perioperative management
TRANSCRIPT
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Perioperative Care of the Perioperative Care of the Cardiac Surgery PatientCardiac Surgery Patient
Lars Hegnell, MDLars Hegnell, MDDept. of Anesthesiology and Perioperative Medicine
OHSU, Portland, Oregon
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Learning ObjectivesLearning Objectives
Identify, evaluate, and treat cardiac risk patients
Minimize intraoperative risk for these patients
Address postoperative care problems in an EBM manner to reduce mortality and morbidity
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Challenge in Care PlansChallenge in Care Plans
Preoperative• Evaluation and risk assessment
Intraoperative• Prevention of acceleration of disease state
• Managing interactions between anesthetic and surgical requirements, primary disease and co-morbidities
Postoperative• Prevention and treatment of adverse events following surgery
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Goals of Preoperative EvaluationGoals of Preoperative Evaluation
Assess surgical disease
Assess functional status
Review associated comorbidities
Explain procedure and postoperative expectations, including pain management
Explain expected outcome
Discuss directives in case of complications
Instruct about preoperative medication, fasting, and pain treatment
Minimize risk factors
Full physical examination
Collect and evaluate cardiac, pulmonary, and/or vascular examinations
Review medications and laboratory results
Prevent adverse events during intra- and postoperative period
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Preoperative EvaluationPreoperative Evaluation
Physical, cardiac, and pulmonary functional status. • Use a functional classification
scale like NYHA• ECG, echo and stress testing• ABG, CXR, and PFTs
History of previous surgeries and adverse events
Allergies
Previous or ongoing medication with • antiplatelet therapy • clot lysing agents • Aprotinin within last 6 months*• ß-blockers • nitroglycerin • ACE-inhibitors • digitalis • diuretics • Ca-channel blockers • lipid lowering agents • anti hyperglycemic drugs
* see next slide
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AprotininAprotinin
A serine protease inhibitor, decreases inflammatory response and inhibits plasmin mediated fibrinolysis.
Prior exposure increases risk of allergic response with peak within the first 6 months post exposure.
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Cardiovascular Risk AssessmentCardiovascular Risk Assessment
Major• Unstable coronary syndrome
• Acute or recent MI• Unstable/sever angina
• Decompensated HF
• Significant arrhythmias• High-grade AV block• Symptomatic ventricular
arrhythmias with concomitant heart disease
• Supraventricular arrhythmias with uncontrolled ventricular rate
• Severe valvular disease
Intermediate• Mild angina pectoris
• Previous MI or Q waves
• Compensated/previous heart failure
• DM (esp. IDDM)
• Renal insufficiency
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Cardiovascular Risk Assessment Cardiovascular Risk Assessment (cont)
Minor• Advanced age
• Abnormal ECG
• Rhythm other than SR
• Low functional capacity
• Previous stroke
• Uncontrolled hypertension
These risk factors are predictors for myocardial infarction, heart failure, and death and should be weighed against surgical risk (see next slide).
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High-risk SurgeriesHigh-risk Surgeries
Aortic and major vascular surgery
Cardiac surgery
Emergency surgical procedures
Prolonged surgery with massive fluid shifts or bleeding
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ComorbiditiesComorbidities
Diabetes mellitus
Hematological disease
Pulmonary disease
Renal disease
Smoking
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Preoperative Medical Treatments with Effect Preoperative Medical Treatments with Effect on Outcome of Surgeryon Outcome of Surgery
Diabetes • Poorly regulated blood glucose levels intra- and postop shown to
negatively affect outcome possibly through effect on neutrophil activity. • Silent ischemia also more likely in diabetic patients.
Hypertension• Considered risk factor for CAD • Uncontrolled HTN (stage 3) indication for postponing surgery if possible
Arrhythmias• Preoperative ß-blockers recommended by ACC/AHA for
supraventricular arrhythmias before cardiac surgery and non-cardiac surgery
• Amiodarone reduces AF after bypass surgery.
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Preoperative Medical Treatments with Preoperative Medical Treatments with Effect on Outcome of SurgeryEffect on Outcome of Surgery
Hyperlipidemia• Statins reduce perioperative cardiac complications undergoing vascular
surgery (StaRRS study)
Smoking cessation• Quitting smoking is associated with a 36% risk reduction of all-cause
mortality among patients with CHD, timeline unclear.
