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Leanna R. Miller, RN, MN,CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP
Education Specialist
LRM Consulting
Nashville, TN
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.
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Report from Anesthesia
procedure performed
height/weight
infusions
pacing options
blood products given
events/concerns
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In the “Huddle”
details of surgical procedure
patient’s history
patient’s anatomy
BP, MAP, titration goals
reverse sedation/maintain sedation
airway difficulty
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
Postoperative Concerns
• Instability
– Hypotension vs. Hypertension
– goal range (upper and lower)
• Bleeding
– Cardiac Tamponade
• Arrhythmias
• Extubation
• Pain/Mobilization
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
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!
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
Instability
• Chest tube output monitoring:
– q15min X 4, q30min until CT output <
100cc/hr then q1h – keep midlevels/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
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
Instability
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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 preoperatively Ex: Aspirin, Plavix
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
• CBC
Screening
–  Hgb/Hct
–  platelets
• PT/PTT
• Bleeding Time
Symptom
INR
aPTT
Platelet #
Platelet
Function
History Diagnosis
Major/minor
bleeding
N
N

N
Massive
transfusion;
fluids
Dilutional
thrombocytopenia
Major/minor
bleeding
N
Prolonged
N
N
negative
Drug induced heparin
Major/minor
bleeding

N
N
n/a
Vitamin K
deficiency
Liver disease,
warfarin,
antibiotics
Major
bleeding
prolonged
prolonged

N
DIC
Postoperative Bleeding
• Vascular integrity
disruption
– reoperation
Medical Causes of Bleeding
• residual heparin effect
• platelet consumption (CPB)
• preoperative platelet inactivation
Medical Causes of Bleeding
• depletion of clotting factors
• preoperative coagulopathy
• fibrinolysis
• Thrombocytopenia
–  platelet destruction
• drug – induced
• DIC
• Thrombocytopenia
– Etiology
• abnormal distribution
or sequestration in
spleen
– portal hypertension
Disseminated Intravascular Coagulation
Definition
• serious bleeding
disorder
• thrombosis; then
hemorrhage
Etiology of DIC
• shock
• IIR
• cardiac tamponade
• infection
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Laboratory Findings
 platelets
 fibrinogen
 PT &/or PTT
 d - dimer or FSP
 ATIII
Management
• Treat underlying cause
– antimicrobials
– product replacement
– surgery - open chest
Management
• Stop Thrombosis
– IV heparin
– AT III
– plasmapheresis
Management
• Administer blood products
– pRBCs
– platelets
– FFP
– cryoprecipitate
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
Bleeding
• Possibly return trip to OR
• Worse case scenario – OPEN chest in unit
Postoperative Arrhythmias
• Atrial Fibrillation
– most common dysrhythmia in the
postoperative period
– incidence 30% to 50%
– consequences include:
• hemodynamic instability
• thromboembolism
• Predictors of Atrial Fibrillation post CABG
– advanced age,
– history of AF
– enlarged left atrial size
– history of CHF
– elevated BNP levels
• 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
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
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
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)
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
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
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
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
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
Pulmonary Problems
• Pulmonary Edema
– most common cause is pre-existing
LV dysfunction
– noncardiogenic – “pump lung”
• inflammatory process leading to
direct lung injury
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
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)
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
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)
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
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)
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
Neurologic Complications
• possible complications
– delirium
– transient or permanent cognitive
deficits
– seizures
– anterior spinal artery infarction
– transient focal cerebral ischemia
– stroke
Neurologic Complications
• Location of strokes
– cerebral hemispheres
– less common
• brainstem
• cerebellum
• deep white and gray matter
Neurologic Complications
• Mechanism of stroke in CABG
– embolization from atheromatous
plaque
– fat embolism
– air embolism
– atrial fibrillation
– hypotension
– intra-operative hypotension
Neurologic Complications
• Predictors of post – CABG stroke
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age
diabetes
hypertension
elevated serum creatinine
recent MI
low EF
atrial fibrillation
Neurologic Complications
• Predictors of post – CABG stroke
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on pump procedure
multiple blood transfusions
IABP
duration of bypass
emergency surgery
combined procedure
Postoperative Infections
• Common postoperative infections
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superficial sternal wound infections
deep sternal wound infections
donor site infections
pulmonary infections
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
Postoperative Infections
• Mediastinitis risk factors:
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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
Postoperative Infections
• Mediastinitis – clinical features
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fever
tachycardia
chest pain or sternal instability
purulent discharge from site
crepitus & edema of chest wall
Hamman’s sign
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
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
Case Study #1
• Patient’s Drips and Labs:
– Propofol 30 mcg/kg/min
– Norepinephrine @ 2mcg/min
– Amicar 1gm/hr
– Carrier fluids running at 150cc/hr
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?
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
Case Study #2
• Patient’s Drips:
– Levophed @ 15mcg/min
– Epinephrine @ 2mg/min
– Propofol @ 20 mcg/kg/min
• What interventions are needed?
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
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
IN CONCLUSION