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Management of the Cardiac Surgical Patient

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1 Management of the Cardiac Surgical Patient
Leanna R. Miller, RN, MN,CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

2 Management of the Cardiac Surgical Patient Behavioral Objectives
Identify common postoperative pulmonary complications. Describe common cardiac complications of CV surgery. Discuss treatment strategies for complications seen in the postoperative CV surgery patient.

3 Management of the Cardiac Surgical Patient Report from Anesthesia
procedure performed height/weight infusions pacing options blood products given events/concerns

4 Management of the Cardiac Surgical Patient
In the “Huddle” details of surgical procedure patient’s history patient’s anatomy BP, MAP, titration goals reverse sedation/maintain sedation airway difficulty

5 Management of the Cardiac Surgical Patient
Assessing Labs assess K+ - replete according to protocol standing order – 2 gm MgSO4 assess ABG are we adequately ventilating patient watch trends with lactate and Hgb Glucose according to SCIP criteria: BG on POD1 and POD2 must be < 200 mg/dL should arrive from the OR on an insulin drip titrate q1h per protocol First goal is to maintain BP that supports tissue perfusion – goal should be given during huddle A definitive plan should be in place for gtt titration/weaning(what should be weaned first & what should be left alone) If total IVF rate > 70cc/hr for two hours we concentrate gtts Aprotinin & Amicar- used to counteract coagulopathy caused by CPB Prevents clot breakdown by inhibiting fibrinolysis Aprotinin used for re-do’s(they bleed more) Amicar should be turned off in the OR, if not clarify with the midlevel that it is to be turned off. Will sometimes finish the bag in the CVICU Propofol - used for sedation, no analgesic properties. If patient not fast tracking, consider moving to Fent/Versed gtts. Milrinone -frequently used to improve CO/CI when SVR high enough to impede LV output Epinephrine- powerful vasoconstrictor & inotrope, increases myocardial 02 demand Norepinephrine- used to counteract vasodilatory effect. Can increase HR therefore 02 demands increased Phenylephrine- anesthesia likes this drug - vasoconstriction(not as good as LEVO) but no increased HR Dopamine - supposedly losing favor, increase CO and vasoconstrictor Nipride: potent vasodilator, decrease SVR

6 Management of the Cardiac Surgical Patient
Postoperative Concerns Instability Hypotension vs. Hypertension goal range (upper and lower) Bleeding Cardiac Tamponade Arrhythmias Extubation Pain/Mobilization

7 Management of the Cardiac Surgical Patient
Instability Patient can quickly shift from hypertension to hypotension Know what your goal for tissue perfusion is - as a general rule keep SBP < 120, currently moving towards using MAP as the goal pressure KNOW the patient’s goal for tissue perfusion

8 Management of the Cardiac Surgical Patient
Instability Hypotension most likely “dry” due to fluid shifts that have occurred consider HCT - would PRBC’s be appropriate? What drips are infusing Are they warming up now and vasodilating? Use of NEOSYNEPHRINE sticks NO!

9 Management of the Cardiac Surgical Patient
Instability Hypertension: Are they waking up? Are they experiencing pain? Which drips are running - should we wean vasopressors? GET HOB UP to at least 30 degrees Might need to start Nipride drip

10 Management of the Cardiac Surgical Patient
Instability Chest tube output monitoring: q15min X 4, q30min until CT output < 100cc/hr then q1h – keep mid-levels/clinicians informed of excessive CT output if output > 100cc in any of the 15 min intervals notify MD/clinician Order set: if  200ml/hr then order stat platelet, PT/PTT

11 Management of the Cardiac Surgical Patient
Instability Chest tube output monitoring: high rate of bleeding is what your are concerned with more so than a specific amount be diligent in declotting chest tubes - no stripping, gentle pinching, twisting keep BP down(SBP 120 mmHg or less) - the higher the BP, the more pressure put on graft & they’ll bleed more

12 Management of the Cardiac Surgical Patient
Instability Consider the use of PEEP on ventilator Assess the PT/PTT sent to lab If INR > 1.5, team will most likely order FFP Consider sending fibrinogen or platelet labs If bleeding is significant - prepare to give blood products: PRBC’s, FFP, platelets, cryoprecipitate Consider what medications patient was on pre-operatively Ex: Aspirin, Plavix

13 Management of the Cardiac Surgical Patient
Coagulation Problems excessive bleeding usually occurs in the 1st POD 5/100 require return to the OR can occur later with development of DIC or tamponade with epicardial wire removal

