Postoperative Cardiac Surgery Patient Research Articles

Modernization of Cardiac Advanced Life Support: Role and Value of Cardiothoracic Anesthesiologist Intensivist in Post–Cardiac Surgery Arrest Resuscitation

Cardiac arrest in the post-operative cardiac surgery patient requires a unique set of management skills that deviates from traditional cardiopulmonary resuscitation and Advanced Cardiovascular Life Support (ACLS). Cardiac Advanced Life Support (CALS) was first proposed in 2005 to address these intricacies. The hallmark of CALS is early chest reopening and internal cardiac massage within five minutes of the cardiac arrest in patients unresponsive to basic life support. Since the introduction of CALS, the landscape of cardiac surgery has continued to evolve.Cardiac intensivists encounter more patients who undergo cardiac surgical procedures performed via minimally invasive techniques such as lateral thoracotomy or mini sternotomy, in which an initial bedside sternotomy for cardiac massage is not applicable. Given the heterogeneous nature of the patient population in the cardiothoracic intensive care unit (CTICU), personnel must expeditiously identify the most appropriate rescue strategy. As such, we have proposed a modified CALS approach to (1) adapt to a newer generation of cardiac surgery patients and (2) incorporate advanced resuscitative techniques. These include rescue-focused cardiac ultrasound to aid in the early identification of underlying pathology and guide resuscitation and early institution of extracorporeal cardiopulmonary resuscitation (ECPR) instead of chest re-opening. While these therapies are not immediately available in all cardiac surgery centers, we hope this creates a framework to revise guidelines to include these recommendations to improve outcomes and how cardiac anesthesiologist intensivists' evolving role can aid resuscitation.

Renal recovery in cardiac surgery patients requiring postoperative renal-replacement therapy

ObjectiveRenal failure after cardiac surgery is associated with increased morbidity and mortality. There is a lack of data examining the rate of renal recovery after patients have started dialysis following cardiac surgery. We aimed to determine the frequency of and time to renal recovery of patients requiring dialysis after cardiac surgery. MethodsAll patients who developed new-onset renal failure requiring dialysis following cardiac surgery at our institution from 2011 to 2022 were included. Renal recovery, time to renal recovery, and mortality at 1 year were merged with patients’ Society of Thoracic Surgeons Adult Cardiac Surgery Database files. Kaplan–Meier analysis was used to predict time to renal recovery; we censored patients who died or were lost to follow up. Cox regression was used for risk-adjustment. ResultsA total of 312 patients were included in the final analysis. Mortality during index hospital admission was 33% (n = 105), and mortality at 1 year was 45% (n = 141). Of those surviving at 1 year, 69% (n = 118) remained renally recovered. Median renal recovery time was 56 (37-74) days. Accounting for mortality as a competing risk, 51% of patients were predicted to achieve renal recovery. Increasing age (hazard ratio, 0.98; 0.514-0.94, P < .026) and increasing total packed red blood cells (hazard ratio, 0.0958; 0.937-0.987, P < .001) received were found to be significant negative predictors of renal recovery in the Fine-Gray model for subhazard distribution. ConclusionsMore than two-thirds of patients with renal failure who survived the perioperative period had renal recovery within 1 year after surgery. Recovery was driven primarily by postoperative complications rather than comorbidities and intraoperative factors, suggesting renal failure in the postoperative cardiac surgery patient surviving to discharge is unlikely to be permanent.

MOVING RIGHT ALONG: INCORPORATING PATIENT-SPECIFIC RISK FACTORS IN POST-CARDIAC SURGERY STERNAL PRECAUTIONS PRESCRIPTIONS

MOVING RIGHT ALONG: INCORPORATING PATIENT-SPECIFIC RISK FACTORS IN POST-CARDIAC SURGERY STERNAL PRECAUTIONS PRESCRIPTIONS

Cardiac Postoperative Use of High-Flow Nasal Cannula: A Retrospective Single-Center Study

