Leanna R. Miller, RN, MN,CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP Education Specialist

1. Management of the Cardiac Surgical Patient Leanna R. Miller, RN, MN,CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN

2. Management of the Cardiac Surgical Patient Behavioral Objectives • Identify common postoperative pulmonary complications. • Describe common cardiac complications of CV surgery. • Discuss treatment strategies for complications seen in the postoperative CV surgery patient.

3. Management of the Cardiac Surgical Patient Report from Anesthesia • procedure performed • height/weight • infusions • pacing options • blood products given • events/concerns

4. Management of the Cardiac Surgical Patient In the “Huddle” • details of surgical procedure • patient’s history • patient’s anatomy • BP, MAP, titration goals • reverse sedation/maintain sedation • airway difficulty

5. Management of the Cardiac Surgical Patient Assessing Labs • assess K+ - replete according to protocol • standing order – 2 gm MgSO4 • assess ABG • are we adequately ventilating patient • watch trends with lactate and Hgb • Glucose • according to SCIP criteria: BG on POD1 and POD2 must be < 200 mg/dL • should arrive from the OR on an insulin drip • titrate q1h per protocol

6. Postoperative Concerns Instability Hypotension vs. Hypertension goal range (upper and lower) Bleeding Cardiac Tamponade Arrhythmias Extubation Pain/Mobilization Management of the Cardiac Surgical Patient

7. Instability Patient can quickly shift from hypertension to hypotension Know what your goal for tissue perfusion is - as a general rule keep SBP < 120, currently moving towards using MAP as the goal pressure KNOW the patient’s goal for tissue perfusion Management of the Cardiac Surgical Patient

8. Instability Hypotension most likely “dry” due to fluid shifts that have occurred consider HCT - would PRBC’s be appropriate? What drips are infusing Are they warming up now and vasodilating? Use of NEOSYNEPHRINE sticks NO! Management of the Cardiac Surgical Patient

9. Instability Hypertension: Are they waking up? Are they experiencing pain? Which drips are running - should we wean vasopressors? GET HOB UP to at least 30 degrees Might need to start Nipridedrip Management of the Cardiac Surgical Patient

10. Instability Chest tube output monitoring: q15min X 4, q30min until CT output < 100cc/hr then q1h – keep mid-levels/clinicians informed of excessive CT output if output > 100cc in any of the 15 min intervals notify MD/clinician Order set: if  200ml/hr then order stat platelet, PT/PTT Management of the Cardiac Surgical Patient

11. Instability Chest tube output monitoring: high rate of bleeding is what your are concerned with more so than a specific amount be diligent in declotting chest tubes - no stripping, gentle pinching, twisting keep BP down(SBP 120 mmHg or less) - the higher the BP, the more pressure put on graft & they’ll bleed more Management of the Cardiac Surgical Patient

12. Instability Consider the use of PEEP on ventilator Assess the PT/PTT sent to lab If INR > 1.5, team will most likely order FFP Consider sending fibrinogen or platelet labs If bleeding is significant - prepare to give blood products: PRBC’s, FFP, platelets, cryoprecipitate Consider what medications patient was on pre-operatively Ex: Aspirin, Plavix Management of the Cardiac Surgical Patient

13. Management of the Cardiac Surgical Patient Coagulation Problems • excessive bleeding usually occurs in the 1st POD • 5/100 require return to the OR • can occur later with development of DIC or tamponade with epicardial wire removal

14. Management of the Cardiac Surgical Patient Screening • CBC •  Hgb/Hct •  platelets • PT/PTT • Bleeding Time

15. Management of the Cardiac Surgical Patient

16. Management of the Cardiac Surgical Patient Postoperative Bleeding • Vascular integrity disruption • reoperation

17. Management of the Cardiac Surgical Patient Medical Causes of Bleeding • residual heparin effect • platelet consumption (CPB) • preoperative platelet inactivation

18. Management of the Cardiac Surgical Patient Medical Causes of Bleeding • depletion of clotting factors • preoperative coagulopathy • fibrinolysis

19. Management of the Cardiac Surgical Patient • Thrombocytopenia •  platelet destruction • drug – induced • DIC

20. Management of the Cardiac Surgical Patient • Thrombocytopenia • Etiology • abnormal distribution or sequestration in spleen • portal hypertension

21. Management of the Cardiac Surgical Patient Disseminated Intravascular Coagulation Definition • serious bleeding disorder • thrombosis; then hemorrhage

22. Management of the Cardiac Surgical Patient Etiology of DIC • shock • IIR • cardiac tamponade • infection

23. Management of the Cardiac Surgical Patient Laboratory Findings •  platelets •  fibrinogen •  PT &/or PTT •  d - dimer or FSP •  ATIII

24. Management of the Cardiac Surgical Patient Management • Treat underlying cause • antimicrobials • product replacement • surgery - open chest

25. Management of the Cardiac Surgical Patient Management • Stop Thrombosis • IV heparin • AT III • plasmapheresis

26. Management of the Cardiac Surgical Patient Management • Administer blood products • pRBCs • platelets • FFP • cryoprecipitate

27. Bleeding Sudden decrease in CT output - be sure your tubes are not clotting, keep them in eyesight at all times. Need to be out on top of sheets/bair hugger Signs & Symptoms of cardiac tamponade: Beck’s triad: muffled heart sounds, distended neck veins, hypotension rule of 20’s: CVP > 20, SBP decreased by 20, HR increased by 20 equalization of cardiac pressures, narrowed pulse press, sudden cessation of CT drainage Management of the Cardiac Surgical Patient

28. Bleeding Possibly return trip to OR Worse case scenario – OPEN chest in unit Management of the Cardiac Surgical Patient