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Extended Workup of the Cardiac PatientExtended Workup of the Cardiac Patient
Exercise stress test• If ECG abnormalities, do exercise echo or exercise myocardial perfusion
imaging
Non-exercise stress test • Dobutamine, not for arrhythmic or severely hypo/hypertensive patients• Dipyridamole, not for patients with obstructive pulmonary or carotid
disease• Myocardial perfusion study
Coronary angiogram• For high-risk patients
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PremedicationPremedication
Opioids• Sedation, risk of respiratory depression and hypoxia
Benzodiazepines• Low risk of respiratory depression, good anxiolytic effect, and sedation
Antiemetics• Sedative, anticholinergic, and antiemetic properties
Alpha-2 agonists• Decreases stress response, lowers BP, amplifies opiod effect
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Goals of Intraoperative ManagementGoals of Intraoperative Management
Protect brain, heart, lung, and kidney function by maintaining organ perfusion
Reduce level of stress hormones
Reduce cardiac oxygen consumption
Reduce risk for arrhythmias
Maintain euglycemia, start insulin infusion early!
Implement plan for postoperative pain management
Plan for postoperative organ support if needed
Adjust anesthetic plan for postoperative care
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Organ ProtectionOrgan Protection
Maintain tissue perfusion by regulating volume status, anesthesia depth, and cardiac function through procedure.
Use Swan-Ganz catheter (not shown to change outcome), CVP, invasive BP, urine output measurements, and ABGs to reach your preset goals.
Use ß-blockers intraoperatively to reduce HR (reducing oxygen consumption and increasing coronary perfusion time), catecholamine response, and minimize risk for AF.
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Methods for Intraoperative Cardiac Methods for Intraoperative Cardiac Function MeasurementsFunction Measurements
ECG with ST-monitoring
Arterial line
CVP
PA-catheter
TEE
Esophageal Doppler
Partial CO2 rebreathing (NICO) for CO measurement
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Goals for Cardiac OptimizationGoals for Cardiac Optimization
Optimize coronary blood flow by keeping a high arterial diastolic pressure, low LV diastolic pressure, and a relative bradycardia, and decrease coronary vascular resistance (pertinent for CAD but less so for some valvular lesions like AI):• Nitrates: vasodilates coronaries, slight to no decrease of diastole,
decrease in preload and afterload• Ca-blockers: dilates coronaries, increases diastolic time, minimal to light
reduction of preload and reduces afterload• ß-blockers: increases diastolic time, slightly increase pre- and afterload
(probably not of clinical importance), decreases contractility and HR, reduces collateral coronary blood flow (metoprolol)
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Anesthetics Effect on Cardiac FunctionAnesthetics Effect on Cardiac Function
Opioid• No myocardial depression• Stable hemodynamics
Volatile agents• Protects ischemic myocardium• Preconditioning • Suppresses sympathetic response• Myocardial depression• Systemic depression and vascular relaxation
Propofol• Vasodilator• Rapid recovery, can be used for postoperative sedation
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Anesthetics’ Effect on Cardiac FunctionAnesthetics’ Effect on Cardiac Function
Regional anesthesia• Epidural: if high (T1-T5), results in cardiac sympathectomy, decreases
oxygen consumption, increases coronary blood flow, and increases LV function
• Gives excellent analgesia, reduces postoperative stress response, and facilitates pulmonary function recovery with reduction in mechanical ventilation and earlier extubation
Benzodiazepines• Midazolam: decreases myocardial oxygen consumption and coronary
sinus blood flow• Diazepam: decrease in LVEDP, reduction in oxygen consumption,
increased myocardial blood flow
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Anesthetics’ Effect on Cardiac FunctionAnesthetics’ Effect on Cardiac Function
Isoflurane, sevoflurane, and desflurane all cause coronary vasodilatation• A hypothesis of “coronary steal” was postulated: Flow change in
coronaries when dilated from normal would reduce flow to poststenotic dilated poorly perfused areas more than areas with good perfusion causing aggravated myocardial ischemia. Shown in animal studies, not a factor in humans if good hemodynamic control is maintained.
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Intraoperative Drug Support Intraoperative Drug Support
Vasopressors• Dopamine
- α-, β- and dopamine receptor agonist; vasodilator at low doses, impairs NE release and vasoconstrictor at higher doses
- Increased risk of AF after cardiac surgery- NO renal protective effect of low-dose dopamine
• Epinephrine- α- and β- receptor activity; inotropic and chronotropic effect with increase in
afterload, also dromotropic and lusitropic effects (with appropriate use the effect on afterload is minimal)
- β-adrenergic activity, increases contractility and HR, reduces systemic and pulmonary vascular resistance
• Norepinephrine- α- and β1 receptor activity; potent α-effect with increase in vascular
resistance
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Intraoperative Drug SupportIntraoperative Drug Support
• Vasopressin- V1 and V2 (and V3) receptor effect; induces coronary vasodilatation at
low doses followed by vasoconstriction at higher doses, promotes platelet aggregation, releases factor VIII and vWf, increases hepatic glycogenolysis, induces mesenteric vasoconstriction, and decreases CO
- The combined effect of NE and vasopressin infusion on catecholamine refractory dilatory shock post CABG seems to be advantageous.
