pressure: Should be <5 mm HgExamine the heart: Distention, contractilityStop ventilation when aortic ejection by the heart ceases

Physiologic effects of CPB • Initiation of CPB is associated with a marked increase in stress hormones and a variable systemic inflammatory response.

Elevated levels of catecholamines, cortisol, arginine vasopressin, and angiotensin are observed.• Multiple humoral systems are also activated, including complement, coagulation, fibrinolysis, and the kallikrein system.

Contact of blood with the internal surfaces of the CPB system activates complement via the alternate pathway (C3) as well as the classic pathway through activation of Hageman factor (XII).

Organ protections during CPB• Myocardial protection- Cardioplegia: antegrade(physiologic) or retrograde (pronounced CAD or aortic valve insufficiency)- keeping myocardium cold- Venting: inadequate venting may result in the development of tension in LV, causing potential ischemia and subendothelial

necrosis.- avoiding electrical activity• Temperature management- Moderate (26-32oC) or deep (20-25oC) hypothermia is used routinely for many procedures.- Deep hypothermic circulatory arrest (DHCA, 18-20oC): repairs of the aortic arch, vena cava, and certain congenital heart

lesions, anterograde or retrograde cerebral perfusion, pharmacologic protection (barbiturates, corticosteroids, mannitol), Large doses of a nondepolarizing muscle relaxant should be given immediately before circulatory arrest

- The lower the temperature, the longer the time necessary for cooling and rewarming.- No monitored temperature should be allowed to exceed 36.5-37oC to prevent cerebral overheating.• Arterial blood gas and acid-base management




- Arterial PO2: 150-300 mmHg, PCO2 ≒ 40 mmHg, avoid hypercapnea (>45 mmHg, respiratory acidosis) or hypocapnea (< 35 mmHg, respiratory alkalosis, left shift of the HbO2 dissociation curve, cerebral vasoconstriction).

• Management of blood glucose < 180mg/dL- Hyperglycemia may exacerbate neuronal injury and increase the risk of wound infection.

Anesthesia during CPB• maintain amnesia, analgesia and muscle relaxation• Potent volatile agent via pump oxygenator or Total intravenous anesthesia • Altered pharmacokinetics and pharmacodynamics.

PK changes during CPB PD changes during CPB

IV anesthetics Effects of hemodilution Altered plasma protein binding Volume of distribution Altered drug clearance Acid-base disturbances Lung isolation Drug sequestrationInhalational anesthetics Altered blood/gas partition coefficient Altered tissue solubility

HypothermiaIncreased IV anesthetic potency during hypothermiaIncreased inhaled anesthetic potency during hypothermiaDecreased inhaled anesthetic potency during rewarming?Increased sensitivity to neuromuscular blockade during hypothermiaDecreased morphine binding to opioid receptors?Impaired cerebral functionMicroembolic phenomenon/systemic inflammatory responseCerebral edema/brain inflammationDecreased cytochrome P-450 activity

Weaning from CPB• Romanoff, and Royster suggest a mnemonic, “CVP,” to help the clinician remember the main tasks necessary for the

successful termination of CPB

- 6C: 1) temperature should be 36-37oC, 2) a heart rate of 80-100 bpm is usually desirable, 3) CO or contractility may

be estimated from TEE or PA catheters, 4) Hb >6.5 g/dL, 5) Ca2+ level should be checked and administer calcium, 6) measurement of ACT after protamine administration

- 4V: 1) ventilation of the lungs, 2) Visualization of heart, both surgical field and TEE 3) reinstitues a low dose of volatile anesthetics 4) crystalloid and albumin or hetastarch if necessary

- 6P: 1) predictors of adverse cardiovascular outcome 2) calibration and rezeroing 3) vassopressors and inotropic agents 4) external pacemaker 5) hyper/hypokalemia correction 6) protamine

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• Algorithm for weaning from CPB




