Anaes · Cardiac anaesthesia & cardiopulmonary bypass
Cardiac anaesthesia and cardiopulmonary bypass
Also known as Cardiac anaesthesia · Cardiopulmonary bypass · CPB · TOE cardiac surgery · SS_CS specialised study unit
Exam-pass cardiac anaesthesia hub (SS_CS): CPB circuit order, heparin/ACT, cardioplegia, TOE-guided weaning (RRAC), protamine reactions, TRICS III restrictive transfusion, valves/CABG leaf links, and mechanical support escalation.
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Red flags
- Never initiate CPB without confirmed adequate anticoagulation (ACT 400 or 480 s after heparin 300 IU/kg surveyed modal).
- Protamine can cause catastrophic systemic hypotension and pulmonary hypertension — give slowly, stop if reaction, support RV.
- Unable to wean from CPB: systematic RRAC (rate/rhythm, preload, afterload, contractility) plus TOE — do not give random boluses.
- Arterial cannula malposition or aortic dissection on cannulation is a surgical emergency.
- Post-CPB bleeding: surgical, residual heparin, platelets, fibrinogen, hyperfibrinolysis — use viscoelastic testing.
Meet the patient
A 68-year-old man with three-vessel disease comes for elective CABG. Induction is smooth, the arterial line is in, the TOE probe passes after induction, and the surgeon calls for heparin. Your job in the next hour is simple to say and unforgiving to execute: anticoagulate, confirm the ACT, go on bypass, protect the heart, and bring him off again in one piece (taught cardiac vignette).[5]
The two questions that decide whether he leaves the table well are the two every cardiac case turns on: is the circuit safe and the ACT therapeutic? and can the heart do the work when you take the pump away? Hold those two and every section below slots into place.[5][6]
References8ShowHide
- [1]Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. N Engl J Med, 2017.PMID 29130845
- [2]Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost, 2023.PMID 37062523
- [3]Fraile-Gutiérrez V, Pérez-Torres D, Martin-Villen L, et al. Transesophageal echocardiography: A comprehensive assessment of the critically ill patient. Med Intensiva (Engl Ed), 2026.PMID 42020231
- [4]Bottiroli M, Ortoleva J, Pisano D, et al. Perioperative Management of Patients With Durable and Temporary Left Ventricular Assist Devices Undergoing Non-Cardiac Surgery: A Comprehensive Review. J Cardiothorac Vasc Anesth, 2026.PMID 42350177
- [5]Pereira RM, Guerra N, Ferreira R, et al. Contemporary Clinical Practices in Anticoagulation Management During Cardiopulmonary Bypass: A Europe-Wide Survey. Interdiscip Cardiovasc Thorac Surg, 2026.PMID 41787968
- [6]Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr, 2013.PMID 23998692
- [7]Landoni G, Fochi O, Tritapepe L, et al. Cardiac protection by volatile anesthetics. A review. Minerva Anestesiol, 2009.PMID 18987572
- [8]Paparella D, Brister SJ, Buchanan MR Coagulation disorders of cardiopulmonary bypass: a review. Intensive Care Med, 2004.PMID 15278267