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Intraoperative Drug SupportIntraoperative Drug Support
Inotropes• Dobutamine
- “Selective” β agonist; positive inotropic effect, augments coronary blood flow, reduces afterload and preload more than dopamine
- The increase in CI with dobutamine early after CPB is mostly heart rate, not SV
• Milrinone (Amrinone)- Phosphodiesterase III inhibitor; positive inotropic effect and dilates pulmonary
and systemic vasculature
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Intraoperative Drug SupportIntraoperative Drug Support
Anti-arrhythmic drugs• Amiodarone
• Minimal effect on LV function, decreases HR
• Magnesium • Intraoperative magnesium seems to contribute to myocardial recovery and
lessen risk of ventricular arrhythmias postop and reduces AF after cardiac surgery
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Intraoperative Drug SupportIntraoperative Drug Support
Antifibrinolytics - these seem to be clinically equal in effect on bleeding during CPB surgery, price and side effects differ• Aprotinin
• Aminocapric acid
• Tranexamic acid
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Postoperative Care of the Cardiac Postoperative Care of the Cardiac Surgery PatientSurgery Patient
Level of care is dependent on present or anticipated problems.• ICU
• Step-down unit
• Telemetry unit
• Ward
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Postoperative Care in the ICUPostoperative Care in the ICU
Admission• Keyword: communication! Direct information from OR
team/anesthesiologist/surgeon to intensivist team on arrival in the unit about:
- Operation
- Complications during op; bleeding, need for transfusion
- Responsiveness to volume, inotropes, and drugs
- Planned care and expected problems
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Initial Review of the Postoperative PatientInitial Review of the Postoperative Patient
ABC
Monitoring
IV lines and sites
Pumps and infusions
Drain catheters and urinary catheter
Temperature
Physical examination
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Postoperative ManagementPostoperative Management
CABG patients info of importance for care: • Time on CPB
• Clamp time
• Ventilation/oxygenation/airway management
• Pressor/inotropic support
• Surgical considerations for postop period
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Postoperative ManagementPostoperative Management
Ventilation• CXR for ETT and chest tube placement, SG-catheter position, and
pulmonary pathology
• ABG for ventilation assessment and support
Circulation• Pressor needs? Inotropes?• CO output and SVR/PVR review• Peripheral perfusion• Kidney function
Coagulation• Output in chest tube/wound per time unit• TEG/ACT/PT/APTT/platelet count for coagulation status• Observe drug effects on platelet function (i.e., milrinone)
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Risk Factors for Postoperative Pulmonary Risk Factors for Postoperative Pulmonary DysfunctionDysfunction
Age < 2 or > 60
Amiodarone
COPD
Pulmonary hypertension
Congenital pulmonary pathology
Down’s syndrome
Long CPB time
Type of oxygenator
Level of C3a activation in bypass circuit
Use of ice for cardioplegia (damage to phrenic nerve)
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Postoperative MedicationsPostoperative Medications
Aspirin• Start within first 48 (24) h post op. Reduces risk of early occlusion of
grafts
Β-blocker• Reduces risk of cardiovascular death and AF/arrhythmia
Ca-channel blocker• Reduced mortality after cardiac surgery, although negative inotropic and
chronotropic effect and platelet inhibitor
Lipid lowering therapy• Aggressive treatment delays progression of atherosclerosis regardless
of risk factors.
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Postoperative Medications Postoperative Medications (cont)
ACE-inhibitors/ARB• Reduces risk of stroke, MI and death in diabetic and vascular
patients, unclear effect after cardiac surgery except for quinapril which reduces risk for ischemic events in postop CAGB patients
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Graft Spasm PreventionGraft Spasm Prevention
Several therapies to maintain graft patency after CABG has been used, side effects and surgeon preference decide choice• Nitroglycerin
• Ca2-channel antagonists
• Phosphodiesterase inhibitors
• α-adrenergic antagonists
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Preventable Postoperative ComplicationsPreventable Postoperative Complications
Arrhythmia• Decreased organ perfusion• Increased risk for MI or fatal arrhythmia • Prolonged ICU care and hospital stay
Hyperglycemia• Increased mortality and morbidity• Impaired wound healing• Decreased cardiac function
Hypertension• Increased risk of stroke and MI• Increased risk of surgical bleeding
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Postoperative ComplicationsPostoperative Complications
Bleeding• Surgical?• Coagulopathy? Lysis? Heparin effect?
