Cardiac/CSICU/ECHO
In this section, you will find:
1) Echo Reporting - QLab 10.7 training Document
2) Recommendations on Perioperative TEE Reporting Document
3) Perioperative TEE Diastolic Assessment Algorithm
6) CSICU - Stat Attendence Pager Code
7) Heparin Resistance & Anti Thrombin III Acquisition in Cardiac Surgery
8) Lumbar CSF Drain (Medtronic) Operating Instructions/Tutorial Video
9) *Echo Rounds Presentations*
10) Septal Myomectomy TEE Protocol
11) SAM Probability
12) TEE and Surgical Decision Making in the Cardiac OR
13) Regional Anesthesia for Cardiac Surgery - Resources
14) SCA Practice Advisory on Cardiac Surgery Transfusion and Hemostasis
15) Ventilation Strategy for Cardiac Surgery
16) SYNGO Quick Guides (In-House Only)
17) Post-Cardiotomy ECLS - 2020 Expert Consensus
18) PCC & rFVIIa Automatic Release for Cardiac Surgery
Echo Reporting - QLab 10.7 Training Document
QLab version 10.7 is now installed on all the Syngo PACS workstation (reading rooms and tech work areas). This version is compatible with Syngo and you can now do Strain (aCMQ) and 3D measurements on all images that have been sent from a Philips machine.
Within Syngo, there is now a spot on the LV measurement page for GLS (Qlab). This number will require manual entry at the present time, we are working on it going automatically but this is not ready yet. As strain is a negative number, the (-) is already entered within the template. You will also notice a QLAB popup button in the area of the template, this is auto filled with additional information that is derived when you do the strain.
Last Updated: Apr 2018
VADA Recommendations on Perioperative TEE Reporting Document
Last Updated: June 2018
aCMQ Quick Guide (QLAB 10.8)
CSICU - Stat Attendance Pager Code
-
When carrying D1/N1 Pager: 44 = STAT to CSICU
Clinical Practice Guideline for the Acquisition and Administration of Antithrombin III (ATIII) for Cardiopulmonary Bypass in Cardiac Surgery
J. Trudeau (Anesthesiology), T. Waters (Anesthesiology), J. Atherstone (Anesthesiology), T. Smith (Hematopathology), Amandeep Sidhu (Perfusion) and A. Shih (Transfusion Medicine)
Background:
Heparin resistance during cardiac surgery is defined as the inability of an adequate heparin dose to increase the activated clotting time (ACT) to the desired level(1). The etiology of heparin resistance in the context of cardiac surgery is complex and multifactorial. Diagnostic difficulty is compounded by the fact that ACT is not specific to the anticoagulant effect of heparin and is affected by multiple factors that are commonly present during cardiac surgery. As a result, ACT is sub-therapeutic more commonly than one would expect based on the incidence of antithrombin deficiency(2). However, it is generally felt that replacement of antithrombin III (ATIII) is the best course of initial action in cases of heparin resistance. Acquisition of ATIII is often delayed as a result of its infrequent occurrence and diagnostic uncertainty. This CPG aims to streamline the criteria and provision of ATIII such that delay is minimized.
Protocol:
-
Target ACT > 480
-
Initial heparin dose = 300 U/kg
-
If ACT remains below 480, administer additional 100 U/kg heparin, up to 500 U/kg (consider alternate lot of IV heparin for additional dosing)
-
If ACT subtherapeutic after 500 U/kg IV heparin, administer 1000 U antithrombin (AT) III* (1 vial = 1000 U)
-
ATIII is ordered by calling the blood bank (62466)
-
If necessary, remind the blood bank that an automatic approval process is in place for ATIII for this clinical scenario
-
-
PRIOR to administering ATIII, collect and send a blue top (citrated) sample to the lab for measurement of ATIII
-
This needs to be an additional blue top tube if you are also sending coags at the same time
-
Fill out a requisition: Tick “other”: and write “Antithrombin III level”
-
Do NOT wait for results prior to administering ATIII)†
-
-
A repeat dose of ATIII (1000 U) should be considered if ACT remains below target as the last step prior to instituting a heparin alternative
* ATIII is a human – derived plasma protein product (would require consent in a patient with signed refusal).
† ATIII levels in patients that receive ATIII for heparin resistance will be determined. Tests will NOT be completed in a timely fashion, and therefore wouldn’t be expected to impact decision making.
Hematopathology approval process:
-
In the context of the above protocol, up to 2 doses of ATIII (1000 U vials) will be automatically released without hematopathology approval. The requirement for repeat dosing (beyond the first dose) of ATIII is rare
-
Expected frequency of ATIII request for this clinical scenario = 5 – 10 times per year
-
-
In the event that ACT remains < 480 after 2 doses of ATIII, a heparin alternative will have to be considered
-
Expected frequency = once per 5 – 10 years (very rare)
-
References:
-
Finley A and Greenberg C. Heparin sensitivity and resistance: Management during cardiopulmonary bypass. Anesth Analg 2013; 116(6):1210-22.
