Cardiac Anesthesia Events

Cardiac Laceration


A cardiac laceration is an inadvertent incision into the right atrium, right ventricle, great vessels, or vein graft(s) during sternotomy or resulting from other traumatic injury


  • Adhesion of scar tissue and/or myocardial tissue to the sternum

  • CPR

  • Penetrating chest trauma (e.g., gunshot wound, knife injury, MVA)

Typical Situations

  • Patients who have had a previous sternotomy (“redo” sternotomy), especially those with vein grafts crossing under the sternum

  • Inexperienced surgeon

  • When the lungs are ventilated during sternotomy

  • Emergency sternotomy

  • Patients with ascending aortic aneurysms or multivessel aortic arch disease

  • Patients with an anatomic abnormality of the chest wall (kyphoscoliosis, pectus excavatum)

  • Patients who have received mediastinal radiation

  • Patients who have had CPR with rib or sternal fractures

  • Patients with penetrating injury to the chest

  • Patients following MVA


  • Obtain preoperative lateral CXR and/or CT scan to evaluate the extent of adhesions to the heart, great vessels, and sternum

  • Stop ventilating the lungs prior to primary sternotomy; maintain ventilation at reduced tidal volumes during redo sternotomy

  • Reduce myocardial chamber size during sternotomy

    • Place the patient in reverse Trendelenburg position

    • Vasodilate the patient with an IV infusion of sodium nitroprusside or NTG

  • Consider instituting femoral artery−to−femoral vein CPB prior to sternotomy

  • Suggest that sternotomy be performed following deep hypothermia and complete circulatory arrest if an aortic aneurysm is adherent to the underside of the sternum


  • Large volumes of blood welling out of the surgical field or other site of injury

  • Hypotension

    • May be due to blood loss

    • Acute cardiac failure may occur if a critical vein or internal mammary artery graft to a coronary artery is lacerated

  • Tachycardia

  • Obvious signs of chest trauma—knife or bullet holes, seat belt burns

  • Hemopneumothorax

Similar Events


Cardiac laceration may occur during any sternotomy or chest trauma.

  • In cardiac surgery, be prepared for major hemorrhage during sternotomy

    • Ensure adequate IV access is in place for redo sternotomy

    • If a blood salvage device is to be used during surgery, have it set up prior to sternotomy

    • Stop ventilating the lungs prior to primary sternotomy; maintain ventilation at reduced tidal volumes during redo sternotomy

    • Ensure at least two units of PRBCs are available in the OR prior to sternotomy

    • Observe the operative field carefully during sternotomy

    • Ensure rapid fluid infuser is available

  • If major hemorrhage is apparent during sternotomy

    • Stop administering volatile anesthetics and flush the anesthesia breathing circuit with 100% O 2

    • Increase FiO 2 to 100% and resume ventilation

    • Stop administering vasodilators

  • Maintain the circulating fluid volume

    • Administer IV fluid (crystalloid, colloid, blood)

    • Get help to administer volume rapidly

    • Hook up rapid fluid infuser

  • Maintain perfusion pressure

    • Administer vasopressors as required (see Event 9, Hypotension )

      • Administer phenylephrine IV, 50 to 200 μg, and escalate as needed

      • Administer epinephrine IV, 10 to 50 μg, and escalate as needed

  • Conserve the patient’s blood

    • Ensure that the blood salvage device is used by the surgeons

  • If surgical repair on CPB is necessary

    • Heparin should be administered (300 to 400 units/kg IV) by the anesthesiologist through a central line

      • Check ACT as soon as feasible

      • Administer more heparin if ACT is less than 400 seconds

    • After heparinization, blood can be salvaged by the cardiotomy suction line of the CPB pump (“sucker bypass”)

    • The femoral artery may have to be cannulated for the arterial perfusion line

    • A right ventriculotomy and the cardiotomy suction can be used as venous return for CPB

  • After CPB is initiated, anticipate and plan for problems associated with prolonged CPB time and myocardial injury (see Event 78, Low Cardiac Output State After Cardiopulmonary Bypass ; Event 75, Coagulopathy Following Cardiopulmonary Bypass ; and Event 15, Acute Coronary Syndrome )

  • Following penetrating or blunt injury to the chest or in patients who have had CPR, patients may need