14 Management of the Cardiac Surgical Patient
Screening CBC  Hgb/Hct  platelets PT/PTT Bleeding Time Anemia occurs in 4% to 9% of patient 70 years of age and older and predicts the need for transfusion in patients at risk for blood loss Thrombocytopenia for platelet problems Coagulation PT alone is a poor screening test and neither predicts nor excludes clinically relevant perioperative bleeding abnormalities Bleeding time – good way to detect abnormalities of platelet function; disruption of platelet function is increasingly common in the aging population – regular use of ASA, ticlid, plavix. Bleeding times normalize after the drug has been discontinued – time is variable.

15 Management of the Cardiac Surgical Patient
Symptom INR aPTT Platelet # Platelet Function History Diagnosis Major/minor bleeding N Massive transfusion; fluids Dilutional thrombocytopenia Prolonged negative Drug induced - heparin n/a Vitamin K deficiency Liver disease, warfarin, antibiotics Major bleeding prolonged DIC

16 Management of the Cardiac Surgical Patient Postoperative Bleeding
Vascular integrity disruption reoperation

17 Management of the Cardiac Surgical Patient Medical Causes of Bleeding
residual heparin effect platelet consumption (CPB) preoperative platelet inactivation Residual heparin effect – treat with protamine Platelet consumption – prolonged bypass time – usually AAA patients Preoperative platelet inactivation – plavix, ASA, glycoprotein IIb/IIIa inhibitors

18 Management of the Cardiac Surgical Patient Medical Causes of Bleeding
depletion of clotting factors preoperative coagulopathy fibrinolysis Depletion of clotting factors – priming the CPB machine, massive transfusion, fluid resuscitation Preoperative coagulopathy – liver dysfunction, residual warfarin effect, vitamin K deficiency, von Willebrand’s disease, fibrinolysis resulting in depletion of clotting factors. Fibrinolysis – IR to CPB circuit results in fibrinolysis with resultant degradation of clotting factors and platelet dysfunction.

19 Management of the Cardiac Surgical Patient
Thrombocytopenia  platelet destruction drug – induced DIC

20 Management of the Cardiac Surgical Patient
Thrombocytopenia Etiology abnormal distribution or sequestration in spleen portal hypertension

21 Management of the Cardiac Surgical Patient
Disseminated Intravascular Coagulation Definition serious bleeding disorder thrombosis; then hemorrhage

22 Management of the Cardiac Surgical Patient
Etiology of DIC shock IIR cardiac tamponade infection

23 Management of the Cardiac Surgical Patient
Laboratory Findings  platelets  fibrinogen  PT &/or PTT  d - dimer or FSP  ATIII

24 Management of the Cardiac Surgical Patient
Treat underlying cause antimicrobials product replacement surgery - open chest

25 Management of the Cardiac Surgical Patient
Stop Thrombosis IV heparin AT III plasmapheresis

26 Management of the Cardiac Surgical Patient
Administer blood products pRBCs platelets FFP cryoprecipitate

27 Management of the Cardiac Surgical Patient
Bleeding Sudden decrease in CT output - be sure your tubes are not clotting, keep them in eyesight at all times. Need to be out on top of sheets/bair hugger Signs & Symptoms of cardiac tamponade: Beck’s triad: muffled heart sounds, distended neck veins, hypotension rule of 20’s: CVP > 20, SBP decreased by 20, HR increased by 20 equalization of cardiac pressures, narrowed pulse press, sudden cessation of CT drainage

28 Management of the Cardiac Surgical Patient
Bleeding Possibly return trip to OR Worse case scenario – OPEN chest in unit

29 Management of the Cardiac Surgical Patient Postoperative Arrhythmias
Atrial Fibrillation most common dysrhythmia in the postoperative period incidence 30% to 50% consequences include: hemodynamic instability thromboembolism

30 Management of the Cardiac Surgical Patient
Predictors of Atrial Fibrillation post CABG advanced age, history of AF enlarged left atrial size history of CHF elevated BNP levels

31 Management of the Cardiac Surgical Patient
Prophylactic -blocker Use 35 of 122 (28.6%) developed AF while on beta blocker whereas only 18 of 109 (16.5%) developed AF in the absence of prophylactic beta blockers. predisposing effect was not significant with Multivariate analysis based on this analysis, BB did not show protection against post CABG AF

