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Perioperative Care of the
Cardiac Surgery Patient
Lars Hegnell, MD
Michael Hutchens, MD, MA
Matthew Griffee, MD
Cardiac, Thoracic, and Surgical ICU,
Department of Anesthesiology and
Perioperative Medicine
Oregon Health & Science University,
™
Portland, Oregon
Learning Objectives
• Understand risk factors for perioperative morbidity and
mortality among adult cardiac surgery patients.
• Identify common perioperative complications
• Integrate scientific evidence and consensus guidelines
into strategies for risk reduction and for treating postoperative complications
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Slide 3
Goals of Preoperative Evaluation
• Identify post-operative risk for resource allocation
(e.g.,1:1 nursing assignment, IABP)
• Counsel patient and family about ICU environment and
expected course
• Modify risk factors for medical optimization (smoking,
lipid control, control of HTN)
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Slide 4
Risk Prediction ToolEUROSCORE
• European System for Cardiac Operative Risk Evaluation
• www.euroSCORE.org
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Slide 5
Euroscore Risk Calculation
• Patient Related Factors
– Age, gender, chronic disease (e.g., COPD, stroke)
• Cardiac Factors:
– 1. Unstable angina
– 2. Recent MI
– 3. Decreased LV function
– 4. Pulmonary Hyptertension
• Operative Factors: Emergency, complex, aortic surgery
Eur J Cardiothorac Surg 1999 Jun;15(6):816-22; discussion 822-3
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Slide 6
Pre-op cardiogenic shock
• Invasive monitoring and inotropic support
• Diuretics, in case of pulmonary edema
• Consider intubation and mech. ventilation
• Echo/cath lab determination of severity of LV dysfunction
• Multidisciplinary discussion of timing of surgery, potential
consults: heart failure/transplant, CT surgery,
interventional cardiology, referral center
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Slide 7
Pre-Op Cardiogenic Shock and
Very High Risk Patients
• Intra-Aortic Balloon Pump Pre-Op placement in high risk
patients (recent MI, EF<30%, severe CAD) associated
with reduced mortality (OR 0.41, 95% CI 0.2-0.8, p=0.01)
• 4% risk of complication; risks include aortic dissection,
limb or visceral ischemia
• Discuss delay of OR for optimization with team
Meta-analysis: Dyub AM, Whitlock RP, J Cardiac Surg 2008; 23: 79-86
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Slide 8
Multisystem Adverse Effects of
Cardiopulmonary Bypass
• BYPASS CAUSES SIRS, wide range of severity
• Coagulopathy, platelet dysfunction, fibrinolysis
• Vasodilatation resembling septic shock, with high levels
of nitric oxide
• Acute kidney injury (especially in case of chronic kidney
disease)
• Neurocognitive deficits
• Hypothermia
• Acute Lung Injury
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Slide 9
Approach to immediate post-op
cardiac surgery patient
• COMMUNICATION
• Discuss procedure and anticipated issues with surgeon and
anesthesiologist:
• Was pt completely revascularized?
• Evidence of post-bypass coagulopathy?
• TEE results: LV performance and volume status
• Is conduction system impaired?
• Did pt require cardioversion?
• Important bolus medications sometimes overlooked: Amiodarone,
milrinone, furosemide, mannitol, paralytic
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Slide 10
Approach to immediate post-op
cardiac surgery patient
• Checklist Items
• Temperature
• Baseline volume in chest
drain
• Vasoactive infusions
• Peripheral pulses,
especially for sites with
arterial lines
• Hemodynamics
• Initial coagulation panel
and other labs
• CXR: PA catheter, ETT,
gastric access
• ABG
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Slide 11
Hemodynamic Goals
• Cardiac Index >2.2 (convention, acceptable range for
individual pt based on organ function, pre-op status)
• SvO2 over 65.
