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REDUCING MORTALITY AND MORBIDITY IN CARDIAC SURGICAL PRACTICE
STANDARDIZED BEST PRACTICES
SUMMARY OF RECOMMENDATIONS
STANDARDIZED BEST PRACTICES CARDIAC SURGERY
• Prevention Stroke• Prevention Renal Failure/Insufficiency• Transfusion Practice• Prompt Extubation Protocol• Prevention/Treatment of LV failure• Perioperative Atrial Fibrillation• Perioperative Glucose Control• Cardiac Surgical Practice• Cardiothoracic Intensive Care: Operation and
Administration
STANDARDIZED BEST PRACTICESOPTIMIZING NEUROLOGICAL OUTCOMES
• Risk Stratification
• Perfusion Practices
• CNS Monitoring
• Atheroma Management
• Pharmacological Neuroprotection
• Glucose Management
RECOMMENDATIONS FOR NEUROLOGICAL RISK REDUCTION
• Routine use of carotid imaging in high risk patients• Routine use of full dose aprotinin• Routine use of intraoperative TEE and Epiaortic Scanning• Algorithm directed strategy for management atherosclerotic aorta• Selective use of OPCAB in high risk patient• Routine use of diffusion tip arterial cannula• For open procedures use of CO2 on the field• Avoidance of aortic cross clamp• High Flow-high pressure cardiopulmonary bypass• Hct on CPB > 25<30• Alpha Stat pH management• Avoid reinfusion of unprocessed cardiotomy blood• Maintenance of normal perioperative blood pressure• Avoidance of introperative and post operative hyperthermia• Maintenance of Blood glucose < 150• Prompt treatment of perioperative arrhythmias
STANDARDIZED BEST PRACTICESOPTIMIZING RENAL OUTCOMES
• Risk Stratification
• Perfusion Practice
• Pharmacologic Renal Preservation
• Perioperative Treatment of Renal Failure
RECOMMENDATIONS FOR PATIENTS AT RISK FOR PERIOPERATIVE RENAL FAILURE
• Avoidance of nephrotoxic drugs in the perioperative period (aminoglycosides, toradol, etc)
• Consideration for OPCAB in patients with severe atherosclerosis of aorta
• Avoidance of prolonged CPB• No evidence for the use of low dose dopamine as a
renoprotective agent• Avoidance of inotropes with alpha effects (high
dose dopamine, norepinephrine)• Avoidance of acidosis • Use of nesiritide in patients with low cardiac output
and /or renal insufficiency• Early treatment of LCOS by goal directed protocol
STANDARDIZED BEST PRACTICESTRANSFUSION PRACTICE
• Transfusion Practice
• POC Testing
• Heparin/Protamine Administration
• Pharmacologic Interventions– Antifibrinolytics– DDAVP
• Algorithm based Transfusion Practice
• Approach to Patients on GP IIb/IIIa agents
RECOMMENDATIONS FOR ALLOGENIC RBC TRANSFUSION IN CARDIAC SURGERY
• Preoperative Treatment of Anemia in Stable Cardiac Surgical Patients with HCT<35– EPO– Iron
• Lowest HCT on CPB – HCT > 22 men – HCT > 25 women
• Postoperatively in Patients with LV dysfunction, Acute MI ,High Risk CVA or who exhibit hemodynamic instability– HCT > 30– HCT > 33 not justified and may increase mortality
• Postoperatively in low risk patients without MI– HCT > 25 < 30
• Directed Efforts to minimize operative blood loss
Preautologous donation of PRBC has been found not to be cost effective or reduce the incidence of RBC Transfusions in cardiac surgery
BLOOD CONSERVATION MULTIMODALITY ALGORITHM FOR CARDIAC SURGERY
PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE
Yes EPO YES Aprotinin Minimize Cyrstal Inf No reinfusion CT Blood Pump Prime < 1000 Transfusion Algorithm
Heparin RAP Transfusion Trigger
ASA< 5days Ultrafiltration 1. HRP Hct > 30<34
HCT < 35 GP IIB/ IIIa Cell Saver Use 2. LRP Hct >24
Stroke Risk Optimal Surgical BP Control
Age > 65 Techn/Hemostasis PEEP < 10 Adeq Rewarming DDAVP CRF
