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Cardiac Anesthesia

Hemodynamics, CPB, and the perioperative ICU mindset.

Cardiac anesthesia covers anesthetic management for open-heart surgery, structural interventions, and high-risk cardiac patients. The hallmarks are invasive monitoring, deliberate manipulation of preload/afterload/contractility, comfort with TEE, and seamless coordination with perfusion during cardiopulmonary bypass.

Key concepts

Pre-bypass goals

Maintain coronary perfusion (DBP × diastolic time / HR), avoid tachycardia in ischemic disease, and avoid hypotension below the autoregulatory threshold. Anticoagulate with heparin 300–400 U/kg targeting ACT >480 sec before bypass.

On bypass

Maintain MAP 50–80 mmHg, monitor ACT q30 min, run blood gases/lactate. Hypothermia (28–34°C) reduces metabolic rate.

Separation from CPB

Mnemonic — 'CVP': Cold? Volume? Pacing? Plus rate, rhythm, contractility (inotropes), and afterload (vasopressor/vasodilator). TEE assesses ventricular function and de-airing.

TEE

Routine for valve, congenital, transplant cases; invaluable for diagnosing tamponade, RV failure, dynamic LVOT obstruction.

Monitoring

  • Arterial line (often pre-induction)
  • Central venous catheter
  • Pulmonary artery catheter (selective)
  • Transesophageal echocardiography
  • Cerebral oximetry (NIRS)
  • Activated clotting time (ACT)

Common drugs

Fentanyl/sufentanilEtomidateCisatracuriumHeparinProtamineEpinephrineNorepinephrineVasopressinMilrinoneNitroglycerinTranexamic acid

Clinical pearls

1Protamine reactions — slow administration; have epinephrine and pulmonary vasodilators ready.
2Right ventricular failure post-bypass is a clinical and TEE diagnosis — treat with inhaled pulmonary vasodilators and inotropes.
3Antifibrinolytics (TXA) reduce transfusion in cardiac surgery — dose-dependent seizure risk at high doses.

References & Further Reading

  1. 1
    Textbook

    Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.

  2. 2
    Textbook

    Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R, Sharar SR, Holt NF. Clinical Anesthesia. 8th ed. Philadelphia: Wolters Kluwer; 2017.

  3. 3
    Textbook

    Butterworth JF IV, Mackey DC, Wasnick JD. Morgan & Mikhail's Clinical Anesthesiology. 6th ed. New York: McGraw-Hill; 2018.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.