Manual of Perioperative Care in Adult Cardiac Surgery, Fourth Edition

617 Pages·2005·9.41 MB·English

by  Robert M. Bojar(auth.)

MANUAL of
PERIOPERATIVE CARE in
ADULT CARDIAC SURGERY
Fourth Edition
MANUAL of Perioperative Care in Adult Cardiac Surgery, Fourth Edition Robert M. Bojar
© 2005, Robert M. Bojar, M.D. ISBN: 978-1-405-10439-5
MANUAL of
PERIOPERATIVE CARE in
ADULT CARDIAC SURGERY
Fourth Edition
By
Robert M.Bojar,M.D.
Associate Professor ofCardiothoracic Surgery
Tufts University School ofMedicine
ChiefofCardiothoracic Surgery
St.Vincent Hospital,Worcester,Massachusetts
Senior Cardiothoracic Surgeon
Tufts-New England Medical Center,Boston,Massachusetts
© 2005,Robert M.Bojar,M.D.
Blackwell Publishing,Inc.,350 Main Street,Malden,Massachusetts 02148-5018,USA
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6 2009
ISBN 978-1-4051-0439-5
Library of Congress Cataloging-in-Publication Data
Bojar,Robert M.,1951–
Manual of perioperative care in adult cardiac surgery/by Robert M.Bojar.—4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-0439-5 (pbk.)
1.Heart—Surgery—Handbooks,manuals,etc. 2.Therapeuticsm Surgical—
Handbooks,manuals,etc.
[DNLM:1.Cardiac Surgical Procedures—Outlines. 2.Perioperative Care—
methods—Outlines. WG 18.2 B685m 2005] I.Bojar,Robert M.,1951–.Manual of
perioperative care in cardiac surgery. II.Title.
RD598.B64 2005
617.4'12—dc22
2004019487
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Dedication
To my wife, Mercedes, for her patience and understanding
as I deprived Alana and Rebecca of their bedtime
stories—but not any longer!
Table of Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
1.Synopsis of Adult Cardiac Surgical Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.Diagnostic Techniques in Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.Preoperative Considerations and Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . 91
4.Cardiac Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
5.Cardiopulmonary Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
6.Myocardial Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
7.Admission to the ICU and Monitoring Techniques . . . . . . . . . . . . . . . . . . . . . . . 217
8.Early Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
9.Mediastinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
10.Respiratory Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
11.Cardiovascular Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
12.Fluid Management,Renal and Metabolic Problems . . . . . . . . . . . . . . . . . . . . . . 467
13.Post-ICU Care and Other Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
Appendix 1 Typical Preoperative Order Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . 573
Appendix 2 Typical Orders for Admission to the ICU . . . . . . . . . . . . . . . . . . . 574
Appendix 3 Transfer Orders from the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
Appendix 4 Typical ICU Flowsheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
Appendix 5 Heparinization Protocol for Cardiac Surgery Patients . . . . . . . . . . . 581
Appendix 6 Hyperglycemia Protocol for Cardiac Surgery Patients . . . . . . . . . . . 582
Appendix 7 Doses of Parenteral Medications Commonly Used in the ICU
and Their Modifications in Renal Failure . . . . . . . . . . . . . . . . . . . . 583
Appendix 8 Doses of Nonparenteral Medications Commonly Used After
Heart Surgery and Their Modifications in Renal Failure . . . . . . . . . 587
Appendix 9 Drug and Food Interactions with Warfarin (Coumadin) . . . . . . . . . 596
Appendix 10 Definitions from the STS Data Specifications (2004) . . . . . . . . . . . 597
Appendix 11Technique of Thoracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
Appendix 12Technique for Tube Thoracostomy . . . . . . . . . . . . . . . . . . . . . . . . . 601
Appendix 13Technique for Insertion of Percutaneous Tracheostomy Tube . . . . . . 603
Appendix 14 Body Surface Area Nomogram for Adults . . . . . . . . . . . . . . . . . . . . 606
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
vii
Preface
Technological advances in cardiovascular care have changed the patient population
referred to cardiac surgeons.At a time when off-pump surgery and robotics are being uti-
lized to offer the patient a less invasive and potentially more benign procedure,the advent of
drug-eluting stents has dramatically decreased referrals for coronary bypass surgery.