No No Amicar HCT>25 on CPB Minimize Labs
RECOMMENDATIONS FOR PATIENT MANAGEMENT
• Heparin 4mg/kg or ACT > 480 on CPB• Quantitative Heparin Monitoring (HMS, Hepcon)• Avoid excessive use Protamine • Heparin bonded circuits high risk patients• Avoidance of infusion of large volume crystalloid intraoperatively• Use of Low pump primes• Routine use of albumen in pump prime• Use of centrifugal pump • HCT above 25 for women 22 for men on CPB• Moderate hypothermia• Avoid reinfusion of unprocessed cardiotomy blood• Full dose aprotinin on High risk patients/Redo and Valves• All other patients amicar• Routine use Hemofiltration• Routine use of Goal Directed Transfusion Algorithm
SIMPLIFIED INTRAOPERATIVE TRANSFUSION ALGORITHM
Platelet Count Celite TEG w/wout Heparinase Fibrinogen
TEG R>2X hTEG R Plt Count < 100K
MA < 45 mmhTEG R >20 mm TEG
LY30>7.5%Fib < 140mg/dl
Protamine Platelets FFP EACA CRYO
GUIDELINES FOR THE USE OF PLATELET INHIBITORS IN CARDIAC SURGERY
GENERAL RECOMMENDATIONS• Preoperative aspirin use is associated with reduced
mortality and does not increased post operative bleeding• GP IIB/IIIA inhibitors/ASA provides significant reduction
in acute ischemic events relative to conventional treatment in both patients undergoing PCI and in those with ACS
• Emergency CABG in patients receiving abciximab and clopidogrel is associated with increased risk of hemorrhage
• Emergency CABG in patients receiving tirofiban and eptifibatide is not associated with increased risk of hemmorrhage
RECOMMENDED STRATEGIES FOR MANAGEMENT OF POST OPERATIVE BLEEDING IN PATIENTS ON
ABCIXIMAB
• Delay surgery > 12 hours since last dose in the urgent but stable patient– In high risk PCI patients do not use abciximab– Delay in surgical intervention balanced against severity and
instability of CAD
• Ensure adequate heparinization– Full heparin dose 3 mg/kg– Titrate heparin to ACT > 480 or Heparin concentration > 2.7 U/cc– Full dose Aprotinin
• Hemoconcentrator (50kD) to eliminate abciximab during CPB
• Post CPB platelet transfusion based on algorithm
RECOMMENDED STRATEGIES FOR MANAGEMENT OF POST OPERATIVE BLEEDING IN PATIENTS ON
CLOPIDOGREL
• Delay surgery > 5 days in stable patients– Do not pre-load with clopidogrel before high risk PCI– PFA to assess platelet function < 5 days
• Ensure adequate heparinization– Full heparin dose 3 mg/kg– Titrate heparin to ACT > 480 or Heparin concentration
> 2.7 U/cc– Full dose Aprotinin
• Hemoconcentrator to eliminate clopidogrel during CPB
• Post CPB platelet transfusion based on algorithm
RECOMMENDED STRATEGIES FOR MANAGEMENT OF POST OPERATIVE BLEEDING IN PATIENTS ON
TIROFIBAN and EPTIFIBATIDE
• No delay in emergent/urgent CABG necessary– Preferred agents for patients likely to need CABG due
to short half life
• Ensure adequate heparinization– Full heparin dose 3 mg/kg– Titrate heparin to ACT > 480 or Heparin concentration
> 2.7 U/cc– Full dose Aprotinin
• Post CPB platelet transfusion based on algorithm
STANDARDIZED BEST PRACTICESPROMPT EXTUBATION PROTOCOL
• Risk Stratification
• Anesthetic Technique
• ICU Sedation
• ICU Pain Management
• Ventilator Management Protocol
RECOMMENDATIONS FOR FAST TRACK EXTUBATION AND ICU SEDATION
• Appropriate selection of patients for FTCA• Use of low dose narcotic anesthesia
– Fentanyl < 10 mcg/kg or sufenta < 2 mcg/kg– Midazolam < 5 mg – Background inhalational agents
• Use of simplified mechanical ventilation protocol• Use of dexmedetomidine on patients for FTCA• Use of propofol for non FTCA patients (>24 hrs intubation)• Multimodal approach to post operative pain management