We aimed to investigate the risk factors and reason for initiation of high-flow nasal cannula (HFNC), its benefit on re-intubation rate, mortality, and length of stay (LOS) in the postoperative cardiac surgery patient in the ICU. Methods: In a retrospective and descriptive study, 200 patients, who underwent cardiac surgery, were randomly included, and screened for initiation of postoperative respiratory support. Demographic patient data and pre-operative patient measurements were sampled. Data concerning the P/F ratio at arrival- and post-extubation, LOS at ICU and overall mortality were sampled. A comparison of those variables was performed between patients with and without need of respiratory support. Results: HFNC was initiated in approximately 22.45% in 2018, and 25% in 2020, of the patients. Comparing both years didn’t reveal a significant rise, but we saw a quicker use of HFNC in 2020. The all-case re-intubation rate and mortality was approximately 3%. The body mass index (BMI) was the only correlation with a higher chance of initiation of HFNC. Other data like age, pre-operative renal- or left ventricle function didn’t show a correlation. Conclusion: In case of respiratory insufficiency in the postoperative cardiac surgery setting, HFNC is a worthy first line treatment option which is initiated if conventional oxygen therapy doesn’t suffice. The mortality was low, and the mean LOS was 4.38 days. If respiratory support was started with HFNC mean LOS rose to 8.35 days. The BMI seems to have a correlation with the development of respiratory failure, which confirms the latest recommendation to start preventive HFNC in the post-extubation cardiac surgery setting and which could be implemented in the daily practice.

Dexmedetomidine's Relationship to Delirium in Patients Undergoing Cardiac Surgery: A Systematic Review.

This systematic review aims to determine the relationship between postoperative delirium and the use of dexmedetomidine in comparison with commonly used sedatives/analgesics in the postoperative cardiac surgery patient. A systematic literature search of PubMed plus, CINAHL, Scopus, and Ovid, and limited to the English language in the last 10 years, was performed. Randomized controlled trials, observational and retrospective studies, and meta-analyses with at least 1 delirium assessment tool were included. The search found 196 potential articles; however, only 12 met the criteria outlined. The systematic review revealed a decrease in postoperative delirium for patients receiving dexmedetomidine in all studies. Seven studies demonstrated statistically significant reductions in postoperative delirium with dexmedetomidine compared with other sedatives/analgesics. One study also revealed reduction of delirium with dexmedetomidine as compared with normal saline. Two studies showed a delayed time to delirium onset in patients receiving dexmedetomidine versus propofol or morphine. The 2 meta-analyses found that all included studies had a statistically significant reduction in postoperative delirium when using dexmedetomidine. Postoperative use of dexmedetomidine in cardiac surgery patients may reduce the incidence of postoperative delirium.

Physiotherapy during and after extracorporeal membrane oxygenation support

Extracorporeal membrane oxygenation (ECMO) is a mechanical heart and/or lung support by a modified heart–lung machine, which enables blood circulation outside the body. The use of ECMO as rescue therapy for the patient in cardiac shock both before and following cardiac surgeries has been increasing over the past two decades. The purpose of this case study is to sensitize the role of the physiotherapist in interventions during and after ECMO in a postoperative cardiac surgery patient. Physical therapy interventions can be provided safely to patients on portable ECMO. These interventions were focused on preventing the negative sequelae of bed rest, improving strength and endurance, preventing ECMO complications as well as improving the level of consciousness and psychological well-being.

Effects of cold application on pain and anxiety during chest tube removal among post operative cardiac surgery adult patients

A study conducted to assess the effectiveness of cold application on Pain and Anxiety during Chest Tube Removal (CTR) among post operative cardiac surgery adult patients. Pre-test post-test control group experimental design was used. Post operative cardiac surgery adult patient of the selected hospital of Delhi were selected. The study sample was purposive sampling technique with random assignment of subjects into two groups: experimental group and control group. The sample size was 60 i.e. 30 in experimental group and 30 in control group. The control group received usual standard care during chest tube removal whereas experimental group received cold application with gel pack (Temp: 0–20C) after wrapping it with sterile gauze, around chest tube (5cms) for a period of 15 minutes before CTR. The tools used for the study were structured questionnaire to obtain demographic data, standardized Numerical Pain Intensity Scale (NPIS) scale to assess pain, C.D. Speilberger's State Trait Anxiety inventory (STAI) scale to assess anxiety. The obtained data was analysed and interpreted in terms of the objectives of the study using descriptive and inferential statistics. The mean post test pain scores with cold application (1.13 ± 1.31; 0.27 ± 0.44; 0.27 ± 0.44) at zero minute, 15 minute and 30 minute respectively were significantly (< 0.05) lower than the mean pre-test score of 6.10 ± 1.27 in the experimental group without cold application. In control group, pre test mean pain score was 6.57 ± 1.12 as compared to mean post test pain score of 8.57 ± 0.49; 8.73 ± 0.57; 8.63 ± 0.48 at zero minute, 15 minute and 30 minute respectively. It indicates that cold application was effective to reduce pain among post operative cardiac surgery patients while removing chest tube. To evaluate the effectiveness of cold application on anxiety related to chest tube removal, in experimental group the mean post cold application anxiety scores 41.93 ± 2.21 were significantly lower (< 0.05) than the mean anxiety score of 53.47 ± 1.84 before cold application. In addition, the mean anxiety score were 53.31 ± 1.81 before CRT and 57.87 ± 3.21 after CRT among post operative cardiac surgery patient in control group. It indicates that the cold application on chest tube removal was effective in reducing anxiety among post operative cardiac surgery patient. Cold application is simple, cheap, non pharmacological anxiety and pain management strategy ensuring good results.

