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Management of Cardiac Management of Cardiac Surgery Patients and role of Surgery Patients and role of
PA’sPA’s
Bharti Daswani MS,PA-CBharti Daswani MS,PA-C
Stanford University Medical CenterStanford University Medical Center
December 4, 2008December 4, 2008
A Day in the life of…A Day in the life of…
1. Rounds (vital signs, overnight 1. Rounds (vital signs, overnight events, order tests, events, order tests, medications, plan)medications, plan)
2. Progress Notes (S.O.A.P. format)2. Progress Notes (S.O.A.P. format)
3. OR (vein harvest, second assist, 3. OR (vein harvest, second assist, remove chest tubes, pacing remove chest tubes, pacing wires, CVP’s etc)wires, CVP’s etc)
A Day in the life of…..A Day in the life of…..
A Day in the life of…A Day in the life of…
4. Pre-op patients (H&P, admits)4. Pre-op patients (H&P, admits)
5. Discharge patients5. Discharge patients
6. Afternoon rounds6. Afternoon rounds
7. Sign-out to fellow, cross cover 7. Sign-out to fellow, cross cover PA,MDPA,MD
Surgical Progress NoteSurgical Progress Note
Typical SOAP formatTypical SOAP format ””S” (Subjective): S” (Subjective):
O/N events, pt complaintsO/N events, pt complaints ””O” (Objective): O” (Objective):
VS, Labs, I/O, Pain!, VS, Labs, I/O, Pain!, CXR/EKG/ECHO/CTA results, medCXR/EKG/ECHO/CTA results, med
””A”/”P” (Assessment/Plan): A”/”P” (Assessment/Plan): ex. S/P AVR POD #3-Stable, ex. S/P AVR POD #3-Stable, increase ambulation, etc…..increase ambulation, etc…..
The surgical process…..The surgical process…..
Admission (pre-op, peri-op, post-op Admission (pre-op, peri-op, post-op care)care)
Surgical Assessment and Surgical Assessment and PreparationPreparation
Common ComplicationsCommon Complications
Discharge (disposition, PT/OT, etc)Discharge (disposition, PT/OT, etc)
Admission ProcessAdmission Process
H&P, ConsentH&P, Consent
Vein harvest, first/second assist Vein harvest, first/second assist
ICU stayICU stay
Step-down unit / telemetry floor (D/C Step-down unit / telemetry floor (D/C drains, pacing wires, central lines)drains, pacing wires, central lines)
..
Wires are in pairs and can be connected into Medtronic pacemaker in 2 ways. Always check your connections
Temporary PacemakerTemporary Pacemaker
Surgical AssessmentSurgical Assessmentand Preparationand Preparation
H&P- thorough, H&P- thorough, Surgical historySurgical history Prior cardiac surgery! Prior cardiac surgery! Previous exposure to blood Previous exposure to blood
transfusion productstransfusion products Previous cardiac operative notePrevious cardiac operative note Dental history (w/ valve surgery)Dental history (w/ valve surgery)
Surgical Assessment and Surgical Assessment and Preparation cont.Preparation cont.
PhysicalPhysical Check BP in both arms- detect Check BP in both arms- detect
SC/innominate a. stenosisSC/innominate a. stenosis Presence of carotid bruits, esp bilat.- ?Presence of carotid bruits, esp bilat.- ?
CVA vs TIACVA vs TIA Pulmonary and cardiac examPulmonary and cardiac exam Peripheral exam with regards to pulses Peripheral exam with regards to pulses Inspect legs for saphenous vein Inspect legs for saphenous vein
LabsLabs CBC,CMP, UA, T&C 4-6U (for re-op may CBC,CMP, UA, T&C 4-6U (for re-op may
need more)need more) Check EKG, Cardiac Cath, CTA, MRA, CXRCheck EKG, Cardiac Cath, CTA, MRA, CXR
Surgical Assessment and Surgical Assessment and PreparationPreparation
Patient EducationPatient Education Hold ASA 7-10dHold ASA 7-10d Hold Coumadin 7-10dHold Coumadin 7-10d INR of <1.5 OK INR of <1.5 OK Special case: CoumadinSpecial case: Coumadin Antimicrobial shower/bath x2 Antimicrobial shower/bath x2
Endoscopic Vein Endoscopic Vein Harvest VideoHarvest Video
Common Common ComplicationsComplications
Mediastinal Bleeding and HemorrhageMediastinal Bleeding and Hemorrhage
ArrhythmiasArrhythmias
Other organ system complications Other organ system complications (Neurologic, Pulmonary,GI, Renal)(Neurologic, Pulmonary,GI, Renal)
Myocardial infarctionMyocardial infarction
InfectionInfection
Mediastinal BleedingMediastinal Bleeding
CPB and systemic heparinizationCPB and systemic heparinization significant disruption of coagulation significant disruption of coagulation systemsystem
Use of anticoagulants (ASA, ASA Use of anticoagulants (ASA, ASA containing compounds,NSAIDs), containing compounds,NSAIDs), altered platelet function, low platelet altered platelet function, low platelet count- count- most common causemost common cause!!
