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Management of Cardiac Surgery Patients and role of PA's

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    • 1. Management of Cardiac Surgery Patients and role of PA’s Bharti Daswani MS,PA-C Stanford University Medical Center December 4, 2008
    • 2. A Day in the life of…
      • 1. Rounds (vital signs, overnight events, order tests, medications, plan)
      • 2. Progress Notes (S.O.A.P. format)
      • 3. OR (vein harvest, second assist, remove chest tubes, pacing wires, CVP’s etc)
    • 3. A Day in the life of…..
    • 4. A Day in the life of…
      • 4. Pre-op patients (H&P, admits)
      • 5. Discharge patients
      • 6. Afternoon rounds
      • 7. Sign-out to fellow, cross cover PA,MD
    • 5. Surgical Progress Note
      • Typical SOAP format
        • ” S” (Subjective): O/N events, pt complaints
        • ” O” (Objective): VS, Labs, I/O, Pain!, CXR/EKG/ECHO/CTA results, med
        • ” A”/”P” (Assessment/Plan): ex. S/P AVR POD #3-Stable, increase ambulation, etc…..
    • 6. The surgical process…..
      • Admission (pre-op, peri-op, post-op care)
      • Surgical Assessment and Preparation
      • Common Complications
      • Discharge (disposition, PT/OT, etc)
    • 7. Admission Process
      • H&P, Consent
      • Vein harvest, first/second assist
      • ICU stay
      • Step-down unit / telemetry floor (D/C drains, pacing wires, central lines)
    • 8. . Wires are in pairs and can be connected into Medtronic pacemaker in 2 ways. Always check your connections Temporary Pacemaker
    • 9. Surgical Assessment and Preparation
      • H&P- thorough,
        • Surgical history
        • Prior cardiac surgery!
        • Previous exposure to blood transfusion products
        • Previous cardiac operative note
        • Dental history (w/ valve surgery)
    • 10. Surgical Assessment and Preparation cont.
      • Physical
        • Check BP in both arms- detect SC/innominate a. stenosis
        • Presence of carotid bruits, esp bilat.- ?CVA vs TIA
        • Pulmonary and cardiac exam
        • Peripheral exam with regards to pulses
        • Inspect legs for saphenous vein
      • Labs
        • CBC,CMP, UA, T&C 4-6U (for re-op may need more)
        • Check EKG, Cardiac Cath, CTA, MRA, CXR
    • 11. Surgical Assessment and Preparation
      • Patient Education
        • Hold ASA 7-10d
        • Hold Coumadin 7-10d
        • INR of <1.5 OK
        • Special case: Coumadin
        • Antimicrobial shower/bath x2
    • 12. Endoscopic Vein Harvest Video
    • 13. Common Complications
      • Mediastinal Bleeding and Hemorrhage
      • Arrhythmias
      • Other organ system complications (Neurologic, Pulmonary,GI, Renal)
      • Myocardial infarction
      • Infection
    • 14. Mediastinal Bleeding
      • CPB and systemic heparinization  significant disruption of coagulation system
      • Use of anticoagulants (ASA, ASA containing compounds,NSAIDs), altered platelet function, low platelet count- most common cause !
      • Activation of fibrinolysis and dilution of clotting factors also causes
    • 15. Mediastinal Bleeding
      • Labs: PT/INR, PTT, ACT, platelet count
      • Treatment
      • -Starts in OR- meticulous technique and hemostatic control
      • - Typical sites- sternal periosteum,sternal notch, mammary bed, mammary pedicle, superior mediastinal fat pad, pericardium, diaphragmatic surface, anastomoses, cannulation and vent sites, incision in heart and great vessels, vein, IMA branches.
    • 16. Mediastinal Bleeding
      • Treatment cont.
        • Chest tubes
        • CT to suction at 20 cm H 2 O
        • Blood/blood products (RBC’s, FFP, platelets)
        • Severe bleeding- Protamine sulfate (25-50 mg IV)
        • Prolonged PT/PTT- 2-4 U FFP
        • Platelets <100,000-platelets (1U/10kg body wt)
        • Persistent bleeding- test for fibrinogen defect, ?cryoprecipitate
    • 17. Mediastinal Bleeding
      • Indications for surgical re-exploration:
        • Bleeding rate >200 ml/hr x 4-6 hrs
        • >1500 ml of blood loss in 12h period
        • Sudden increase (300-500 ml) in CT output
        • Evidence of pericardial tamponade
    • 18. Arrhythmias
      • Common post-op
      • 2 categories: ventricular (early, most common) and supraventricular (24h-5d post-op)
      • Diagnosed via ECG strip or 12 Lead ECG
      • Common causes :  Ca,  K,  Mg
      • Other causes: acidosis, uremia, hyperthyroidism, reversible surgical trauma, hemorrhage, ischemia, edema
    • 19. Arrhythmias
      • Irreversible: conduction tissue trauma
      • Suture placement/valve debridement  BBB
      • Temporary epicardial pacing useful
    • 20. Sinus tachycardia
      • Common
      • Sinus tachycardia
        • HR>100
        • Vagal blockade or beta-adrenergic stimulation
        • Appropriate response to underlying stimuli (pain, fever, hypovolemia, hypoxia)
    • 21. Sinus tachycardia
        • May precipitate myocardial ischemia
        • Treatment: correct underlying cause- normalize volume status, correct hypoxia, provide adequate pain control
        • Meds: Metoprolol 12.5-50 mg BID, 5 mg IV Q6
    • 22. Sinus Bradycardia
        • HR <60
        • Due to drugs (narcotics or BB) / intrinsic sinus node disease
        • Treatment: temporary atrial pacing at 90-110 beats/min
        • Severe bradycardia-Atropine 0.5 mg -2.0 mg IV
        • ?placement of temp/PPM
    • 23. Atrial Flutter/Fibrillation
      • MOST COMMON!!!!!!