32 Management of the Cardiac Surgical Patient
Arrhythmias Consider electrolyte assessment VT/Vfib – SHOCK FIRST!!! Then CPR/ACLS treat it according to ACLS protocol, but look further because it’s not common in the post op setting

33 Management of the Cardiac Surgical Patient
Arrhythmias Bradycardia/Asystole: use your pacing wires immediately - pace before CPR & drugs if possible. Emergency pacer kept in supply room Don’t hold back with CPR if pulseless

34 Management of the Cardiac Surgical Patient
Arrhythmias Atrial Fibrillation/Aflutter: In immediate post-op period drug of choice will be Metoprolol or Amiodarone Peak incidence in post-op setting is Day 2 & 3 Are they mobilizing fluids now & need Lasix (right atrium distended) Consider ABG - check their oxygenation status(low 02 makes heart irritable)

35 Management of the Cardiac Surgical Patient
Arrhythmias Atrial Fibrillation/Aflutter: Are they hypovolemic - what’s their HCT? Is their SVR too high - heart pushing against narrow opening makes it more irritable, might need to get SVR down with Nipride Valve patients have higher incidence Common time is when they’re getting ready to transfer to floor

36 Management of the Cardiac Surgical Patient
Pulmonary Problems pulmonary function 13% to 64% decrease in VC, FEV1, & FRC diaphragmatic dysfunction atelectasis chest wall instability hypoxemia is exacerbated usually lowest within 2 to 3 days postoperative Decrease in FVC, FRC cause physiologic right – to – left shunting and a decrease in ventilation perfusion ratio leads to decreased oxygenation Hypoxemia is exacerbated by pulmonary edema, pneumonia or COPD

37 Management of the Cardiac Surgical Patient
Pulmonary Problems Atelectasis 80% of patients post-CABG risk factors for atelectasis phrenic nerve palsy intra-operative compression of lung ischemia during CPB endothelial damage cardiomegaly/supine positioning

38 Management of the Cardiac Surgical Patient
Pulmonary Problems Diaphragmatic Dysfunction decline in inspiratory/expiratory pressures as much as 17% to 47% uncoordinated rib cage expansion muscle strength improves over 6 weeks following surgery diaphragmatic flutter

39 Management of the Cardiac Surgical Patient
Pulmonary Problems Pleural Effusions develop in 50% to 89% of patients less likely post valve surgery usually left – sided (bilateral in 10%) causes include: hemorrhage or contusion pulmonary emboli postcardiotomy syndrome

40 Management of the Cardiac Surgical Patient
Pulmonary Problems Pulmonary Edema most common cause is pre-existing LV dysfunction noncardiogenic – “pump lung” inflammatory process leading to direct lung injury

41 Management of the Cardiac Surgical Patient
Extubation Goal is typically 4-6 hours from being “stable” Strike a balance between letting patient wake up and over-breathe vent and giving pain medicine Patient preferably needs to have paralytic reversed

42 Management of the Cardiac Surgical Patient
Extubation Once to minimal vent settings (40% fio2, simv rate 4, ps 5, peep 5) perform 30 min cpap trial In some instances this can be skipped draw ABG can patient lift their head patient not bleeding Hemodynamically stable ectopy Notify clinician of all findings and obtain order for extubation (be sure to chart extubation in HED)

43 Management of the Cardiac Surgical Patient
Post - Extubation Goal is to have patient sitting up within 1-2 hours after extubation Patient may begin PO intake 2-4 hours after extubation - begin with ice chips Be careful with carbonated drinks/juice Be mindful of diabetics ½ strength juice

44 Management of the Cardiac Surgical Patient
Pain Management Contrary to popular belief, pain is not intense for all - some have very little, while others it is extremely difficult to manage Fentanyl: commonly used IV analgesic Short half-life Dilaudid: IV Longer half-life Percocet: PO pain med, better pain relief than Fentanyl (Percocet lasts longer)

45 Management of the Cardiac Surgical Patient
Pain Management Toradol: for musculoskeletal pain, not routinely ordered, must have good kidney function & no bleeding Demerol – used for post-op shivering only Dilaudid – IV or SQ, watch your orders Morphine SQ

46 Management of the Cardiac Surgical Patient
Mobilization Patient will still get up with pacemaker in place DO NOT AMBULATE WITH pacemaker Be diligent with coaching patient to use incentive spirometer ( keep it handy for them to reach)

47 Management of the Cardiac Surgical Patient Neurologic Complications
Stroke most common neurologic complication of revascularization go undetected within the 1st 24 hours incidence 2% to 9% most occur within the 1st 48 hours postoperative

