Total Circulatory Arrest
1/13/99

• used during aortic arch reconstruction, etc.
• Cerebral Protection:
• Solumedrol: 10-30 mg/kg
• MgSO4:

Children: 20 mg/kg
Adults: 2 grams
• Pentothal: 3-5 mg /kg just before circulation interrupted
• Ice Bags to head

Systemic cooling to 27 degrees C.

CABG without CPB: Guidelines
By Saul Katz, M.D., January 1999
The goal is to perform CAB with a minimum of insult and preservation of normal physiology.

• NORMOTHERMIA
• Start Heating blanket when patient placed on OR table.
• Keep warm until patient draped.
• Bair Hugger to warm head after drapes placed.
• OXIMETRIC SWAN GANZ CATHETER
• HEMODYNAMIC function should be stable and optimal prior to the incision.
• ELEVATION AND ROTATION of the heart for exposure may require slow manipulation and sometimes IV fluid and inotropic support to maintain blood pressure and cardiac output.
• TRENDELENBURG POSITION may be required during grafting of right coronary or circumflex coronary arteries.
• ROTATION OF THE TABLE to the right may be needed for grafting the circumflex coronary artery.
• FLUID ADMINISTRATION of several liters to restore preload and hemodynamics to allow distortion of the heart may be required.
• PACING of the atrium for rates under 70 is useful. A-V pacing may be required if heart block occurs during occlusion of the RCA.
• INOTROPIC SUPPORT Dopamine (2-6 mcg/kg/min) is the drug of choice to elevate BP after adequate volume has been administered.
• HEPARINIZATION 5000 U IV and then 1000 U every 40 minutes.
• PROTAMINE 100 mgs (usually) at end of anastomoses.
• ISCHEMIA occurring after the coronary artery is occluded and open can often be relieved by an intra-luminal shunt.

EXTUBATION IN THE OPERATING ROOM is, I feel, desirable and feasible for most patients if anesthesia is administered with this goal in mind.

Risk of Fatal Low Cardiac Output
in CABG Patients-1999

(not for valve or aortic surgery)

Variable	Risk Points
Age 70-79	1.5
Age 80 -	3
Female	1.5
Prior CABG	1.5
Emergency	6
Urgent	2
EF <40%	2.5
3 vessel Dz	1.5
Diabetes	1.5
PVD	2.5
Renal Failure	3

add up the points to determine patient score

Implications:

Risk Total 0-3: No PA Catheter
Risk Total 4-6: Use PA Catheter
Risk Total >6: Consider IABP

1999

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