Management of Cardiac Surgery Patients and role of PA's

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Management of Cardiac Surgery Patients and role of PA's

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

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