48 Management of the Cardiac Surgical Patient Neurologic Complications
possible complications delirium transient or permanent cognitive deficits seizures anterior spinal artery infarction transient focal cerebral ischemia stroke

49 Management of the Cardiac Surgical Patient Neurologic Complications
Location of strokes cerebral hemispheres less common brainstem cerebellum deep white and gray matter

50 Management of the Cardiac Surgical Patient Neurologic Complications
Mechanism of stroke in CABG embolization from atheromatous plaque fat embolism air embolism atrial fibrillation hypotension intra-operative hypotension

51 Management of the Cardiac Surgical Patient Neurologic Complications
Predictors of post – CABG stroke age diabetes hypertension elevated serum creatinine recent MI low EF atrial fibrillation

52 Management of the Cardiac Surgical Patient Neurologic Complications
Predictors of post – CABG stroke on pump procedure multiple blood transfusions IABP duration of bypass emergency surgery combined procedure

53 Management of the Cardiac Surgical Patient Postoperative Infections
Common postoperative infections superficial sternal wound infections deep sternal wound infections donor site infections pulmonary infections

54 Management of the Cardiac Surgical Patient Postoperative Infections
Mediastinitis 0.4% to 5% incidence 2.5% to 7.5% in heart transplant higher is patients with cardiac assist devices generally noted within 14 days of surgery

55 Management of the Cardiac Surgical Patient Postoperative Infections
Mediastinitis risk factors: diabetes/perioperative hyperglycemia obesity peripheral artery disease tobacco use prior cardiac surgery mobilization of IMA procedure > 5 hours return to OR within 4 days postop prolonged postoperative intensive care

56 Management of the Cardiac Surgical Patient Postoperative Infections
Mediastinitis – clinical features fever tachycardia chest pain or sternal instability purulent discharge from site crepitus & edema of chest wall Hamman’s sign Hamman’s sign – crunching sound that is synchronous with the heart beat and heard by chest auscultation

57 Management of the Cardiac Surgical Patient
Case Study #1 65 yo F, S/P CABG X 3 Patient history CAD Atrial fibrillation Ejection Fraction 45% HTN previous MI’s in past with stents placed on Plavix pre-op

58 Management of the Cardiac Surgical Patient
Case Study #1 Pt arrives from OR: VS’s: BP 130/70, HR 112, CVP = 4, 02 sat 98% Chest tube output: 200cc in 1st 30 minutes Initial ABG results: PO2 – 178 (60% FiO2), pH 7.34, pCO2 46, BE -2.2 Vent settings: TV 600, SIMV 12, PEEP 5, PS 5

59 Management of the Cardiac Surgical Patient
Case Study #1 Patient’s Drips and Labs: Propofol 30 mcg/kg/min 2mcg/min Amicar 1gm/hr Carrier fluids running at 150cc/hr

60 Management of the Cardiac Surgical Patient
Case Study #1 What needs some work? BP too high – get their head up, get Norepinphrine gtt off, maybe Nipride gtt to be started, high BP will cause more CT OP HR too high – is the patient dry and that is why HR is too high, does the patient need blood CT OP is too high – make sure MD is aware, do we need to send COAGS to lab, does the patient need FFP or cryoprecipitate, could use extra PEEP, field trip to OR?

61 Management of the Cardiac Surgical Patient
Case Study #2 Patient arrives from OR: Vital Signs Temp: 34.2 (Core) HR 65 BP 95/52 CO/CI: 3.2/2.0 CT OP: Currently 50cc/q15 min PAP: 22/15 CVP: 8

62 Management of the Cardiac Surgical Patient
Case Study #2 Patient’s Drips: 15mcg/min 2mg/min 20 mcg/kg/min What interventions are needed?

63 Management of the Cardiac Surgical Patient
Case Study #2 Interventions WARM the patient up!! Heat to the vent Bair hugger Cover head with blankets/plastic Possibly send COAGS/Plt count Will need fluids/blood products If giving platelets: premedicate

64 Management of the Cardiac Surgical Patient
Case Study #2 Interventions Watch VS/BP as patient warms up Go ahead and hook patient to pacemaker in back-up rate. Won’t reverse patient might need more than/something different from Propofol

65 Management of the Cardiac Surgical Patient
IN CONCLUSION

66 Management of the Cardiac Surgical Patient

67 Management of the Cardiac Surgical Patient


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