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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3753_Библиотеки_им_академика_М_И_Перельмана
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Anaesthesia for Endoscopic Cardiac Surgery 19
Video 4 Video Laryngoscopy (▶ https://doi.org/10.1007/000-a6q)
eye and broken. If DLT is used, its position in
left main bronchus is confirmed using flexible
bronchoscopy.
a. To confirm the adequacy of venous drainage
with or without neck cannula,
b. A marker of perfusion with retrograde
peripheral bypass and
c. An adjunct to the two arterial lines system of
8 Cerebral Oximetry
monitoring the position of an endo balloon
(intra aortic occlusion balloon).
The use of cerebral oximetry in cardiac surgery
has been much debated and usually in relation to
post-operative cognitive dysfunction [6, 7].
However in endoscopic cardiac surgery it is a
vital monitor
The right arm pressure and right cerebral
oximetry are set to display above the respective
left side measurements for standardisation and
ease of visual identification during placement of
endo balloon.
20 A. Knowles and P. Saravanan
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Video 5 Insertion of bronchial blocker (▶ https://doi.org/10.1007/000-a6r)
more than 4cms, significant and/or mobile
9 Transoesophageal
Echocardiography
atheroma in descending and/or ascending thoracic aorta and complicated mitral valve disease.
The details of TOE are discussed elsewhere
After induction of anaesthesia, TOE is performed
and reviewed. This serves us a final check and
confirmation to rule out echocardiographic contraindications to perform aspects of minimal
access surgery. These include, significant aortic
valve regurgitation, ascending aorta diameter
(Chap. 3).
Guidelines for performing a comprehensive
echocardiographic examination is described by
Hahn et al. [8]. A thorough step wise initial
assessment based on standard views is mandatory followed by dynamic monitoring of line
Anaesthesia for Endoscopic Cardiac Surgery 21
insertion, establishment of cardiopulmonary
bypass (CPB), intra aortic occlusion balloon
positioning, cardioplegia delivery, de-airing and
separation from bypass and the assessment of the
specific surgery, ventricular performance and
aortic integrity.
10 Jugular Vein Cannulation
Additional venous drainage may be required via
the SVC. In our practice this is utilised in patients
over 75–80 kg or in those undergoing right heart
surgery. Following a perfusion strategy discussion, a 15F, 17F or 19F cannula (Medtronic
Biomedicus) is inserted via a percutaneous
technique (Videos 6, 7 and 8). Cannulation is
performed under TOE guidance. The TOE probe
and machine are set up so that the anaest hetist
can perform the cannulation with minimal additional help.
It is the authors’ preference to insert this
cannula alongside a central line into the right IJV
thereby avoiding the, albeit rare complication of
vascular injury on the left side when one lung
(left) ventilation is to be utilised. The case of a
persistent left superior vena cava may be an
exception to this rule.
The procedure commences with ultrasound
examination of the internal jugular vein to ensure
adequacy of calibre to accommodate the number
and size of cannulae required for the case which
is generally more than 1 cm in diameter.
A Kimal 80 cm Guide wire insertion (Fig. 5)is
performed under ultrasound guidance and then
correct passage into the SVC confirmed on TOE.
Prior to cannula insertion a dose of 5000u heparin is administered.
In left side heart surgery, the tip of the cannula
is positioned at the junction of the right atrium
and SVC. In right side surgery the cannula is
withdrawn into the SVC to allow for snaring of
the vena cava. In the case of re-do surgery a
Fogarty balloon is used to achieve caval occlusion instead of an external venous snare. Positioning of the cannula is confirmed by TOE .
Video 6 SVC cannulation 1 (▶ https://doi.org/10.1007/000-a6s)
22 A. Knowles and P. Saravanan
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Video 7 SVC cannulation 2 (▶ https://doi.org/10.1007/000-a6t)
Video 8 SVC cannulation 3 (▶ https://doi.org/10.1007/000-a6v)
the venous drainage cannula and to create a
11 Jugular Vein Cannulation in Re-
do Right Heart Surgery
bloodless field it is our strategy in such cases to
occlude the SVC opening by means of a Fogarty
balloon inserted via a cannula in the right IJV
In redo surgery ability of to snare the vena cava
to facilitate right heart surgery may be lost due to
[9]. The inferior caval opening is occluded by
surgical swabs placed under vision.
tissue adhesions. In order to prevent air entering
Anaesthesia for Endoscopic Cardiac Surgery 23
previously described (Fig. 7). In such cases there
is dilatation of the right heart due to tricuspid
regurgitation which leads to an enlarged SVC
which allows sufficient calibre for multiple cannulae insertion. Adequacy of venous drainage is
confirmed by the perfusionist together with adequacy of cerebral oximetry.
