10 Questions must be answered i n Cardiac Surgical ICU

1. 10 Questions must be answered in Cardiac Surgical ICU Dr. Saffarian

2. Question 1 • Which factors must be checked when patients transferred from the operating room to the cardiac surgical ICU? Dr. Saffarian

3. The patients is being well ventilated by: • Observing chest movement • Auscultating bilateral breath sounds Dr. Saffarian

4. The ECG tracing demonstrates satisfactory rate and rhythm on the transport and then the bedside monitor. Dr. Saffarian

5. The blood pressure is adequate on the portable monitor and remains so after the arterial line is transduced and calibrated on the bedside monitor Dr. Saffarian

6. Question 2 • Which factors must be monitored in the ICU? Dr. Saffarian

7. 1. ECG display and ECG 12-leads for detecting : • Rate • Rhythm • ST analysis Dr. Saffarian

8. 2. Endotracheal tubes: • Confirmation of bilateral breath sounds and chest movement • Rechecking of the ventilator settings • Assessment of ABGs every 4hrs or after every major ventilator change • Very gentle suctioning of tracheal tube every few hours. Dr. Saffarian

9. 3. Arterial lines for: • Monitoring of blood pressure • Obtaining of ABG Dr. Saffarian

10. Point Radial arterial line pressure measurements may not reflect the central aortic pressure when peripheral vasoconstriction is marked. In this situations, brachial or femoral arterial catheters provide more accurate measurement. Dr. Saffarian

11. Point Arterial lines should be connected to continuous heparin flushes to improve patency rates and minimize thrombus formation. Dr. Saffarian

12. Point Maintaining a radial arterial line for more than 3 days is associated with an increased risk of vessel thrombosis and line sepsis. Dr. Saffarian

13. Point Removal is indicated urgently if hand ischemia develops. Dr. Saffarian

14. 4. Swan-Ganz pulmonary artery (PA) catheter: • Measuring LV filling pressure • Obtaining mixed venous oxygen saturation • Determining thermodilution cardiac output Dr. Saffarian

15. 5. Central venous catheter (CVP): • Measuring RV filling pressure • Estimating of LV filling pressure in the absence of RV failure or mitral stenosis. • Determining of volume status Dr. Saffarian

16. 6. Chest tube: • In mediastinum and into the pleural spaces if they are entered during surgery. • Drainage should be recorded hourly or more frequently if there is evidence of significant bleeding. • Chest tubes are connected to a drainage system o which 20 cm H2O suction is applied. Dr. Saffarian

17. Point Suctioning of clotted chest tubes with endotracheal suction catheters should be discouraged because it may introduce infection. Dr. Saffarian

18. Point When pleural tubes were placed, intrapleural pressure became equal to atmospheric pressure therefore pleural tubes must be removed in full inspiration because of minimal distance between viseral & pariental surface of pleura at this stage. Dr. Saffarian

19. Question 3 • Guideline for removal of lines and tubes in ICU. Dr. Saffarian

20. The Swan-Ganz catheter should be removed when inotropic support and vasodilators are no longer necessary. Dr. Saffarian

21. The CVP catheter should be removed when hemodynamic and volume status were stable. Dr. Saffarian

22. Arterial line should be removed after a stable postextubation blood gas has been obtained. Dr. Saffarian

23. The urinary catheter can be left in place if the patient is undergoing vigorous diuresis or has an increased risk of urinary retention. It should otherwise be removed once the patient is mobilized out of bed, usually on the second postoperative day. Dr. Saffarian

24. Chest tubes should be removed when the total drainage is < 100cc for 8hrs. Mediastinal tubes should always be removed off suction because graft avulsion has been know to occur if suction is maintained. Dr. Saffarian

25. A CXR is not essential after mediastinal tube removal but should be performed after removal of pleural chest tubes to rule out a pneumothorax. Dr. Saffarian

