Critical Care Intensivists: Critical Care Intensivists staffing our Cardiac Surgery ICU- Intensivists care for critically ill patients who require a higher level of care because they have complex medical conditions. Search for alternate explanations for the low cardiac output (i.e., hypovolemia, myocardial ischemia, etc.). Acute myocardial ischemia including medically-refractory ischemia pre-operatively and post-operative myocardial ischemia. Thus, there is a rapid transfer of blood from atrium to ventricle and the pressure drops significantly in the atrium - the "y-descent". and should be corrected. This can lead to significant hypokalemia and hypomagnesaemia which increases the likelihood of post-operative dysrhythmias. Hemodilution on CPB or consumption. Verify correct position of the Swan-Ganz catheter. The following is an approach to managing the hypotensive patient; The following is a very simplified approach to the choice of inotropes and vasopressors. Post cardiac surgery transfer orders. ß2 effect can sometimes decrease SVR and BP. Quantitative platelet defects. This can lead to a rapid deterioration in the patient’s condition that requires a quick recognition and intervention. Check the ABG results as soon as they are available. This is written with a busy, fatigued resident in mind. Post-operative cardiogenic shock not responding to medical therapy. The absence of respiratory variation on the CVP monitor tracing is also suggestive that the patient has an adequate preload and that further volume therapy is unlikely to increase cardiac output. The only treatment for cardiac tamponade is return to the OR, re-sternotomy, and evacuation of the clot with hemostasis of any ongoing bleeding. Most post-operative cardiac patients, who are hemodynamically stable, are not actively bleeding, and are following an otherwise uncomplicated post-operative course, tolerate a Hgb as low as 7.0 g/dL without problems. ON-LINE ICU MANUAL The target audience for this on-line manual is the resident trainees at Boston Medical Center. That is, to restart the heart contracting normally. Heart transplant: Immunosuppressive protocol. Remember, left ventricular coronary flow occurs during diastole with the gradient to flow being the difference between the aortic diastolic pressure (ADP) and the right atrial pressure (RAP). Thus the use of phosphodiesterase inhibitors "bypass" the beta-receptor. In the post-op cardiac surgery patient, it is possible to have a small, well-localized clot that impedes filling to only one chamber and thus cause unequal pressure changes.. For example, a right sided clot may raise only the CVP and impair filling to only the right atrium or ventricle. Introducing a nurse-led extubation protocol may lead to reduced extubation time. To perform the surgery, the patient is usually put on "pump" or cardiopulmonary bypass (CPB). Check the initial hemodynamic readings (HR, BP, cardiac output and index, CVP, PCWP) and determine what vasoactive infusions the patient is on and at what rates. The Respiratory Technician will place the patient on a ventilator. Or is it due to low SVR? Check pupillary reflexes. Deficits may begin to appear early in the form of postoperative delirium, which has been observed to occur in 10% to 30% of cardiac surgery patients. Helium is pumped into the balloon to inflate it at the beginning of diastole. By continuing to use this site you are giving us your consent. Current inotropes, vasopressors, or anti-hypertensives (if any). Rapid Extubation Following Cardiac Surgery With a Nurse Driven Protocol Previous Article Extubation Criteria for Patients With Total Artificial Heart (TAH) Next Article To Determine the Predictors of Mortality and Morbidity of Sepsis in Medical ICU of All India Institute of Medical Sciences (AIIMS), New Delhi, India The IABP console allows for manual adjustment of the balloon inflation and deflation. In some operations involving the aortic root, cross-clamping and cannulation of the aorta are not feasible. Several myocardial preservation techniques are used to protect the heart from ischemic damage during this period. Start at 2.5 mcg/kg/min. Protocol for Cardiac Surgical Patients in the Intensive Care Unit The recommended modification of the AHA algorithm to be applied in cases of cardiac arrest after cardiac surgery is presented in Figure 1. Author(s): Patrick Michaelis, BSN, RN, Richard J. Leone, MD, PhD. In fact the majority of uncomplicated patients have CVP's in the 6 to 10 mmHg range. Phenylephrine (Neosynephrine) - Pure alpha agonist. And every day, as a writer for UCHealth, Kati meets inspiring people, learns about life-saving technology, and gets to know the amazing people who are saving lives each day. Remember that PEEP can decrease preload by decreasing venous return. Recently, the Society of Thoracic Surgeons in the United States endorsed the guidelines. Occlusion of a large aortic branch including renal, SMA, or subclavian arteries with distal ischemia. This leads to a sudden decrease in the aortic pressure and thus LV afterload. Check for lobar collapse, atelectasis, effusions, pulmonary edema. 