-
Tait RC et al. Prevalence of antithrombin deficiency in healthy populations. Br J Haematol 1994; 87:106-12.
-
Pagano D et al. 2017 EACTS/EACTA guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothoracic Surg 2018; 53(1):79-111.
Last Updated: June 2018
Medtronic Lumbar CSF Drain Instructions/Tutorial Video
https://www.youtube.com/watch?v=T-FR7fDLXHc
Septal Myomectomy TEE Protocol
SAM Probability
TEE and Surgical Decision Making in the Cardiac Or
SCA Practice Advisory on Cardiac Surgery Transfusion and Hemostasis
Protective Ventilation in Cardiac Surgery
Post-Cardiotomy ECLS: Expert Consensus
PCC & rFVIIa Automatic Release for Cardiac Surgery - Updated Sept 14th, 2022
PCC Automatic Release for Cardiac Surgery
-
1st dose of PCC (up to 3000 units) will be automatically approved for cardiac surgery cases.
-
Currently, all subsequent doses require hematopathology (HP) approval.
Recombinant Factor VIIa (rFVIIa) for Cardiac Surgery
-
1st dose rFVIIa up to 2 mg will be released automatically (for cardiac surgery ORs only). (dosing rationale below)
-
All subsequent doses require hematopathology (HP) approval.
Summary statement and dosing rationale
Canadian guidelines (National Advisory Committee on Blood and Blood Products; nacblood.ca) recommend that rFVIIa not be used for off-label indications (including bleeding in cardiac surgery) given “the absence of strong evidence of benefit and with evidence demonstrating greater risk of harm”. This is in contrast to the STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management (2021) which states “Use of recombinant factor VIIa concentrate may be considered for the management of intractable nonsurgical bleeding that is unresponsive to routine hemostatic therapy after cardiac procedures using CPB (class IIB)”. (this recommendation was carried over from their 2011 guideline and not the focus of the review; no update on evidence).
CV surgery recommendations are based on 5 available RCTs and a systematic review. In 4/5 RCTs cited by the NAC guidelines, rFVIIa usage was prophylactic, and administered at doses ranging from 40-90ug/kg after coming off cardiopulmonary bypass and reversing heparin. This is distinct from one RCT (Gill et al. 2009) which I'll detail below since it seems to be the differentiating paper.
Gill (2009) included 179 patients who had undergone cardiac surgery on cardiopulmonary bypass (CPB) and admitted to the CVICU for at least 30 minutes. They were randomized if they had a pre-specified bleeding rate (>200ml/hr for any hour or >2ml/kg/hr for 2 consecutive hours). Randomization and trial drug dosing occurred on average 2.8 hours after admission to the postoperative care unit. There were 3 cohorts: placebo, FVIIa r40mcg/kg, FVIIa 80mcg/kg. At the time of randomization, a standardized transfusion protocol was initiated for blood products. There seemed to be minimal incremental benefit with 80mcg/kg vs 40mcg/kg: Decreased re-operation (placebo 25%, 40uh/kg 14%, 80uh/kg 12%), allogenic blood volume (placebo 825ml, 40ug/kg 640ml, 80ug/kg 500ml). There was a numerical but not statistically significant trend towards increased thromboembolic complication in the rFVIIa groups. The authors acknowledge that they cannot confirm the safety of rFVIIa use given the trend towards increased complications and likelihood of type II error.
The Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients (2019) states: “the off-label use of rFVIIa is effective in decreasing blood loss and allogenic blood transfusions in patients with severe intractable post-CPB coagulopathic bleeding. The working group cautions that there may be a risk of arterial thrombosis with the use of rFVIIa that can result in myocardial infarction, especially in older patients. Therefore, when possible, clinicians should consider a lower dose of factor rFVIIa (20-40mcg/kg) to minimize the risk for thrombotic complications”. [cites Gill (2009) for decreased reoperation, and Karkouti (2005, 2008) regarding efficacy. Regarding their dosing recommendation of 20-40mcg/kg they cite the above studies along with Levi (2010) which was a meta-analysis of RCTs involving rFVIIa to assess safety. Levi found higher rates of thromboembolic complications with rFVIIa overall, with greatest risk for those >age 75. There was also a dose dependent effect with the lowest risk for patients receiving <80mcg/kg (5.4% rate of thromboembolic events in placebo vs 6% VIIa)].
ERAS MIS Cardiac Surgery Protocol - Infographic
Cardiac EP Lab Resources