Jetpearl Number 7

[jetproppilot]

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SEPARATING FROM BYPASS after a CABG/valve is a crucial time where alotta things are happening at once. It is very easy to forget even the simplest action...like turning your ventilator back on.....all you have to do to totally obliterate a great operation is forget something SIMPLE...like the ventilator. Every time an airline pilot does anything: engine start/taxi/takeoff/land, they are required by the Federal Aviation Administration and their individual airline to vocalize the appropriate checklist between crewmembers, assuring no task is left undone. I'M SUGGESTING YOU FORMULATE A CHECKLIST FOR COMING OFF BYPASS THAT YOU USE EVERY. SINGLE. TIME. Since forgetting a crucial part will be deleterious to your goal of separating from the bypass machine hemodynamically stable. The list is up to you but there are essential parts of the list that MUST be included, namely:

1)Are you ventilating again? Is your gas on? Paralyzed? Midazolam while warming? Mg++?
2)Is the blood pressure at least 90 systolic?
3)Is the heart rate 80-90?
4)Does the EKG show a sustainable rhythm?
5)HCT acceptable?
6)K+ is OK?
7)Temperature OK?

If abnormal, the above parameters need to be fixed while still on bypass. Crits 19? Ask the pump tech to blow in a cuppla units of prbcs. Temp is 35.2? WAIT. Believe me. Aint worth enduring refractory v fib for. BP too low for your comfort? Figure out if its inotropic/chronotropic dysfunction, volume, SVR, etc and fix it. Etc etc.

TAKE HOME MESSAGE:

This is a crucial time. Theres alotta things you've gotta remember. You could easily forget something which will haunt you when ten minutes later you figure out what was forgotten...but now the patient is acidotic, BP in the toilet, etc etc.

So formulate a checklist of all the crucial stuff you CANNOT FORGET TO DO OR FORGET TO ADDRESS

during that crucial time.

And, like every airline pilot on planet earth, use the checklist.

Every. Single. Time.

 

[2win]

SEPARATING FROM BYPASS after a CABG/valve is a crucial time where alotta things are happening at once. It is very easy to forget even the simplest action...like turning your ventilator back on.....all you have to do to totally obliterate a great operation is forget something SIMPLE...like the ventilator. Every time an airline pilot does anything: engine start/taxi/takeoff/land, they are required by the Federal Aviation Administration and their individual airline to vocalize the appropriate checklist between crewmembers, assuring no task is left undone. I'M SUGGESTING YOU FORMULATE A CHECKLIST FOR COMING OFF BYPASS THAT YOU USE EVERY. SINGLE. TIME. Since forgetting a crucial part will be deleterious to your goal of separating from the bypass machine hemodynamically stable. The list is up to you but there are essential parts of the list that MUST be included, namely:

1)Are you ventilating again? Is your gas on? Paralyzed? Midazolam while warming? Mg++?
2)Is the blood pressure at least 90 systolic?
3)Is the heart rate 80-90?
4)Does the EKG show a sustainable rhythm?
5)HCT acceptable?
6)K+ is OK?
7)Temperature OK?

If abnormal, the above parameters need to be fixed while still on bypass. Crits 19? Ask the pump tech to blow in a cuppla units of prbcs. Temp is 35.2? WAIT. Believe me. Aint worth enduring refractory v fib for. BP too low for your comfort? Figure out if its inotropic/chronotropic dysfunction, volume, SVR, etc and fix it. Etc etc.

TAKE HOME MESSAGE:

This is a crucial time. Theres alotta things you've gotta remember. You could easily forget something which will haunt you when ten minutes later you figure out what was forgotten...but now the patient is acidotic, BP in the toilet, etc etc.

So formulate a checklist of all the crucial stuff you CANNOT FORGET TO DO OR FORGET TO ADDRESS

during that crucial time.

And, like every airline pilot on planet earth, use the checklist.

Every. Single. Time.

👍👍👍

Jet - how many "pearls" do you have in your bag?
Keep it on buddy!
2win

 

[rsgillmd]

SEPARATING FROM BYPASS after a CABG/valve is a crucial time where alotta things are happening at once. It is very easy to forget even the simplest action...like turning your ventilator back on.....all you have to do to totally obliterate a great operation is forget something SIMPLE...like the ventilator. Every time an airline pilot does anything: engine start/taxi/takeoff/land, they are required by the Federal Aviation Administration and their individual airline to vocalize the appropriate checklist between crewmembers, assuring no task is left undone. I'M SUGGESTING YOU FORMULATE A CHECKLIST FOR COMING OFF BYPASS THAT YOU USE EVERY. SINGLE. TIME. Since forgetting a crucial part will be deleterious to your goal of separating from the bypass machine hemodynamically stable. The list is up to you but there are essential parts of the list that MUST be included, namely:

1)Are you ventilating again? Is your gas on? Paralyzed? Midazolam while warming? Mg++?
2)Is the blood pressure at least 90 systolic?
3)Is the heart rate 80-90?
4)Does the EKG show a sustainable rhythm?
5)HCT acceptable?
6)K+ is OK?
7)Temperature OK?

