Management-of-Cardiac-surgery-Patient

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Management of the Cardiac Surgical Patient Leanna R. Miller, RN, MN,CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

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Management of the Cardiac Surgical Patient Behavioral Objectives Identify common postoperative pulmonary complications. Describe common cardiac complications of CV surgery. 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 Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Management of the Cardiac Surgical Patient Assessing Labs assess K+ - replete according to protocol standing order – 2 gm MgSO 4 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

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Postoperative Concerns Instability Hypotension vs. Hypertension goal range (upper and lower) Bleeding Cardiac Tamponade Arrhythmias Extubation Pain/Mobilization Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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! Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Instability Chest tube output monitoring: q15min X 4, q30min until CT output < 100cc/hr then q1h – keep mid-levels/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 Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Instability 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 pre-operatively Ex: Aspirin, Plavix Management of the Cardiac Surgical Patient

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Coagulation Problems excessive bleeding usually occurs in the 1 st POD 5/100 require return to the OR can occur later with development of DIC or tamponade with epicardial wire removal Management of the Cardiac Surgical Patient

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Screening CBC  Hgb/Hct  platelets PT/PTT Bleeding Time Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Postoperative Bleeding Vascular integrity disruption reoperation Management of the Cardiac Surgical Patient

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Medical Causes of Bleeding residual heparin effect platelet consumption (CPB) preoperative platelet inactivation Management of the Cardiac Surgical Patient

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Medical Causes of Bleeding depletion of clotting factors preoperative coagulopathy fibrinolysis Management of the Cardiac Surgical Patient

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Thrombocytopenia  platelet destruction drug – induced DIC Management of the Cardiac Surgical Patient

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Thrombocytopenia Etiology abnormal distribution or sequestration in spleen portal hypertension Management of the Cardiac Surgical Patient

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Definition serious bleeding disorder thrombosis; then hemorrhage Disseminated Intravascular Coagulation Management of the Cardiac Surgical Patient

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Etiology of DIC shock IIR cardiac tamponade infection Management of the Cardiac Surgical Patient

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Laboratory Findings  platelets  fibrinogen  PT &/or PTT  d - dimer or FSP  ATIII Management of the Cardiac Surgical Patient

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Management Treat underlying cause antimicrobials product replacement surgery - open chest Management of the Cardiac Surgical Patient

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Management Stop Thrombosis IV heparin AT III plasmapheresis Management of the Cardiac Surgical Patient

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Management Administer blood products pRBCs platelets FFP cryoprecipitate Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Bleeding Possibly return trip to OR Worse case scenario – OPEN chest in unit Management of the Cardiac Surgical Patient

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Postoperative Arrhythmias Atrial Fibrillation most common dysrhythmia in the postoperative period incidence 30% to 50% consequences include: hemodynamic instability thromboembolism Management of the Cardiac Surgical Patient

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Predictors of Atrial Fibrillation post CABG advanced age, history of AF enlarged left atrial size history of CHF elevated BNP levels Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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 0 2 makes heart irritable) Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Pulmonary Problems pulmonary function 13% to 64% decrease in VC, FEV 1 , & FRC diaphragmatic dysfunction atelectasis chest wall instability hypoxemia is exacerbated usually lowest within 2 to 3 days postoperative Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Pulmonary Problems Pulmonary Edema most common cause is pre-existing LV dysfunction noncardiogenic – “pump lung” inflammatory process leading to direct lung injury Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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) Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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) Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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) Management of the Cardiac Surgical Patient

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Neurologic Complications Stroke most common neurologic complication of revascularization go undetected within the 1 st 24 hours incidence 2% to 9% most occur within the 1 st 48 hours postoperative Management of the Cardiac Surgical Patient

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Neurologic Complications possible complications delirium transient or permanent cognitive deficits seizures anterior spinal artery infarction transient focal cerebral ischemia stroke Management of the Cardiac Surgical Patient

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Neurologic Complications Location of strokes cerebral hemispheres less common brainstem cerebellum deep white and gray matter Management of the Cardiac Surgical Patient

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Neurologic Complications Mechanism of stroke in CABG embolization from atheromatous plaque fat embolism air embolism atrial fibrillation hypotension intra-operative hypotension Management of the Cardiac Surgical Patient

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Neurologic Complications Predictors of post – CABG stroke age diabetes hypertension elevated serum creatinine recent MI low EF atrial fibrillation Management of the Cardiac Surgical Patient

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Neurologic Complications Predictors of post – CABG stroke on pump procedure multiple blood transfusions IABP duration of bypass emergency surgery combined procedure Management of the Cardiac Surgical Patient

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Postoperative Infections Common postoperative infections superficial sternal wound infections deep sternal wound infections donor site infections pulmonary infections Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Postoperative Infections Mediastinitis risk factors: 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 Management of the Cardiac Surgical Patient

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Postoperative Infections Mediastinitis – clinical features fever tachycardia chest pain or sternal instability purulent discharge from site crepitus & edema of chest wall Hamman’s sign Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Case Study #1 Pt arrives from OR: VS’s: BP 130/70, HR 112, CVP = 4, 0 2 sat 98% Chest tube output: 200cc in 1 st 30 minutes Initial ABG results: PO 2 – 178 (60% FiO 2 ), pH 7.34, pCO 2 46, BE -2.2 Vent settings: TV 600, SIMV 12, PEEP 5, PS 5 Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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? Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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Case Study #2 Patient’s Drips: Levophed @ 15mcg/min Epinephrine @ 2mg/min Propofol @ 20 mcg/kg/min What interventions are needed? Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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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 Management of the Cardiac Surgical Patient

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IN CONCLUSION Management of the Cardiac Surgical Patient

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Management of the Cardiac Surgical Patient

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Management of the Cardiac Surgical Patient