Approach to the Post

Operative Patient
K E A LA C LA R K M D
P ROVIDE NCE S T. VINCENT, P ORT LAND OR
N OV ICK WOR LD C A RDIAC A LLI A NCE, M E M P HI S T N
Postoperative Cardiac Care
Postoperative care of cardiac patients requires a comprehensive and multidisciplinary approach
to critically ill patients with cardiac disease whose care requires a clear understanding of
cardiovascular physiology
Optimal postoperative care in the ICU requires
Accurate preoperative assessment of congenital heart disease and discussion of proposed repair.
Effective communication of accurate intraoperative findings, data and management
Meticulous anticipatory guidance
Postoperative Cardiac Care
When patients fail to progress along their predicted clinical course
Prompt hands on and continuous reassessment at the bedside is essential

Deviations from the predicted clinical course may necessitate urgent cardiac catheterization and
angiography for diagnostic and therapeutic purposes
Postoperative Cardiac Care: Preoperative
Assessment and Plan of Care
After diagnosis and stabilization of the patient there should be a multidisciplinary team meeting
to discuss
Accurate diagnosis with review of diagnostic modalities
Surgical plan
Intraoperative management by anesthesia and perfusion
Expected postoperative course

Cardiology Cardiothoracic Surgery Cardiac Anesthesia Cardiac ICU

Postoperative Cardiac Care: Preoperative
Assessment and Plan of Care
This may occur as either a scheduled, routine meeting (elective surgeries/cath procedures) or on
an as needed basis (emergency surgeries/cath procedures)
This allows for group discussion, education and preparation.
Postoperative Cardiac Care: Preoperative
Assessment and Plan of Care
Day of Surgery
ICU team discusses and prepares for post-operative patient
Expected monitoring lines, infusions, respiratory support etc
Completion of surgery: communication of OR course and expectations
Transition to ICU is initiated in OR
Postoperative Cardiac Care: Preoperative
Assessment and Plan of Care
ICU nurse transports bed to OR and helps with transition from OR to ICU cares
ICU nurse communicates with ICU team expectant management (infusions, ventilation issues etc)
ICU team prepares current and expected infusions prior to arrival of patient
Surgical team, anesthesia team, perfusion team and ICU nurse transport patient to ICU together.
Postoperative Cardiac Care: Preoperative
Assessment and Plan of Care
Issues in the OR related to ICU expectations
Surgery team:
Ease/difficulty of repair including approach and chest closure, postoperative drains, pacer wires, intracardiac lines
Unexpected findings, complications or events during operation
Blood loss
Anesthesia team:
Airway anatomy and Vascular access
Arrhythmias coming off pump
Inotroic/pressor/venodilator support
Last sedation and NMB given
Antibiotics
Cadiology
PostOp TEE, EP guidance, historical background
Perfusion team:
CBP time
Cross clamp time
MUF
Post CPB hematocrit
Postoperative Cardiac Care:
Communication
The ICU team assumes the postoperative management after a patient has been successfully
transitioned to the ICU environment.
This transition includes
Full monitoring on the ICU devices
Appropriate support of the respiratory system without manual ventilation
Medication infusions administered by the appropriate ICU equipment
A systematic and comprehensive surgical and anesthesia handoff is essential to optimal patient
management.
Postoperative Cardiac Care:
Communication
INSERT HANDOVER TOOL
Postoperative Cardiac Care:
Complete initial survey followed by regular focused exams with special attention to markers of
cardiac output and respiratory mechanics
Blood gas analysis
Serum electrolytes and glucose
CBC and coagulation profile
Serum lactate
CXR
EKG
Postoperative Cardiac Care:
Ensure all lines and lumens are patent
Confirm position of ETT, NG, drains
Check for patency of all drains, MT, CTs
Check pacer wire position, capture and function
Postoperative Cardiac Care: Monitoring
Establish an objective assessment of patients overall clinical status, predict potential adverse
events, guide proactive management
Level of monitoring is dictated by level of complexity of underlying CHD and repair as well as
hemodynamic and respiratory data.
All
Continuous ECG monitoring
Invasive or noninvasive blood pressure monitoring
Respiratory monitoring including pulse oximetry
UOP (with or without foley)
Postoperative Cardiac Care: Monitoring
Mechanical Ventilated patients
End-tidal carbon dioxide
Carbon dioxide elimination
Dead space ventilation
Respiratory compliance
Airway resistance
Postoperative Cardiac Care: Monitoring
Cerebral near-infrared spectroscopy
Trends in cerebral oximetry are a helpful marker
of alterations in cardiac output
Postoperative Cardiac Care: Monitoring
Central Venous Pressure Monitoring
Percutaneous central line or surgically placed
transthoracic line
RA pressure monitoring provides a continuous
assessment of filling pressures in hypotensive
patients and may suggest the need for fluid
resuscitation
Judicious Fluid resuscitation post cardiac
surgery/CPB
Elevated RA pressure may suggest tamponade,
arrhythmia, poor RV compliance or function or
acute pulmonary processes (PTX)
Postoperative Cardiac Care: Monitoring
Indirect assessment of cardiac output
Mixed venous saturation
AVDO2

