Download management of the postoperative cardiac surgery patient

Intensive Care Unit, Prince of Wales Hospital, Chinese University of Hong Kong
MANAGEMENT OF THE POSTOPERATIVE CARDIAC SURGERY
PATIENT
General Principles
• Admission notes: preop – comorbidities
cardiac investigations
medications
intraop – operation notes and anaesthetic record
particular problems – weaning off bypass,
ventricular function, bleeding
• Examination – vitals, circulation, drains, pacemaker wires
• Routine bloods – CBP, Clotting, LFT, RFT, ACT, ABG
• CXR, ECG
• Follow target filling pressures by surgeons
• Medications: Cefuroxime 750mg Q8H for 3 doses (unless allergy)
Bactroban topical nasal tds
Continue inotropes and/or vasodilators from OT and wean as appropriate.
If increasing inotropic support is required – inform ICU senior and surgeon
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Important ***:
• Keep patients on GTN infusion for patients with LIMA graft (to reduce
vasospasm risk)
• The cardiac surgeons in our hospital has specifically requested that we
keep a low-dose dopamine infusion on for at least the first 24 hours
post-operatively, irrespective of a good BP or diuresis. You may have
to end up using an anti-hypertensive to maintain BP within agreed
parameters and fluids to maintain CVP
Intravenous fluids: 5% dextrose with KCl 20mmol in 500 ml solution at
1ml/kg/hr. If K+ level > 5.5 mmol/l omit KCl supplement
ABG on admission: if K+ level between 4.5-5.5 mmol/l repeat ABG Q2H for
24 hours. If K+ level < 4.5 or > 5.5mmol/l, repeat ABG until corrected.
Glucose control: follow glucose nomogram
If urine output < 1ml/kg/hr, consider frusemide especially in patients
receiving it preoperatively and if CVP/PCWP > 14mmHg with
good peripheral perfusion
Pacemaker at the bedside of all cardiac patients while in ICU
Identify if pacing wires present
If pacemaker from OT attached and operational, continue with
appropriate pacing.
If no pacemaker from OT or patient is NOT being paced by OT
pacemaker, replace OT pacemaker with ICU pacemaker
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Intensive Care Unit, Prince of Wales Hospital, Chinese University of Hong Kong
Respiratory Management
• Following surgery commence all patients on an ICU ventilator
• After the first ABG, adjust the FiO2 to maintain a PaO2 >10kPa
• Wean from ventilation according to past medical history, surgery
performed and current clinical status
• Extubation criteria:
Temperature > 360C
Awake, analgesed, able to protect airway with a good cough
Cardiovascularly stable - MAP >60mmHg, pH 7.35-7.45
Adequate gaseous exchange – PaO2 >10kPa on FiO2 0.4
Minimal bleeding – drain output <100ml/hour
• Respiratory failure post-op secondary to collapse/consolidation is
common. Ensure good analgesia and frequent, effective physiotherapy.
Management of Bleeding
• *** Call cardiac surgeon early whilst you are continuing with your
management
• Perform appropriate investigations: ACT, INR, APTT, platelet count
• Treat abnormalities of above:
Protamine 50mg if ACT >150 s
FFP if INR abnormal
If no response then platelet transfusion of 5 units, irrespective of platelet
count
• If on aprotinin, continue at 50ml/hr (500,000 units) until bleeding
<50ml/hr from pericardial drain
• If bleeding continues or is brisk, perform CXR (look for enlarging heart
shadow) and echocardiogram* to exclude tamponade and obtain early
review by cardiothoracic surgeons.
• * echocardiogram can be performed by some of our ICU doctors.
Otherwise get on-call cardiologist. Check with chief cardiac surgeon first
before you consult cardiologist.
• Ensure that bedside sternotomy set ready at all times
• Consider re-opening if:
bleeding >200ml/hr for 3-4 hours
bleeding >400ml/hr in 1 hour
total loss >1500-2000mls
Hypotension (SBP <100mmHg or MAP <60mmHg)
Gradual decline in BP
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Intensive Care Unit, Prince of Wales Hospital, Chinese University of Hong Kong
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Correct fluid/blood losses as appropriate using blood or colloid
Early ECG, Echo and inform cardiothoracic surgeons
Treat reversible causes – bleeding, pneumothorax, tamponade, kinked
graft, graft vasospasm
• Treat arrhythmia
• Inotropes
Dopamine/dolbutamine – mild hypotension
Adrenaline
Noradrenaline – severe resistant hypotension with low SVR
IABP
Sudden and severe hypotension
• Call chief cardiac surgeon and senior ICU staff immediately. Inform
theatre
• While routine resuscitation underway – exclude tension pneumothorax,
echocardiography, consider opening chest in ICU
Hypertension
• The MAP is to be kept quite strictly at about 60-80mmHg for the first 2436hours
• This may vary according to the patient’s preoperative blood pressure and
condition (e.g. carotid stenosis). Must discuss with cardiothoracic team if
the targets need to be adjusted
• Ensure adequate analgesia: give morphine if patient is in pain
• Titrate GTN infusion or Nitroprusside infusion to maintain MAP of 6080mmHg
• If hypertension persists – (please discuss with ICU senior and surgeon
first) β blocker: atenolol 1-2mg IV or esmolol 10-25mg IV (if no
contraindication and good LV). Must be used cautiously after valve
surgery.
Arrhythmias
• Treat electrolyte abnormalities, hypoxia, hypercarbia, tamponade,
hypotension
• Bradycardia – AV sequential pacing first if < 60 beats per minute
• Atrial fibrillation – if K+< 4 give potassium, if K+ >4.5 give amiodarone,
cardioversion (inform ICU senior and surgeon first)
• VPB – lignocaine – check K+ and Mg++
• Pulseless VT or VF – defibrillate (observe protocol for defibrillation, inform
ICU senior and surgeon)
• Note
o Defibrillation for monophasic defibrillators: 200J, 300J, 360J
o Defibrillation for biphasic defibrillators: 150J non-escalating
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Intensive Care Unit, Prince of Wales Hospital, Chinese University of Hong Kong
Anticoagulation
• Patients with saphenous vein grafts should receive aspirin 160mg oral
after 24 hours if not bleeding
• Commence patients with valve replacements on warfarin from the second
post-operative day if extubated (we very rarely have to prescribe as
majority of patients discharged by then. Dosing, best check with surgeon
first)
• Patients with a valve replacement ventilated >48hours may require
heparinisation
ST Segment Elevation (new! Pending approval from ICU director and
chief cardiac surgeon)
• All cardiac patients should have continuously ST segment monitoring
• Note pattern of ST elevation (site, up slopping etc)
• Check patient’s clinical status (e.g. check vitals, ask for chest pain, check
if patient cold and sweaty, check peripheral circulation and auscultate for
pericardial rub)
• Check preoperative ECG and compare
• Inform cardiac surgeon
• For patients with arterial grafts, continue GTN infusion.
Consider diltiazem if suspect graft vasospasm (discuss with ICU senior and
cardiothoracic surgeons first)
If a cardiac patient deteriorates acutely for whatever reason:
• Call cardiac surgeon (as well as chief) and ICU senior stat
• Immediate availability of sternotomy set, gowns, gloves, towels,
betadine
• Immediate availability of resuscitation trolley
• Inform OT control and request OT nurse for assisting surgeon
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