Activation of fibrinolysis and dilution Activation of fibrinolysis and dilution of clotting factors also causesof clotting factors also causes
Mediastinal BleedingMediastinal Bleeding
Labs: PT/INR, PTT, ACT, platelet countLabs: PT/INR, PTT, ACT, platelet count TreatmentTreatment
-Starts in OR- meticulous technique and -Starts in OR- meticulous technique and hemostatic controlhemostatic control
--Typical sites- Typical sites- sternal sternal periosteum,sternal notch, mammary bed, periosteum,sternal notch, mammary bed, mammary pedicle, superior mediastinal mammary pedicle, superior mediastinal fat pad, pericardium, diaphragmatic fat pad, pericardium, diaphragmatic surface, anastomoses, cannulation and surface, anastomoses, cannulation and vent sites, incision in heart and great vent sites, incision in heart and great vessels, vein, IMA branches.vessels, vein, IMA branches.
Mediastinal BleedingMediastinal Bleeding
Treatment cont.Treatment cont. Chest tubesChest tubes CT to suction at 20 cm HCT to suction at 20 cm H22OO Blood/blood products (RBC’s, FFP, Blood/blood products (RBC’s, FFP,
platelets)platelets) Severe bleeding- Protamine sulfate (25-Severe bleeding- Protamine sulfate (25-
50 mg IV)50 mg IV) Prolonged PT/PTT- 2-4 U FFPProlonged PT/PTT- 2-4 U FFP Platelets <100,000-platelets (1U/10kg Platelets <100,000-platelets (1U/10kg
body wt)body wt) Persistent bleeding- test for fibrinogen Persistent bleeding- test for fibrinogen
defect, ?cryoprecipitatedefect, ?cryoprecipitate
Mediastinal BleedingMediastinal Bleeding
Indications for surgical re-Indications for surgical re-exploration:exploration:
Bleeding rate >200 ml/hr x 4-6 hrsBleeding rate >200 ml/hr x 4-6 hrs >1500 ml of blood loss in 12h >1500 ml of blood loss in 12h
periodperiod Sudden increase (300-500 ml) in Sudden increase (300-500 ml) in
CT outputCT output Evidence of pericardial tamponadeEvidence of pericardial tamponade
ArrhythmiasArrhythmias
Common post-opCommon post-op 2 categories: ventricular (early, most 2 categories: ventricular (early, most
common) and supraventricular (24h-5d common) and supraventricular (24h-5d post-op)post-op)
Diagnosed via ECG strip or 12 Lead ECGDiagnosed via ECG strip or 12 Lead ECG Common causesCommon causes: : Ca, Ca, K, K, Mg Mg Other causes: acidosis, uremia, Other causes: acidosis, uremia,
hyperthyroidism, reversible surgical hyperthyroidism, reversible surgical trauma, hemorrhage, ischemia, edematrauma, hemorrhage, ischemia, edema
ArrhythmiasArrhythmias
Irreversible: conduction tissue Irreversible: conduction tissue traumatrauma
Suture placement/valve Suture placement/valve debridement debridement BBBBBB
Temporary epicardial pacing Temporary epicardial pacing usefuluseful
Sinus tachycardiaSinus tachycardia
CommonCommon Sinus tachycardiaSinus tachycardia
HR>100HR>100 Vagal blockade or beta-adrenergic Vagal blockade or beta-adrenergic
