Intra-Operative

• Versed 2-5 mg IV

  • • minimize dose (try not to use if ≥ 65 years old), use dexmedetomidine

• Arterial line placement

Induction

• Opioid

  • • Limit opioid administration

• Dexmedetomidine 0.25-0.5 mcg/kg loading dose over 30-45 min

• Ketamine 0.5mg/kg IV bolus

• Esmolol 0.5 mg/kg IV bolus PRN for tachycardia/hypertension

Prior to CPB

• Cordis/PAC placement

• Placement of TEE

• Antibiotic prophylaxis

• Inhalation anesthetic

  • • Titrate to mean systemic pressure goals and Massimo 25-50

• Maintain normothermia

  • • With underbody forced air warming

• Insulin drip if needed

  • • PAA Blood Glucose Management Protocol

    • Hourly BS checks

• Dexmedetomidine 0.2-0.5 mcg/kg/hr infusion – continue into CVRU

• Decadron 10 mg IV – PONV prophylaxis

• Esmolol 0.5 mg/kg IV PRN for tachycardia/hypertension

• Cardiac Index and Output

  • • Document as soon after PAC placement as possible

During CPB

• Maintain pH balance

Off CPB

• Tolerate permissive oliguria

  • • (UOP < 0.5 mL/kg/hr) if no other signs of hypovolemia

• Blood glucose monitoring

  • • PAA Blood Glucose Management Protocol

• Limit opioids

• Medications

  • • Esmolol 0.5 mg/kg IV bolus PRN for tachycardia/hypertension

    • Propofol 25-50 mcg/kg IV infusion – continue into CVRU

    • Ofirmev 1 g IV (only if case is >4 hours)

    • OTHER MULTIMODAL CONSIDERATIONS: Ketamine 0.1-0.5 mg/kg (max bolus dose of 50mg)

• Consider Rigid Sternal Fixation- Especially in patients with:

  • • High BMI,

    • Previous chest wall radiation

    • COPD

    • Steroid use

    • Females with large breasts

    • Diabetics

    • Osteoporosis

• AT END OF CASE or JUST PRIOR TO REVERSAL IN CVRU

  • • Ondansetron 4mg IV– PONV prophylaxis

• Rapid extubation

  • • If patient meets rapid extubation criteria, reverse in the OR as determined by Anesthesia

• Confirm ALL fluids both input and output are documented

CVRU

• Identify patient as ERAS

• Hand Off

  • • Ensure to relay ALL medications given intraop to PACU RN as to safeguard against double dosing

• Reversal

  • • Per reversal order set, if not initiated in OR

• Unless existing confounding factors

  • • Anesthesia to communicate to CVRU RN/RT the patient will be a rapid extubation

• Continue Dexmedetomidine 0.2-0.7 mcg/kg/hr infusion