    • Chest tube placement

    • Fluid resuscitation

    • Sternotomy/thoracotomy to control bleeding and/or cross-clamping of the descending aorta

    • Transfer to the OR for definitive surgery


  • Failure to wean from CPB

  • Acute myocardial failure

  • Myocardial ischemia

  • Arrhythmias

  • Cardiac arrest

  • ARDS

  • Hypothermia

  • Systemic air embolism

Suggested Reading

  • 1. Mehta A.R., Romanoff M.E., Licina M.G.: Anesthetic management in the precardiopulmonary bypass period. Hensley F.A. Martin D.E. Gravlee G.P. The practical approach to cardiac anesthesia . 2008. Lippincott Williams & Wilkins Philadelphia: pp. 182-183.
  • 2. Despotis G., Avidan M., Eby C., et. al.: Prediction and management of bleeding in cardiac surgery. J Thromb Haemost 2009; 7: pp. 111-117.
  • 3. Misao T., Yoshikawa T., Aoe M., et. al.: Bronchial and cardiac ruptures due to blunt trauma. Gen Thorac Cardiovasc Surg 2011; 59: pp. 216-219.
  • 4. Nyawo B., Botha P., Pillay T., et. al.: Clinical experience with assisted venous drainage cardiopulmonary bypass in elective cardiac reoperations. Heart Surg Forum 2008; 11: pp. E21-E23.
  • 5. Hellevuo H., Sainio M., Nevalainen R., et. al.: Deeper chest compression: more complications for cardiac arrest patients?. Resuscitation 2013; 84: pp. 760-765.

  • Coagulopathy Following Cardiopulmonary Bypass


    Coagulopathy following CPB as a result of deficiency or dysfunction of platelets or of the coagulation cascade


    • Circulating anticoagulant

      • Inadequate heparin neutralization

      • Heparin rebound

      • Protamine overdose

    • Thrombocytopenia

    • Impaired platelet function

    • Low plasma concentrations of coagulation factors

    • DIC

    • Primary fibrinolysis

    • Preexisting congenital or acquired coagulopathy

    Typical Situations

    • Postoperative cardiac surgery patients

    • Prolonged time on CPB

      • Increased platelet activation

      • Thrombocytopenia

      • Consumption of coagulation factors

    • Massive hemorrhage or transfusion

    • Vigorous cardiotomy suction

    • Patients requiring a circulatory assist device

    • Patients undergoing deep hypothermia (core temperature below 20° C)

    • Preexisting coagulopathy

      • Drug therapy inhibiting platelet function (aspirin, dipyridamole, clopidogrel)

      • Anticoagulant therapy

      • Thrombolytic therapy (streptokinase or similar agents)

      • Hepatic dysfunction

      • Chronic renal failure

      • Myeloproliferative disorders


    • Identify patients with preexisting clinical, subclinical, or pharmacologically induced coagulation disorders

      • Obtain preoperative laboratory studies of coagulation function

        • PT, PTT

        • Platelet count

        • Thromboelastogram, if available

    • Keep CPB time as short as possible

    • Minimize the negative pressure applied to the cardiotomy suction to reduce platelet trauma

    • Administer heparin and protamine in appropriate doses

      • Monitor coagulation during and immediately after CPB

      • Maintain adequate anticoagulation during CPB (ACT > 400 seconds)

    • Consider the use of acute normovolemic hemodilution (remove whole blood pre-CPB for retransfusion post-CPB)

    • Coordinate the discontinuation of preoperative medications known to cause platelet dysfunction with the surgical team

    • Consider administering pharmacologic therapy in high-risk cases

      • ε-Aminocaproic acid

      • Tranexamic acid

    • Have blood products available at the end of CPB for patients at high risk of a coagulopathy

      • Patients who have had previous cardiac surgery

      • Duration of CPB longer than 3 hours


    • Bleeding into the surgical field from multiple sites and from wound edges after administration of an adequate dose of protamine

    • Increased mediastinal chest tube output after the chest has been closed

    • Bleeding from IV insertion sites, wounds, or mucous membranes

    • Abnormalities in laboratory tests of coagulation function

      • Prolonged ACT that does not correct with additional protamine

      • Thrombocytopenia

      • Prolonged PT and PTT

      • Decreased fibrinogen level

      • Increased levels of fibrin split products

      • Abnormal thromboelastogram

    • Hypotension, tachycardia

    • Cardiac tamponade

    Similar Events


    • Surgical exploration is indicated if

      • The mediastinal chest tube drainage exceeds 300 to 400 mL in 1 hour, drainage is continuing, and laboratory tests of coagulation are normal