stimulationstimulation Appropriate response to underlying Appropriate response to underlying
stimuli (pain, fever, hypovolemia, stimuli (pain, fever, hypovolemia, hypoxia)hypoxia)
Sinus tachycardiaSinus tachycardia
May precipitate myocardial ischemiaMay precipitate myocardial ischemia Treatment: correct underlying cause- normalize volume Treatment: correct underlying cause- normalize volume
status, correct hypoxia, provide adequate pain controlstatus, correct hypoxia, provide adequate pain control Meds: Metoprolol 12.5-50 mg BID, 5 mg IV Q6Meds: Metoprolol 12.5-50 mg BID, 5 mg IV Q6
Sinus BradycardiaSinus Bradycardia
HR <60HR <60 Due to drugs (narcotics or BB) / intrinsic sinus node Due to drugs (narcotics or BB) / intrinsic sinus node
diseasedisease Treatment: temporary atrial pacing at 90-110 Treatment: temporary atrial pacing at 90-110
beats/minbeats/min Severe bradycardia-Atropine 0.5 mg -2.0 mg IV Severe bradycardia-Atropine 0.5 mg -2.0 mg IV ?placement of temp/PPM?placement of temp/PPM
Atrial Flutter/FibrillationAtrial Flutter/Fibrillation
MOST COMMON!!!!!!MOST COMMON!!!!!! Disorganized atrial Disorganized atrial
depolarizationsdepolarizations ““irregularly irregular” irregularly irregular”
rhythm- AF, “saw rhythm- AF, “saw tooth”- A. Fluttertooth”- A. Flutter
Urgency of therapy Urgency of therapy dictated by ventricular dictated by ventricular response rate, pt’s response rate, pt’s hemodynamic tolerancehemodynamic tolerance
Atrial Fibrillation/FlutterAtrial Fibrillation/Flutter
Treatment: Amiodarone bolus Treatment: Amiodarone bolus 150 mg IV, drip at 1 mg/min. Re-150 mg IV, drip at 1 mg/min. Re-bolus prnbolus prn
0.5 mg/min 6 hrs post conversion.0.5 mg/min 6 hrs post conversion. PO Amio 400 mg TID once in SR. PO Amio 400 mg TID once in SR.
Maintenance dose200 mg BID or Maintenance dose200 mg BID or QD. Taper dose over 30 days or 3 QD. Taper dose over 30 days or 3 monthsmonths
Atrial Fibrillation/FlutterAtrial Fibrillation/Flutter
Treatment cont.Treatment cont. Digoxin as an alternative Digoxin as an alternative
Loading dose- 0.5 mg IV, 0.25 mg IV Q4h x 2 Loading dose- 0.5 mg IV, 0.25 mg IV Q4h x 2 dosesdoses
Onset IV Digoxin 30 min, peak at 3 hrs. Onset IV Digoxin 30 min, peak at 3 hrs. Maintenance dose 0.125 mg-0.5 mg QPMMaintenance dose 0.125 mg-0.5 mg QPM Check serum K levels! Check serum K levels! Check serum Digoxin once steady state (4hrs Check serum Digoxin once steady state (4hrs
post IV, 6-7 hrs after PO)post IV, 6-7 hrs after PO) Great for poor LV fxn, asthmaGreat for poor LV fxn, asthma
Replete serum electrolytes (K, Mg, Ca)Replete serum electrolytes (K, Mg, Ca)
Atrial Fibrillation/FlutterAtrial Fibrillation/Flutter
Recent studies no difference Recent studies no difference between rate/rhythm between rate/rhythm
Anticoagulation key if no Anticoagulation key if no conversion in 48 hrs!conversion in 48 hrs!