Insertion and Management of Temporary Pacemakers.

Temporary pacemakers are used in a variety of critical care settings. These life-saving devices are reviewed in 2 major categories in this review: first, the insertion and management of epicardial pacemakers after and during cardiac surgery; and second, the insertion of transvenous temporary pacemakers for the emergent treatment of bradyarrhythmias. Temporary epicardial pacemakers are used routinely in patients recovering from cardiac surgery. Borrowing from advances in cardiac resynchronization therapy there are many theoretical and untested benefits to pacing the postoperative cardiac surgery patient. Temporary transvenous pacing is traditionally an emergency procedure to stabilize patients suffering from hemodynamically unstable bradyarrhythmia. We review the traditional and expanding use of transvenous pacemakers inside and outside the operating room.

Development of an Audit Tool for Evaluating Team Competency for the Simulation Procedure “Emergency Resternotomy” in the ICU Post Cardiac Surgery

Emergency Resternotomy, reopening of the sternum at the bedside in the postoperative cardiac surgery patient requires a high –level team response and a unique skill sets. Timing of the chest reopening is critical to survival of the patient Success of this low frequency (0.8-2.7% of post cardiac surgery patients) but high stakes procedure is dependant upon team performance in a crisis situation. A search of the literature did not provide a tool to measure team competency for this procedure.

N015 Dexmedetomidine in Management of Agitated Delirium in the Postoperative Cardiac Surgery Patient

Delirium is a reversible organic mental syndrome whose chief characteristic is anxiety. When excessive motor activity is associated with delirium it is referred to as agitated delirium. Delirium occurs in 80% of intensive care unit (ICU) patients and is associated with prolonged length of stay (LOS) and increased mortality. In the postoperative cardiac surgery patient agitated delirium can result in difficulty breathing causing ventilator dyssynchony, hypertension, tachycardia, and combative behaviour. The risk of prolonged ventilation and integrity of sternal incisions are very real complications.The diagnosis and pharmacological management of delirium is an important quality of care issue for the postop cardiac surgery patient. Pharmacoeconomics involves the right drug, the right dose, at the right time and by the right route. Typically neuroleptics such as haloperidol and a combination of benzodiazepines namely ativan are used to treat delirium but neither have any analgesia properties. Dexmedetomidine (Dex) has a rapid onset and provides sedation and analgesia with no respiratory depression and can be used as a bridge to weaning mechanical ventilation.A review of two challenging patients will be used to describe our experience using Dex as an alternative to managing postoperative delirium. The pharmacologic management in the cardiac surgical patient in these times of economic constraints has stimulated interest in early extubation or fast track pathways. A brief discussion on a study with Dex will be discussed. Delirium is a reversible organic mental syndrome whose chief characteristic is anxiety. When excessive motor activity is associated with delirium it is referred to as agitated delirium. Delirium occurs in 80% of intensive care unit (ICU) patients and is associated with prolonged length of stay (LOS) and increased mortality. In the postoperative cardiac surgery patient agitated delirium can result in difficulty breathing causing ventilator dyssynchony, hypertension, tachycardia, and combative behaviour. The risk of prolonged ventilation and integrity of sternal incisions are very real complications. The diagnosis and pharmacological management of delirium is an important quality of care issue for the postop cardiac surgery patient. Pharmacoeconomics involves the right drug, the right dose, at the right time and by the right route. Typically neuroleptics such as haloperidol and a combination of benzodiazepines namely ativan are used to treat delirium but neither have any analgesia properties. Dexmedetomidine (Dex) has a rapid onset and provides sedation and analgesia with no respiratory depression and can be used as a bridge to weaning mechanical ventilation. A review of two challenging patients will be used to describe our experience using Dex as an alternative to managing postoperative delirium. The pharmacologic management in the cardiac surgical patient in these times of economic constraints has stimulated interest in early extubation or fast track pathways. A brief discussion on a study with Dex will be discussed.