      • Signs of cardiac tamponade are occurring (see Event 18, Cardiac Tamponade )

        • Equilibration of filling pressures

        • TEE/TTE examination is suggestive of cardiac tamponade

      • Provide supportive therapy until bleeding is controlled

      • Maintain the circulating fluid volume

        • Infuse crystalloid, colloid, and blood products as necessary to maintain perfusion pressure

      • Administer vasopressors as required to maintain perfusion pressure (see Event 9, Hypotension )

        • Phenylephrine IV, 50 to 100 μg, and escalate as needed

        • Epinephrine IV, 10 to 50 μg, and escalate as needed

      • Maintain normothermia (see Event 44, Hypothermia )

        • Use heating blankets and/or a forced-air warming device

        • Warm all IV fluids

      • Prevent hypertension

        • Maintain adequate sedation

        • Administer vasodilator agents as needed

      • Consider PEEP to decrease the amount of venous mediastinal bleeding following chest closure

    • Assess laboratory tests of coagulation function

      • Check the ACT

        • Administer additional protamine until the ACT returns to control or until there is no further reduction in the ACT

      • Send samples to the clinical laboratory for

        • Platelet count

        • PT

        • PTT

        • Fibrinogen

        • Fibrin split products

      • Check thromboelastogram

    • Begin empirical therapy while waiting for laboratory results if bleeding is severe (see Event 1, Acute Hemorrhage )

      • Restore platelet numbers and function

        • Reinfuse any fresh whole blood removed from the patient prior to CPB after administration of protamine

        • Administer platelets (one apheresis unit should increase platelet count by 50,000 to 80,000/μL)

        • Consider desmopressin (DDAVP) IV by slow infusion, 0.3 μg/kg. Can cause hypotension if given too quickly

      • Infuse 2 to 4 units of fresh frozen plasma (adults)

      • Further use of blood products should be guided by laboratory results if practical

      • Consult a hematologist for further management of a coagulopathy that does not resolve

      • Consider recombinant factor VIIa IV, 15 to 180 μg/kg (dosage for the treatment of uncontrolled hemorrhage in nonhemophiliac patients vary; consult a hematologist)

    • If primary fibrinolysis is thought to be the cause of bleeding

      • Administer ε-aminocaproic acid IV, 5 g bolus infusion followed by 1 g/hr for 6 hours


    • Transfusion reaction

    • Hypovolemia

    • Hypervolemia

    • DIC

    • Hypercoagulable states

    • Renal failure

    • Mediastinitis following reexploration

    • Bloodborne virus infection

    • Death

    Suggested Reading

  • 1. Avery E.G.: Massive bleeding post bypass: rational approach to management. ASA refresher course lectures . 2012. American Society of Anesthesiologists Park Ridge, Ill: pp. 214.
  • 2. Mazer C.D.: Update on strategies for blood conservation and hemostasis in cardiac surgery. ASA refresher course lectures . 2012. American Society of Anesthesiologists Park Ridge, Ill: p. 424
  • 3. Romanoff M.E., Royster R.L.: The postcardiopulmonary bypass period: weaning to ICU transport. Hensley F.A. Martin D.E. Gravlee G.P. The practical approach to cardiac anesthesia . 2008. Lippincott Williams & Wilkins Philadelphia: p. 233
  • 4. DiNardo J.A.: Management of cardiopulmonary bypass. DiNardo J.A. Zvara D.A. Anesthesia for cardiac surgery . 2008. Blackwell Malden, Mass: pp. 369.
  • 5. Speiss B.D., Horrow J., Kaplan J.A.: Transfusion medicine and coagulation disorders. Kaplan J.A. Kaplan’s cardiac anesthesia . 2006. Saunders Philadelphia: pp. 972.
  • 6. Lam M.S., Sims-McCallum R.P.: Recombinant factor VIIa in the treatment of nonhemophiliac bleeding. Ann Pharmacother 2005; 39: pp. 885-891.

