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REDUCING MORTALITY AND MORBIDITY IN CARDIAC SURGICAL PRACTICE STANDARDIZED BEST PRACTICES

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

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REDUCING MORTALITY AND MORBIDITY IN CARDIAC SURGICAL PRACTICE STANDARDIZED BEST PRACTICES

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  1. REDUCING MORTALITY AND MORBIDITY IN CARDIAC SURGICAL PRACTICE STANDARDIZED BEST PRACTICES SUMMARY OF RECOMMENDATIONS

  2. 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

  3. STANDARDIZED BEST PRACTICESOPTIMIZING NEUROLOGICAL OUTCOMES • Risk Stratification • Perfusion Practices • CNS Monitoring • Atheroma Management • Pharmacological Neuroprotection • Glucose Management

  4. ALGORITHM FOR NEUROLOGICAL RISK REDUCTION

  5. 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

  6. STANDARDIZED BEST PRACTICESOPTIMIZING RENAL OUTCOMES • Risk Stratification • Perfusion Practice • Pharmacologic Renal Preservation • Perioperative Treatment of Renal Failure

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. SIMPLIFIED INTRAOPERATIVE TRANSFUSION ALGORITHM Celite TEG w/wout Heparinase Platelet Count Fibrinogen Plt Count < 100K MA < 45 mm TEG R>2X hTEG R hTEG R >20 mm TEG LY30>7.5% Fib < 140mg/dl Protamine Platelets FFP EACA CRYO

  13. GUIDELINES FOR THE USE OF PLATELET INHIBITORS IN CARDIAC SURGERYGENERAL 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

  14. 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

  15. 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

  16. 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

  17. STANDARDIZED BEST PRACTICESPROMPT EXTUBATION PROTOCOL • Risk Stratification • Anesthetic Technique • ICU Sedation • ICU Pain Management • Ventilator Management Protocol

  18. CRITERIA FOR WEANING AND EARLY EXTUBATION

  19. Wean to CPAP Over 30 minutes Check ABG

  20. 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

  21. STANDARDIZED BEST PRACTICES MANGEMENT OF PERIOPERATIVE LV DYSFUNCTION • Risk Stratification • Monitoring • Goal Directed Hemodynamic Management • Pharmacologic Support • Surgical Approach • IABP • Assist Devices

  22. MANAGEMENT OF POST OPERATIVE LV DYSFUNCTION GENERAL PRINCIPLES

  23. 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 > 1.4 NISERITIDE YES NO NORMAL PVR/SVR Hx CHF/ Beta Blockers Increased PVR Low SVR hyperventilation Dopamine Epinephrine Norepinephrine YES NO RV Failure No RV Failure Dobutamine Milrinone Pulmonary Vasodilators Pulmonary Vasodilators NTG/SNP Milrinone Niseritide Alprostadol NO Milrinone Epinephrine Dobutamine Dopamine Milrinone Epinephrine Vasodilatory Shock NL CI Low SVR NL SVR Low C.I. IABP Milrinone PA BCP RVAD AVP VAD IABP

  24. RECOMMENDATIONS FOR MANAGEMENT OF PERIOPERATIVE LV DYSFUNCTIONHEMODYNAMIC 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

  25. STANDARDIZED BEST PRACTICESPERIOPERATIVE ATRIAL FIBRILLATION • Risk Factors • Antiarrhythmia Treatment • Perioperative Beta Blockade

  26. GENERAL ALGORITHM FOR MANAGEMENT OF POSTOPERATIVE ATRIAL FIBRILLATION NL EF LOW EF AMIODARONE

  27. UCSF PERIOPERATIVE BETA BLOCKADE PROTOCOL

  28. 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.

  29. PERIOPERATIVE GLYCEMIC CONTROL • Intraoperative Glucose Management • ICU Glucose Management

  30. RECOMMENDATIONS FOR GYCLEMIC CONTROL • Intraoperative management with insulin infusions to maintain blood glucose < 150 • ICU management by current established protocol

  31. 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

  32. 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

  33. 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

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