Heparin-induced thrombocytopenia with thrombosis syndrome managed with plasmapheresis

Heparin-induced thrombocytopenia with thrombosis syndrome is an antibody-mediated disorder that has a high mortality in cardiac surgical patients in spite of early diagnosis and management with direct thrombin inhibitors. Plasmapheresis, an extracorporeal technique that has been designed for the removal of large molecular weight substances from the plasma, can remove the offending antibodies from these desperately ill patients. We describe a case of a postoperative cardiac surgery patient with heparin-induced thrombocytopenia with thrombosis syndrome and multi-system failure who was dependent upon a left ventricular assist device. He was treated successfully with plasmapheresis with recovery of his platelet count from 25,000/microl to over 200,000/microl, along with multi-organ recovery. This patient survived because of plasmapheresis. Removing the antibodies to the heparin-platelet factor four complex with plasmapheresis is an effective strategy to treat these patients. We believe that the use of plasmapheresis as a bail-out procedure in these often desperately ill post-operative cardiac surgical patients who have heparin-induced thrombocytopenia with thrombosis syndrome could be lifesaving.

Lack of irrefutable validation does not negate clinical utility of near-infrared spectroscopy monitoring: Learning to trust new technology

Reliance on new monitoring device technology is based upon an understanding of how the device operates and its reliability in a specific clinical setting. The introduction of new monitoring devices will therefore elicit either distrust of the new technology and the data presented or adoption of new devices. The use of near-infrared spectroscopy (NIRS) technology to monitor vital organs in postoperative pediatric cardiac surgery patients has been extensively described yet controversy remains as to the use of this monitoring device. The following retrospective case series demonstrates how learning from trends in data elicited from 2-site NIRS monitoring provided important bedside insights. These insights led to changes in clinician behavior and reliance on NIRS monitoring for early recognition of clinically silent deteriorations. Disregard for the NIRS data may have led to a fatal outcome in an unstable patient who might have received more timely intervention if the NIRS data had been acknowledged earlier. This case series demonstrates that 2-site NIRS monitoring accurately reflects situations in which poor clinical outcomes may occur when declining trends in somatic tissue oxygen saturations are not corrected. Physician management of the postoperative pediatric cardiac surgery patient can change based upon the insights gained through the application of NIRS monitoring.

Brain-natriuretisches Peptid für die postoperative Überwachung der Flüssigkeitsbelastung bei einem herzchirurgischen Patienten

Brain natriuretic peptide is a neurohormone used for estimation of left ventricular wall tension and volume overload. We describe the use of this parameter in a postoperative cardiac surgery patient for detection and monitoring of left ventricular failure in a postoperative intensive care unit at a tertiary care center. Left ventricular failure was detected by brain natriuretic peptide levels, while x-ray and values obtained by the pulmonary artery catheter were inconclusive.

Co-existence of heparin-induced thrombocytopenia and thrombotic thrombocytopenic purpura in a postoperative cardiac surgery patient

Up to 50% of patients undergoing coronary artery bypass surgery will develop antibodies against the heparin-platelet factor 4 complex, and a small percentage of those will go on to develop heparin-induced thrombocytopenia. Thrombotic thrombocytopenic purpura has also been reported post-coronary artery bypass surgery. In this case report, we describe a patient who developed both heparin-induced thrombocytopenia and thrombotic thrombocytopenic purpura post-coronary artery bypass surgery. This patient had clinical features consistent with both entities, and the clinical picture could not be explained by either heparin-induced thrombocytopenia or thrombotic thrombocytopenic purpura alone. It is hypothesized that these two entities may be related in this patient population, and this case report emphasizes the challenges in the diagnosis of thrombocytopenia in this patient population.

Substernal epicardial echocardiography may be a critical diagnostic tool in the postoperative cardiac surgery patient

Substernal epicardial echocardiography may be a critical diagnostic tool in the postoperative cardiac surgery patient

Cardiothoracic intensive care: operation and administration.

The cardiothoracic surgery intensive care unit (CTICU) has evolved as a separate entity from the general surgical intensive care unit as management for cardiac surgery patients has become streamlined and algorithm driven. Critical care is best managed when the service is designed for a homogeneous population with a circumscribed set of medical and surgical issues. The repetition involved with the subspecialty care allows health care providers such as primary care nurses, nurse practitioners, physician assistants, and other ancillary services to become appropriately focused on issues pertinent to this population. The goals of the CTICU include the attainment of rapid and safe recovery from surgery and anesthesia despite decreasing resources, increasing patient age and comorbidity, and increasing complexity of the operative procedure. The coordinated and systematic approach to the postoperative cardiac surgery patient under the direction of a staff physician offers the most effective opportunity to achieve these expectations at this time. The traditional model of staffing by a physician with responsibilities that conflict temporally with the immediacy often needed for the postoperative care of cardiac patients may expose patients to unnecessary risks. A responsible physician should be available in the CTICU, especially during the immediate postoperative period when physical assessment and direct hands-on involvement are essential. In an era when the operative team (ie, cardiac surgeon and cardiac anesthesiologist) must return to the surgical suite soon after the patient arrives in the intensive care unit, the presence of a physician dedicated to postoperative medical and surgical management becomes mandatory. According to the Joint Commission on Accreditation of Healthcare Organizations, "Each special care unit is properly directed and staffed according to the nature of the special patient care needs anticipated and scope of services provided." The assignment of staff is designed to match experience with patient acuity.

