1 / 18

Immediate Post-Operative Care—Cardiac Surgery

Immediate Post-Operative Care—Cardiac Surgery. Brett Sheridan, M.D. Assistant Professor Division of Cardiothoracic Surgery University of North Carolina. History. Pre-op hemodynamics Operation Ischemia time Complications Inotropes. Examination. ABC’s- Endotracheal tube/ventilator EKG

lisbet
Download Presentation

Immediate Post-Operative Care—Cardiac Surgery

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Immediate Post-Operative Care—Cardiac Surgery Brett Sheridan, M.D. Assistant Professor Division of Cardiothoracic Surgery University of North Carolina

  2. History Pre-op hemodynamics Operation Ischemia time Complications Inotropes

  3. Examination • ABC’s- Endotracheal tube/ventilator • EKG • Pulse Oximetry • Blood Pressure • Color / Peripheral pulses / Temperature of extremties • Chest tubes • Foley catheter / Urine o/p • Inotropes- what drugs/infusions running/correct dosages

  4. Chest X-Ray • ET tube • NGT • Chest tubes • Lung fields-fluid/air • Heart shadow • Swan catheter tip • IABP tip • Mediastinal width

  5. Laboratory • ABG • K+ • Hct • Bleeding-PT/INR, PTT, Platelets • Impaired renal Function Cr

  6. Assessment of perfusion How do you do it? • What is “Shock”? • Blood Pressure • LE temperature and pulses • Urine output • Cardiac output

  7. Metabolic Shock • Acid/Base balance • Anaerobic metabolism Lactic acidosis Base deficit • Mixed Venous (SVO2) • SvO2= SaO2 – VO2/ (Hgb x 1.39 x CO) x 10

  8. Acute Management of HemodynamicsR/O Mechanical causes of cardiogenic shock • Tension pneumothorax • Hypoxia • Tamponade • Pressors inadvertently d/c’d • Acute MI-thrombosed graft • Bleeding- open line/intraabdominal hemorrhage from femoral access

  9. Determinants of Cardiac Output • Stroke volume x heart rate • Stroke volume • preload • afterload • contractility

  10. Hemodynamic Management – Strategy to Optimize Cardiac Function • Rate • Rhythm • Preload • Afterload • Contractility

  11. Rate • Optimal rate 90-100 bpm • Atrial pace if AV node functioning • A-V pace if some degree of heart block

  12. Rhythm • Identify rhythm • If HR>120 slow rate pharmacologically • Inadequate diastolic filling • If lack of A-V synchrony  A-V sequentially pace • to optimize atrial transport

  13. Preload • Maximizing Frank-Starling relationship • If CVP or PCWP <15  volume • crystalloid • colloid • blood • If CVP or PCWP > 15 • afterload or contractility

  14. Afterload • Resistance (increases work) • SVR= MAP- CVP x 80 800-1200 dyne-sec/cm5 CO • SVR increased low CO hypertensive • reduce afterload(NTG/SNP) • SVR decreased high CO hypotensive • increase afterload (vasopressin, phenylepherine, levophed)

  15. Contractility • Persistent low BP and low CO despite optimization of above parameters. • The only remaining reason for poor CO is intrinsic myocardial dysfunction. • This is closely associated w/ ischemia/reperfusion. Injury of muscle with troponin leak. • There is a fairly predictable time line of myocardial recovery ( majority but not all cases).

  16. ContractilityPharmacologic support-Pressors • Dopamine- 3-8 ug/kg/min-mild inotropy, huge chronotropy and increasing alpha • Dobutamine- 2.5- 10 ug/kg/min-mod chronotropy and w/ moderate pulmonary and peripheralvasodilatory properties. +/- chronotropy • Epinephrine- 0.01- 0.1 ug/kg/min- potent inotropy, mild chronotropy, increasing alpha • Milrinone- excellent for right heart failure as it is a more potent pulmonary vasodilator than dobutamine. Also has potent systemic vasodilating properties so often used in conjunction w/ Epinephrine. Moderate inotropy as well.

  17. Mechanical Support • Intra-aortic ballon pump (IABP) • reduces afterload • increases diastolic coronary perfusion pressure • Left ventricular assist device • temporary or permenant • Bi-ventricular device • short term or long term • Extracorporeal membrane oxygentation (ECMO)

  18. Heart Transplant

More Related