• Characteristics and treatment modalities of weaning difficulties

Termination of CPB• Reversal of anticoagulation: 1-1.3 mg protamine/100 units of heparin

or a dose calculated from heparin concentration (heparin dose-response curve)• Protamine reactions: endothelial nitric oxide release, mast cell degradation and histamine release associated with rapid

infusion- protamine should be administered slowly (over 5 mins)- pts documented adverse events: pharmacologic alternatives to protamine or not to reverse heparin or non-heparin based

CPB, OPCAB with alterantive to heparin or if heparin is used, administering nonprotamine heparin reversal drugs (PF4 or heparinase) or simply waiting

- severe hypotension and elevated PA pressures: vasoactive medications (phenylephrine or ephedrine) or inotropic support, nebulized albuterol in management of bronchospasm

• Heparin rebound (rare): clinical bleeding that occurs within approximately 1 hour of protamine neutralization, accompanied by coagulation test results indicating residual heparinization

- Mechanisms: slow dissociation of protein-bound heparin after protamine clearance, more rapid clearance of protamine than of heparin, lymphatic return of extracellular sequestered heparin, and the clearance of an unknown heparin antagonist.

- With coagulation monitoring, heparin rebound is easily prevented or treated with supplemental protamine.

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Anesthetic management of postbypass periodCommon Problems After CPB• Awareness- administer a volatile anesthetic agent once pulmonary ventilation is reestablished and to administering additional sedative

hypnotic doses, an opioid, or both.- falsely high BIS values: interference from pump head rotation, pacemakers, and hypothermia • Cardiovascular Decompensation- causes: failure of Lt. or Rt. Ventricle partially due to preexisting chronic ventricular dysfunction exacerbated by the ischemia-

reperfusion injury, myocardial injury, thrombosis, emboli- treatment: LV failure → positive inotropic a and vasodilator drugs, sympathomimetic amines, phosphodiesterase inhibitors, intraaortic

balloon pump or VADRV failure → increasing preload, inotropic support; milrinone, dobutamine and isoproterenolInappropriate vasodilation with a low SVR → vasoconstrictor or methylene blue (rarely successful)• Dysrhythmias- Ventricular flutter or fibrillation → immediately defibrillation with internal paddles applied directly to the heart (10-20 J) →

lidocaine or amiodarone (If ventricular arrhythmias persist or recur)- Atrial fibrillation or atrial flutter → immediate postbypass period, convert to normal sinus rhythm with synchronized

cardioversion (especially if sinus rhythm was present before CPB) → Mg, amiodarone (primary drug), esmolol, diltiazem, and digoxin.

- bradycardia, complete heart block, or asystole develops after CPB: apply temporary epicardial pacing wires (AV sequential pacing)

- no organized atrial rhythm is present (as in patients with atrial fibrillation) and the ventricular response rate is slow, ventricular pacing is the only option

• Bleeding and Coagulopathy- causes of bleeding: inadequate surgical hemostasis, coagulopathy resulting from excessive contact activation, platelet

dysfunction, fibrinolysis and previous administration of glycoprotein IIb/IIIa inhibitors or ADP receptor antagonist (clopidogrel) or re-do op

- Pharmacologic treatment: i) synthetic antifibrinolytic agents: ε-aminocaproic acid (Amicar), 50-150 mg/kg load followed by an infusion of 15 to 25 mg/

kg/hour; Tranexamic acid, 10-30 mg/kg load followed by an infusion of 1 to 15 mg/kg/hourii) Desmopressin (von Willebrand factor or factor VIII deficiencies, cirrhosis, aspirin use, and uremic platelet dysfunction):

0.3-0.4 μg/kg (over 20 to 30 mins)iii) recombinant factor VIIa (factor rVIIa)- Point-of-Care monitors for transfusion: thromboelastography, Sonoclot, rotational thromboelastometry• Metabolic Disturbances• Pulmonary Complications- Atelectasis: common cause of decreased arterial oxygenation in the postbypass period, lungs are fully reinflated manually

before machine ventilation is reestablished during weaning from CPB.




- Chronic obstructive pulmonary disease (COPD) or any preexisting tendency toward bronchospasm may be exacerbated during CPB.