7 Introduction | UHS Cardiac ICU Handbook – Second edition 2016 dependency unit, the coronary care unit (both on D-level), and cardiothoracic theatres, cardiac pre and post-op wards and cardiac catheter laboratories (all on E level). If it shows great outcomes, the protocol could expand to UCHealth’s other cardiac ICUs, he said. Look for a "loss of the y-descent" on the CVP or PCWP tracing. Note that repositioning the patient (turning on their side) may also cause the drainage of a pre-existing collection of "old" darker blood that had pooled in the thorax. It also decreases Pulmonary Vascular Resistance (PVR) and thus can be useful if pulmonary hypertension or significant right ventricular dysfunction is a problem. Potassium, magnesium - a vigorous diuresis is common in the first few hours after the OR. Check the patient's heart rhythm. Is this an acute dehiscence of a valve repair? There are eight distinct strata or sub-populations within the SCIP Topic Population, each identified by a specific group of procedure codes. The balloon should also be placed so that it does not occlude the renal or mesenteric arteries. To perform the surgery, the patient is usually put on "pump" or cardiopulmonary bypass (CPB). The intensivist has the primary responsibility for the ICU patient’s care versus acting as a consultant, as many specialists do. But for those who do, the survival rate is low. Residual heparin effect; patients are anticoagulated before going on CPB with a large dose of heparin to maintain their ACT >400. Over the past year, Miller and Roberts have trained more than 60 nurses and other members of the ICU cardiac team in CALS, and each month, the unit holds mock training to keep their skills sharp. Further information on the IABP can be found at the following websites: Intra-Aortic Balloon Pumping - Internet Journal of Thoracic and Cardiovascular Surgery, IABP - A systematic review of the literature, Management of post-op cardiac surgery patients, Critical Care Drug Manual - London Health Sciences Centre, UWO, Type of operation (CABG, valve, elective vs. urgent etc), Pre-operative cath report (vessels involved, LVEF), Success of operation (completely or incompletely revascularized, difficulties, complications). Heart transplant immunosuppressive protocol for patients with renal dysfunction. Milrinone - phosphodiesterase inhibitors decrease the metabolism (breakdown) of cAMP. The IABP consists of a long cylindrical balloon placed at the end of a catheter placed in the descending thoracic aorta. Fibrinogenolysis; plasminogen activation during CPB. It’s a small number — 3%— of heart surgery patients who go into cardiac arrest in the days following their procedure. In each folder the following items can be found: 1. “There are a lot of interventions you can do with CALS while the patient is deteriorating. Check the position of all other tubes and drains. Negative effects include myocardial and mesenteric ischemia, LIMA spasm, dysrhythmias, and decreased cardiac output due to afterload increases. Other significant co morbidity, with emphasis on those conditions that may alter the post-operative management or course (carotid artery disease, COPD, asthma, diabetes, renal failure, hepatic failure, etc.). Norepinephrine (Levophed) -Strong alpha agonist with beta activity as well. Platelet numbers can be decreased following CPB due to hemodilution, destruction, and aggregation. Dobutamine - beta-agonist (ß1 >ß2). A valve repair or replacement can rarely have acute dehiscence. Persistent bleeding in the absence of a specific haemostatic defect (normal coagulation parameters). "Diastolic decrement" .The balloon deflates just before cardiac systole (just before opening of the aortic valve). Vaccines have arrived and we are implementing the distribution plan in coordination with the State. In the usual situation, there is a pressure gradient between the atrium and the ventricle because the ventricle has just emptied and the atrium has filled while the AV valve was closed during systole. More information can be found at the Critical Care Drug Manual - London Health Sciences Centre, UWO. HTN 5. For CCU, include cardiac studies in your note and cardiac systems in you’re A/P: 1. Start at 0.5 to 1.0 mcg/min and increase by these amounts until adequate cardiac index. Risk of thrombosis including acute graft thrombosis, DVT, PE. Traditional life support methods — which usually start with CPR — don’t make sense in an ICU where life-saving interventions are immediately available. Milrinone increases cardiac output. Assure that the endotracheal tube is in proper position and the patient has equal air entry bilaterally. BACKGROUND: Protocols for nurse-led extubation are as safe as a physician-guided weaning in general intensive care unit (ICU). ACLS guidelines don’t address this specific group, but CALS does. Predisposes to ventricular dysrhythmias and lowers VF threshold, Increases SVR; increases afterload and myocardial workload, Patient shivering causes increased peripheral O2 consumption, Decreases CO2 production; a patient who has a respiratory alkalosis (low PCO2) on initial ABG usually will increase their PCO2 with rewarming. Ease of separation from CPB ( dysrhythmias, need for inotropes, pacing, etc). There appears to be little benefit over Dobutamine as an inotrope. The urine output typically decreases and other signs of end-organ hypoperfusion develop including CNS changes and acidosis. 