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Postoperative Care of the Cardiac Surgical Patient

Postoperative Care of the Cardiac Surgical Patient. Timothy A. Denton, M.D. High Desert Heart Institute Victorville, CA. Outline. Overview of surgical patients Cardiac Surgery Knowledge base Intraop issues Postop Issues Systems of care. PTCA. 7.5%. 14%. CABG.

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Postoperative Care of the Cardiac Surgical Patient

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  1. Postoperative Care of theCardiac Surgical Patient Timothy A. Denton, M.D. High Desert Heart Institute Victorville, CA

  2. Outline • Overview of surgical patients • Cardiac Surgery Knowledge base • Intraop issues • Postop Issues • Systems of care

  3. PTCA 7.5% 14% CABG National Hospital Discharge Survey National Center for Health Statistics

  4. Cardiac Surgery Knowledge Base

  5. Outline • Pump -- Off-pump • Conduits • Low cardiac output • Hypotension • Bleeding • Hypertension • Altered mental status • Afib prophylaxis -- afib • Anticoagulation • DC protocol

  6. John Gibbon’s First Pump-Oxygenator 1935 - Cat bypass for 26 minutes 1953 - Cecelia Bavolek ASD repair

  7. Bubble Oxygenator + pump Disk Oxygenator

  8. Cobe Oxygenator Reservoir Oxygenator 6”

  9. Cardio-Pulmonary Bypass Bubble/debris filter B Membrane Oxygenator A B Shunt Heater/ Cooler Yankauer Coronary Reservoir Rotary Pump Drug infusion manifold

  10. Effects of Cardiopulmonary Bypass Systemic Inflammatory Response Syndrome (SIRS) • Cytokine activiation IL-1 Procalcitonin Heat shock protein 70 IL-6 C3a IL-8 C5a IL-18 TNFalpha • Microemboli -- intrinsic cascade • Hemolysis • Platelet activation (small aggregates only, not large) • Granulocyte activation • Monocyte activation • Ischemia/reperfusion injury • Operative trauma • Endotoxemia

  11. Effects of Cardiopulmonary Bypass Systemic Inflammatory Response Syndrome (SIRS) • Third-spacing (non-pulmonary) • Non-cardiogenic pulmonary edema • Fever • Vasodilatation • Coagulopathy • Hemolysis • “Post-pump syndrome” • Thrombocytopenia • Increased risk of infection

  12. Mechanical Aspects of Cardiopulmonary Bypass • Coronary suction • Cannulation of the aorta • Cannulation of the RA appendage • Handling of the heart • Aortic, Mitral, Tricuspid surgery

  13. Chemical Effects of Cardiac Surgery • Heparin • Anesthesia • Protamine Other Effects of Cardiopulmonary Bypass • Hypothermia

  14. Off-Pump Coronary Bypass Surgery

  15. Beating Heart Against Cardioplegic Arrest Study Angelini et al, Lancet 2002;359:1194

  16. Beating Heart Against Cardioplegic Arrest Study Angelini et al, Lancet 2002;359:1194

  17. Minimally Invasive Cardiac Surgery OPCAB Easier recovery? Fewer complications? Cheaper? Good anastomoses? Small Scar Cosmesis

  18. Rates of Graft Patency in Each Territory in the On-Pump and Off-Pump Groups Khan, N. E. et. al. N Engl J Med 2004;350:21-28

  19. Outline • Pump -- Off-pump • Conduits • Low cardiac output • Hypotension • Bleeding • Hypertension • Altered mental status • Afib prophylaxis -- afib • Anticoagulation • DC protocol

  20. Conduits • Saphenous vein • IMA • Radial • Artificial • Other lesser saphenous arm veins gastroepiploic inferior epigastric

  21. Patency of Various Conduits 2-3 weeks post-op Endo et al. Circulation 2001;104:2164

  22. Patency of Various Conduits

  23. RA Background • Long-term patency from 83-96% • Radial artery used in 50% of all CABG’s at CSMC • Anecdotal complaints of sensory abnormalities and rare complaints of hand weakness

  24. Radialmuscles -- Triceps brachii Anconeus Brachioradialis Extensor carpi radialis longus sensory -- none Superficial radial nervemuscles -- none sensory -- dorsal hand

  25. Path of Radial Nerve in the Forearm

  26. Superficial Radial Nerve

  27. Patient Population • 2/20/96 to 12/31/99 • All patients with radial arteries • Compared to patients without radial arteries over same time period.

  28. Results

  29. Results

  30. Problems • Usually, thumb strength complaints via Flexor pollicus longus MOTOR MEDIAN NERVE • Most palmar sensation abnormalities SENSORY MEDIAN NERVE

  31. Results

  32. Median Nerve

  33. Problems Data support median nerve damage • Palmar abnormalities • Thumb weakness • Statistical associations What is the mechanism of median damage?

  34. Vascular Supply of Median Nerve Type 1 - 70% Type 2 - 10% Type 3 - 20% Clin Orth and Rel Res 1973;97:144

  35. Summary • Clear evidence for radial nerve damage • Clear evidence for median nerve damage • Vascular disease contribution to damage

  36. Outline • Pump -- Off-pump • Conduits • Low cardiac output • Hypotension • Bleeding • Hypertension • Altered mental status • Afib prophylaxis -- afib • Anticoagulation • DC protocol

  37. PAD = 24 RA = 20 No Y descent What is this?

  38. Therapy for Tamponade Return mediastinum to atmospheric pressure

  39. Differential Diagnosis of Low Cardiac Output/Hypotension • Tamponade • Tamponade • Tamponade • Tamponade • Hypovolemia • LV dysfunction / infarction • Hemorrhage

  40. Chuttani et al. Am Heart J 1994;127:913 Entire Group Circumferencial Effusion Local Effusion

  41. Outline • Pump -- Off-pump • Conduits • Low cardiac output • Hypotension • Bleeding • Hypertension • Altered mental status • Afib prophylaxis -- afib • Anticoagulation • DC protocol

  42. Mechanical Coagulopathy + 2 SD’s

  43. Etiology • Mechanical • Coagulopathy Heparin Coumadin Antiplatelet agents Temperature Low platelet count (rare) Poor platelet function

  44. Therapy • Mechanical Return to surgery • Coagulopathy Correct PT (FFP 2 or more units) Correct PTT (Protamine 20-40 mg) Correct PFA (DDAVP 20-40 units) Correct Platelet count (platelets) Empiric therapy

  45. Outline • Pump -- Off-pump • Conduits • Low cardiac output • Hypotension • Bleeding • Hypertension • Altered mental status • Afib prophylaxis -- afib • Anticoagulation • DC protocol

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