Substernal epicardial echocardiography: A new ultrasonic window to the postoperative heart

Echocardiographic examination of the postoperative cardiac surgery patient is often problematic because of a poor acoustic window that requires imaging by transesophageal echocardiography. Furthermore, no available echocardiographic methods exist for simple ongoing beat-to-beat assessment of postoperative left ventricular size and function. We designed a modification of a mediastinal drain to allow a transesophageal echocardiography probe to be placed adjacent to the epicardial surface of the heart. After chest closure in a series of 13 patients, we were able to obtain 5- and 7-MHz epicardial images of high quality in both short- and long-axis planes, which also allowed Doppler examination of aortic, mitral, and tricuspid valves in 10 patients. This technique was suitable for prologned and serial assessment of left ventricular size and function. Though preliminary, these observations suggest that this new substernal epicardial echocardiographic window to the postoperative heart offers a potential for prolonged monitoring of cardiac function as well as rapid and accurate diagnosis in problematic patients.

Hypothermia and Rewarming after Cardiac Surgery

Ensuring adequate oxygen delivery to the tissues with respect to oxygen demand is an important operative challenge during cardiac surgery. The state of the art in myocardial preservation in the 1990s has evolved to include pretreatment of the myocardium; intraoperative use of systemic hypothermia with cardiopulmonary bypass (CPB), topical cooling of the myocardium, cold cardioplegia, and myocardial reperfusion; and postoperative oxygen transport support. These techniques optimize myocardial preservation while providing adequate cardiac surgery operative times by decreasing the myocardial ischemic period, decreasing cellular metabolic requirements, and preserving energy stores. Awareness of the physiologic consequences of hypothermia in the postoperative cardiac patient improves nursing assessment of the hypothermic patient. Appropriate temperature monitoring and reporting support timely medical and nursing interventions for hypothermia, such as internal and external rewarming techniques or drug administration to facilitate the rewarming process and suppress or treat shivering. This article addresses the physiologic condition of hypothermia, the elective hypothermia techniques used during cardiac surgery, and the medical or nursing rewarming and management techniques for the postoperative cardiac surgery patient.

ARDS in the postoperative cardiac surgery patient: a case study

ARDS in the postoperative cardiac surgery patient: a case study

Stability of arterial to end-tidal carbon dioxide gradients during postoperative cardiorespiratory support

The changes in the arterial to end-tidal carbon dioxide gradient. P(a-ET)CO2, were studied in postoperative cardiac surgery patients from the time of admission to the intensive care unit, during changing cardiorespiratory support, up to the time of tracheal extubation. Individual factors evaluated for their effects on P(a-ET)CO2 included rate of mechanical ventilation, infusion of vasoactive agents (nitroglycerin, nitroprusside, dopamine, dobutamine, and metariminol), and associated changes in haemodynamic pathophysiology (cardiac index, pulmonary artery pressure, pulmonary vascular resistance index, systemic vascular resistance index, and pulmonary capillary wedge pressure). After approval by the Clinical Investigation Committee, 59 patients, age 63 +/- 9 (41 to 75) yr, were studied and 382 individual gradient determinations made. Mean P(a-ET)CO2 was 5.47 +/- 5.21 mmHg, with the mean PaCO2, 36.51 +/- 5.89 mmHg and mean ETCO2, 31.04 +/- 6.44 mmHg. For the population as a whole, the correlation between PaCO2 and ETCO2 determined by regression analysis was maintained (R = 0.644, P less than 0.001). Comparison of the individual and population correlation coefficients by Student's t test showed no significant difference, but a normal population distribution of the gradients (P less than 0.05). None of the variables assessed could be determined to influence P(a-ET)CO2 significantly. For many of the individual patients, however, the relationship between PaCO2 and ETCO2 did not maintain a significant correlation throughout the study period. In the postoperative cardiac surgery patient population P(a-ET)CO2 follows a normal distribution and PaCO2 and ETCO2 maintain a statistically significant correlation. However, when evaluating individual patients, this relationship has wide variability.