• SvO2 expected to fall with extubation, mobilizaiton,
shivering, agitation
• Warm extremities and urine output >0.5ml/kg/hr
• Maintain MAP>60 but SBP<120 (to reduce risk of
hemorrhage from aortotomy sites
• Higher MAP necessary in older pts, HTN pts
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Slide 12
Early-Onset Hemodynamic
Instability
Common
Uncommon
HYPOVOLEMIA
Severe mitral regurgitation
Low systemic vascular
resistance
Other acute valvular pathology
LV systolic or diastolic
dysfunction
Dynamic LVOT obstruction
RV dysfunction/pulm HTN
Lung hyperinflation
Tamponade
Tension pneumothorax
Patient-Ventilator
Dysynchrony/Pain/Agitation
Massive hemothorax
Arrhythmia/Pacer
malfunction/poor timing
Cardiothoracic Critical Care, D. Sidebotham, Elsevier, 2007, chapter 20.
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Slide 13
Initial Resuscitation Strategy
based on most likely etiology
• Fluid challenge
• Pattern recognition of hemodynamic data (subsequent
slide)
• Examine chest tubes, CXR, serial hematocrit levels for
evidence of bleeding
• Work through components of cardiac output: Preload,
afterload, inotropic state, rhythm, return of blood to R
heart
• If persisent difficulty, obtain a stat echo
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Slide 14
Ongoing shock, Unclear cause
• Stepwise optimization of preload, inotropic support,
afterload, rate, electrolytes, analgesia, oxygenation.
• Obtain an echocardiogram (TEE if TTE inadequate)
• Obtain a CXR, eval for PTX, hemothorax, widening
mediastinum, increasing distance between swan in RA
and border of heart (signs of tamponade)
• Increase inotropic support; check ionized calcium
• Consider increasing pacer rate to 90-100 in case intrinsic
rate is lower
• Communicate with surgeon
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Slide 15
Case Study 1
The following are case studies that can be used for review
of this presentation.
Review Case Studies
Skip Case Studies
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Slide 16
65 YOM with low BP
after re-do CABG
• You are called to the bedside to assess decreasing
blood pressure despite increase in phenylephrine, 60
minutes after transfer from OR to ICU.
• Vital signs: pulse 110, sinus, BP 85/60, SpO2 98% on
0.5 FiO2, PEEP 5, Vt 8ml/kg
• Initial 30 min 300ml in chest tube, second half hour 20ml
in chest tube
• Breath sounds symmetric, pedal pulses weak but
palpable
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65 YOM after re-do CABG
• Bypass time 119 minutes
• Hemodynamics: CI 2.1, PAP 26/17, CVP 19
• Gtts: Phenylephrine 2mcg/kg/min, Vasopressin 1U/hr,
Epi 0.02mcg/kg/min
• Report from OR: good revascularization, LVH, looked dry
and received 3L crystalloid, 1 L albumin with transient
improvement in CI
• Coags: PTT slightly elevated, platelets 110,000,
fibrinogen 200, heparin level undetectable
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Re-do sternotomy, low BP
• 1. Does hemodynamic profile suggest vasoplegia
(distributive shock) as primary problem?
• 2. What further diagnostic maneuvers will you perform?
• 3. Will you change pressors? If so, how?
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Slide 19
Hemodynamic Patterns
Shock State
CVP
CO/CI
PAP
PAWP
Hypovolemia
↓
↓
↓
↓
Vasoplegia/
Distributive
↓ or normal
INCREASED
Low or normal
Low or normal
Chronic LV
dysfunction
↑ or normal
↓
↑ or normal
↑ or normal
Acute LV
systolic failure
Variable
↓
↑↑
↑↑
LV diastolic
dysfunction
Normal or ↑
Normal or ↓
↑
↑↑
RV Failure
↑↑
↓
Variable
Variable
Our patient has LOW cardiac output, not INCREASED.
Cardiothoracic Critical Care, D. Sidebotham, 2007 Elsevier
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Slide 20
Diagnostic Tests
• 12-lead EKG: no evidence of ischemia
• CXR- cardiomegaly, also seen post-operative
• Fluid challenge: transient increase in cardiac output,
then CI decreases to 1.8
• Chest tube output 5ml in next 40 minutes
• Pressor changes??
• Most logical step: increase Epi, repeat fluid challenge
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Slide 21
Conclusion
• Hct repeated. Unexplained drop from 27 to 19, Same on
repeat.
• Echocardiogram:
• LV hyperdynamic, RV collapses at end diastole, RA
collapses during systole. Pericardial space with anterior
fluid collection, distorting RA, RV shape.
