Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Cardiac Surgery - What Can Go Wrong?

1,870 views

Published on

Cardiac surgery can vary from being routine elective surgery to time-critical emergency surgery. The term encompasses a broad range of procedures carried out on patients from neonates to nonagenarians. In the 63 years since the first open heart surgery was performed using cardiopulmonary bypass enormous advances have been made in the field such that an average person presenting for coronary bypass grafting in 2016 can expect a very low chance of peri-operative morbidity or mortality. When things go wrong however they can go badly wrong and at the worst possible moment (see Murphy’s Law). This talk focuses on describing common complications encountered in the postoperative period, with a focus on anticipation, prevention and planning for rapid recognition and successful management of potentially life threatening complications.

Published in: Health & Medicine
  • ♣♣♣
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • I've seen harder erections, veins more noticeable. The amount of come is slightly higher but semen is thicker. ■■■ https://tinyurl.com/semenax101
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Cardiac Surgery - What Can Go Wrong?

  1. 1. CARDIAC SURGERY- WHAT CAN GO WRONG…. DEIRDRE MURPHY
  2. 2. WHAT CAN GO WRONG WILL GO WRONG Murphy’s Law
  3. 3. .. AND AT THE WORST POSSIBLE MOMENT Finagle’s corollary
  4. 4. ORIGINS OF MURPHY’S LAW REVISITED "ANYTHING THAT CAN POSSIBLY GO WRONG, DOES. -- Ancient mountaineering adage" John Sack, _The Butcher: The Ascent of Yerupaja_ (1952), epigram, page 2 “ Fred Shapiro ED Yale Dictionary of Quotations
  5. 5. CARDIAC SURGERY IS LOW RISK….
  6. 6. SOCIETY OF CARDIOTHORACIC SURGERY DATABASE 2.73 CABG 1.9 % Valve alone 2.1 % CABG + Valve 3.8 %
  7. 7. CABG AND RISK BENEFIT CABG offers long term morbidity and mortality benefit for a range of conditions The risks are mainly during and shortly after the operation Coronary Artery Bypass Grafting , Alexander J and Smith P NEJM 2016; 374: 1954-64
  8. 8. COMMON COMPLICATIONS PREVENTION/RX UNCOMMON COMPLICATIONS IMPORTANT TO KNOW ABOUT AVALANCHES
  9. 9. Pneumonia Mediastinitis
  10. 10. GI haemorrhage Ischaemic bowel (IABP, A fib)
  11. 11. AKI 20-30% RRT 2-3% (40% mortality)
  12. 12. No difference in hospital length of stay or mortality in rate vs. rhythm control NEJM 2016 A Fib 30-50% Increased hospital LOS Stroke risk x 5
  13. 13. Stroke 1-2% Air embolism (open chamber) role for HBO Delirium Pumphead Neurologic deficits ascribed to “pump” but no difference vs CABG vs PCI
  14. 14. BLEEDING Time post surgery Blood loss expected 30 mins 100mls 1 hour 200 mls/hr 2 hours 100/hr 3 hours 50 mls/hr Useful to look at rate/ pattern of bleeding
  15. 15. medical bleeding vs. surgical bleeding
  16. 16. medical bleeding vs. surgical bleeding Fix Coagulation Deficit (POC tests) Ensure adequate reversal of heparin (“Pump Blood”) Platelets/ Fibrinogen/FFP Prothrombinex Tranexamic acid (ATACAS) Temperature, Ca, pH Operation
  17. 17. WHAT HAPPENS WHEN PATIENTS STOP BLEEDING??
  18. 18. TAMPONADE….
  19. 19. RA LA SVC IVC LA RA RV
  20. 20. PREVENTING TAMPONADE Correct significant coagulopathy (but don't overdo it!!) Keep drains patent…… fan-folding milking rolling
  21. 21. TAMPONADE Recognise and treat urgently!! Low cardiac index, rising filling pressures, increasing inotrope/ vasopressor requirement Be aware of MIMICS
  22. 22. Cardiorespiratory interactions- waking and “bearing down” CONDITIONS MIMICKING TAMPONADE
  23. 23. CONDITIONS MIMICKING TAMPONADE Pneumothorax-lung point Haemothorax- TOE
  24. 24. LATE TAMPONADE often recognised late also mortality high may follow therapeutic anticoagulation or pacing wire removal
  25. 25. 62 y.o F 3 weeks post CAGS and AVR. PEA arrest with peaked t waves
  26. 26. TOE shows late tamponade
  27. 27. MURPHY’S LAW AMENDMENT… THERE CAN BE MORE THAN ONE CAUSE OF AN ARREST Murphy
  28. 28. HAEMODYNAMICS
  29. 29. LOW OUTPUT STATES- PUMP FAILURE Pre-existing poor LV Graft spasm Mitral valve surgery often “unmasks” poorly performing LV Perioperative MI KNOW YOUR PATIENT’S SURGERY
  30. 30. Normal coronary arteries pre-op doesn't mean there can’t be a problem post operatively From File Titled“Things I Wish I had Known”
  31. 31. CORONARY INJURY POST OPERATIVELY L Main stenosis / R coronary injury 2nd aortic valve surgery- (immediate or months ) Circumflex injury post mitral prosthesis, annuloplasty JACC Standardized Imaging for Aortic Annulus Sizing. Kasel et al 2013 Visualisation of the Circumflex in The Perioperative Setting with Transesophageal Echocardiography Ender et al. Anesth Analg 2012
  32. 32. RV DYSFUNCTION Some degree of RV dysfunction expected RV protection on bypass (esp RCA stenosis) Associated with longer bypass time
  33. 33. KEEP THE RV HAPPY Maintain perfusion pressure Adequate preload Low PVR (ventilator settings) Inodilator (Milrinone) Selective pulmonary vasodilators e.g iNO Maintain sinus rhythm
  34. 34. COMBINATIONS OF VENTRICULAR DYSFUNCTION CAN BE TRICKY TO MANAGE
  35. 35. POST PUMP SYNDROME High output , low SVR. Up to 5% Valve>>CABG ? inflammatory mediators secondary to CPB vasopressors, methylene blue (Sepsis may be a cause )
  36. 36. CARDIAC ARREST AFTER CARDIAC SURGERY Multifactorial EACTS guidelines Important differences in ALS approach
  37. 37. ALWAYS DO CPR ! Dunning J, et al. Guideline for resuscitation in cardiac arrest after cardiac surgery. European Journal of Cardio-Thoracic Surgery. 2009 50-60%
  38. 38. !
  39. 39. “Between living and dying is the calmest place I’ve ever been He stood opposite me and smiled. I smiled too, I think, because this was the first time I’d seen a man made of rain though once or twice my heart was chilled by men of ice.”
  40. 40. Prevent complications Recognise complications early Train for avalanches

×