2013;146(1):172-178. doi: 10.1016/j.jtcvs.2012.12.042 PubMed … The nurse will then do the initial set of hemodynamic readings. Increases HR, CO, and SVR. Patients are rewarmed using the "Bear Hugger". Definitive studies are lacking. and a CVP that is "relatively" low should be given a fluid challenge. Design: Retrospective analysis of patients treated with the proposed ERACS bundle in comparison to matched controls. Topic Summary –1-2 page handout summary of the topic. Ideally should confirm fibrinolysis before use ( elevated D-dimers, low fibrinogen). EP 4. Critical Care Medicine www.ccmjournal.org 1477 Objectives: Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. The heart is usually cooled. The resident should be present in the ICU when the patient arrives from the operating room to receive a sign-over from the anesthesiologist and the cardiac surgical team. Verify correct position of the ETT. The goal is to facilitate learning of critical care medicine. Persistent hypotension is a frequent complication after cardiac surgery with cardiopulmonary bypass (CPB). In cardiac surgery, only few ERAS protocols have been described in the past. The safety and convenience of early extubation and reduced mechanical ventilation is well documented. It is sometimes difficult to liberate the patient from CPB or "get him off pump." “ACLS [advanced cardiac life support] guidelines are designed with out-of-hospital arrest in mind,” Willard added. Faisy et al demonstrated that large, negative energy balance increases with duration of ICU stay, becoming most relevant during prolonged mechanical ventilation, in patients fed under standardized nutrition management protocol. Echocardiogram. Before visiting a UCHealth facility, please be sure to read our visitor policy. Chest compressions can cause injury to the patient, so if other interventions can treat the problem and be initiated immediately they should be done first, both Miller and Roberts reiterated. Proper management of the hypotensive patient in the ICU requires that the precise etiology for the hypotension is determined and therapy is directed towards reversal of this specific problem. Is this a "pump" problem? The ng tube, chest tubes, and mediastinal sumps. Titrate upward by 2.5 mcg/kg/min until adequate cardiac index. The algorithms involved in the CALS protocol are designed to facilitate treatment and prevent catastrophic deterioration. We’ve had a lot of administration changes over the years, but this change directly affects patient care, and there is a lot of excitement around that.”. During this period, the ICU nurses will be transferring the patient to the ICU monitors and checking all lines and infusions. Midodrine, an orally administered alpha agonist, could potentially reduce intravenous vasopressor use and accelerate ICU discharge of otherwise stable patients. It has been described as the "ideal inotrope". Consider a "surgical" source of bleeding in the following situations: If any of the above criteria are noted you must notify the ICU Fellow or Attending and the Cardiac Surgery Fellow immediately. The protocol was applied to all elective post-operative cardiac surgery patients. This has been shown to improve platelet function and decrease active bleeding in uremia or vonWillebrand's disease. The SCIP Topic Population (common to all SCIP measures) is defined as patients admitted to the hospital for inpatient acute care with an ICD-9-CM Principal Procedure Code for SCIP as defined in Appendix A, Table 5.10, a Patient Age (Admission Date – Birthdate) >= 18 years, and a Length of Stay (Discharge Date - Admission Date) <= 120 days. 1 unit is 20 to 25cc. Heart transplant orders. However, with a patient who is not bleeding rapidly, one can take a more deliberate approach to transfusion. If it inflates too late, its ability to "augment" and effectiveness will be limited. They should be assessed as part of the overall clinical picture including the hemodynamic status of the patient and the EKG. Preliminary CALS outcomes are showing that the new protocol — and the early interventions it promotes — are keeping patients from arresting because it allows staff to pace (using a pacemaker) the patient before they go into full arrest, whereas ACLS would have them doing chest compressions. Starting dose is usually 2 to 5 mcg/min. Collect the following information from the anesthesiologist, surgeon, and the patient chart. “This will continue to protect our patients when problems are anticipated and should help to ensure our already excellent outcomes.”, Get the most popular stories delivered to your inbox monthly. Cardiac tamponade is compression of the heart that impairs ventricular filling and leads to a low cardiac output. In low doses ( 2 - 4 mcg/kg/min) it has been purported to have beneficial renal protective effects ("renal-dose dopamine"). Even better, she gets to share their stories with the world. Distal pulses should be monitored at least hourly. DDAVP 20 mcg iv. The incidence of cardiac tamponade post-cardiac surgery has been reported to be as high as 3 to 6 %. is a new unit of Joint Corps Armed Forces since March 2013. Pressors or inotropes are often used in order to aid "coming off pump." Remember, what you really are interested in is a volume measurement (preload= right or left end-diastolic volume), but what you are measuring are pressures (CVP or PCWP = Right or left ventricular end-diastolic pressures). Data were collected 3 Two methods are commonly used to time or "trigger" the IABP. Successful outcomes after cardiac surgery depend on … They soon received the support of the cardiothoracic surgeons, quality and code committees and senior leadership. It is also possible to decrease the volume the balloon inflates to by decreasing the amount of gas injected into it. Antifibrinolytic agents; Episilon-aminocaproic acid (AMICAR), tranexemic acid, or aprotinin. This involves cannulation of the right atrium and aorta (and later cross-clamping of the aorta), allowing the entire cardiac output to bypass the patient's heart and lungs. 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