Postop Care of the Cardiac Surgery Patient

Question 1

What monitoring, labs, and imaging are needed immediately postop cardiac CPB surgery?

Answer 1

Continuous ECG, pulse ox, art line.
12 lead ECG w/ pacemaker off (new q-waves are assd w/ 5-yr cardiac mortality).
CXR (confirm ETT, CVL, pulm art cath, circ support position).
CTbs to suction.
ABG, CBC, coags, lytes. +/- lactate and LFTs.
HoB 30 degrees.

Question 2

When have pulm art catheters been found to be most useful (postop cardiac care)?

Answer 2

EF < 30%, R heart failure, pulm HTN, heart and/or lung txp.

Question 3

Vent mgmt postop cardiac CPB surgery?

Answer 3

Extubation within 6 hrs.
Watch for restrictive physiology, pulm edema, poor lung compliance, atelectasis. Phrenic or RLN injury.
Start at 100%, PEEP 5, 14 rate w/ volume 8 ml/kg of predicted bw. Adjust w/ initial ABG.
Pressure support seems to have fewer failed extubations w/ 30 min SBT.
RSBI <80.

Question 4

What is an issue with reversing NM blockade early in postop cardiac surgery patients who required bypass?

Answer 4

If the patient is cold (< 35.5 degrees), it can lead to uncontrolled shivering.

Question 5

What are sequelae and postop manifestations of aortic cannulation and clamping?

Answer 5

Atheroembolism and aortic dissection - stroke, splanchnic embolization, organ ischemia.

Question 6

What are sequelae and postop manifestations of R atrial cannulation?

Answer 6

Atrial wall injury - bleeding arrhythmias.

Question 7

What are sequelae and postop manifestations of femoral artery cannulation?

Answer 7

Distal leg ischemia, vascular trauma, retrograde aortic perfusion - muscle injury and necrosis, compartment syndrome, hematoma, need for vascular repair, lymphocele, retrograde embolism, cerebral hypoxemia, L ventricular distention.

Question 8

What are sequelae and postop manifestations of high-dose heparin?

Answer 8

Coagulopathy and HIT.

Question 9

What are sequelae and postop manifestations of crystalloid priming of CPB circuit?

Answer 9

Hemodilution - volume overload, dilutional anemia, dilutional coagulopathy.

Question 10

What are sequelae and postop manifestations of the extracorporeal circuit in CPB?

Answer 10

Complement activation, fibrinolysis, systemic inflammation, microvascular hypoperfusion, microemboli - coagulopathy, vasoplegia, hypotension, AKI, mesenteric ischemia, stroke

Question 11

How do the myocardium and ventricles function after cardiac operations?

Answer 11

Myocardial depression and ventricular dysfunction are the rules. Monitor and control output - rate, contractility, preload, afterload.

Question 12

What are reasonable hemodynamic goals on CPB?

Answer 12

MAP 60-90.
Adjust higher for patients with HTN, CKD, older age, stroke.
Adjust lower in pts w/ poor ventricular function, mitral repair, and bleeding.

Question 13

What’s a goal for stroke volume variation postop cardiac surgery?

Answer 13

Can guide volume responsiveness. Goal < 13%. Can use FloTrac. Most validated for pts w/ NSR on full mechanical ventilation.

Question 14

When is the ideal moment for CVP measurement (postop cardiac surgery care)?

Answer 14

End expiration (when pleural P = atm P) and right before ventricular contraction (correlates most closely w/ end diastolic pressure and preload - the target of estimation).

Question 15

On CVP tracing, when is the moment before ventricular contraction?

Answer 15

This occurs at the peak of the c-wave.

Question 16

What is a physical exam maneuver to test for volume responsiveness in hemodynamics?

Answer 16

Passive leg raise. Look for changes in arterial blood flow and pulse pressure, which correlate w/ fluid challenge.
Take a patient from a semi-recumbent position at 45 degrees, then shift the bed so legs are up at 45 degrees and the upper body is recumbent.

Question 17

What labs values can predict poor postcardiac surgical outcomes?

Answer 17

Lactate >3.