INTRAOPERATIVE MANAGEMENT

Operating Room Preparation

Advanced, careful preparation of the operating room is essential. The anesthesia machine must have the capacity to provide air, oxygen, carbon dioxide, and nitric and nitrous oxide to help balance pulmonary and systemic blood flow. Intravenous tubing must be free from air bubbles to prevent paradoxical air embolism. Resuscitative drugs, labeled and ready for administration, should include succinylcholine, calcium gluconate or calcium chloride, sodium bicarbonate, atropine, phenylephrine, lidocaine, and epinephrine. An inotropic infusion, usually dopamine, should be premixed and ready for administration in high-risk cases, but additional infusions are prepared if their need is strongly suspected. For all pediatric cases, certain anesthetic drugs should be available (thiopental, propofol, ketamine). In pediatric cardiac anesthesia, many patients have limited reserve as well as high endogenous catecholamine levels released in an adaptive response to their underlying cardiac disease. The resuscitative drugs should therefore be prepared and immediately available prior to anesthetic induction.

For congenital heart surgery, the ability to alter body temperature rapidly for cooling and rewarming is essential. During deep hypothermic CPB, patients are cooled to 18°C. Surface cooling with a heating/cooling water mattress and an efficient room-ambient temperature control system is important in the operative management of these patients.