Saphenous vein graft disease,multivessel disease,and at times,left main disease have become
“endovascular”problems to be approached by percutaneous coronary interventions (PCI) in
the cath lab.Seemingly,coronary artery bypass surgery (CABG) has become reserved for
patients with failed stents,unstentable disease,or such diffuse disease that even the most
aggressive cardiologist admits defeat and refers the patient to surgery.The percentage of
patients requiring valve or combined surgery has increased,although isolated coronary sur-
gery still remains the most common procedure.Yet,despite these trends,surgical results,as
tracked by the Society of Thoracic Surgeons database,continue to improve.So,we must be
doing something right!
Improvements in intraoperative management have contributed to better patient out-
comes.Excellence in cardiac anesthesia with protocols to achieve early extubation and rou-
tine use of intraoperative transesophageal echocardiography play a major role in optimizing
surgical outcome.Surgeons have also become more technically proficient and recognize the
importance of excellent myocardial protection.Despite improvements in cardiopulmonary
bypass (CPB) technology,off-pump surgery (OPCAB) has been promoted as a means of
minimizing the adverse effects of CPB,although its advantages over traditional on-pump
CABG are somewhat controversial.Some surgeons reserve its use for patients with advanced
comorbidities that might otherwise contraindicate on-pump CABG.However,no matter
which technique of surgery is used and how well it is performed,excellence in perioperative
care will affect the outcome in critically ill patients.That is why an update of the manual is
timely,now 6 years since the last edition.
In an attempt to keep this manual at a reasonable length and not weigh down the pocket
of the user,the decision was made to retain only the Adult Cardiac Surgery section of the
book.Each chapter has been extensively updated and rereferenced to include the latest infor-
mation on perioperative care. The outline format, which most readers have found quite
beneficial in providing easy access to information,has been retained.It should be noted that
the book is written in a chronological fashion from Chapters 2 to 8,covering diagnostic tests,
then preoperative,intraoperative,and early postoperative care issues.Chapters 9–12 discuss
bleeding,and the respiratory,cardiac,and renal subsystems in depth,and the final chapter
covers additional problems and issues on the postoperative floor.Thus,there is no chapter
devoted specifically to off-pump surgery, which is discussed primarily in the chapters on
intraoperative and postoperative management (Chapters 4 and 8).
I am hopeful that this 4th edition will provide a timely update on perioperative care that
will allow its readers to provide the best possible care to their adult cardiac surgical patients.
Robert M.Bojar,M.D.
December 2004
viii
Acknowledgments
Close cooperation and communication among all members of the healthcare team are
essential to provide the best possible care to patients undergoing cardiac surgical operations.
This often involves consultation with specialty services which can offer their expertise in the
management of difficult management problems.The breadth of knowledge and technology
in the medical subspecialties has achieved such expansion that it is difficult to remain abreast
of all the latest developments.Therefore,I am grateful to many individuals who set aside
valuable time to review sections of this manuscript.I would like to acknowledge the assis-
tance of Drs. Robert Black, George Gordon, Munther Homoud, Charles Zee,Timothy
Hastings CRNA,and Wanda Reynolds CRT for their comments.I specifically would like
to acknowledge the outstanding physician assistants with whom I work for their support and
expertise in patient care.Those who reviewed sections of the manuscript to make sure every-
thing was “just right” include Theresa Phillips, Jennifer Hardy, Jennifer Delhotal, Joshua
Deisenroth, and Philip Carpino.The section on cardiopulmonary bypass and myocardial
protection was reviewed by members of the outstanding perfusion team at St. Vincent
Hospital,Bettina Alpert,Anne Oulton,and Mark Wante.