Pain• Secondary hypertension• Reduced pulmonary function• Hyperdynamic circulation• Impaired wound healing• Use multimodal approach: acetaminophen, NSAID, opioid and/or LA
(PainBuster®) from the OR, add opioids in the unit
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Postoperative ComplicationsPostoperative Complications
Coronary ischemia• Increased risk of MI/arrhythmias/circulatory arrest
Renal failure• 1 - 2% of CPB patient, associated with high mortality especially if ARF is
associated with dialysis• Fenoldopam, dopamine – 1 agonist, improves outcome in patients with
low CO?
Prolonged ventilation• Increased risk of VAP
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Problem Directed ManagementProblem Directed Management
Hypertension
• Pain? - PCA, iv/po medications or epidural
• Postoperative stress response?- ß-blocker if tachycardia and good LV function
- Nicardipine, does not decrease preload, other vasodilators if hypovolemia is excluded
- Fenoldopam, for patient with renal insufficiency?• Tachycardia and pronounced hypotension, usefulness in ICU patients
unclear
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Problem Directed ManagementProblem Directed Management
Hyperglycemia• Insulin infusion to maintain blood glucose < 110 mg/dl (< 6.1 mmol/l)
has shown to decrease in mortality/morbidity in postoperative ICU patients.
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Problem Directed ManagementProblem Directed Management
Arrhythmias• Amiodarone has good prophylactic effect and shown good rhythm
control on postoperative AF. Secondary effect is reduced morbidity and cost in the ICU
• ß-blockers should be continued if started, but keep in mind the negative effect on a “stunned” myo-cardium.
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CoagulopathyCoagulopathy
Hypothermia?• Rewarm!
Residual heparin effect?• Give 50-mg protamine
Intraoperative major bleed?• Supply missing components – platelets, coagulation factors
• Potentiate vWF and activate platelets with DDAVP
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Special CasesSpecial Cases
Pacemaker and/or ICD pre-, intra-, and postop.• Investigate type, function, possibility to turn off during and susceptibility
to cauterization before surgery. Backup needed?
Mechanical support for failing heart postoperatively: IABP, VAD (L/R/Bi) • IABP improves coronary circulation during diastole and reduces LV
afterload
• VAD therapy: temporary measurement, bridge-to-transplant or bridge-to-destination
• High complication risk of bleeding and/or infection
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Special CasesSpecial Cases
Postoperative vasodilatory shock• Common post CBP and probably exacerbated by preoperative use of
ACE-inhibitor and intraop milrinone.
• CPB appears to stimulate nitric oxide production thru an effect on the inducible NOS.
• Trend today to use vasopressin infusion, no randomized studies available comparing NE/E/vasopressin and outcome.
SIRS • Use of low-dose steroids seems to attenuate cytokine response post
bypass and improve outcome.
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Special CasesSpecial Cases
Pulmonary hypertension• PVR increased or RV overload/failure? Use of milrinone, prostaglandin
analogs, nicardipine, diuretics or sildenafil (or combinations) to improve RV function are treatment modalities currently used.
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ReferencesReferences
ACC/AHA Guideline 2002. Update on peri-operative cardiovascular evaluation for noncardiac surgery.
Gunjan YG et al. Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients. Mayo Clin Proc. 2005;80:862-866.
Van den Berghe et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 200;345(19):1359-67.
Practice Advisory for the Perioperative Management of Patients with Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter-Defibrillators. Anesthesiology 2005;103(1).
Louis E Samuels et al. Selective use of amiodarone and early cardioversion for postoperative atrial fibrillation. Ann Thorac Surg. 2005;79:113-116.
Eugene Chrystal et al. Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery: a meta analysis. Circulation. 2002;106:75-80.
ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery.
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ReferencesReferences (cont)
Erich Kilger et al. Stress doses of hydrocortisone reduce severe systemic inflammatory response syndrome and improve early outcome in a risk group of patients after cardiac surgery. Crit Care Med. 2003; 31(4):1068-1074.
Roger JF, Baskett et al. The intraaortic balloon pump in cardiac surgery. Ann Thorac Surg. 2002;74:1276-87.