A pacing catheter introducer is also inserted
in most redo cases in view of anticipated difficulties in placing epicardial pacing wires because
of right ventricular adhesions to chest wall
(Fig. 8).
12 Patient Positioning
The patient is placed supine upon the operating
Fig. 5 Kimal 80 cm guidewire
An 8F Fogarty balloon is inserted via a
haemostatic valve in Edwards Intraclude introducer attached to a 19F or 21 Fr Medtronic
Biomedicus cannula (Video 9). This is inserted
either alongside a separate venous drainage
cannula (Fig. 6) or through a Y introducer as
table with an inflatable bag under the right side of
the chest (Video 10). On inflation of the bag care
must be taken to support the head and neck in a
neutral position, particularly in the elderly, with a
head ring and padding (Fig. 9). The arms are
placed at the side of the patient with padding to
protect the ulnar nerve at the elbow. The right arm
may require to be placed away from the body in
order to facilitate surgical access (Video 11).
Video 9 SVC cannulation in re-do surgery (▶ https://doi.org/10.1007/000-a6w)
24 A. Knowles and P. Saravanan
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Fig. 6 Fogarty balloon catheter inserted via Edwards Intraclude introducer and separate venous drainage catheter
Fig. 7 Fogarty balloon inserted via Y-piece and via single 21Fr venous drainage catheter
Anaesthesia for Endoscopic Cardiac Surgery 25
Fig. 8 CVC, Pacing PA introducer and 21Fr SVC drainage cannula with Y-piece
Video 10 Positioning inflatable bag under right chest (▶ https://doi.org/10.1007/000-a6x)
26 A. Knowles and P. Saravanan
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Fig. 9 Head ring and padding for support following right chest bag inflation
The defibrillator pads should be connected
and checked whether they are working by
obtaining ECG trace from paddles and the
default current setting (Fig. 10).
required in the form of intrave nous opioids. The
authors prefer ventilating patients on pressure
controlled ventilation on 100% O2 to facilitate
lung collapse during chest opening (Fig. 11).
Inspiratory pressures are adjusted to achieve
adequate tidal volumes. Pre bypass blood tests
13 Start of Surgery
usually include arterial blood gases, near patient
clotting tests such as INR, thromboelastography
After timeout to go through routine pre incision
checks, usually a groin is opened first to assess
vascular access. If additional surgical expertise is
present, both groin and chest may be opened at
or platelet function test as appropriate. The
authors also use HMS Plus haemostasis man-
agement system (Medtronic) for heparin and
protamine dosing.
the same time. Additional analgesia may be
Anaesthesia for Endoscopic Cardiac Surgery 27
Video 11 Positioning of right arm away from the trunk (▶ https://doi.org/10.1007/000-a6y)
Fig. 10 Display from external defibrillation pads
28 A. Knowles and P. Saravanan
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Fig. 11 Ventilatory settings prior to one-lung ventilation
One lung ventilation should be initiated prior
to chest opening. While no special technique is
required when DLT is used, additional steps as
described by Yoo et al. are required with BB [9].
14 One Lung Ventilation with Use
of Bronchial Blocker
1. Confirmation of anatomy in lower trachea,
showing RUL bronchus
2. BB balloon inflated in right main bronchus
To achieve good lung deflation the foll owing
steps are used (Video 12) [10]
1. Ventilation of both lungs with 100% oxygen
prior to balloon inflation
2. The ventilator is stopped and expiratory valve
is fully open allowing time for the End tidal
CO2 (EtCO2) trace to disappear indicating
complete exhalation of gases.
3. The balloon is inflated in the right main
bronchus under direct vision with
bronchoscope.
4. If the lung collapse is found to be unsatisfactory upon chest opening, the steps are
repeated.
5. To repeat the steps, once the chest cavity is
open the ventilator should be stopped, the
balloon deflated and SLT disconnected from
the circuit to allow raid deflation of the right
lung which can be observed via the camera to
display satisfactory collapse
6. The balloon is the reinflated under vision in
the right main bronchus, circuit reconnected
and single lung ventilation commenced with
FiO2 adjusted as required.
15 Prebypass Management
Heparin is administered prior to placement of
peripheral cannulas. Once the activated clotting
time (ACT) of 480 s is achieved indicating full
anticoagulation, the peripheral cannulas are
placed in femoral vessels for by pass under TOE
guidance. The venous cannula is inserted first
followed by arterial cannula. The pressure in the
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