LA and PA lines are rarely used in the modern era

LA lines can provide objective data in the management of patients with LV dysfunction, mitral valve
disease and or abnormalities in coronary artery perfusion
PA lines can provide useful information in patients with pulmonary hypertension
Intravascular Monitoring Catheters
Postoperative Cardiac Care: Monitoring
Low Cardiac Output Syndrome
Common after CPB (25%)
~12 hours after surgery
Risk is greatest in neonates undergoing complex surgeries
Tachycardia, poor peripheral perfusion
LCOS requires increased inotropic support and may cause cardiac arrest
Postoperative Cardiac Care:LCOS
Contributing factors
Hemodynamically significant residual lesions
Myocardial dysfunction probably resulting from prolonged cardioplegia
Myocardial ischemia
Reperfusion injury
Inflammatory response to CPB
Increased SVR, PVR, capillary leak and pulmonary dysfunction
Prolonged CPB time
Prolonged cross clamp time
Preoperative circulatory collapse
Preoperative ventricular dysfunction
Postoperative Cardiac Care:LCOS
LCOS
Focused physical exam and laboratory investigations (worsening acidosis and end organ function)
Echocardiography may be necessary to aid in discovering the cause of LCOS ie presence of an
unexpected murmur or ventricular dysfunction
Discovery of a residual lesion can be accurately made in the ICU but the overall contribution to a patients clinical deterioration may
be difficult to ascertain
2 main categories
Require surgical intervention
Amenable to medical intervention
Postoperative Cardiac Care:LCOS
LCOS
Medical therapy is geared toward the perceived cause but should always include
Adequate fluid resuscitation to maintain preload and systemic blood pressure
Appropriate use of inotropic agents to support myocardial contractility and afterload
Timely use of reducing agents to decrease ventricular work load, enhance cardiac output and improve perfusion
Milrinone and low dose epinephrine often used (prophylaxis)
Hypothermia 11111111111111
Open chest

In the absence of a surgical cause, if LCOS remains refractory to medical therapy then mechanical
support with ECMO should be considered.
Postoperative Cardiac Care:PHTN
Pulmonary Hypertension
Elevated PVR and resultant pulmonary artery hypertension is common post operative complication after
congenital heart surgery
Increased RV afterload and resultant RV dysfunction is a common cause of cardiac arrest in the
postoperative period.
CPB causes SIRS
Elevated IL-6, IL-10, TNF alpha, P-selectin and E-selectin, among others
Postoperative Cardiac Care:PHTN
Pulmonary Hypertension
Cardiac physiologies most at risk
Increased pressure load to the PA system (truncus, VSD, AV canal defect, Aortopulmonary window, PDA
Impaired egress of blood from the pulmonary artery tree (obstructed veins, MV stenosis, restrictive ASD in HLHS
Heart transplant patients with preexisting pulmonary hypertension.
Comorbid conditions
CDH
Genetic Disorders
Postoperative Cardiac Care:PHTN
Pulmonary Hypertensive Crisis
Acute RV failure
TR
Decreased CO
MI

