perioperative management

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Perioperative Care of Perioperative Care of the Cardiac Surgery the Cardiac Surgery Patient Patient Lars Hegnell, MD Lars Hegnell, MD Dept. of Anesthesiology and Perioperative Medicine OHSU, Portland, Oregon

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Page 1: Perioperative Management

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

Page 2: Perioperative Management

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

Page 3: Perioperative Management

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

Page 4: Perioperative Management

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

Page 5: Perioperative Management

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

Page 6: Perioperative Management

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.

Page 7: Perioperative Management

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

Page 8: Perioperative Management

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).

Page 9: Perioperative Management

High-risk SurgeriesHigh-risk Surgeries

Aortic and major vascular surgery

Cardiac surgery

Emergency surgical procedures

Prolonged surgery with massive fluid shifts or bleeding

Page 10: Perioperative Management

ComorbiditiesComorbidities

Diabetes mellitus

Hematological disease

Pulmonary disease

Renal disease

Smoking

Page 11: Perioperative Management

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.

Page 12: Perioperative Management

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.

Page 13: Perioperative Management

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

Page 14: Perioperative Management

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

Page 15: Perioperative Management

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

Page 16: Perioperative Management

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.

Page 17: Perioperative Management

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

Page 18: Perioperative Management

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)

Page 19: Perioperative Management

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

Page 20: Perioperative Management

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

Page 21: Perioperative Management

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.

Page 22: Perioperative Management

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

Page 23: Perioperative Management

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.

Page 24: Perioperative Management

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

Page 25: Perioperative Management

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

Page 26: Perioperative Management

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

Page 27: Perioperative Management

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

Page 28: Perioperative Management

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

Page 29: Perioperative Management

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

Page 30: Perioperative Management

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

Page 31: Perioperative Management

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)

Page 32: Perioperative Management

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)

Page 33: Perioperative Management

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.

Page 34: Perioperative Management

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

Page 35: Perioperative Management

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

Page 36: Perioperative Management

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

Page 37: Perioperative Management

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

Page 38: Perioperative Management

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

Page 39: Perioperative Management

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

Page 40: Perioperative Management

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.

Page 41: Perioperative Management

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.

Page 42: Perioperative Management

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

Page 43: Perioperative Management

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

Page 44: Perioperative Management

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.

Page 45: Perioperative Management

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.

Page 46: Perioperative Management

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.

Page 47: Perioperative Management

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

Page 48: Perioperative Management

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

Page 49: Perioperative Management

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.

Page 50: Perioperative Management

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?

Page 51: Perioperative Management

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?

Page 52: Perioperative Management

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?

Page 53: Perioperative Management

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.