Dr. Saffarian

10 Questionsmust be answered in Cardiac Surgical

ICU

Dr. Saffarian

Question 1

Which factors must be checked when patients transferred from the operating room to the cardiac surgical ICU?

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The patients is being well ventilated by:1. Observing chest movement2. Auscultating bilateral breath sounds

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The ECG tracing demonstrates satisfactory rate and rhythm on the transport and then the bedside monitor.

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The blood pressure is adequate on the portable monitor and remains so after the arterial line is transduced and calibrated on the bedside monitor

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Question 2

Which factors must be monitored in the ICU?

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1. ECG display and ECG 12-leads for detecting :

Rate Rhythm ST analysis

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2. Endotracheal tubes: Confirmation of bilateral breath

sounds and chest movement Rechecking of the ventilator settings Assessment of ABGs every 4hrs or

after every major ventilator change Very gentle suctioning of tracheal

tube every few hours.

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3. Arterial lines for:Monitoring of blood pressureObtaining of ABG

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Point

Radial arterial line pressure measurements may not reflect the central aortic pressure when peripheral vasoconstriction is marked.

In this situations, brachial or femoral arterial catheters provide more accurate measurement.

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Point

Arterial lines should be connected to continuous heparin flushes to improve patency rates and minimize thrombus formation.

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Point

Maintaining a radial arterial line for more than 3 days is associated with an increased risk of vessel thrombosis and line sepsis.

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Point

Removal is indicated urgently if hand ischemia develops.

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4. Swan-Ganz pulmonary artery (PA) catheter:Measuring LV filling pressureObtaining mixed venous oxygen

saturationDetermining thermodilution cardiac

output

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5. Central venous catheter (CVP):Measuring RV filling pressureEstimating of LV filling pressure in the

absence of RV failure or mitral stenosis.

Determining of volume status

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6. Chest tube:In mediastinum and into the pleural

spaces if they are entered during surgery.

Drainage should be recorded hourly or more frequently if there is evidence of significant bleeding.

Chest tubes are connected to a drainage system o which 20 cm H2O suction is applied.

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Point

Suctioning of clotted chest tubes with endotracheal suction catheters should be discouraged because it may introduce infection.

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Point

When pleural tubes were placed, intrapleural pressure became equal to atmospheric pressure therefore pleural tubes must be removed in full inspiration because of minimal distance between viseral & pariental surface of pleura at this stage.

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Question 3

Guideline for removal of lines and tubes in ICU.

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The Swan-Ganz catheter should be removed when inotropic support and vasodilators are no longer necessary.

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The CVP catheter should be removed when hemodynamic and volume status were stable.

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Arterial line should be removed after a stable postextubation blood gas has been obtained.

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The urinary catheter can be left in place if the patient is undergoing vigorous diuresis or has an increased risk of urinary retention. It should otherwise be removed once the patient is mobilized out of bed, usually on the second postoperative day.

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Chest tubes should be removed when the total drainage is < 100cc for 8hrs.

Mediastinal tubes should always be removed off suction because graft avulsion has been know to occur if suction is maintained.

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A CXR is not essential after mediastinal tube removal but should be performed after removal of pleural chest tubes to rule out a pneumothorax.

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Question 4

Etiology of mediastinal bleeding.

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1. Surgical bleeding: Suture lines, soft tissues, sternum Raw surface caused by previous

surgery, pericarditis or radiation therapy.

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2. Anticoagulant effect:Residual heparin effectQuantitative platelet defects (heparin,

quinidine, antibiotics, hemodilution, protamine)

Qualitative platelet defects ( ASA, uremia, CPB)

Depletion of coagulation factorsFibrinolysisPre-existing coagulation abnormalities

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Question 5

Preventilation of perioperative blood loss

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Warfarin should be stopped about 4 days before surgery to allow for resynthesis of Vit-K dependent clotting factors.

ASA should be stopped 7 days before surgery.

BT is usually normal with PLT counts as low as 70,000 and also in patients taking ASA.

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Heparin induced thrombocytopenia, may develop in patients receiving IV heparin for several days before surgery .

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Surgery should be delayed at least 24 hrs, in patients receiving thrombolytic therapy.

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Pre-operative dipyridamole 100mg qid leading to improved platelet function after CABG.

Aprotinin is a serine protease inhibitor that prevent bleeding. It has been associated with an increased risk of graft thrombosis.

Tranexamic acid is a potent inhibitor of plasminogen.

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Question 6

Management of postoperative mediastinal bleeding.

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Ensure that chest tubes are patent Warm patient to normothermia Control hypertension and shivering PEEP in 2.5-5 cm H2O increments Check results of coagulation

studies

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Protamine 25mg IV for two doses Desmopressin (DDAVP) 0.3 g/kg IV

over 20 minute Packed cell if Hct< 28% PLT, 1 unit/10 kg

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FFP, 2-4 units Cryoprecipitate, 1 u/10kg Avoid hetastarch and 5% Albumin Epsilon-aminocaproic acid (EACA) if

fibrinolysis is confi…..

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Question 7

Diagnosis of cardiac tamponade

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Elevated central Venous pressure Decreased blood pressure Reflex tachycardia Shortness of breath Wide mediastinom Occasionally decreased mediastinal

tube drainage

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Treatment of cardiac tamponade

Volume expansion Control of mediastinal bleeding Pericardial drainage

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Question 8

Post operative fever

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Fever is very common during the first 48-72 hrs and is usually caused by atelectasis from splinting and poor respiratory effect.

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Etiology of fever after the first 72 hrs

Atelectasis or pnemonia Urinary tract infections Sternal or leg wound infections Post pericardiatomy syndrome Drug fever Catheter sepsis Endocarditis Intra abdominal process DVT or pulmonary emboli

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Question 9

ECG changes after CABG

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These changes are nonspecific Convex ST elevation revealed

pericardial irritation Concave ST elevations associated

with significant rise of CPK-MB and traponins revealed postoperative MI

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New Q wave without rise of cardiac enzymes just revealed myocardial irritation or cardiac rotation.

Nonspecific T wave changes are not important.

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New LBBB associated with rise of cardiac enzyme may be a sign of MI.

Inflammation of bundle branch can lead to different types of bundle branch block

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Question 10

Fluid administration in early post operation period

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Most patients return from the operating room about 5-10 kg above their pre-operative weight because of interaoperative fluid administration this represents a state of both total body sodium and water overload

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In general, DS/0.2% normal saline is given at a maintenance rate of 50cc/hr on arrival in the ICU to minimize an additional sodium load at a time when the kidneys have a tendency to retain sodium

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Any fluid infused during a period of altered capillary membrane integrity will expand the interstitial space, but fluids then can more effectively expand the intravascular space while minimizing expansion of the interstitial space should be administered.

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These fluids increase intravascular volume in order to :

DW 5% Ringer Normal Saline Albumin Hespan Packed cell