      • Disorganized atrial depolarizations
      • “ irregularly irregular” rhythm- AF, “saw tooth”- A. Flutter
      • Urgency of therapy dictated by ventricular response rate, pt’s hemodynamic tolerance
    • 24. Atrial Fibrillation/Flutter
      • Treatment: Amiodarone bolus 150 mg IV, drip at 1 mg/min. Re-bolus prn
        •  0.5 mg/min 6 hrs post conversion.
        • PO Amio 400 mg TID once in SR. Maintenance dose200 mg BID or QD. Taper dose over 30 days or 3 months
    • 25. Atrial Fibrillation/Flutter
      • Treatment cont.
      • Digoxin as an alternative
        • Loading dose- 0.5 mg IV, 0.25 mg IV Q4h x 2 doses
        • Onset IV Digoxin 30 min, peak at 3 hrs.
        • Maintenance dose 0.125 mg-0.5 mg QPM
        • Check serum K levels!
        • Check serum Digoxin once steady state (4hrs post IV, 6-7 hrs after PO)
        • Great for poor LV fxn, asthma
      • Replete serum electrolytes (K, Mg, Ca)
    • 26. Atrial Fibrillation/Flutter
      • Recent studies no difference between rate/rhythm
      • Anticoagulation key if no conversion in 48 hrs!
      • Give Warfarin, goal INR 2.0-2.5
      • DC cardioversion, anticoagulate prior
    • 27. Premature Atrial Contractions
      • Atrial impulse discharges prematurely!
      • P wave premature, may be buried in preceding T wave
      • QRS usually normal and short pause before next beat
      • Common, may be precursor to AF
      • Treatment: none, replete lytes, BB, Amio helps prevent progression of rhythm to AF
    • 28. Ventricular arrhythmias
      • Primarily ectopic
      • Potential for fatal VT or VF
      • May be improved post-op by revascularization of ischemic areas of the myocardium
      • ABG’s, serum K, ECG
    • 29. Premature Ventricular Contractions (PVCs)
      • Impulse occurs earlier than next normal sinus beat
      • Wide QRS complex: much wider, taller and deeper than normal QRS (>0.12 sec)
      • Occurs after T wave of normal cycle
      • Followed by compensatory pause
    • 30. Premature Ventricular Contractions (PVCs)
      • Unifocal or multifocal
      • Many unifocal PVCs  poor oxygenation. Treat if > 6 PVCs per minute!
      • Many multifocal PVCs  severe cardiac hypoxia! Dangerous, needs intervention!
    • 31. Premature Ventricular Contractions (PVCs)
      • Treatment:
        • Replete serum K to 4.5 mEq/L. Give IV or PO.
        • Order K sliding scale!
        • Replete Magnesium sulfate for levels <2.0 mEq/L. Give 1-4 g IV
    • 32. Ventricular tachycardia
      • 3 successive runs >100 bpm
      • Wide bizarre QRS occurring regularly
      • Precursor of VF
      • Occurs in underlying structural heart disease w/ damage to ventricles
    • 33. Ventricular tachycardia
      • Sustained VT dangerous!
      • Treatment: initiate CPR, emergent defibrillation, antiarrhythmic drugs. CALL CODE TEAM!!!!!
      • Consider ICD in pts with resolved VT
    • 34. Ventricular Fibrillation
      • Dangerous, LETHAL if not treated emergently!!!!!
      • Call CODE team!
      • Start CPR ASAP!, Defibrillate!!!
      • Antiarrhythmics to maintain normal rhythm
      • ICD if successful conversion
    • 35. Other organ system complications
      • Neurologic Dysfunction
        • CVA if >24hr deficit persists and confirmed on Head CT
          • Hypoperfusion or embolic event commonly
          • Focal motor/sensory deficits or cognitive deficits
          • Prognosis variable (age, degree of initial impairment, mechanism of injury, area of brain involved).
          • Obtain neuro consult, vigorous PT/OT optimizes recovery
    • 36. Other organ system complications
      • Neurologic cont.
        • Seizures
          • Structural brain injury or metabolic encephalopathy
          • Look for contributing cause if metabolic process if suspected
          • EEG helpful, treat with phenytoin, BZD, call neurologist!
