CARDIAC SURGERY- WHAT CAN GO WRONG….

DEIRDRE MURPHY

WHAT CAN GO WRONG WILL GO WRONG

Murphy’s Law

.. AND AT THE WORST POSSIBLE MOMENT

Finagle’s corollary

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 EDYale Dictionary of Quotations

CARDIAC SURGERY IS LOW RISK….

SOCIETY OF CARDIOTHORACIC SURGERY DATABASE 2.73

CABG 1.9 %

Valve alone 2.1 %

CABG + Valve 3.8 %

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

COMMON COMPLICATIONS PREVENTION/RX

UNCOMMON COMPLICATIONS IMPORTANT TO KNOW ABOUT

AVALANCHES

Pneumonia

Mediastinitis

GI haemorrhage

Ischaemic bowel

(IABP, A fib)

AKI 20-30%

RRT 2-3% (40% mortality)

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

Stroke 1-2%

Air embolism

(open chamber)

role for HBO

Delirium

Pumphead

Neurologic deficits ascribed to “pump” but no difference vs CABG vs PCI

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

medical bleeding

vs. surgical bleeding

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

WHAT HAPPENS WHEN PATIENTS STOP BLEEDING??

TAMPONADE….

RA

LA

SVCIVC

LA

RA

RV

PREVENTING TAMPONADE

Correct significant coagulopathy (but don't overdo it!!)

Keep drains patent……

fan-folding milking rolling

TAMPONADE

Recognise and treat urgently!!

Low cardiac index, rising filling pressures, increasing inotrope/vasopressor requirement

Be aware of MIMICS

Cardiorespiratory interactions- waking and “bearing down”

CONDITIONS MIMICKING TAMPONADE

CONDITIONS MIMICKING TAMPONADE

Pneumothorax-lung point Haemothorax- TOE

LATE TAMPONADE

often recognised late also

mortality high

may follow therapeutic anticoagulation or pacing wire removal

62 y.o F 3 weeks post CAGS and AVR. PEA arrest with peaked t waves

TOE shows late tamponade

MURPHY’S LAW AMENDMENT…THERE CAN BE MORE THAN ONE CAUSE OF AN ARREST

Murphy

HAEMODYNAMICS

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

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”

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

RV DYSFUNCTION

Some degree of RV dysfunction expected

RV protection on bypass (esp RCA stenosis)

Associated with longer bypass time

KEEP THE RV HAPPY

Maintain perfusion pressure

Adequate preload

Low PVR (ventilator settings)

Inodilator (Milrinone)

Selective pulmonary vasodilators e.g iNO

Maintain sinus rhythm

COMBINATIONS OF VENTRICULAR DYSFUNCTION CAN BE TRICKY TO MANAGE

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 )

CARDIAC ARREST AFTER CARDIAC SURGERY

Multifactorial

EACTS guidelines

Important differences in ALS approach

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%

!

“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.”

Prevent complicationsRecognise complications early

Train for avalanches