STS E Book - Postop Care of the Cardiac Surgery Patient Flashcards

1
Q

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

A

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.

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2
Q

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

A

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

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3
Q

Vent mgmt postop cardiac CPB surgery.

When should they be extubated?
What complications should you watch for?
Vent settings?
How do you know when you can extubate?

A

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.

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4
Q

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

A

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

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5
Q

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

A

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

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6
Q

What are sequelae and postop manifestations of R atrial cannulation?

A

Atrial wall injury - bleeding arrhythmias.

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7
Q

What are sequelae and postop manifestations of femoral artery cannulation?

A

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.

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8
Q

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

A

Coagulopathy and HIT.

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9
Q

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

A

Hemodilution - volume overload, dilutional anemia, dilutional coagulopathy.

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10
Q

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

A

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

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11
Q

How do the myocardium and ventricles function after cardiac operations?

A

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

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12
Q

What are reasonable hemodynamic goals on CPB?

A

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.

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13
Q

What’s a goal for stroke volume variation postop cardiac surgery?
What patient population is this most validated for?

A

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

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14
Q

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

A

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).

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15
Q

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

A

This occurs at the peak of the c-wave.

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16
Q

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

A

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.

17
Q

What labs values can predict poor postcardiac surgical outcomes?

A

Lactate >3.