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Leanna R. Miller, RN, MN,CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN.

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Presentation on theme: "Leanna R. Miller, RN, MN,CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN."— Presentation transcript:

1 Leanna R. Miller, RN, MN,CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

2 Behavioral Objectives 1.Identify common postoperative pulmonary complications. 2.Describe common cardiac complications of CV surgery. 3.Discuss treatment strategies for complications seen in the postoperative CV surgery patient.

3 Report from Anesthesia procedure performed height/weight infusions pacing options blood products given events/concerns

4 In the Huddle details of surgical procedure patients history patients anatomy BP, MAP, titration goals reverse sedation/maintain sedation airway difficulty

5 Assessing Labs assess K+ - replete according to protocol standing order – 2 gm MgSO 4 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

6 Postoperative Concerns Instability –Hypotension vs. Hypertension –goal range (upper and lower) Bleeding –Cardiac Tamponade Arrhythmias Extubation Pain/Mobilization

7 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 patients goal for tissue perfusion

8 Instability Hypotension –most likely dry due to fluid shifts that have occurred –consider HCT - would PRBCs be appropriate? –What drips are infusing –Are they warming up now and vasodilating? –Use of NEOSYNEPHRINE sticks NO!

9 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 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 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 & theyll bleed more

12 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: PRBCs, FFP, platelets, cryoprecipitate Consider what medications patient was on pre- operatively Ex: Aspirin, Plavix

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

14 Screening CBC – Hgb/Hct – platelets PT/PTT Bleeding Time

15 SymptomINRaPTTPlatelet #Platelet Function HistoryDiagnosis Major/minor bleeding NN N Massive transfusion; fluids Dilutional thrombocytopenia Major/minor bleeding N Prolonged NN negativeDrug induced - heparin Major/minor bleeding NNn/a Vitamin K deficiency Liver disease, warfarin, antibiotics Major bleeding prolonged N DIC

16 Postoperative Bleeding Vascular integrity disruption –reoperation

17 Medical Causes of Bleeding residual heparin effect platelet consumption (CPB) preoperative platelet inactivation

18 Medical Causes of Bleeding depletion of clotting factors preoperative coagulopathy fibrinolysis

19 Thrombocytopenia – platelet destruction drug – induced DIC

20 Thrombocytopenia –Etiology abnormal distribution or sequestration in spleen –portal hypertension

21 Definition serious bleeding disorder thrombosis; then hemorrhage Disseminated Intravascular Coagulation

22 Etiology of DIC shock IIR cardiac tamponade infection

23 Laboratory Findings platelets fibrinogen PT &/or PTT d - dimer or FSP ATIII

24 Management Treat underlying cause –antimicrobials –product replacement –surgery - open chest

25 Management Stop Thrombosis –IV heparin –AT III –plasmapheresis

26 Management Administer blood products –pRBCs –platelets –FFP –cryoprecipitate

27 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: –Becks triad: muffled heart sounds, distended neck veins, hypotension –rule of 20s: CVP > 20, SBP decreased by 20, HR increased by 20 –equalization of cardiac pressures, narrowed pulse press, sudden cessation of CT drainage

28 Bleeding Possibly return trip to OR Worse case scenario – OPEN chest in unit

29 Postoperative Arrhythmias Atrial Fibrillation –most common dysrhythmia in the postoperative period –incidence 30% to 50% –consequences include: hemodynamic instability thromboembolism

30 Predictors of Atrial Fibrillation post CABG –advanced age, –history of AF –enlarged left atrial size –history of CHF –elevated BNP levels

31 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 Arrhythmias Consider electrolyte assessment VT/Vfib – –SHOCK FIRST!!! –Then CPR/ACLS treat it according to ACLS protocol, but look further because its not common in the post op setting

33 Arrhythmias Bradycardia/Asystole: use your pacing wires immediately - pace before CPR & drugs if possible. Emergency pacer kept in supply room Dont hold back with CPR if pulseless

34 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 0 2 makes heart irritable)

35 Arrhythmias Atrial Fibrillation/Aflutter: –Are they hypovolemic - whats 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 theyre getting ready to transfer to floor

36 Pulmonary Problems pulmonary function –13% to 64% decrease in VC, FEV 1, & FRC diaphragmatic dysfunction atelectasis chest wall instability –hypoxemia is exacerbated –usually lowest within 2 to 3 days postoperative

37 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 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 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 Pulmonary Problems Pulmonary Edema –most common cause is pre-existing LV dysfunction –noncardiogenic – pump lung inflammatory process leading to direct lung injury

41 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 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 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 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 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 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 Neurologic Complications Stroke –most common neurologic complication of revascularization –go undetected within the 1 st 24 hours –incidence 2% to 9% –most occur within the 1 st 48 hours postoperative

48 Neurologic Complications possible complications –delirium –transient or permanent cognitive deficits –seizures –anterior spinal artery infarction –transient focal cerebral ischemia –stroke

49 Neurologic Complications Location of strokes –cerebral hemispheres –less common brainstem cerebellum deep white and gray matter

50 Neurologic Complications Mechanism of stroke in CABG –embolization from atheromatous plaque –fat embolism –air embolism –atrial fibrillation –hypotension –intra-operative hypotension

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

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

53 Postoperative Infections Common postoperative infections –superficial sternal wound infections –deep sternal wound infections –donor site infections –pulmonary infections

54 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 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 Postoperative Infections Mediastinitis – clinical features –fever –tachycardia –chest pain or sternal instability –purulent discharge from site –crepitus & edema of chest wall –Hammans sign

57 Case Study #1 65 yo F, S/P CABG X 3 Patient history –CAD –Atrial fibrillation –Ejection Fraction 45% –HTN –previous MIs in past with stents placed –on Plavix pre-op

58 Case Study #1 Pt arrives from OR: VSs: –BP 130/70, HR 112, CVP = 4, 0 2 sat 98% –Chest tube output: 200cc in 1 st 30 minutes –Initial ABG results: PO 2 – 178 (60% FiO 2 ), pH 7.34, pCO 2 46, BE -2.2 Vent settings: –TV 600, SIMV 12, PEEP 5, PS 5

59 Case Study #1 Patients Drips and Labs: –Propofol 30 mcg/kg/min 2mcg/min –Amicar 1gm/hr –Carrier fluids running at 150cc/hr

60 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 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 Case Study #2 Patients Drips: 15mcg/min 2mg/min 20 mcg/kg/min What interventions are needed?

63 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 Case Study #2 Interventions Watch VS/BP as patient warms up Go ahead and hook patient to pacemaker in back-up rate. Wont reverse patient –might need more than/something different from Propofol




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