• Diagnosis: Tamponade, occluded drains, obstructive and
hypvolemic shock. -> to OR
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Slide 22
Post-Bypass Hemorrhage: Tips
• 1. When examining a patient with suspected
coagulopathy/ongoing mediastinal bleeding, ensure
drains are patent; strip drains periodically
• 2. The most likely lesion of hemostasis after bypass is
platelet dysfunction. Platelets are the most rational
empiric treatment of post-bypass bleeding especially
after long bypass/complex cases
• 3. Rule out persistent heparin with a heparin level or
coag tests performed with heparinase.
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Slide 23
Peculiar Complications of
Bypass
• Air bubbles inadvertently left in the LV at end of bypass
preferentially travel to the right coronary (non-dependent
position); the emboli cause acute RV ischemia/acute RV
failure.
• Keys to treatment:
– Recognition of acute RV failure (Echo best test)
– Avoiding high airway pressure
– Avoiding hypercapnia, acidosis, and hypoxemia
– Milrinone is pressor of choice
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Circulation. 2008; 117:1717-1731
Special Problems After Bypass
• Profound vasodilatation causing distributive shock
refractory to vasoconstrictors, “vasoplegia”.
– Consider steroids in moderate doses* X 24-48 hours
– High-dose vasopressin X 12-24 hours
– Several reports and some animal models support
rescue therapy with methylene blue
• Ref: Eur J Cardiothorac Surg 2005 Nov; 28(5): 705-10
*240mg hycrocortisone/day after 100mg hydrocortisone bolus.
See Crit Care Med 2009;37:1685-90
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Slide 25
Glucose Control in Cardiac
Surgery
• Evidence stronger for intensive glucose control in
cardiac surgery compared to MICU population
• Aggressive control of blood glucose reduces sternal
wound rates
• Anticipate increased insulin needs with patients on
epinephrine
• Increased needs when steroids are used
• Concerning increased CVA risk with intensive insulin
therapy in one RCT of intensive control
Ann Int Med 2007 Feb 20; 146(4): 233-43
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Slide 26
Post-Op Atrial Fibrillation:
Prevention
• Increases morbidity, cost, length of stay
• Common, 30-50% of pts in post-op period
• Amiodarone effective in prevention, yet 25% of pts have
side effects, ranging from bradycardia to pulmonary or
hepatic toxicity that can be rapidly lethal
• ACC/AHA/ESC guideline: Beta blockers IA, amiodarone
IIA, sotalol IIB for prophylaxis
•
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Slide 27
J Int Care Med 24(1) pp. 18-25, 2009
Treatment of A-fib: Overview
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Slide 28
Atrial fibrillation: Unstable
Patient
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Slide 29
Case Study 2
The following are case studies that can be used for review
of this presentation.
Review Case Studies
Skip Case Studies
™
Slide 30
Tachycardia after AoVR for AS
• 77 YOF with a history of calcification of aortic valve and
slowly developing critical Aortic Stenosis undergoes
single vessel CABG and Aortic Valve Replacement.
• Salient facts include prominent LVH, including septal
hypertrophy and MR. There is systolic anterior motion of
the anterior mitral leaflet.
• After extubation, the pt coughs violently. Her BP then
drops to 77/40 with a pulse in 160s- the QRS compex is
narrow.
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Slide 31
Treatment Options?
• How will you treat the hypotension?
• Will you re-intubate the patient ASAP?
• Suppose cardioversion is successful in restoring sinus
rhythm.
• If the BP remains low after a fluid challenge, what is your
vasoactive medication of choice?
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Slide 32
Dynamic LV outflow tract
obstruction
• Patient is unstable and
immediate cardioversion is
indicated.
