Anesthesia Module

7/29/2019 Anesthesia Module

1/21


2/21

Edwards Lifesciences Confidential

SOP4407EL25 Rev. A Issued 07/28/2011 ECN:78281

Evaluate the patient as you would any high-risk candidatefor cardiac surgery

Consider the anesthetic implications present in mostTAVR patients

Multiple co-morbid conditions

Advanced age

Frailty

2


3/21



Routine ECG

Pulse oximetry

Capnography

Invasive and noninvasive blood pressure Large-bore peripheral and central venous access

TEE

Foley catheter

3


4/21



Important Considerations Pulmonary artery catheter

Frequent MR/MS, pulmonary hypertension, RV failure, low cardiacoutput

Systolic and/or diastolic dysfunction

EEG monitor Frequent difficult anesthetic depth titration

4


5/21



General anesthesia preferred by most anesthesiologists No adequate published data providing superiority of any particular

anesthetic technique

Advantages to general anesthesia

Maintains patient immobility to permit stable valve positioning and

deployment Maximizes patient comfort during TEE and direct repair of the vascular

access site, if necessary

Facilitates patient management should complications that require CPBand/or sternotomy occur

5


6/21



Short-acting agents used most frequently Facilitates fast-tracking

Supine position

Pressure-points padded

Radiolucent external defibrillator pads Warming devices

Blankets, forced-air heating

Fluids

6


7/21



Assess adequacy of cardiovascular function Maintain euvolemia

Improve cardiac output

May require > 1 liter IV fluid

Guidance

Adequate LV filling on TEE

Consider trends of CVP and PCWP

Consider urine output > 1 cc/kg/hr

Beware of over-hydration

Systolic and diastolic dysfunction

7


8/21



If cardiac index remains low despite volume Consider inotropic support

Dobutamine

especially if HR is low

Milrinone

If cardiac index remains low despite inotropic support Consider mechanical support

IABP

Cardiopulmonary bypass

8


9/21



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 ensurecoronary and cerebral perfusion

Vasopressors

Phenylephrine, norepinephrine, vasopressin, ephedrine

Vasodilators

Nitroglycerin, short-acting calcium channel blocker

9


10/21



Rapid ventricular burst pacing

Induces an instantaneous, reversible fall in cardiac output Reduces ejection of balloon and valve from aortic annulus during inflation

Pacemaker settings

Ventricular rate

Start rapid pacing at 180 bpm

Rate should be adjusted (typical pacing rates range between 160 and220 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 primaryimplanting physician

10


11/21



Backup pacemaker available Primary pacemaker fails

Treat bradycardia

Faster solution than trying to reset primary pacemaker

Backup pacemaker settings

Ventricular rate80 bpm

MA > threshold

Synchronous

Atrial off

11


12/21



Assess cardiovascular stability prior to rapid burst pacing Rule-out a serious or prolonged cause of ventricular dysfunction

Ensure balloon-manipulation hypotension is transient

Consider removing balloon and further optimization

Consider a bolus dose of phenylephrine or norepinephrineto achieve faster recovery of blood pressure and coronaryperfusion pressure after rapid burst pacing

Target SBP 100 mmHg prior to pacing

Allow sufficient hemodynamic recovery before initiating

another episode of rapid pacing

Minimize the number and duration of rapid burst pacingepisodes

12


13/21



Refractory hemodynamic instability after BAV Echocardiographic findings key

Acute aortic insufficiency

May not be tolerated, particularly in patients without preexisting aorticinsufficiency

Treat with immediate valve deployment

Stunned myocardium after pacing-induced subendocardialischemia

Optimize coronary perfusion

Aortic rupture/dissection

Emergent CPB

13


14/21



Rapid ventricular burst pacing Pacemaker settings same as BAV

Consider a bolus dose of phenylephrine or norepinephrineto achieve faster recovery of blood pressure and coronaryperfusion pressure after rapid burst pacing

Target SBP 100 mmHg prior to pacing

Hold ventilation during valve deployment

Decreases ventricular ejection

Decreases motion artifact

14


15/21



Successful valve deployment typically results in a rapidreturn or increase in cardiac output and blood pressure

Sustained significant hypertension

Nitroglycerin, short-acting calcium channel blocker

Refractory hemodynamic instability

Echocardiographic findings key

Aortic insufficiency

Severe paravalvular leak

Balloon dilatation of valve

Severe transvalvular leak

Valve-in-a-valve*

* No testing has been performed to determine the long-term durability in this configuration

15


16/21



Myocardial ischemia Stunned myocardium after pacing-induced subendocardial ischemia

Optimize coronary perfusion

Coronary artery obstruction

PCI, IABP, CPB, mechanical ventricular assistance

Acute aortic or ventricular rupture/dissection CPB

AV block

Pacemaker

16


17/21



Refractory hemodynamic instability Vascular-access bleeding

Fluid replacement

Balloon occlusion of vascular injury site and repair of artery

Reverse anticoagulation

Protamine

Administer when no more interventions are anticipated

Dosage strategies

Heparin-level based

Fixed ratio from heparin dose

17


18/21



Extubate when meets standard criteria Immediate extubation in the OR is appropriate for most

Minimum patient core temperature > 36 C

Patient awake and able to follow simple commands

Patient able to protect airway and has a normal respiratory pattern and

rate, with oxygen saturation > 90% Full reversal of neuromuscular blockade if utilized

Patient is not bleeding significantly

Patient is hemodynamically stable

18


19/21



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


20/21



1. Fassl J, Augoustides JGT: Transcatheter Aortic Valve Implantation - Part 2: Anesthesia Management. J Cardiothorac Vasc Anesth 24:691-

699, 20102. 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

3. Ree RM, Bowering JB, Schwarz SK: Case series: Anesthesia for retrograde percutaneous aortic valve replacementExperience with thefirst 40 patients. Can J Anaesth 55:761-768, 2008

4. Covello RD, Maj G, Landoni G, et al: Anesthetic management of percutaneous aortic valve implantation: Focus on challenges encounteredand proposed solutions. J Cardiothorac Vasc Anesth 23:280-285, 2009

5. Fassl J, Kodavatiganti R, Ingerski MS: Anesthesia management for retrograde aortic valve replacement. Can J Anaesth 56:336, 2009

6. Fassl J, Seeberger M, Augoustides JGT: Transcatheter Aortic Valve Implantation: Is General Anesthesia Superior to Conscious Sedation? J

Cardiothorac Vasc Anesth 25:576-577, 20117. 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

8. Bergmann L, Kottenberg E, Heine T, et al: [Anesthesia with transfemoral and transapical aortic valve implantation. Periinterventionalmanagement and hemodynamic observations]. Herz 34:381-387, 2009

9. Frederic T. Billings IV, Susheel K. et al: Transcatheter Aortic Valve Implantation: Anesthetic Considerations. Anesth Analg 108:1453-1462,2009

10. Cheung A: Transcatheter aortic valve replacement. Anesthesiol Clin 26:465-479, 2008

11. Klein AA: Transcatheter aortic valve insertion: Anaesthetic implications of emerging new technology. Br J Anaesth 103:792-799, 2009

12. Heinze H: Percutaneous aortic valve replacement: Overview and suggestions for anesthestic management. J Clin Anesth 22:373-8, 2010

20


21/21



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. All other trademarks are the property of their

respective owners.

2011 Edwards Lifesciences Corporation. All rights reserved.

21

Documents

Anesthesia Module