– Narcotics– Acetaminophen– NSAIDS– Dexmedetomidine
STANDARDIZED BEST PRACTICES MANGEMENT OF PERIOPERATIVE LV
DYSFUNCTION
• Risk Stratification
• Monitoring
• Goal Directed Hemodynamic Management
• Pharmacologic Support
• Surgical Approach
• IABP
• Assist Devices
GENERAL GUIDELINES FOR HEMODYNAMIC MANAGEMENT
No Inotropes Indicated Unless
C.I. < 2.2 PAWP > 18 MAP < 50
And/or Signs of Inadequate Tissue Perfusion
SV02 < 70 Lactate > 3 Base Deficit > -3.0 UO < 50 cc/hr
Hx CHF And/Or Renal Dysfunction
Preop Serum Creatinine > 1.4NISERITIDE
NORMAL PVR/SVR
Hx CHF/ Beta Blockers
Milrinone
Epinephrine
Dobutamine
Dopamine
Milrinone
Epinephrine
YES NORV Failure No RV Failure
Low SVRIncreased PVR
IABP
VAD
Pulmonary Vasodilators
NTG/SNP
Milrinone
Niseritide
Alprostadol
NO
Dobutamine
Milrinone
Pulmonary Vasodilators
PA BCP
RVAD
Dopamine
Epinephrine
Norepinephrine
NL SVR
Low C.I.
Milrinone
IABP
Vasodilatory Shock
NL CI Low SVR
AVP
NO
YES
hyperventilation
RECOMMENDATIONS FOR MANAGEMENT OF PERIOPERATIVE LV DYSFUNCTION
HEMODYNAMIC MANAGEMENT
• Risk Stratification• Monitoring CVP Low Risk Patients• Monitoring PA CCO/Sv02 and TEE High Risk Patients• Prophylactic IABP High Risk Patients• Consideration For OPCAB• Limit CPB time (<180 minutes)• Combination Beta agonist/PDI • Nesiritide for patients with low EF and renal insufficiency
(Creat > 1.4)• Goal Directed Hemodynamic Management
STANDARDIZED BEST PRACTICESPERIOPERATIVE ATRIAL FIBRILLATION
• Risk Factors
• Antiarrhythmia Treatment
• Perioperative Beta Blockade
Recommendations• Postoperative AF should be aggressively treated.• Prophylactic beta blockade reduces postoperative AF by more
than 75% and should be administered in all patients without contraindications
• Amiodarone as prophylactic agent should be considered in the preoperative setting in high risk patients
• Unstable AF patients should be promptly cardioverted.• Ibutilide should be used in patients who need repeat cardio
versions• Amiodarone should be used in all low EF patients in
postoperative AF• All postoperative patients in AF for more than 48 hours should
be anticoagulated.• High risk patients in AF for more than 24 hours should be
anticoagulated.
RECOMMENDATIONS FOR GYCLEMIC CONTROL
• Intraoperative management with insulin infusions to maintain blood glucose < 150
• ICU management by current established protocol
STANDARDIZED BEST PRACTICESCARDIAC SURGICAL PRACTICE
• Timing of surgery after acute MI– CABG in the emergent situation– CABG in LVA– CABG in post MI VSD– CABG in post MI rupture
• Surgical approaches to mitral valve disease– Degenerative– Ischemic– rheumatic
• Considerations For AVR and Treatment of the Dilated Ascending Aorta
• Valve Considerations For Endocarditis• Perioperative Strategy For The High Risk patient
Emergency CABG
Cardiogenic shock complicates 7-10% of MI’s and is associated with a 70-80% mortality
Leading cause of death in pts. with AMI
CABG has extremely high and protracted periprocedural risk
RECOMMENDATIONS FOR EMERGENT CABG
• Unstable patients in the cardiac catheterization lab must be stabilized prior to transfer to surgery
– Intubation/ventilation
– IABP
– Perfusion catheters
– Pacemaker
– Cardiogenic drugs
• If patient does not respond but continues to deteriorate in spite of all supportive measures surgical risk is prohibitive
• Patients not candidates for surgery– Questionable reversible ischemia– Age > 75 with multiple comorbidities– CPR with pH < 7.1– No arterial pressure without IABP – No or minimal wall motion on TEE
Recommended