Escolar Documentos
Profissional Documentos
Cultura Documentos
Routine
ECG Pulse oximetry Capnography Invasive and noninvasive blood pressure Large-bore peripheral and central venous access TEE Foley catheter
Important Considerations
Pulmonary artery catheter
Frequent MR/MS, pulmonary hypertension, RV failure, low cardiac output Systolic and/or diastolic dysfunction
EEG monitor
Frequent difficult anesthetic depth titration
Supine position
Pressure-points padded
Heparin dose
Maintain ACT > 250 seconds
1 - 1.5 mg/kg unfractionated heparin
Emergent CPB
Bolus additional heparin to maintain ACT > 400 seconds
Systemic blood pressure maintained at a level to ensure coronary and cerebral perfusion
Vasopressors
Phenylephrine, norepinephrine, vasopressin, ephedrine
Vasodilators
Nitroglycerin, short-acting calcium channel blocker
Pacemaker settings
Ventricular rate Start rapid pacing at 180 bpm Rate should be adjusted (typical pacing rates range between 160 and 220 bpm) and the pacing sequence should be repeated until sustained 1:1 capture, SBP of 50 mmHg or below is achieved, and pulse pressure < 10 mmHg 20 MA Asynchronous Atrial off
Pacemaker operator should only act on the direction of the primary implanting physician
Edwards Lifesciences Confidential SOP4407EL25 Rev. A Issued 07/28/2011 ECN:78281
10
11
Consider a bolus dose of phenylephrine or norepinephrine to achieve faster recovery of blood pressure and coronary perfusion pressure after rapid burst pacing
Target SBP 100 mmHg prior to pacing
Allow sufficient hemodynamic recovery before initiating another episode of rapid pacing
12
Aortic rupture/dissection
Emergent CPB
13
Consider a bolus dose of phenylephrine or norepinephrine to achieve faster recovery of blood pressure and coronary perfusion pressure after rapid burst pacing
Target SBP 100 mmHg prior to pacing
14
Successful valve deployment typically results in a rapid return or increase in cardiac output and blood pressure
Sustained significant hypertension
Nitroglycerin, short-acting calcium channel blocker
15
Myocardial ischemia
Stunned myocardium after pacing-induced subendocardial ischemia Optimize coronary perfusion Coronary artery obstruction PCI, IABP, CPB, mechanical ventricular assistance
AV block
Pacemaker
16
Reverse anticoagulation
Protamine
Administer when no more interventions are anticipated Dosage strategies Heparin-level based Fixed ratio from heparin dose
17
18
Pain management
Typically minimal postoperative pain unless extensive vascular access issues Medications
Consider dexmedetomidine Analgesia and sedation without delirium Narcotics Judicious doses Delirium frequent in elderly population Non-narcotic analgesics
19
1.
2.
Fassl J, Augoustides JGT: Transcatheter Aortic Valve Implantation - Part 2: Anesthesia Management. J Cardiothorac Vasc Anesth 24:691699, 2010
Guinot P, Depoix J, Etchegoyen L, et al: Anesthesia and Perioperative Management of Patients Undergoing Transcatheter Aortic Valve Implantation: Analysis of 90 Consecutive Patients With Focus on Perioperative Complications. J Cardiothorac Vasc Anesth 24:752-761, 2010 Ree RM, Bowering JB, Schwarz SK: Case series: Anesthesia for retrograde percutaneous aortic valve replacement Experience with the first 40 patients. Can J Anaesth 55:761-768, 2008 Covello RD, Maj G, Landoni G, et al: Anesthetic management of percutaneous aortic valve implantation: Focus on challenges encountered and proposed solutions. J Cardiothorac Vasc Anesth 23:280-285, 2009 Fassl J, Kodavatiganti R, Ingerski MS: Anesthesia management for retrograde aortic valve replacement. Can J Anaesth 56:336, 2009 Fassl J, Seeberger M, Augoustides JGT: Transcatheter Aortic Valve Implantation: Is General Anesthesia Superior to Conscious Sedation? J Cardiothorac Vasc Anesth 25:576-577, 2011 Covello D, Maj G, Landoni G, et al: Anesthetic Management of Percutaneous Aortic Valve Implantation: Focus on Challenges Encountered and Proposed Solutions. J Cardiothorac Vasc Anesth 23:280-285, 2009 Bergmann L, Kottenberg E, Heine T, et al: [Anesthesia with transfemoral and transapical aortic valve implantation. Periinterventional management and hemodynamic observations]. Herz 34:381-387, 2009 Frederic T. Billings IV, Susheel K. et al: Transcatheter Aortic Valve Implantation: Anesthetic Considerations. Anesth Analg 108:1453-1462, 2009 Cheung A: Transcatheter aortic valve replacement. Anesthesiol Clin 26:465-479, 2008 Klein AA: Transcatheter aortic valve insertion: Anaesthetic implications of emerging new technology. Br J Anaesth 103:792-799, 2009 Heinze H: Percutaneous aortic valve replacement: Overview and suggestions for anesthestic management. J Clin Anesth 22:373-8, 2010
20
For professional use. CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Edwards Lifesciences, Edwards and the stylized E logo are trademarks of Edwards Lifesciences Corporation. respective owners. 2011 Edwards Lifesciences Corporation. All rights reserved. All other trademarks are the property of their
21