Cardiac Surgery Advanced Life Support 3-24-14

16 Pages·2014·3.62 MB·English

3/29/2014
• In the immediate postop recovery in a cardiac surgery patient is
typically related to reversible causes
•Tamponade
•Bleeding
•Ventricular arrhythmias
•Blocks associated with conduction problems
• Survival to discharge can be up to 79%
• If treated promptly
UnityPoint Health-Methodist, Peoria
Heart of IL AACN –President
www.cherylherrmann.com
• Pros
•EBP resuscitation guidelines
•Standardized approach
• Hospitals developed own guidelines and protocols
•Easy to teach and implement
• No standardization
• Cons:
•Do not specifically address
cardiac surgery arrests
2009
European Association
for Cardio-Thoracic
Surgery
1
3/29/2014
California Pacific Medical Center/Sutter
Health
Mayo Clinic
Duke University Medical Center
Temple University Hospital Beth Israel
Deaconess Medical Center
Society of ‘Thoracic Surgeons (STS) soon!
www.csu-als.com
• CALS
• CSU-ALS
•CALS- S
Cardiac Advanced Life
Support - Surgery
• Assess Rhythm • Ventricular Tach or Fib
• Shock before • Asytole or severe
Compressions bradycardia
• Pace/Atropine –not Epi
• Pulseless Electrical
• Identify reversible causes Activity
• Early resternotomy
2
3/29/2014
• No evidence to support CPR prior to defibrillation for in-hospital
arrests
• Best survival for in-hospital arrests is when defibrillation occurs within
two minutes of VF/VT Sternum during CPR
• Successful restoration of rhythm may occur after the first defibrillation Rewired sternum
in 86-96% of patients
• Success declines with each sequential shock with unlikely success after
the fourth shock
• Potential trauma or complications from the compressions.
•The unstable sternum or sternal wires may cause disruption of vascular sutures RV tear after sternum recoils
or right ventricular tear.
• Thus, defibrillation is recommended first, if it can be achieved within
sixty seconds
References listed in EACTs Cardiac Surgery Guideline Photos courtesy of Jill Ley
• Restoration of sinus rhythm after early
defibrillation or resternotomy is highly
successful
• Iwf idtheinf ib3r0il lsaetcoorn advsailable • Administration of epinephrine may result in X
• 3sequential shocks severe rebound hypertension leading to
• Compressions suture line disruption or aortic rupture
• Amiodarone
• Prepare for resternotomy
• CPR with shock every two
minutes
2ndperson
manages airway
• Pace if wires available
• DDD 90 bpm and max MA
• CPR
• Atropine 3 mg IV
• Consider external pacing
• Prepare for resternotomy
• CPR
2ndperson
manages airway
3
3/29/2014
• No evidence available in
favor of atropine in cardiac
surgery arrests
• Relatively benign drug with • CPR
• If paced, turn off pacer
few side effects to assess for VF
• Thus recommended for • Prepare for
resternotomy
asystole or extreme
• Determine and treat
bradycardia causes –H & Ts
2ndperson
manages airway
• Cardiac surgery patients who arrest with PEA are typically Hs Ts
Four Four
experiencing treatable causes
Hypoxia * Tamponade *
•Hypovolemia --severe
•Hypoxia
•Tamponade Hypovolemia* Tension
•Tension pneumothorax Pneumothorax
• Prompt treatment results in good outcomes Hypokalemia/ Thromboembolism
• To assess for causes of PEA/nonschockablerhythm Hyperkalemia
•Consider the 4 “Hs” and 4 “Ts Hypothermia Toxin
* = Most common causesof cardiac surgery arrests
Hypoxia Hypovolemia and Tamponade
• Treat per airway • Severe hypovolemia is
management and assessment typically due to bleeding
• If ventilated, turn Fi02
• Severe hypovolemia and to 100% and turn off
tamponade both require PEEP
• Assess for airway
emergent resternotomy to
patency and lung
correct sounds
2ndperson
manages airway
4
3/29/2014
• Check endotracheal tube (ET) position and end tidal • Feel the trachea to verify it is midline.
carbon dioxide (EtCO2) waveform and reading • If a tension pneumothorax is suspected, insert a large
• Listen for an ETT airleakand verify that is properly bore needle into the 2ndintercostal space, mid-
inflated clavicularline.
