STS E Book - Postop Care of the Cardiac Surgery Patient Flashcards
What monitoring, labs, and imaging are needed immediately postop cardiac CPB surgery?
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.
When have pulm art catheters been found to be most useful (postop cardiac care)?
EF < 30%, R heart failure, pulm HTN, heart and/or lung txp.
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?
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.
What is an issue with reversing NM blockade early in postop cardiac surgery patients who required bypass?
If the patient is cold (< 35.5 degrees), it can lead to uncontrolled shivering.
What are sequelae and postop manifestations of aortic cannulation and clamping?
Atheroembolism and aortic dissection - stroke, splanchnic embolization, organ ischemia.
What are sequelae and postop manifestations of R atrial cannulation?
Atrial wall injury - bleeding arrhythmias.
What are sequelae and postop manifestations of femoral artery cannulation?
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.
What are sequelae and postop manifestations of high-dose heparin?
Coagulopathy and HIT.
What are sequelae and postop manifestations of crystalloid priming of CPB circuit?
Hemodilution - volume overload, dilutional anemia, dilutional coagulopathy.
What are sequelae and postop manifestations of the extracorporeal circuit in CPB?
Complement activation, fibrinolysis, systemic inflammation, microvascular hypoperfusion, microemboli - coagulopathy, vasoplegia, hypotension, AKI, mesenteric ischemia, stroke
How do the myocardium and ventricles function after cardiac operations?
Myocardial depression and ventricular dysfunction are the rules. Monitor and control output - rate, contractility, preload, afterload.
What are reasonable hemodynamic goals on CPB?
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.
What’s a goal for stroke volume variation postop cardiac surgery?
What patient population is this most validated for?
Can guide volume responsiveness.
Goal < 13%.
Can use FloTrac.
Most validated for pts w/ NSR on full mechanical ventilation.
When is the ideal moment for CVP measurement (postop cardiac surgery care)?
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).
On CVP tracing, when is the moment before ventricular contraction?
This occurs at the peak of the c-wave.
