Transcatheter Aortic Valve Replacement (TAVR)

Anesthesia Implications

Position: Supine, arms tucked
Time: 1-2 hours (average)
Blood Loss: Low (10-50 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: No

TIVA – On a three-way stopcock add a Propofol drip (25mcg/kg/min), Precedex (0.2 mcg/kg/hr – this is diluted by adding 200mcg in 50 ml crystalloid), Phenylephrine drip (ready to go as needed)

Be Prepared – Always have an ETT and equipment ready in case the patient needs to be intubated.

Suggested Routines:

Once in room, monitors and oxygen on
Give Pepcid/Zofran, 50mcg fent and 1mg versed
Put TIVA pigtail to closest port of IV and start drips.
Position your Aline for left radial
After Aline, TTE is going to be done. Give antibiotics. Catch up with charting and adjust drips.
Heparin per body weight and protamine is full reversal per body weight
Rapid pacing: this is where the phenylephrine drip will be especially useful
Turn off propofol and precedex when sheath is out.

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Preop – Give Precedex loading bolus of up to 10-25mcg in preop and remainder totaling max loading of 25mcg upon entering the room.
Monitors On – Start the Precedex drip (1.5 mcg/kg/hr) and give a fentanyl bolus (25 mcg). At this phase, you may need to give small bumps of propofol (10mg) PRN.
Incision – Give another 25-50 mcg of Fentanyl before initial incision/localizing.
After Deployment (Deployment refers to the valve being actively opened and placed and to its new home in the patients body) – Turn precedex down to 0.5-1 mcg/kg/hr.
Monitors Removed – turn off Precedex.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.