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All patients undergoing cardiac surgery require basic monitoring plus invasive arterial pressure monitoring and central venous line placement. The latter is used to monitor central venous pressure and as a conduit for volume and pharmacologic resuscitation. Pulmonary artery catheter use in patients undergoing cardiac surgery has spurred enormous debate and a generous literature[168] [169] [170] [171] [172] [173] [174] [175] [176] [177] [178] related to its cost-benefit ratio, which is defined especially by modulation of outcome. It is reasonable to conclude
| Surgical procedure—indication for surgery |
| Risk factors for cardiovascular disease and their implications for comorbid disease (e.g., cigarette use, hypertension, diabetes) |
| Functional status |
| Symptoms and signs |
| New York Heart Association classification |
| Cardiac symptoms but no limitation in physical activity |
| Cardiac symptoms and slight limitation in physical activity |
| Cardiac symptoms and marked limitation in physical activity |
| Cardiac symptoms preclude physical activity |
| Basic investigative data |
| Electrocardiogram—ischemia, infarction, conduction abnormalities, hypertrophy, drug effects |
| Hematologic/coagulation and electrolyte data, including especially the prothrombin time, partial thromboplastin time, platelet count, glucose, and creatinine |
| Specialized investigative data |
| Ischemia—exercise stress tests, myocardial perfusion imaging (rest, exercise, pharmacologic), angiography |
| Myocardial function/valve function—hemodynamics (cardiac output, pressure gradients, valve areas), ventriculography, echocardiography |
| Preoperative medications |
| Airway |
| Systemic disease |
| Cerebrovascular diseases (± duplex studies) |
| Atherosclerotic aortic disease |
| Renal impairment |
| Chronic obstructive pulmonary disease |
| Class | Drug | Dose (mg) | Dose by Weight (mg/kg) | Route |
|---|---|---|---|---|
| Opioids | Morphine | 5–15 | 0.2 | IM |
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Meperidine | 50–100 | 1.0–1.5 | IM |
| Benzodiazepines | Diazepam | 5–10 | 0.1–0.15 | PO, IM |
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Lorazepam | 2–4 | 0.03–0.06 | PO, IM |
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Midazolam | 2.5–5 | 0.03–0.07 | IM |
| Anticholinergic | Scopolamine | 0.3–0.6 | 0.006 | IM |
| Phenothiazine | Perphenazine | 2.5–5 | 0.03–0.07 | IM |
| α2 -Agonist | Clonidine | 0.5 | 5 µg/kg | PO |
| From Cheng D, Vegas A: Anesthesia for the surgical management of ischemic heart disease. In Thys DM (ed): Textbook of Cardiothoracic Anesthesiology. New York, McGraw-Hill, 2001, pp 530–588. Copyright © by McGraw-Hill, Inc. Used by permission of McGraw-Hill Book Company. | ||||
The use of TEE as a monitoring tool has also been cast in the context of cost-benefit ratio. It is reasonable at a minimum to use TEE in patients undergoing valve procedures and those with compromised ventricular function. TEE is also extremely and uniquely useful in assessing atherosclerotic disease of the aorta ( Table 50-12 , Fig. 50-30 )[179] and, thus, optimizing aortic cannula placement and dictating the surgical approach (off-pump coronary artery bypass [OPCAB] versus CPB, proximal vein grafting anastomosis with aortic cross-clamp on, minimizing the number of proximal grafts/using side grafts or jump grafts). In other patients, the decision to use TEE is one of clinical judgment. Many centers have now extended this concept to epiaortic ultrasonography mapping, which is not limited by an "acoustic window"
| No or mild intimal thickening | Grade I |
| Severe intimal thickening without protruding atheroma | Grade II |
| Atheroma protruding <5.0 mm into the lumen | Grade III |
| Atheroma protruding 5.0 mm or more in the lumen | Grade IV |
| Mobile atheroma of any size | Grade V |
| From Nan Y, Mysore S, Hillel Z: Echocardiography. In Thys DM (ed): Textbook of Cardiothoracic Anesthesiology. New York, McGraw-Hill, 2001, pp 119–181. Copyright © by McGraw-Hill, Inc. Used by permission of McGraw-Hill Book Company. | |
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