Initial approach to PHC is prevention

Minimize noxious stimulation
Sedation with cares and suctioning
Avoid hypercarbia
Judicious use of supplemental oxygen

Emergency management
Sedation
Oxygen
Bicarbonate
Consider iNO
Minimize potential cardiopulmonary contributors (
Postoperative Cardiac Care: Tamponade
Cardiac tamponade
Postoperative Cardiac Care:Arrhythmia
Postoperative Arrhythmia
Reported in 15-50% of cases following CHD repair
Most arrhythmias seen are clinically unimportant
JET, EAT, rSVT, VT
Prolonged mechanical ventilation
Increased inotropic use
Prolonged ICU LOS
Increased risk of cardiac arrest
Decreased survival
Risk for arrhythmia increased with prolonged CPB and cross clamp times, use of deep hypothermic
circulatory arrest
Postoperative Cardiac Care:Arrhtymia
Wide complex tachycardia
VT rapid hemodynamic compromise; uncommon
SVT (aberrantly conducted)
Narrow complex tachycardia
Automatic
JET, EAT
Warm up and cool down phenomena
Catecholamine responsive
Do not respond to overdrive pacing
ECG with rhythm strip may be necessary to make diagnosis and in some cases atrial electrogram is necessary to id P waves.

Reentrant
Sudden onset, respond to pharmacologic agents (adenosine) or cardioversion
Overdrive pacing
Abrupt termination
Postoperative Cardiac Care:Arrhythmia
Prevention
Aggressive repletion of electrolytes
Correction of significant acid-base disturbances
Minimize catecholamine state
Avoid fever

Treatment
Stable or unstable?
rSVT, maneuvers, adenosine, beta blockers or sCardioversion
EAT: b-blockers,
JET: cooling to 36 degrees C, decrease catechol infusions, sedation, NMB (shivering causes an increase in
endogenous catechols)
Amiodarone (be wary of its dose related alpha blockade)
Postoperative Cardiac Care: Arrhythmia
Bradyarrhythmias
Sinus bradycardia (SSS): A pacing
Varying degrees of AV node block: AV pacing
Postoperative Cardiac Care: Respiratory
Management
PPV may have major influences on hemodynamics after CH surgery
Significantly impaired myocardial function
Pulmonary vascular disease
Passive pulmonary blood flow

Early extubation
Postoperative Cardiac Care:
FEN
Fluid restriction following CPB
Total continuous fluid restriction
Monitoring lines, carrier fluids, continuous infusions, large volume medications
Volume resuscitation
Fluid choice
Dose
Infusion site
Electrolyte replacement
K
Ca
Mg
Stress ulcer prophylaxis>
NPO until consistent cardiac output to gut established
Role of trophic feeds in maintaining gut health and preventing bacterial translocation
Feeding protocol
Create protocol

Add bullet points on feeds

Postoperative Cardiac Care:
Renal
Fluid Overload
how to avoid

Diuresis
when

ATN
RRT
Postoperative Cardiac Care:
Hemostasis
CT and MT output should equal less than 2cc/kg/hr
Medical bleeding
Replace PRBCs to achieve goal hematocrit
Frequent monitoring and replacement of coags
Replace platelets to goal levels (maybe above too)
Fibrinogen
Non surgical bleeding
Use of amicar
Surgical bleeding
Factor 7a, thrombin
Heparin infusion for shunt patency
Transfusion related risks
Postoperative Cardiac Care:ID
Postoperative antibiotics
Routine perioperative antibiotics
Chest tube prophylaxis
Open chest prophylaxis
Presence of postoperative SIRS, sepsis difficult to detect
Postoperative Cardiac Care: Endocrine
Relative adrenal insufficiency

Glycemic control
Postoperative Cardiac Care: Neurology
Adequate pain management
Sedation
NMB
Seizure management and investigation of post surgical neurologic changes
Postoperative Cardiac Care: Family
Centered care
Very stressful time for the family
Preparation of family members for special circumstances (ETT, NMB, lines, open chest)
Maintain a quiet low stimulous environment.