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You are here: Home / 09. Medical/Surgical / cardiology / Post-Cardiac Surgical Management

Post-Cardiac Surgical Management

July 14, 2011 by CrashMaster

 

ACLS in the CTICU

EACTS

Bypass Types

Hypothermic Cardiopulmonary Bypass

Venous cannula in right atria, cannula is aorta. Heart is cooled down, once proper tem is reached, the aorta is cross clamped and cardioplegia is achieved by injection. The blood is pumped from the right atria to a reservoir where blood suctioned from the field also goes to. It is pumped through a heat exchanger and an oxygenator. Anticoagulation with heparin which is reversed with protamine at the completion of the procedure.

Warm Bypass

Total circulatory Arrest with Whole Body Hypothermia

Phenobarb is given to slow cerebral metabolism; the patient may remain unresponsive for 24-48 hours post procedure

Off Pump Bypass

uses cardiac stabilizers to allow the heart to keep beating during surgery

Post-Operative Care

Post Op platelets may drop to <40000 and may have qualitative defects Hypothermic patients are vasoconstricted with high SVR and low CO   Protamine Reactions

  • Hypotension
  • Anaphylaxis
  • Thromboxane release from capillary bed can cause right heart failure
  • Give Steroids and Antihistamines

 

Hypotension

hypovolemia is the most common cause Card. tamponade, MI, Ischemia, Tension Pneumo, Valve Fx Give empiric volume replacement and consider dopamine ? of relative deficiency of vasopressin

Perioperative MI

Trop >5 Sensitivity of 91%, Specificity of 82% (Parrillo)

Postoperative Hypertension

30-60% of patients will develop Increased risk of graft bleeding and aortic dissection Start with nitroprusside, move to ACEI

Atrial / Ventricular Arrhythmias

Heart Block

Post-Op Bleeding

Protamine’s half life is shorter than heparins

Respiratory Complications

Diaphragmatic dysfunction secondary to cold injury of phrenic nerve Have patient sniff while examining diaphragms with UTS or fluoroscopy Pleural Effusions and ARDS

GI

GI bleeding Can have increased billi from RBC breakdown

Neurologic

Post Pump Syndrome-persistent personality changes which can last for years Aortic cross clamping can cause embolization and post-op strokes

Normal Postoperative Care

Most patients will have two mediastinal drainage tubes Pacing wires to the right of midline are usually atrial and to the left are ventricular   In uncomplicated cases, patients can be extubated soon post-op, ~7hrs, use t-tube trial Remove tubes/wires as soon as possible Give a-fib prophylaxis with b-blockers Agents to decrease post-op bleeding such as Aprotinin, EACA, or DDAVP ASA and SC heparin Arterial graft spasm proph with Ca-Blockers   Patients may need ventricular assist devices(VAD)   The post-op cardiac heart is noncompliant, therefore PAOP and CVP may be artificially high; the patient may need volume in the face of these high seemingly high filling pressures. If the heart was chronically volume overloaded from valve insufficiency,

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then immediately post-op this same degree of volume should be maintained. Tachycardia is horrible for the stiff heart as adequate filling times are lost.   | | |

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