29. Management of the Cardiac Surgical Patient Postoperative Arrhythmias • Atrial Fibrillation • most common dysrhythmia in the postoperative period • incidence 30% to 50% • consequences include: • hemodynamic instability • thromboembolism

30. Management of the Cardiac Surgical Patient • Predictors of Atrial Fibrillation post CABG • advanced age, • history of AF • enlarged left atrial size • history of CHF • elevated BNP levels

31. Management of the Cardiac Surgical Patient • Prophylactic -blocker Use • 35 of 122 (28.6%) developed AF while on beta blocker whereas only 18 of 109 (16.5%) developed AF in the absence of prophylactic beta blockers. • predisposing effect was not significant with Multivariate analysis • based on this analysis, BB did not show protection against post CABG AF

32. Arrhythmias Consider electrolyte assessment VT/Vfib – SHOCK FIRST!!! Then CPR/ACLS treat it according to ACLS protocol, but look further because it’s not common in the post op setting Management of the Cardiac Surgical Patient

33. Arrhythmias Bradycardia/Asystole: use your pacing wires immediately - pace before CPR & drugs if possible. Emergency pacer kept in supply room Don’t hold back with CPR if pulseless Management of the Cardiac Surgical Patient

34. Arrhythmias Atrial Fibrillation/Aflutter: In immediate post-op period drug of choice will be Metoprolol or Amiodarone Peak incidence in post-op setting is Day 2 & 3 Are they mobilizing fluids now & need Lasix (right atrium distended) Consider ABG - check their oxygenation status(low 02 makes heart irritable) Management of the Cardiac Surgical Patient

35. Arrhythmias Atrial Fibrillation/Aflutter: Are they hypovolemic - what’s their HCT? Is their SVR too high - heart pushing against narrow opening makes it more irritable, might need to get SVR down with Nipride Valve patients have higher incidence Common time is when they’re getting ready to transfer to floor Management of the Cardiac Surgical Patient

36. Management of the Cardiac Surgical Patient Pulmonary Problems • pulmonary function • 13% to 64% decrease in VC, FEV1, & FRC • diaphragmatic dysfunction • atelectasis • chest wall instability • hypoxemia is exacerbated • usually lowest within 2 to 3 days postoperative

37. Management of the Cardiac Surgical Patient Pulmonary Problems • Atelectasis • 80% of patients post-CABG • risk factors for atelectasis • phrenic nerve palsy • intra-operative compression of lung • ischemia during CPB • endothelial damage • cardiomegaly/supine positioning

38. Management of the Cardiac Surgical Patient Pulmonary Problems • Diaphragmatic Dysfunction • decline in inspiratory/expiratory pressures as much as 17% to 47% • uncoordinated rib cage expansion • muscle strength improves over 6 weeks following surgery • diaphragmatic flutter

39. Management of the Cardiac Surgical Patient Pulmonary Problems • Pleural Effusions • develop in 50% to 89% of patients • less likely post valve surgery • usually left – sided (bilateral in 10%) • causes include: • hemorrhage or contusion • pulmonary emboli • postcardiotomy syndrome

40. Management of the Cardiac Surgical Patient Pulmonary Problems • Pulmonary Edema • most common cause is pre-existing LV dysfunction • noncardiogenic – “pump lung” • inflammatory process leading to direct lung injury

41. Extubation Goal is typically 4-6 hours from being “stable” Strike a balance between letting patient wake up and over-breathe vent and giving pain medicine Patient preferably needs to have paralytic reversed Management of the Cardiac Surgical Patient

42. Extubation Once to minimal vent settings (40% fio2, simv rate 4, ps 5, peep 5) perform 30 min cpap trial In some instances this can be skipped draw ABG can patient lift their head patient not bleeding Hemodynamically stable ectopy Notify clinician of all findings and obtain order for extubation (be sure to chart extubation in HED) Management of the Cardiac Surgical Patient

43. Post - Extubation Goal is to have patient sitting up within 1-2 hours after extubation Patient may begin PO intake 2-4 hours after extubation - begin with ice chips Be careful with carbonated drinks/juice Be mindful of diabetics ½ strength juice Management of the Cardiac Surgical Patient

44. Pain Management Contrary to popular belief, pain is not intense for all - some have very little, while others it is extremely difficult to manage Fentanyl: commonly used IV analgesic Short half-life Dilaudid: IV Longer half-life Percocet: PO pain med, better pain relief than Fentanyl (Percocet lasts longer) Management of the Cardiac Surgical Patient

45. Pain Management Toradol: for musculoskeletal pain, not routinely ordered, must have good kidney function & no bleeding Demerol – used for post-op shivering only Dilaudid – IV or SQ, watch your orders Morphine SQ Management of the Cardiac Surgical Patient

46. Mobilization Patient will still get up with pacemaker in place DO NOT AMBULATE WITH pacemaker Be diligent with coaching patient to use incentive spirometer ( keep it handy for them to reach) Management of the Cardiac Surgical Patient

47. Management of the Cardiac Surgical Patient Neurologic Complications • Stroke • most common neurologic complication of revascularization • go undetected within the 1st 24 hours • incidence 2% to 9% • most occur within the 1st 48 hours postoperative

48. Management of the Cardiac Surgical Patient Neurologic Complications • possible complications • delirium • transient or permanent cognitive deficits • seizures • anterior spinal artery infarction • transient focal cerebral ischemia • stroke

49. Management of the Cardiac Surgical Patient Neurologic Complications • Location of strokes • cerebral hemispheres • less common • brainstem • cerebellum • deep white and gray matter

50. Management of the Cardiac Surgical Patient Neurologic Complications • Mechanism of stroke in CABG • embolization from atheromatous plaque • fat embolism • air embolism • atrial fibrillation • hypotension • intra-operative hypotension