26. Question 4 • Etiology of mediastinal bleeding. Dr. Saffarian

27. 1. Surgical bleeding: • Suture lines, soft tissues, sternum • Raw surface caused by previous surgery, pericarditis or radiation therapy. Dr. Saffarian

28. 2. Anticoagulant effect: • Residual heparin effect • Quantitative platelet defects (heparin, quinidine, antibiotics, hemodilution, protamine) • Qualitative platelet defects ( ASA, uremia, CPB) • Depletion of coagulation factors • Fibrinolysis • Pre-existing coagulation abnormalities Dr. Saffarian

29. Question 5 • Preventilation of perioperative blood loss Dr. Saffarian

30. Warfarin should be stopped about 4 days before surgery to allow for resynthesis of Vit-K dependent clotting factors. ASA should be stopped 7 days before surgery. BT is usually normal with PLT counts as low as 70,000 and also in patients taking ASA. Dr. Saffarian

31. Heparin induced thrombocytopenia, may develop in patients receiving IV heparin for several days before surgery . Dr. Saffarian

32. Surgery should be delayed at least 24 hrs, in patients receiving thrombolytic therapy. Dr. Saffarian

33. Pre-operative dipyridamole 100mg qid leading to improved platelet function after CABG. Aprotinin is a serine protease inhibitor that prevent bleeding. It has been associated with an increased risk of graft thrombosis. Tranexamic acid is a potent inhibitor of plasminogen. Dr. Saffarian

34. Question 6 • Management of postoperative mediastinal bleeding. Dr. Saffarian

35. Ensure that chest tubes are patent Warm patient to normothermia Control hypertension and shivering PEEP in 2.5-5 cm H2O increments Check results of coagulation studies Dr. Saffarian

36. Protamine 25mg IV for two doses Desmopressin (DDAVP) 0.3 g/kg IV over 20 minute Packed cell if Hct< 28% PLT, 1 unit/10 kg Dr. Saffarian

37. FFP, 2-4 units Cryoprecipitate, 1 u/10kg Avoid hetastarch and 5% Albumin Epsilon-aminocaproic acid (EACA) if fibrinolysis is confi….. Dr. Saffarian

38. Question 7 • Diagnosis of cardiac tamponade Dr. Saffarian

39. Elevated central Venous pressure Decreased blood pressure Reflex tachycardia Shortness of breath Wide mediastinom Occasionally decreased mediastinal tube drainage Dr. Saffarian

40. Treatment of cardiac tamponade Volume expansion Control of mediastinal bleeding Pericardial drainage Dr. Saffarian

41. Question 8 • Post operative fever Dr. Saffarian

42. Fever is very common during the first 48-72 hrs and is usually caused by atelectasis from splinting and poor respiratory effect. Dr. Saffarian

43. Etiology of fever after the first 72 hrs Atelectasis or pnemonia Urinary tract infections Sternal or leg wound infections Post pericardiatomy syndrome Drug fever Catheter sepsis Endocarditis Intra abdominal process DVT or pulmonary emboli Dr. Saffarian

44. Question 9 • ECG changes after CABG Dr. Saffarian

45. These changes are nonspecific Convex ST elevation revealed pericardial irritation Concave ST elevations associated with significant rise of CPK-MB and traponins revealed postoperative MI Dr. Saffarian

46. New Q wave without rise of cardiac enzymes just revealed myocardial irritation or cardiac rotation. Nonspecific T wave changes are not important. Dr. Saffarian

47. New LBBB associated with rise of cardiac enzyme may be a sign of MI. Inflammation of bundle branch can lead to different types of bundle branch block Dr. Saffarian

48. Question 10 • Fluid administration in early post operation period Dr. Saffarian

49. Most patients return from the operating room about 5-10 kg above their pre-operative weight because of interaoperative fluid administration this represents a state of both total body sodium and water overload Dr. Saffarian

50. In general, DS/0.2% normal saline is given at a maintenance rate of 50cc/hr on arrival in the ICU to minimize an additional sodium load at a time when the kidneys have a tendency to retain sodium Dr. Saffarian