    • 37. Other organ system complications
      • Pulmonary
        • Atelectasis
          • Most common
          • Resultant of mucous plugging and mechanical ventilation
          • Tx- incentive spirometry, bronchodilators, pulmonary toilet
        • Pleural effusion
          • Post-op bleed, interstitial edema, excess fluid not absorbed by body
          • Tx- thoracentesis/chest tube for large effusions, diuretics (IV and PO)
    • 38. Other organ system complications
      • Pulmonary cont .
      • Pneumonia
        • Prolonged ventilation, immunocompromised patient, emergent operation, age, preexisting lung disease
        • Tx: antibiotics, good pulmonary hygiene, mobilization of secretions
      • Pulmonary Embolism
        • Prolonged hospitalization/bed rest, recent groin catherization, or hypercoagulable state
        • Not seen much since use of heparin and hemodilution during surgery
        • Tx: Heparin/Warfarin, INR goal ~2.0, IVC filter
    • 39. Other organ system complications
      • GI
      • Ileus
        • Due to anesthesia/narcotics commonly
        • Usually self limiting
        • Usually resolved with DC of narcotics, restriction of PO intake, IV fluids, and ambulation
        • Severe cases may need gastric decompression with NG tube, or surgical evaluation if SBO or peritonitis, initiate TPN
    • 40. Other organ system complications
      • Renal
        • 1-5% of patients
        • Age, history of DM,prior renal insufficiency, CPB
        • Perioperative hypotension, atheroembolism, sepsis or nephrotoxic drugs
        • Major mechanisms : prerenal azotemia, ATN.
        • Others: acute interstitial nephritis, acute glomerulonephritis, obstructive uropathy
        • Tx: high arterial perfusion pressure, renal dose Dopamine (1-3 mcg) drip, free water hydration, Lasix/ Mannitol
        • Monitor I/O carefully, and check electrolytes, esp. K + !!
        • Temporary HD vs permanent
    • 41. Myocardial infarction
      • 1-2 % of patients
      • Common causes: inadequate myocardial protection, incomplete revascularization, premature graft closure
      • Sx: angina, diaphoresis
      • ST elevation, high troponin and CK
      • Medical therapy (ASA,Plavix) when appropriate, ? angioplasty, ? CCB for vasospasm of arterial grafts
    • 42. Wound infection
      • Fever, leukocytosis, wound drainage, sternal instability
      • Superficial subcutaneous infection  isolated sternal wound infection (w/ no mediastinal involvement)  severe cases mediastinitis with sepsis
      • Tx: broad spectrum antibiotics, blood cultures, wound debridement, VAC, or pectoral or omental muscle flaps
      • DM, bilateral IMA harvest, immunocompromised predisposed
    • 43. Discharge
      • Mobilize patients quickly (within 1-2 days)
      • Ambulation most common form of endurance activity
      • Order PT/OT evaluation when ready
      • Cardiac rehab RN, dietician and case manager see patients prior to discharge.
      • Sternal precautions (no heavy lifting >5lbs x 6 weeks), heart pillow
      • Case mgt: SNF v Acute Rehab, Home PT/OT, IV antibiotics, wound care, INR checks
    • 44.
      • QUESTIONS?????
    • 45. Appendix
    • 46. Monitoring- ICU/OR
      • ECG leads- 3 electrode system, aVR- right arm, aVL- left arm, aVF- left leg
      • Arterial line/BP cuff
      • Central venous pressure (CVP)- vasoactive drugs,venous access, parenteral nutrition
      • Pulmonary artery pressure: RA pressure, PA pressure, PCW, CO, blood temp.
        • assess volume status, ventricular fxn, presence of pulm. HTN
    • 47. Monitoring cont.
      • Transesophageal Echo (TEE)- eval LV fxn, WMA, native and prosthetic valve dysfunction, aortic aneurysms, masses, vegetations.
      • Pulse oximetry- measure oxygenation
      • Temperature- initiating/ terminating CPB
      • Urine output- adequate blood volume, CO, peripheral perfusion
    • 48. Common Medications
      • Beta Blockers- HR/BP control
      • -Metoprolol
      • -Esmolol- Type B dissections
      • Antiarrhythmics- Afib,etc
        • Amiodarone
        • Digoxin
        • CCB
      • ACE-Inhibitors- LV dysfunction, ventricular remodeling, afterload reduction
        • Lisinopril
      • Lipid lowering agents- post-CABG,HLD
        • Lipitor
        • Zetia
    • 49. Common Medications
      • Pain medications
        • IV: fentanyl, Morphine, Dilaudid. Also use PCA versions
        • PO: Vicodin, Percocet, Oxycodone, Tylenol #3
      • Diuretics
      • -Lasix IV and PO, drip (ICU)
      • -HCTZ
      • -Spironolactone
      • Anticoagulants
      • -Heparin/Warfarin- AF, mechanical valves
      • -ASA- all patients unless contraindicated!

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