• Listen and look for bilateral breath sounds. • If unable to ventilate the patient with a bag-mask-
•Consider removing the patient from the ventilator and give 100% oxygen valve, attempt to suction the ET tube.
via bag-mask-valve to more easily assess lung sounds and determine lung • If unable to pass the suction catheter, ETT occlusion or malposition should
compliance
be suspected.
•If bilateral lung sounds are present, reconnect the ETT to ventilator. •Remove the ETT and ventilate with a bag-mask-valve.
Team leader
1. External cardiac • Conducts the management of the
massage arrest
• Ensures the protocol is followed
2. Management of
• Assigns roles
airway and breathing
ICU nursing Coordinator
3. Defibrillation
• Manages the arrest from the
4. Team leader peripheral bedside
• Resternotomy preparation
5. Medication
• Managing additional personnel
administration • Calling for expert assistance as
needed
6. ICU nursing
• Reporting back to the team leader
Coordinator
Medication Administration
• CALS-S recommends as best practice
to stop all medication infusions • In all three arms of the algorithm, prepare for
• Continuing pre-arrest medication
emergent resternotomy if:
infusions is unlikely to assist resolution
of the cardiac arrest •The initial treatment is unsuccessful
• An inadvertent flushing of a •Resuscitation efforts are likely to last longer than 5 –10
vasodilator or residual medication in
minutes
a central line lumen causing the arrest
• May be restarted as needed for • Internal cardiac massage is superior to external
hemodynamic stability cardiac massage in cardiac surgery patients
• Sedative infusions may be continued
if there is a concern about patient
awareness.
5
3/29/2014
Open Chest Cart
Cart &
SternalSaw
Top of Cart
• Sterile all-in-one thoracic
drape
• Scalpel
• Wire cutter
• Heavy needle holder
• Sternal retractor.
Drawer #1: Drapes, Towels Drawer #2: SternalSaw
Photos courtesy of Jill Ley Photos courtesy of Jill Ley Drawer #3: SternotomySet Drawer #4: IntPaddles & Headlamp
Upon calling of cardiac arrest, prepare for
emergent resternotomy
• Emergent situation –Aseptic Technique --
hand washing is not necessary prior to • EACTS guidelines suggest if a
sterile gloves surgeon is not immediately
• Two staff members available resternotomy by
•Put on sterile gowns and gloves another staff member maybe
•Prepare the emergency sternotomy set be lifesaving.
• A third person should be the circulator to
hand-in or open sterile equipment. • State licensure regulations
• The surgeon and all assistants determine who is eligible to
•Wear sterile gowns and gloves, but face-masks perform the resternotomy and
and surgical caps are not essential per EACTS internal massage.
guidelines.
•However, CDC guidelines for invasive
procedures recommend personnel wearing
face-masks and surgical caps.
Photos courtesy of Jill Ley Photos courtesy of Jill Ley
The sternotomy
manikin
Photos courtesy of Jill Ley www.csu-als.com Photos courtesy of Jill Ley
6
3/29/2014
• Bleeding
• Ischemia
• Tamponade
• Respiratory failure
• High output failure
• Acute mitral regurgitation
• Bradyarrhythmia
• Ventricular tachycardia
• Supraventricular tachycardia
Photos courtesy of Jill Ley
Photos courtesy of Jill Ley
CALS-S ACLS
• Review equipment For VF/VT
•Internal paddles, cart trays Defibrillation takes priority; may defer Externalmassage should be performed on
•Pacemakers massage for up to 1 minute all patients
• Resuscitation responses 3 successiveshocks before CPR CPR fi 1 shock fi CPR
•Defibrillation/pacing For Asystole
•Code management DDD pacing at maximal output External massage & vasopressor
•Teamwork For VF/VT, Asystole, Pulseless Electrical Activity
• Pre-resuscitation management No vasopressor unless seniorMD Epinephrine 1000 mcg every 3-5 minutes
Pre-arrest: Epidose < 100 mcg +/-vasopressin 40units x 1
•Early recognition and management of
Utilize 6key roles during arrest Similar roles withemphasis on team leader
hypotension
Additional 2 people gown & glove
•Avoidance of full blown arrest
Rapidresternotomy (<5 min) if no N/A
•Critical thinking skills! response to defib/pacing
Recopied with permission from Kiermani B, Ley J, Bartley T, Strang T, Levine A, Dunning J. The Cardiac Surgery
Photos courtesy of Jill Ley Advanced Life Support Course, 2nded. Lulu Publishers at www.lulu.com. 2012.
