Cardiothoracic Surgery

868 Pages·2013·7.73 MB·English

by  Joanna Chikwe

The EuroSCORE
The most up to date version (EuroSCORE II) of this risk calculator can be
found at www.euroscore.org/calc.html
European System for Cardiac Operative Risk Evaluation Score
Eur. J. Cardiothorac. Surg. 1999 16; 1; 9–13
Weights add up to an approximate percentage predicted mortality
E.g. a 70 year old female undergoing elective CABG + AVR has a predicted
percentage mortality of (age: 2) + (gender: 1) + (operative factors: 2) = 5%
Factor Defi nition Score
Patient Age Per 5 years or part thereof over 60 1
related
Gender Female 1
factors
COPD Long term use of bronchodilators or 1
steroids for lung disease
Extra-cardiac Any one or more of: claudication, 2
arteriopathy carotid occlusion or >50% stenosis,
previous or planned surgery on the
abdominal aorta, limb arteries, carotid.
Neurological Disease severely affecting ambulation 2
dysfunction or day-to-day functioning
Previous cardiac Previous surgery requiring opening of 3
surgery the pericardium
Serum creatinine >200μmol/l preoperatively 2
Endocarditis Patient still under antibiotic treatment 3
for endocarditis at the time of surgery
Critical Ventilation before arrival in anaesthetic 3
preoperative room, preoperative inotropic support,
state intraaortic balloon counterpulsation
or preoperative acute renal failure:
oliguria <10ml/hr
Cardiac Unstable angina Angina requiring iv nitrates until arrival 2
factors in the operating room
LV dysfunction Moderate (EF 30–50%) 1
Poor < 30% 3
Recent MI <90 days 2
Pulmonary Systolic PA pressure >60mmHg 2
hypertension
Operative Emergency Carried out on referral before the 2
factors beginning of the next working day
Other than Major cardiac operation other than or 2
isolated CABG in addition to CABG
Surgery on Ascending, arch or descending aorta 3
thoracic aorta
Post infarct septal rupture 4
ALS algorithm
Unresponsive?
Not breathing or
only occasional gasps
Call
resuscitation team
CPR 30:2
Attach defibrillator / monitor
Minimize interruptions
Assess
rhythm
Shockable Non-Shockable
(VF / Pulseless VT) (PEA/Asystole)
Return of
1 Shock spontaneous
circulation
Immediately resume Immediate post cardiac Immediately resume
CPR for 2 min arrest treatment CPR for 2 min
Minimize interruptions •Use ABCDE approach Minimize interruptions
•Controlled oxygenation and
ventilation
•12-lead EKG
•Treat precipitating cause
•Temperature control/
therapeutic hypothermia
During CPR Reversible Causes
•Ensure high-quality CPR: rate, depth, recoil •Hypoxia
•Plan actions before interrupting CPR •Hypovolaemia
•Give oxygen •Hypo-/hyperkalaemia/metabolic
•Consider advanced airway and capnography •Hypothermia
•Continuous chest compressions when advanced
airway in place •Thrombosis - coronary or pulmonary
••VGaivsecu aldarr eancacleinsse (einvetrrayv 3e–n5o ums,i nintraosseous) •••TTTaoemnxsipnioosnn apdnee u- mcaortdhiaocrax
•Correct reversible causes
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Oxford Specialist
Handbook of
Cardiothoracic
Surgery
Second edition
Joanna Chikwe
Associate Professor, Department of Cardiothoracic
Surgery, Mount Sinai Medical Center,
New York, United States
David Tom Cooke
Assistant Professor, Division of Cardiothoracic
Surgery, University of California, Davis Medical Center,
Sacramento, United States
Aaron Weiss
Resident, Department of Cardiothoracic Surgery,
Mount Sinai Medical Center, New York,
United States
1
3
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Second Edition published in 2013
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v
Preface to second edition
I wrote the fi rst edition of this book when I was a cardiothoracic surgery
resident because I wanted facts, tips, and advice covering the whole spec-
trum of this brilliant specialty instantly available in my pocket—a compact
insurance policy against errors and ignorance in a spill-proof cover. Six
years on, the cover has changed, but the aim stays the same—and largely
thanks to two simply great new co-authors who totally understood the