Give Warfarin, goal INR 2.0-2.5Give Warfarin, goal INR 2.0-2.5 DC cardioversion, anticoagulate DC cardioversion, anticoagulate
priorprior
Premature Atrial Premature Atrial ContractionsContractions
Atrial impulse discharges prematurely!Atrial impulse discharges prematurely! P wave premature, may be buried in preceding T P wave premature, may be buried in preceding T
wavewave QRS usually normal and short pause before next QRS usually normal and short pause before next
beatbeat Common, may be precursor to AFCommon, may be precursor to AF Treatment: none, replete lytes, BB, Amio helps Treatment: none, replete lytes, BB, Amio helps
prevent progression of rhythm to AFprevent progression of rhythm to AF
Ventricular arrhythmiasVentricular arrhythmias
Primarily ectopicPrimarily ectopic Potential for fatal VT or VFPotential for fatal VT or VF May be improved post-op by May be improved post-op by
revascularization of ischemic revascularization of ischemic areas of the myocardiumareas of the myocardium
ABG’s, serum K, ECGABG’s, serum K, ECG
Premature Ventricular Premature Ventricular Contractions (PVCs)Contractions (PVCs)
Impulse occurs earlier than next normal Impulse occurs earlier than next normal sinus beatsinus beat
Wide QRS complex: much wider, taller and Wide QRS complex: much wider, taller and deeper than normal QRS (>0.12 sec)deeper than normal QRS (>0.12 sec)
Occurs after T wave of normal cycleOccurs after T wave of normal cycle Followed by compensatory pauseFollowed by compensatory pause
Premature Ventricular Premature Ventricular Contractions (PVCs)Contractions (PVCs)
Unifocal or multifocalUnifocal or multifocal Many unifocal PVCs Many unifocal PVCs poor oxygenation. poor oxygenation.
Treat if > Treat if > 66 PVCs per minute! PVCs per minute! Many multifocal PVCs Many multifocal PVCs severe cardiac severe cardiac
hypoxia! Dangerous, needs intervention! hypoxia! Dangerous, needs intervention!
Premature Ventricular Premature Ventricular Contractions (PVCs)Contractions (PVCs)
Treatment:Treatment: Replete serum K to 4.5 mEq/L. Give Replete serum K to 4.5 mEq/L. Give
IV or PO.IV or PO. Order K sliding scale!Order K sliding scale! Replete Magnesium sulfate for Replete Magnesium sulfate for
levels <2.0 mEq/L. Give 1-4 g IV levels <2.0 mEq/L. Give 1-4 g IV
Ventricular tachycardiaVentricular tachycardia
3 successive runs >100 bpm3 successive runs >100 bpm Wide bizarre QRS occurring regularlyWide bizarre QRS occurring regularly Precursor of VFPrecursor of VF Occurs in underlying structural heart Occurs in underlying structural heart
disease w/ damage to ventriclesdisease w/ damage to ventricles
Ventricular tachycardiaVentricular tachycardia
Sustained VT dangerous!Sustained VT dangerous! Treatment: initiate CPR, emergent Treatment: initiate CPR, emergent
defibrillation, antiarrhythmic drugs. defibrillation, antiarrhythmic drugs. CALL CODE TEAM!!!!! CALL CODE TEAM!!!!!
Consider ICD in pts with resolved VTConsider ICD in pts with resolved VT
Ventricular FibrillationVentricular Fibrillation
Dangerous, LETHAL if not treated emergently!!!!!Dangerous, LETHAL if not treated emergently!!!!! Call CODE team!Call CODE team! Start CPR ASAP!, Defibrillate!!!Start CPR ASAP!, Defibrillate!!! Antiarrhythmics to maintain normal rhythmAntiarrhythmics to maintain normal rhythm ICD if successful conversionICD if successful conversion
Other organ system Other organ system complicationscomplications
Neurologic DysfunctionNeurologic Dysfunction CVACVA if >24hr deficit persists and if >24hr deficit persists and
confirmed on Head CTconfirmed on Head CT Hypoperfusion or embolic event commonlyHypoperfusion or embolic event commonly Focal motor/sensory deficits or cognitive Focal motor/sensory deficits or cognitive
deficitsdeficits Prognosis variable (age, degree of initial Prognosis variable (age, degree of initial
impairment, mechanism of injury, area of impairment, mechanism of injury, area of brain involved). brain involved).
Obtain neuro consult, vigorous PT/OT Obtain neuro consult, vigorous PT/OT optimizes recoveryoptimizes recovery
Other organ system Other organ system complicationscomplications
Neurologic cont.Neurologic cont. SeizuresSeizures
Structural brain injury or metabolic Structural brain injury or metabolic encephalopathyencephalopathy
Look for contributing cause if Look for contributing cause if metabolic process if suspectedmetabolic process if suspected
EEG helpful, treat with phenytoin, EEG helpful, treat with phenytoin, BZD, call neurologist!BZD, call neurologist!