  • Emergent “Crash” onto Cardiopulmonary Bypass


    Emergent initiation of CPB


    • Cardiac surgery

      • Perioperative cardiac arrest, myocardial ischemia, hypotension, or massive hemorrhage

    • Airway catastrophe

      • Inability to establish an airway by routine methods (e.g., anterior mediastinal mass with tracheomalacia)

    • LAST requiring prolonged CPR

    Typical Situations

    • Acute coronary graft occlusion

    • Failure of PCI

    • Severe valvular dysfunction

      • Failure of valve (e.g., ruptured chordae), valve repair or replacement

      • Endocarditis with acute severe valvular incompetence

    • Acute severe myocardial dysfunction

      • Severe hypotension

      • Severe protamine reaction

    • Massive perioperative hemorrhage

    • Massive PE

    • Obstetrical catastrophes (e.g., LAST, AFE, and cardiac arrest in the parturient)


    • Wean from CPB with all necessary inotropic and mechanical myocardial support

    • Verify protamine reversal and obtain good hemostasis prior to chest closure

    • Perform a post-CPB TEE examination to evaluate ventricular and valvular function


    • Signs of global or regional myocardial dysfunction

      • Visible cardiac distention and poor myocardial contractility

      • Systemic hypotension with increased filling pressures

      • Wall motion abnormalities on TEE (global or regional)

      • Abnormalities of ECG morphology or rhythm

        • ST elevation, often on the inferior leads II, III, AVF

        • Heart block

        • Ventricular arrhythmias (VT, VF)

        • Asystole

    • Severe hemorrhage

    • EEG activity may slow or become quiescent

    • Cardiac arrest


    • Alert cardiac surgeon, perfusionist, and nursing team of the situation

      • Emergent CPB usually takes some time to organize for heparinization, CPB circuit preparation, and placement of arterial and venous cannulae (not in the context of ongoing cardiac surgery)

    • Resuscitate the patient

      • Check that the patient is being oxygenated (deliver 100% O 2 ) and ventilated and that infusions of vasopressors are running; adjust ventilation and infusion rates as necessary

      • Administer boluses of vasopressors IV as necessary (see Event 9, Hypotension )

        • Phenylephrine IV, 100 to 200 μg, and escalate as necessary

        • Ephedrine IV, 10 to 20 mg

        • Epinephrine IV, 10 to 50 μg, and escalate as necessary

      • Administer IV fluids

        • Crystalloid bolus IV, 500 mL, and additional boluses as needed

        • Colloid bolus IV

          • Hetastarch 500 mL

          • 5% albumin 250 to 500 mL

          • RBCs—if massive hemorrhage, inform blood bank of the ongoing need for blood products; initiate your facility’s MTP

    • Once the decision has been made to go on CPB stat, ANTICOAGULATE THE PATIENT

      • Administer heparin through a central line or surgeons may choose to administer heparin intra-atrially

      • Heparin dose will depend on the current level of anticoagulation and whether the patient has received protamine.

        • Aim for ACT > 400 seconds

      • Initial heparin dose should be at least 300 units/kg

    • Perfusionist should immediately prime the oxygenator and CPB pump circuit

      • If there is any question about the circulation of heparin, have an additional 15,000 units of heparin added to the pump prime

      • Volume can be delivered to the patient via arterial cannula once it is in place

    • Cardiac surgeon should cannulate the arterial system (aorta or femoral artery) first, then the venous system (right atrium or femoral vein)

      • If there is massive hemorrhage, the cardiotomy suction cannulae can be used as the source of venous drainage (MUST heparinize before doing this)

    • Anesthesiologist should consider administering additional anesthetic agents if the case is prolonged once the patient is stable

    • Check an ABG; correct acidosis if present


    • Difficulty in separation from CPB

    • Myocardial ischemia or infarction

    • Coagulopathy

    • Stroke

    • Arrhythmias

    • Cardiac arrest

    • Death

    Suggested Reading

  • 1. Mora-Mangano C.T., Chow J.L., Kanevsky M.: Cardiopulmonary bypass and the anesthesiologist. Kaplan J.A. Kaplan’s cardiac anesthesia . 2006. Saunders Philadelphia: pp. 908.
  • 2. Birdi I., Chaudhuri N., Lenthall K., Reddy S., Nashef S.A.: Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: outcome justifies the cost. Eur J Cardiothorac Surg 2000; 17: pp. 743-746.
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    Feb 22, 2019 | Posted by in ANESTHESIA | Comments Off on Cardiac Anesthesia Events
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