whole idea. This second edition has been expanded, updated and revised
for an international audience.
It is usually much easier to understand stuff if you can see it or simplify
it—so the book is full of drawings, lists, and tables. It is nice to have answers
for those ‘Why do we do that?’ moments—this book will give you those,
as well as a good framework for further reading and exam revision. But
mainly, this handbook is for making sure you have the facts and practical
advice you need, in front of you, to provide the best cardiothoracic care
you can, in the ICU, at the bedside, and in the operating room.
Now, go save some more lives!
JC
2012
vi
PPrreeffaaccee to fi rst edition
This handbook is aimed at doctors embarking on their fi rst job in cardio-
thoracic surgery. We hope it will also be useful for junior doctors and
allied health professionals working in cardiac anesthesia, cardiothoracic
intensive care units, coronary care units, and cardiothoracic theatres.
Cardiothoracic surgery is an exciting, fast-moving, and sometimes daunt-
ing speciality. The primary concern of junior doctors is correctly diagnos-
ing and managing the life-threatening problems that can rapidly develop
in the postoperative patient. From their fi rst day on a cardiothoracic unit,
junior surgeons are also expected to play a part in preoperative decision-
making; and they need to rapidly acquire a fi rm grasp of the principles of
operative surgery. This handbook brings together these aspects of this
challenging speciality, covering adult and pediatric cardiac and thoracic
surgery. It is not intended to be a comprehensive text, or a ‘do-it-yourself’
guide to cardiothoracics: it is designed to accompany practical training
under direct supervision, enabling junior doctors and healthcare profes-
sionals to gain the most from their time in the speciality.
The evidence base behind daily practice is outlined in sections that
include the basic sciences applied to cardiothoracic surgery, key references
from the literature, and a bibliography of text and web-based resources.
JC
EB
BG
2006
vii
Acknowledgements
I would like to record my heartfelt thanks to our many contributors:
Miss N Kahn, Consultant Congenital Surgeon, Birmingham Children’s
Hospital, completely revised Chapter 12.
Dr A Pawale, Integrated Cardiothoracic Surgery Resident, Mount Sinai
Medical Center revised Chapter 11.
Particularly extensive and helpful changes to the fi rst edition were
made by Dr P Jones, Consultant Cardiac Anaesthetist and Intensivist,
St Bartholomew’s Hospital, London, most of which have been retained
in chapters 3 and 5.
Prof J Pepper, Professor of Cardiothoracic Surgery, Royal Brompton
Hospital, London; Dr K Mandal, Assistant Professor, Cardiac Surgery, Johns
Hopkins University School of Medicine, Baltimore; Mr B Sethia, Consultant
Cardiac Surgeon, Royal Brompton Hospital, London; and Mr A Cherian,
Consultant Cardiothoracic Surgeon, London reviewed initial drafts of the
fi rst edition, and their infl uence carries over into this one.
I am also very grateful to our junior advisers who road-tested early
drafts: Dr A Weiss, Dr C Critchley, Dr M Ridgeway, and Dr A Smith.
I thank Mr M Poullis, Consultant Cardiothoracic Surgeon, the
Cardiothoracic Centre, Liverpool for allowing us to use images from
his library in Chapter 5; the Resuscitation Council UK for permission to
reproduce the ALS algorithm from their 2000 guidelines; and the Society
of Cardiothoracic Surgeons of Great Britain and Ireland for their permis-
sion to reprint the Euroscore table on the inside cover. The table on
p361 was adapted from Kirklin/Barratt-Boyes Cardiac Surgery, 3rd edition,
Volume 1, Nicholas T Kouchoukos, Eugene H Blackstone, Donald B Doty,
Frank L Hanley, Robert B Karp, Table 7.7 p391, copyright 2003, with per-
mission from Elsevier.
Illustrations are drawn by me, except where otherwise acknowledged.
Finally I would like to thank the staff at OUP for their help and support,
particularly Helen Liepman, Imogen Lowe, Susan Crowhurst, Tessa Eaton,
Kate Smith, and Fiona Chippendale.
JC