Medical Therapy for Pulmonary Arterial Hypertension, ACCP Evidence-Based Clinical Practice Guidelines. Chest. 2004;126:35S-62S.
O’Neil-Callahan K et al. Statins decrease perioperative cardiac complications in patients undergoing noncardiac vascular surgery: the statins for risk reduction in surgery (StaRRS) study. J Am Coll Cardiol. 2005;45:336-42.
Martin W. Dünser et al. Arginine vasopressin in advanced vasodilatory shock: a prospective, randomized, controlled study. Circulation. 2003;107:2313-2319.
Martin W Dünser et al. The effects of vasopressin on systemic hemodynamics in catecholamine-resistant septic and postcardiotomy shock: a retrospective analysis. Anesth Analg. 2001;93:7-13.
Daniel M. Thys et al. Textbook of Cardiothoracic Anesthesiology; McGraw-Hill Companies ISBN 0-07-079188-0
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References References (cont)
Dennis T Mangano. Aspirin and mortality from coronary bypass surgery. N Engl J Med. 2002;347(17):1309-1317.
Emile G Daoud, et al. Preoperative amiodarone as prophylaxis against atrial fibrillation after heart surgery. N Engl J Med. 1997;337:1785-91.
Trevor WR Lee, et al. High spinal anesthesia for cardiac surgery. Anesth. 2003;98:499-510.
Stefan G de Hert, et al. Choice of primary anesthetic regimen can influence intensive care unit length of stay after coronary surgery with cardiopulmonary bypass. Anesth. 2004;101:9-20.
Stefan G De Hert, et al. Cardioprotection with volatile anesthetics: mechanism and clinical implications. Anesth Analg. 2005;100:1584-93.
PWC ten Broecke, et al. Effect of preoperative ß-blockade on perioperative mortality in coronary surgery. Br J Anesth. 2003;90 (1): 27-31.
Peter K Lindenauer, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349-360.
Cardiac Surgery. Kirkland/Barratt-Boyes 2003; Churchill, Livingstone: New York, NY
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ReferencesReferences (cont)
S Miller, at al. Effects of magnesium on atrial fibrillation after cardiac surgery: a meta-analysis. Heart. 2005;91:618-623.
A Thompson, et al. Perioperative cardiac arrhythmias. Brit J Anesth. 2004;93(1):86-94.
B Erstad. Antifibrinolytic agents and desmopressin as hemostatic agents in cardiac surgery. Ann Pharmacother. 2001;1075-84.
S Mussa, et al. Radial artery conduits for coronary artery bypass grafting: current perspective. J Thorac Cardiovasc Surg. 2005;129:250-253.
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Case 1Case 1
59-year-old male presents to emergency dept. with chest discomfort. Hx. of smoking, hypertension, and hyperlipidemia. Newly prescribed nitroglycerin for intermittent chest pain that started 3 months ago. Now chest pain during night that resolved after nitro. Meds: atenolol, ASA, lisinopril, lovastatin, and nitroglycerin. ECG: SR, 70 Hz, no ST/T changes. Troponin 0.02.
Admitted to Obs. Unit for follow up. Second ECG showed T-inversions in aVL, V4-5. Second troponin 0.02, no chest pain.
What next?
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Case 1Case 1 (cont)
Patient sent for exercise treadmill test: Chest pain, ST depression in II, III, aVF, V5, and V6. Chest pain and ECG resolved.
What now?
Cardiac cath lab: EF 45%, severe multivessel CAD, referred to CT surgeon for surgery
Which medications do you continue with or start?
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Case 1Case 1 (cont)
Patient started on heparin until surgery. ASA, metoprolol, lisinopril, and lovastatin cont’d.
Day 2: CABG x 5, intraop CBG 98-177, started on insulin infusion. Anesthesia with isoflurane/fentanyl/pancuronium. CPB 109 minutes, clamp time 85 minutes. Postop sedation with dexmedetomidine.
Admitted to ICU, initial review showed bibasilar atelectasis and minimal left pleural effusion on CXR, stable circulatory values, normal SVR/PVR and SvO2 and ABG: 7.23,56,126,-5.3,22. Good UO and temp 35.7º C.
What do you do now?
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Case 1Case 1 (cont)
Decision to “fast track” patient to extubation; patient extubated after 2 hours in ICU. ABG pre-extubation: 7.37/40/123/-1.6/23 after some volume replacement.
Minimal pain issues postop, continued on opioids and acetaminophen.
Day 3: Stable patient. No chest drain output, stable circulation and respiration. Chest tubes and S-G catheter d’ced and patient moved to floor unit.
Day 5: Discharged home.