Other organ system Other organ system complicationscomplications
PulmonaryPulmonary
AtelectasisAtelectasis Most common Most common Resultant of mucous plugging and mechanical Resultant of mucous plugging and mechanical
ventilationventilation Tx- incentive spirometry, bronchodilators, Tx- incentive spirometry, bronchodilators,
pulmonary toiletpulmonary toilet
PleuralPleural effusion effusion Post-op bleed, interstitial edema, excess fluid Post-op bleed, interstitial edema, excess fluid
not absorbed by bodynot absorbed by body Tx- thoracentesis/chest tube for large Tx- thoracentesis/chest tube for large
effusions, diuretics (IV and PO)effusions, diuretics (IV and PO)
Other organ system Other organ system complicationscomplications
Pulmonary contPulmonary cont..PneumoniaPneumonia Prolonged ventilation, immunocompromised Prolonged ventilation, immunocompromised
patient, emergent operation, age, preexisting patient, emergent operation, age, preexisting lung diseaselung disease
Tx: antibiotics, good pulmonary hygiene, Tx: antibiotics, good pulmonary hygiene, mobilization of secretionsmobilization of secretions
Pulmonary EmbolismPulmonary Embolism Prolonged hospitalization/bed rest, recent groin Prolonged hospitalization/bed rest, recent groin
catherization, or hypercoagulable statecatherization, or hypercoagulable state Not seen much since use of heparin and Not seen much since use of heparin and
hemodilution during surgeryhemodilution during surgery Tx: Heparin/Warfarin, INR goal ~2.0, IVC filterTx: Heparin/Warfarin, INR goal ~2.0, IVC filter
Other organ system Other organ system complicationscomplications
GIGI
IleusIleus Due to anesthesia/narcotics commonlyDue to anesthesia/narcotics commonly Usually self limitingUsually self limiting Usually resolved with DC of narcotics, Usually resolved with DC of narcotics,
restriction of PO intake, IV fluids, and restriction of PO intake, IV fluids, and ambulationambulation
Severe cases may need gastric Severe cases may need gastric decompression with NG tube, or surgical decompression with NG tube, or surgical evaluation if SBO or peritonitis, initiate TPN evaluation if SBO or peritonitis, initiate TPN
Other organ system Other organ system complicationscomplications
RenalRenal 1-5% of patients 1-5% of patients Age, history of DM,prior renal insufficiency, CPBAge, history of DM,prior renal insufficiency, CPB Perioperative hypotension, atheroembolism, Perioperative hypotension, atheroembolism,
sepsis or nephrotoxic drugssepsis or nephrotoxic drugs Major mechanismsMajor mechanisms: prerenal azotemia, ATN. : prerenal azotemia, ATN. Others: acute interstitial nephritis, acute Others: acute interstitial nephritis, acute
glomerulonephritis, obstructive uropathyglomerulonephritis, obstructive uropathy Tx: high arterial perfusion pressure, renal dose Tx: high arterial perfusion pressure, renal dose
Dopamine (1-3 mcg) drip, free water hydration, Dopamine (1-3 mcg) drip, free water hydration, Lasix/ MannitolLasix/ Mannitol
Monitor I/O carefully, and check electrolytes, Monitor I/O carefully, and check electrolytes, esp. Kesp. K++!!!!
Temporary HD vs permanentTemporary HD vs permanent
Myocardial infarctionMyocardial infarction
1-2 % of patients1-2 % of patients Common causes: inadequate Common causes: inadequate
myocardial protection, incomplete myocardial protection, incomplete revascularization, premature graft revascularization, premature graft closureclosure
Sx: angina, diaphoresisSx: angina, diaphoresis ST elevation, high troponin and CK ST elevation, high troponin and CK Medical therapy (ASA,Plavix) when Medical therapy (ASA,Plavix) when
appropriate, ? angioplasty, ? CCB for appropriate, ? angioplasty, ? CCB for vasospasm of arterial graftsvasospasm of arterial grafts
Wound infectionWound infection
Fever, leukocytosis, wound drainage, Fever, leukocytosis, wound drainage, sternal instabilitysternal instability
Superficial subcutaneous infectionSuperficial subcutaneous infection isolated sternal wound infection (w/ isolated sternal wound infection (w/ no mediastinal involvement) no mediastinal involvement) severe severe cases mediastinitis with sepsiscases mediastinitis with sepsis
Tx: broad spectrum antibiotics, blood Tx: broad spectrum antibiotics, blood cultures, wound debridement, VAC, or cultures, wound debridement, VAC, or pectoral or omental muscle flapspectoral or omental muscle flaps
DM, bilateral IMA harvest, DM, bilateral IMA harvest, immunocompromised predisposedimmunocompromised predisposed
DischargeDischarge
Mobilize patients quickly (within 1-2 days)Mobilize patients quickly (within 1-2 days)
Ambulation most common form of endurance activityAmbulation most common form of endurance activity
Order PT/OT evaluation when ready Order PT/OT evaluation when ready
Cardiac rehab RN, dietician and case manager see Cardiac rehab RN, dietician and case manager see patients prior to discharge. patients prior to discharge.