• Intubation and positive
pressure ventilation may
exacerbate the SAM/outflow
obstruction
• Phenylephrine and maintaining
LV filling addresses the
physiology: Maintain afterload,
avoid hyperdynamic LV
function, and avoid endsystolic obstruction of LVOT
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Slide 33
LV to LVOT Gradient
Copywright 2009
UpToDate; Version
17.1: Pathophysiology of
Obstructive
Hypertrophic
Cardio-myopathy,
Author McKenna
WJ
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Slide 34
Hypertrophic Cardiomyopathy
• Hypertrophied septum
approaches anterior
mitral valve at endsystole
• Gradient develops
between LV cavity and
LVOT
• Gradient worsens and
LVOT can become
obstructed with empty LV
and hyperdynamism of
LV (pain, stress,
epinephrine, dobutamine,
dopamine)
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Slide 35
Blood Conservation in Cardiac
Surgery
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Slide 36
Blood Conservation Key Points
relevant to ICU providers
• Class I recommendations:
• Preop identification of high-risk patients
• A “multimodal approach involving multiple stakeholders
and enforceable transfusion algorithms supplemented
with point-of-care testing”
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Slide 37
Example Algorithm for Blood
Conservation
• Agreement among ICU,
surgeons, anesthesiologists for
transfusion trigger Hct
• Treating coagulopathy based
on labs and targeting specific
hemostatic defect, when
possible
• Limiting phlebotomy and using
pediatric test tubes
• Uniform dosing of
aminocaproic acid
• Pocket cards with algorithm for
all providers
• Communication
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Slide 38
Heparin-Induced
Thrombocytopenia
• Life-threatening
prothrombotic disorder
after heparin exposure.
• 25-50% of cardiac
surgery pts develop
heparin-dependent
antibodies;
• 1-3% develop HIT
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Slide 39
HIT in Cardiac Surgery
• A non-heparin anticoagulant is indicated
• Options include argatroban and lepirudin
• Hematology consultation recommended for suspected
cases
• LMWH recommended for post-op prophylaxis over UFH,
lower-associated incidence of HIT
CHEST supplement 133(6), p. 384, 2008
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Slide 40
Self Assessment
• Ready to test your knowledge?
Take the Review
Skip the Review
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Slide 41
References
• 1. Nashef SA, Roques F, Hammill BG, Peterson ED, Michel P,
Grover FL, Wyse RK, Ferguson TB. Validation of European System
for Cardiac Operative Risk Evaluation (EuroSCORE) in North
American cardiac surgery. Eur J Cardiothorac Surg. 2002
Jul;22(1):101-5.
• 2. Roques F, Nashef SA, Michel P, Gauducheau E, de Vincentiis C,
Baudet E, Cortina J, David M, Faichney A, Gabrielle F, Gams E,
Harjula A, Jones MT, Pintor PP, Salamon R, Thulin L. Risk factors
and outcome in European cardiac surgery: analysis of the
EuroSCORE multinational database of 19030 patients. Eur J
Cardiothorac Surg. 1999 Jun;15(6):816-22; discussion 822-3.
• 3. Dyub AM, Whitlock RP, Abouzahr LL. Preoperative intra-aortic
balloon pump in patients undergoing coronary bypass grafting. J
Card Surg 2008; 23: 79-86.
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Slide 42
References
• 4. Cardiothoracic Critical Care. Sidebotham D, McKee A, Gillham M,
Levy JH. Elsevier, Philadelphia, PA, 2007.
• 5. Khoo WC, Lip GY. Acute management of atrial fibrillation. Chest
2009; 135: 849-859.
• 6. Society of Thoracic Surgeons Blood Conservation Guideline Task
Force. Perioperative blood transfusion and blood conservation in
cardiac surgery. Ann Thorac Surg 2007; 83: 527-86
• 7. Antithrombotic and Throbolytic Therapy: ACCP Evidence-Based
Clinical Practice Guidelines (8th ed). Chest 2008; 133(6): 381S453S.
• 8. Haddad F, Doyle R, Murphy DJ, Hunt SA. Right ventricular
function in cardiovascular disease. Circulation. 2008;117: 17171731.
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Slide 43
References
• 9. Weis F, Beiras-Fernandez A, Schelling G. Stress doses of
hydrocortisone in high-risk patients undergoing cardiac surgery. Crit
Care Med 2009; 37: 1685-1690.
• 10. Shanmugam G. Review- the role of methylene blue in
vasoplegic syndrome. Eur J Cardiothorac Surg 2005 Nov; 28(5):
705-10
• 11. Gandhi GY, Nuttall GA, Abel MD. Intensive intraoperative insulin
therapy versus conventional glucose management in cardiac
surgery. Ann Int Med 2007 Feb 20; 146(4): 233-43
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Slide 44