If abnormal, the above parameters need to be fixed while still on bypass. Crits 19? Ask the pump tech to blow in a cuppla units of prbcs. Temp is 35.2? WAIT. Believe me. Aint worth enduring refractory v fib for. BP too low for your comfort? Figure out if its inotropic/chronotropic dysfunction, volume, SVR, etc and fix it. Etc etc.

TAKE HOME MESSAGE:

This is a crucial time. Theres alotta things you've gotta remember. You could easily forget something which will haunt you when ten minutes later you figure out what was forgotten...but now the patient is acidotic, BP in the toilet, etc etc.

So formulate a checklist of all the crucial stuff you CANNOT FORGET TO DO OR FORGET TO ADDRESS

during that crucial time.

And, like every airline pilot on planet earth, use the checklist.

Every. Single. Time.

👍👍

Excellent post, especially for those beginning cardiac. Approaching things in a systematic/logical manner makes coming off bypass less mysterious.

 

[sevoflurane]

#8:

TEE: Air, RWMA, LV failure, RV failure, pum HTN, underfilled, overfilled,... etc.

 

[dhb]

Jet - how many "pearls" do you have in your bag?

I would've guessed 2 😀 but he's surprising me

 

[leaverus]

Speaking of hearts, what's with DOCS who decide to not do them once they're out of residency?? Seriously, there are nurses doing hearts and i think every MD/DO should be doing 'em. Yes, they tend to be sick patients; and yes, hearts can be stressful but that's the nature of the field you chose. I don't see other specialties "choosing" not to take care of a particular patient because they're "too sick" or whatever. For every anesthesiologist who won't do hearts, i'm sure there's a CRNA eager to step up and take their place...

 

[Bertelman]

Speaking of hearts, what's with DOCS who decide to not do them once they're out of residency?? Seriously, there are nurses doing hearts and i think every MD/DO should be doing 'em. Yes, they tend to be sick patients; and yes, hearts can be stressful but that's the nature of the field you chose. I don't see other specialties "choosing" not to take care of a particular patient because they're "too sick" or whatever. For every anesthesiologist who won't do hearts, i'm sure there's a CRNA eager to step up and take their place...

😕

Nearly every other specialty does that. Patient with chronic liver disease? Gastroenterologist. CKD? Nephrologist. CAD? Cardiologist.

I actually think there are a great number of anesthesiologists out there that shouldn't come near the heart rooms. Some just aren't cut out for the stress.

 

[Bertelman]

....something else to consider is number of available cases. It takes a routine to do those complex cases well, a routine that is played out frequently enough to become second nature. If every anesthesiologist in the country did hearts, consider that many of them may do less ten a year. At two a day, that's less than one heart day every other month. Is that really enough exposure to stay up to date on TEE, etc? You may only work with a particular heart surgeon or team once a year. You'd practically have to reintroduce yourself each time.

Without looking, I'm not even sure if that's enough echo exams to maintain certification.

 

[Planktonmd]

There are many hospitals out there that don't do hearts and if you end up in one of these hospitals you will not be doing hearts.
It's not about not wanting to do the patients who are "too sick", it's about the location and the group where you end up working.

Speaking of hearts, what's with DOCS who decide to not do them once they're out of residency?? Seriously, there are nurses doing hearts and i think every MD/DO should be doing 'em. Yes, they tend to be sick patients; and yes, hearts can be stressful but that's the nature of the field you chose. I don't see other specialties "choosing" not to take care of a particular patient because they're "too sick" or whatever. For every anesthesiologist who won't do hearts, i'm sure there's a CRNA eager to step up and take their place...

 

[Mman]

At my place of work, only the cardiac fellowship trained folks do the hearts and I think that is perfectly reasonable. About half of our anesthesiologists are fellowship trained in hearts and that is more than enough people to do the cases.

As a recent graduate, I'd have an easy enough time doing the cases. Actually, though, I find them fairly boring for the most part. Other than evaluating the TEE, it's a lot of cookie cutter stuff. Everyone gets a big IV. Everyone gets an aline. Everyone gets a neck line. Sometimes people get a swan. Everyone gets heparin. Most people go on bypass (the occasional OPCAB would keep me on my toes). Coming off pump is mostly a function of evaluating the TEE prepump and onpump and deciding if and what support you need. Then when hemostasis is acheived and the chest is closed, they get dragged to the unit. The answer to almost anything going wrong at any point is to simply go on bypass. Code on induction? ACLS + heparin + crack the chest open. Failed to come off bypass twice? Go back on and come up with another plan of attack.