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

ALGORITHM FOR NEUROLOGICAL RISK REDUCTION

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

CRITERIA FOR WEANING AND EARLY EXTUBATION

Wean to CPAP Over 30 minutes

Check ABG

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

MANAGEMENT OF POST OPERATIVE LV DYSFUNCTION

GENERAL PRINCIPLES

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

GENERAL ALGORITHM FOR MANAGEMENT OF POSTOPERATIVE ATRIAL FIBRILLATION

AMIODARONE

LOW EFNL EF

UCSF PERIOPERATIVE BETA BLOCKADE PROTOCOL

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.

PERIOPERATIVE GLYCEMIC CONTROL

• Intraoperative Glucose Management

• ICU Glucose Management

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