Treatment: inhaled β2-agonists (e.g., albuterol), inhaled anticholinergic drugs (e.g., ipratropium), epinephrine, and corticosteroids.

- cardiogenic pulmonary edema: preexisting HF exacerbated by the additional fluid load in the pump prime, Ultrafiltration during CPB and diuresis during and after CPB may minimize such pulmonary edema.

- Noncardiogenic pulmonary edema: after prolonged CPB with sequestration of neutrophils in the pulmonary capillaries & elevation of lysosomal enzyme activity → a localized “inflammatory response” & increased capillary permeability.

Chest Closure & Transport to the ICU• hemodynamic deterioration during chest closure: R/O cardiac tamponade with ongoing bleeding, hypovolemia, ischemia

secondary to kinking of an arterial or venous coronary graft, impairment of RV contractility and venous return in pts with significant myocardial edema

- determination of causes by TEE and quick management

References1. Marc Licker, John Diaper et al. Clinical Review: Management of weaning from cardiopulmonary bypass after cardiac surgery. An-

nals of Cardiac Anaesthesia Vol. 15:3 Jul-Sep-2012

2. Hensley, Frederick A., Gravlee, Glenn P. A practical approach to cardiac anesthesia. 5th edition, Lippincott Williams & Wilkins 2013

3. Nancy A. Nussmeier et al. Anesthesia for cardiac surgical procedures. Chap. 67. pp 2007-2091 Miller, Ronald D. et al. Miller’s anes-

thesia. 8th edition, Saunders 2015

4. Christina Mora-Mangano et al. Cardiopulmonary Bypass and the Anesthesiologist. Chap 22. pp 513-545 in Kaplan’s Cardiac Anes-

thesia 5th Edition. 2011. Elsevier Health Sciences.

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Protocol for pediatric cardiac anesthesia

김미현

서울성모병원 마취통증의학과

1. 약준비

1) Bolus

약 용량 용도

Atropine 0.02 mg/kg Induction

TPT 5-6 mg/kg Induction

Ketamine 1-1.5 mg/kg Induction

ROC 1.2 mg/kg Induction, incision

MDZ 0.1 mg/kg Induction, incision

2-5 mg Pump

FTN 100 mcg Induction, incision

200-500 mcg pump

Roc 20-50 mg pump

Heparin 300 iu/kg Protamine 3 mg/kg (upto 4.5 mg/kg)

2) Continuous infusion: total 50 cc each. Epinephrine 10 mcg/cc Dopamine 1 mg/cc Nitroglycerine 0.1 mg/cc Milrinone 0.1 mg/cc H-solution: MDZ 10 mg + SuFTN 250 mcg + esmerone 100 mg+N/S 총 100 cc

2. Monitoring1) EKG, SpO2, NIBP2) A-line3) C-line, CVP4) Cerebral oximeter




3. 수술시작

Incision 전 initial ABGA, ACT. Incision 전 induction 용량의 FTN, MDZ, ROC.

4. CPB 시작

Heparinization, Ao cannulation, SVC cannulation, partial CPB, IVC cannulatoin, total CPB. CPB진행 전 환자의 circulatory volume dilution → FTN, MDZ, ROC via pump. 5. During Pump Monitoring of cerebral oximeter Blood prep: irradiated PRC - 심폐기에서 1-2 u 사용. Weaning 시 수혈요구량에 대비: irradiated PRC, SDP, FFP… Target Hct> acyanotic heart: 25-30, cyanotic heart: 30-40.

6. Weaning 체온 올리기 시작; drug infusion start (dopa, NTG, milrinone ± epi), E-tube suction. TEE prep. Prn> NO ventilator prep. Modified ultrafiltration → protamine infusion → ACT, ABGA (→ electrolyte, Ca, Hct, glucose 조절) prn> Irradiated PRC, SDP, FFP prn> Vit K, transamine. Echocardiographic confirmation

7. 수술종료

H-sol stop, cardiovascular medication 유지. Tf to CCU with monitoring of EKG, IABP, SpO2. Epi, phenyl bolus prep during transfer.

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