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Dr. Leanna R. Miller DNP, RN, CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP

LRM Consulting

Nashville, TN

Behavioral Objectives 1. Identify common postoperative pulmonary

complications.

2. Describe common cardiac complications of CV surgery.

3. Discuss treatment strategies for complications seen in the postoperative CV surgery patient.

Report from Anesthesia • procedure performed

• height/weight • infusions

• pacing options

• blood products given • events/concerns

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In the “Huddle” • details of surgical procedure

• patient’s history • patient’s anatomy

• BP, MAP, titration goals

• reverse sedation/maintain sedation • airway difficulty

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

Postoperative Concerns

• Instability

– Hypotension vs. Hypertension

– goal range (upper and lower)

• Bleeding

– Cardiac Tamponade

• Arrhythmias

• Extubation

• Pain/Mobilization

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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

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!

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 Nipride drip

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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

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

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

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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

Screening • CBC

– Hgb/Hct

– platelets

• PT/PTT • Bleeding Time

Symptom INR aPTT Platelet # Platelet

Function

History Diagnosis

Major/minor bleeding

N N N Massive

transfusion; fluids

Dilutional

thrombocytopenia

Major/minor bleeding

N Prolonged N N negative Drug induced -

heparin

Major/minor bleeding

N N n/a Vitamin K

deficiency

Liver disease,

warfarin, antibiotics

Major bleeding

prolonged prolonged N DIC

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Postoperative Bleeding

• Vascular integrity disruption – reoperation

Medical Causes of Bleeding • residual heparin effect • platelet consumption (CPB) • preoperative platelet inactivation

Medical Causes of Bleeding • depletion of clotting factors • preoperative coagulopathy • fibrinolysis

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• Thrombocytopenia – platelet destruction

• drug – induced

•DIC

• Thrombocytopenia – Etiology

• abnormal distribution or sequestration in spleen – portal hypertension

Definition

• serious bleeding disorder

• thrombosis; then hemorrhage

Disseminated Intravascular Coagulation

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Etiology of DIC

• shock

• IIR

• cardiac tamponade

• infection

Laboratory Findings • platelets • fibrinogen • PT &/or PTT • d - dimer or FSP • ATIII

Management

• Treat underlying cause

– antimicrobials

– product replacement

– surgery - open chest

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Management

• Stop Thrombosis

– IV heparin

–AT III

– plasmapheresis

Management • Administer blood products – pRBCs – platelets – FFP – cryoprecipitate

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

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Bleeding • Possibly return trip to OR

• Worse case scenario – OPEN chest in unit

Postoperative Arrhythmias • Atrial Fibrillation

– most common dysrhythmia in the postoperative period

– incidence 30% to 50%

– consequences include: • hemodynamic instability • thromboembolism

• Predictors of Atrial Fibrillation post CABG – advanced age, – history of AF – enlarged left atrial size – history of CHF – elevated BNP levels

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• 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

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

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

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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)

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

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

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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

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

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

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Pulmonary Problems • Pulmonary Edema

– most common cause is pre-existing LV dysfunction

– noncardiogenic – “pump lung”

• inflammatory process leading to direct lung injury

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

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

– no ectopy

• Notify clinician of all findings and obtain order for extubation (be sure to chart extubation)

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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

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)

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

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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)

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

Neurologic Complications • possible complications

– delirium

– transient or permanent cognitive deficits

– seizures

– anterior spinal artery infarction

– transient focal cerebral ischemia – stroke

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Neurologic Complications • Location of strokes

– cerebral hemispheres

– less common • brainstem

• cerebellum • deep white and gray matter

Neurologic Complications • Mechanism of stroke in CABG

– embolization from atheromatous plaque

– fat embolism

– air embolism

– atrial fibrillation

– hypotension – intra-operative hypotension

Neurologic Complications • Predictors of post – CABG stroke

– age

– diabetes – hypertension

– elevated serum creatinine

– recent MI

– low EF – atrial fibrillation

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Neurologic Complications • Predictors of post – CABG stroke

– on pump procedure

– multiple blood transfusions – IABP

– duration of bypass – emergency surgery

– combined procedure

Postoperative Infections • Common postoperative infections

– superficial sternal wound infections

– deep sternal wound infections – donor site infections

– pulmonary infections

Postoperative Infections • Mediastinitis

– 0.4% to 5% incidence

– 2.5% to 7.5% in heart transplant – higher is patients with cardiac

assist devices

– generally noted within 14 days of surgery

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Postoperative Infections • Mediastinitis risk factors:

– diabetes/perioperative hyperglycemia – obesity – peripheral artery disease

– tobacco use – prior cardiac surgery – mobilization of IMA – procedure > 5 hours

– return to OR within 4 days postop – prolonged postoperative intensive care

Postoperative Infections • Mediastinitis – clinical features

– fever

– tachycardia – chest pain or sternal instability

– purulent discharge from site

– crepitus & edema of chest wall

– Hamman’s sign

Case Study #1

• 65 yo F, S/P CABG X 3

• Patient history

– CAD

– Atrial fibrillation

– Ejection Fraction 45%

– HTN

– previous MI’s in past with stents placed

– on Plavix pre-op

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Case Study #1

• Pt arrives from OR:

• VS’s:

– BP 130/70, HR 112, CVP = 4, 02 sat 98%

– Chest tube output: 200cc in 1st 30 minutes

– Initial ABG results:

• PO2 – 178 (60% FiO2), pH 7.34, pCO2 46,

BE -2.2

• Vent settings:

– TV 600, SIMV 12, PEEP 5, PS 5

Case Study #1

• Patient’s Drips and Labs:

– Propofol 30 mcg/kg/min

– Norepinephrine @ 2mcg/min

– Amicar 1gm/hr

– Carrier fluids running at 150cc/hr

Case Study #1

• What needs some work?

– BP too high – get their head up, get Norepinphrine gtt off, maybe Nipride gtt to be started, high BP will cause more CT OP

– HR too high – is the patient dry and that is why HR is too high, does the patient need blood

– CT OP is too high – make sure MD is aware, do we need to send COAGS to lab, does the patient need FFP or cryoprecipitate, could use extra PEEP, field trip to OR?

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Case Study #2

• Patient arrives from OR:

• Vital Signs

– Temp: 34.2 (Core)

– HR 65

– BP 95/52

– CO/CI: 3.2/2.0

– CT OP: Currently 50cc/q15 min

– PAP: 22/15

– CVP: 8

Case Study #2

• Patient’s Drips:

– Levophed @ 15mcg/min

– Epinephrine @ 2mg/min

– Propofol @ 20 mcg/kg/min

• What interventions are needed?

Case Study #2

Interventions

• WARM the patient up!!

– Heat to the vent

– Bair hugger

– Cover head with blankets/plastic

• Possibly send COAGS/Plt count

• Will need fluids/blood products

– If giving platelets: premedicate

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Case Study #2

Interventions

• Watch VS/BP as patient warms up

• Go ahead and hook patient to

pacemaker in back-up rate.

• Won’t reverse patient

– might need more than/something

different from Propofol

IN CONCLUSION

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