Sternal precautions (no heavy lifting >5lbs x 6 Sternal precautions (no heavy lifting >5lbs x 6 weeks), heart pillowweeks), heart pillow
Case mgt: SNF v Acute Rehab, Home PT/OT, IV Case mgt: SNF v Acute Rehab, Home PT/OT, IV antibiotics, wound care, INR checksantibiotics, wound care, INR checks
QUESTIONS?????QUESTIONS?????
AppendixAppendix
Monitoring- ICU/ORMonitoring- ICU/OR
ECG leads- 3 electrode system, aVR- ECG leads- 3 electrode system, aVR- right arm, aVL- left arm, aVF- left legright arm, aVL- left arm, aVF- left leg
Arterial line/BP cuffArterial line/BP cuff Central venous pressure (CVP)- Central venous pressure (CVP)-
vasoactive drugs,venous access, vasoactive drugs,venous access, parenteral nutritionparenteral nutrition
Pulmonary artery pressure: RA Pulmonary artery pressure: RA pressure, PA pressure, PCW, CO, pressure, PA pressure, PCW, CO, blood temp.blood temp. assess volume status, ventricular fxn, assess volume status, ventricular fxn,
presence of pulm. HTNpresence of pulm. HTN
Monitoring cont.Monitoring cont.
Transesophageal Echo (TEE)- eval Transesophageal Echo (TEE)- eval LV fxn, WMA, native and prosthetic LV fxn, WMA, native and prosthetic valve dysfunction, aortic valve dysfunction, aortic aneurysms, masses, vegetations.aneurysms, masses, vegetations.
Pulse oximetry- measure Pulse oximetry- measure oxygenationoxygenation
Temperature- initiating/ Temperature- initiating/ terminating CPBterminating CPB
Urine output- adequate blood Urine output- adequate blood volume, CO, peripheral perfusionvolume, CO, peripheral perfusion
Common MedicationsCommon Medications
Beta Blockers- HR/BP controlBeta Blockers- HR/BP control-Metoprolol-Metoprolol-Esmolol- Type B dissections -Esmolol- Type B dissections
Antiarrhythmics- Afib,etcAntiarrhythmics- Afib,etc Amiodarone Amiodarone DigoxinDigoxin CCB CCB
ACE-Inhibitors- LV dysfunction, ventricular ACE-Inhibitors- LV dysfunction, ventricular remodeling, afterload reductionremodeling, afterload reduction LisinoprilLisinopril
Lipid lowering agents- post-CABG,HLDLipid lowering agents- post-CABG,HLD LipitorLipitor Zetia Zetia
Common MedicationsCommon Medications
Pain medicationsPain medications IV: fentanyl, Morphine, Dilaudid. Also use PCA IV: fentanyl, Morphine, Dilaudid. Also use PCA
versionsversions PO: Vicodin, Percocet, Oxycodone, Tylenol #3PO: Vicodin, Percocet, Oxycodone, Tylenol #3
DiureticsDiuretics-Lasix IV and PO, drip (ICU)-Lasix IV and PO, drip (ICU)-HCTZ-HCTZ-Spironolactone-Spironolactone
AnticoagulantsAnticoagulants-Heparin/Warfarin- AF, mechanical valves-Heparin/Warfarin- AF, mechanical valves-ASA- all patients unless contraindicated! -ASA- all patients unless contraindicated!