• Recommended up to POD #10 • What happens when we get standardized, “bundle”
• Beyond POD #10, senior clinician should decide approaches to patient care?
• Internal cardiac massage should still be considered in •VAP
preference to prolonged external compressions especially if a •Sepsis
reversible cause is suspected •CAUTI
• EACTs recommends only use in the ICU
•May consider use in progressive units in early post op days
•Cardiovascular ICU nurses would respond and direct the emergent
resternotomy
7
3/29/2014
• Literature
• Thorough review of the guidelines to determine the
•Published guidelines applicability to your institution’s cardiac surgery population
•Pocket guide
• Identify a change champion and key team members
•Course book
•Listserve • Get approval Medical Executive Committee
• Web •Not currently a course in the USA
•Create written approved internal protocols for management of cardiac
•csu-als.com
surgery arrest patients
•Youtube
• Attend CALS-S or create your own
•www.lulu.com
• Practice
• Other
Herrmcnn, C. Cardiac Advanced
Life Support-Surgical Guideline.
AACN Advanced Critical Care
2014: 26 (2).
• Assess Rhythm
• Shock before
Compressions
• Pace/Atropine –not Epi
• Identify reversible causes
• Early resternotomy
Conquering Complications:
Cheryl Herrmann, APN, CCNS-CSC-CMC
8
3/29/2014
Trauma Triad of Death
Coagulopathy
Death
Hypothermia
Acidosis
Decreased myocardial performance
Cardiac Surgery Hypoperfusion Starts
Triad of Disaster the Triad of Disaster
Coagulopathy Coagulopathy
(cid:1)LOS (cid:1)LOS
Complications Complications
Hypothermia Death Metabolic Hypothermia Death Metabolic
Acidosis Acidosis
Decreased myocardial performance Decreased myocardial performance
Hypoperfusion Starts Cardiac Surgery
the Triad of Disaster Triad of Disaster
Coagulopathy Coagulopathy
(cid:1)LOS (cid:1)LOS
Complications Complications
Hypothermia Death Metabolic Hypothermia Death Metabolic
Acidosis Acidosis
Decreased myocardial performance Decreased myocardial performance
9
3/29/2014
Hypothermia
Causes of Heat Loss
♥ Cooled during CPB
♥ Cold OR room
♥ Cool room and/or fan on
♥ Cold fluids
• 1 unit of pRBC can lower body Temp 0.25o C
• 1 liter of fluids unit can lower body Temp 0.5o C
♥ No blankets
♥ Head uncovered
Ugly consequences of hypothermia
Causes of Heat Loss
1. Increased oxygen debt
• Cold hemoglobin can not release oxygen to the cells
♥ Cooled during CPB 2. •IncrLeeafst sehdi ftla ocft tich ea ocxidy hpermodougclotbioinn dissociation curve
♥ Cold OR room • Change from aerobic to anaerobic metabolism
• Leads to acidosis
♥ Cool room and/or fan on 3. Coagulopathy
♥ Cold fluids • Prolonged clotting cascade
• Platelet dysfunction –platelets are extremely temperature dependent
• 1 unit of pRBC can lower body Temp 0.25o C • Altered fibrinolytic system
• 1 liter of fluids unit can lower body Temp 0.5o C 4. •AlteDreedc recaasrdeido cvaarsdciaucla oru ftupnucttion
♥ No blankets • Risk of arrhythmias
• Increased SVR due to vasocontriction
♥ Head uncovered 5. Hyperglycemia
• Decrease insulin production
6. Decreased cerebral blood flow
• 6 –7% decrease in CBF with body temp decrease of 10C
Cardiac Surgery
Rewarming techniques
Triad of Disaster
Coagulopathy
♥ Warm room –no fan
♥ Warm blankets –keep patient covered
♥ Bare Hugger
♥ Use blood warmer to give blood products
• Have blood warmer and bare hugger in room (cid:1)LOS
Complications
Metabolic
Hypothermia Death
Acidosis
Decreased myocardial performance
10