Postoperative Critical Care for Adult Cardiac Surgical Patients

Abstract

Cardiac operations represent one of the most common categories of surgery in developed countries with an annual cost in excess of $20 billion in the United States alone. Cardiac surgery is continuously evolving and modern practice has come to include minimally invasive, hybrid, and transcatheter techniques with the patient managed by “the heart team.” An increasing age and medical complexity of patients considered for cardiac surgical procedures mean that the critical care management needs to adapt to meet increasingly broad and elaborate needs. The second edition of Postoperative Critical Care for Adult Cardiac Surgical Patients remains edited by Dr Dabbagh, cardiac anesthetist, and Drs Esmailian and Aranki, both cardiac surgeons. Together they form an extensive body of professional expertise in all aspects of care of the adult cardiac surgical patient. They have supervised 26 chapter contributors representing anesthetic, critical care, and surgical departments mainly in Iran and the United States with a few Italian institutions represented as well. The book has an ambitious scope with the aim to cover all perioperative aspects of the cardiac surgical patient in 22 chapters totaling 670 pages with 60 tables and 97 illustrations, the majority in color. The format is conducive to a general discussion with a few aspects covered more in depth. All chapters are informative albeit some provide more guidance than others. The chapter of hemodynamic monitoring is detailed and includes an up-to-date overview of cardiac output monitors. A short final paragraph explains that transesophageal echocardiography is beyond the scope of this book and the reader is referred to other specialized resources. The chapter on postoperative coagulation and management of bleeding provides an excellent summary of point-of-care testing of coagulation in the intensive care unit with succinct presentations of both thromboelastography and rotational thromboelastometry. Interpretation and suggestions for actions based on results using both devices are presented and clearly summarized in table format. All relevant anticoagulants in current clinical practice and guidelines for their reversal are nicely presented. The chapter on “Postoperative Safety in Adult Cardiac Surgery Intensive Care Unit” includes a useful section on handoff protocols and also covers team huddles and team performance. In particular, the example multidisciplinary simulation scenario demonstrates the approach to building and improving teamwork along all facets of perioperative care, with a natural emphasis on postoperative complications. The chapter on cardiac anatomy is overly basic and lacking in terms of functional aspects and clinical implications. The chapter on cardiac physiology to some extent suffers from the same shortcomings and aspects of regulation of blood flow would seem to warrant a more comprehensive consideration. Some readers will surely be surprised that no references are made to the state-of-the-art research performed by Arthur Guyton. The pharmacology chapter provides a clinically orientated overview of most drugs likely to be encountered in a cardiac, or for that sake general, intensive care unit, while an approach of listing rather than categorizing by postoperative scenarios renders the text somewhat insipid. The chapter devoted to mechanical circulatory support includes rather extensive pharmacological and physiological considerations that are already covered in other chapters. This sidetracks the main theme of the text, in particular for the modality of venoarterial extracorporeal membrane oxygenation that has most relevance to cardiac intensive care practitioners. The chapter on renal complications focuses on basic principles, while renal replacement therapy is covered on less than 1 page. This appears cursory given the significance of dialysis-dependent renal failure on long-term clinical outcomes. Unfortunately, the presentation is at times distracted by a below-par English style and grammar that should have been addressed in a second revision. There is also a tendency for repetition and overlap between chapters, and a more effective use of cross-referencing would have been useful to the reader. An eBook edition is available but was not accessed for this review. The book navigates difficult waters between a preparatory text and a complete reference textbook. Those with some experience of general intensive care wanting to explore cardiac intensive care will likely find the book rewarding, while it is arguably a bit unwieldy to use as an introductory text. The fellow or specialist colleague with experience in a cardiac intensive care unit might find the text lacking in detail and depth compared to textbooks of cardiac surgery but still useful as a source for refreshing clinical knowledge. We recommend the advanced trainee or junior consultant looking for 1 manageable volume to cover the field to buy the book. Anders Aneman, MD, PhD, FCICMWilliam O’Regan, MD, FCICM, FANZCADepartment of Intensive CareLiverpool Hospital, South Western Sydney Local Health DistrictMacquarie University HospitalSydney, Australia[email protected]