I would also like to acknowledge the comments of Eric H. Awtry, MD, FACC, Julie
Pappalardo, MHS, PA-C, and Loisann Stapleton, RN, MSN, ACNP, CCRN, whose
reviews and suggestions framed the content of the current edition.
ix
Notice:The indications and dosages of all drugs in this book have been recom-
mended in the medical literature and conform to the practices of the general com-
munity.The medications described do not necessarily have specific approval by the
Food and Drug Administration for use in the diseases and dosages for which they are
recommended.The package insert for each drug should be consulted for use and
dosage as approved by the FDA.Because standards for usage change,it is advisable
to keep abreast of revised recommendations, particularly those concerning new
drugs.
Abbreviations used throughout this book are typeset and easy to read. However,
many hospitals have lists of approved abbreviations designed to prevent medication
errors often caused by inability to interpret handwriting.It is therefore advisable
that all orders be written according to individual hospital regulations to ensure that
accurate medication doses and intervals are provided to patients.
CHAPTER 1
Synopsis of Adult Cardiac
Surgical Disease
Coronary Artery Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Left Ventricular Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Ventricular Septal Defect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Aortic Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Aortic Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Mitral Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Mitral Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Tricuspid Valve Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Endocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Hypertrophic Obstructive Cardiomyopathy . . . . . . . . . . . . . . . . . . . . .31
Aortic Dissections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Thoracic Aortic Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Ventricular Tachycardia and Sudden Death . . . . . . . . . . . . . . . . . . . .40
Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
End-Stage Heart Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
Pericardial Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
MANUAL of Perioperative Care in Adult Cardiac Surgery, Fourth Edition Robert M. Bojar
© 2005, Robert M. Bojar, M.D. ISBN: 978-1-405-10439-5
Coronary Artery Disease 3
1 Synopsis of Adult Cardiac
Surgical Disease
It is essential that all individuals involved in the assessment and management of patients with
cardiac surgical disease have a basic understanding of the disease processes that are being
treated.This chapter presents the spectrum of adult cardiac surgical disease that is encoun-
tered in most cardiac surgical practices.The pathophysiology,indications for surgery,specific
preoperative considerations, and surgical options for various diseases are presented.
Diagnostic techniques and general preoperative considerations are presented in subsequent
chapters,and postoperative issues specific to each type of surgical procedure are discussed in
Chapter 8.
I. Coronary Artery Disease
A. Pathophysiology. Coronary artery disease (CAD) results from progressive blockage
of the coronary arteries by atherosclerosis.Clinical syndromes result from an imbal-
ance of oxygen supply and demand resulting in inadequate myocardial perfusion to
meet metabolic demand (ischemia).Plaque rupture with superimposed thrombosis is
responsible for most acute coronary syndromes.
B. Management strategies
1. Symptomatic coronary disease is initially treated with nitrates,β-adrenergic block-
ers, calcium channel blockers, and aspirin.1 Angiotensin-converting enzyme
(ACE) inhibitors are generally used for hypertension control,and “statins”are ben-
eficial for hyperlipidemia and plaque stabilization.2
2. ST-segment infarctions should be treated by either primary angioplasty and stent-
ing or thrombolytic therapy if the patient presents within 6 hours of the onset of
chest pain.3,4
3. Patients presenting with acute coronary syndromes with non–ST-segment myocar-
dial infarctions should be administered unfractionated or low-molecular-weight
heparin, aspirin, and clopidogrel (Plavix).5–10 The latter should not be given if
urgent surgery is considered likely.
4. In patients with continuing ischemia and high-risk features (crescendo angina over
48 hours, rest pain, electrocardiographic changes at rest, congestive heart failure
[CHF],or elevated troponins levels),platelet glycoprotein IIb/IIIa inhibitors,such
as tirofiban or eptifibatide,should also be given with plans to proceed to an early
invasive strategy of catheterization,at which time the appropriate means of inter-
vention (angioplasty and stenting versus surgery) can be determined.11
C. Selection of an interventional procedure12
1. An assessment of the patient’s clinical presentation,coronary anatomy,degree of
inducible ischemia on stress testing, and status of ventricular function is taken
into consideration in determining whether the patient is an appropriate candidate
for an interventional procedure.The primary objective of any intervention is the
relief of ischemia,and it should be considered for any patient with the appropriate