Manual of Perioperative Care in Adult Cardiac Surgery,Fifth Edition

807 Pages·2011·9.51 MB·English

by  Robert M. Bojar

MANUAL of
PERIOPERATIVE CARE in
ADULT CARDIAC SURGERY
Fifth Edition
Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition Robert M. Bojar
© 2011 Robert M. Bojar. ISBN: 978-1-444-33143-1
MANUAL of
PERIOPERATIVE CARE in
ADULT CARDIAC SURGERY
Fifth Edition
By
Robert M. Bojar, MD
Chief of Cardiothoracic Surgery
Saint Vincent Hospital
Worcester, Massachusetts, USA
Thiseditionfirstpublished2011(cid:1)2011byRobertM.Bojar
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LibraryofCongressCataloging-in-PublicationData
Bojar,RobertM.,1951-
Manualofperioperativecareinadultcardiacsurgery/byRobertM.Bojar.–5thed.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN978-1-4443-3143-1
1. Heart–Surgery–Handbooks,manuals,etc.2. Therapeutics,Surgical–Handbooks,manuals,etc. I.Title.
[DNLM:1.CardiacSurgicalProcedures–Outlines.2.PerioperativeCare–methods–Outlines.WG18.2B685m2011]
RD598.B642011
6170.412–dc22
2010010689
AcataloguerecordforthisbookisavailablefromtheBritishLibrary.
Thisbookispublishedinthefollowingelectronicformats:ePDF9781444325294;WileyOnlineLibrary9781444325287
Setin9/11pt,CaslonbyThomsonDigital,Noida,India
1 2011
Dedication
To my parents, Leah and Samuel Bojar, who instilled
in me a lifelong desire for learning, the importance of
sharing knowledge, and a dedication to provide all
patients with the best possible care.
Table of Contents
Preface.......................................................................................................................................ix
Acknowledgments.......................................................................................................................xi
1. SynopsisofAdultCardiacSurgicalDisease...................................................................1
2. DiagnosticTechniquesinCardiacSurgery..................................................................85
3. GeneralPreoperativeConsiderationsandPreparationofthe
PatientforSurgery......................................................................................................129
4. CardiacAnesthesia......................................................................................................173
5. CardiopulmonaryBypass.............................................................................................227
6. MyocardialProtection.................................................................................................263
7. AdmissiontotheICUandMonitoringTechniques.................................................279
8. EarlyPostoperativeCare.............................................................................................301
9. MediastinalBleeding...................................................................................................345
10. RespiratoryManagement............................................................................................383
11. CardiovascularManagement.......................................................................................437
12. FluidManagement,Renal,Metabolic,andEndocrineProblems..............................581
13. Post-ICUCareandOtherComplications.................................................................641
Appendices............................................................................................................................727
Appendix1A AmericanCollegeofCardiologyClassesofRecommendation
andLevelsofEvidence.........................................................................729
Appendix1B NewYorkHeartAssociationFunctionalClassification......................729
Appendix2 TypicalPreoperativeOrderSheet.........................................................730
Appendix3 TypicalOrdersforAdmissiontotheICU...........................................731
Appendix4 TypicalTransferOrdersfromtheICU................................................734
Appendix5 TypicalICUFlowsheet.........................................................................737
Appendix6 HyperglycemiaProtocolforCardiacSurgeryPatients.........................738
Appendix7 HeparinizationProtocolforCardiacSurgeryPatients.........................739
Appendix8 ProtocolforInitiatingWarfarin...........................................................740
Appendix9 INRReversalProtocol..........................................................................741
Appendix10 Drug,Food,andDietarySupplementInteractions
withWarfarin.........................................................................................742
Appendix11 DosesofParenteralMedicationsCommonlyUsedin
theICUandTheirModificationinRenalFailure...............................743
vii
viii TABLEOFCONTENTS
Appendix12 DosesofNonparenteralDrugsCommonlyUsed
AfterHeartSurgeryandTheirModificationsin
RenalFailure..........................................................................................747
Appendix13 DefinitionsfromtheSTSDataSpecifications(Version2.72011)......753
Appendix14 BodySurfaceAreaNomogram..............................................................756
Appendix15 BodyMassIndexChart.........................................................................757
Appendix16 TechniqueofThoracentesis...................................................................758
Appendix17 TechniqueforTubeThoracostomy.......................................................759
Appendix18 TechniqueofInsertionofPercutaneousTracheostomyTube..............761
Index......................................................................................................................................765
Preface
Thefutureofcardiacsurgeryfacessignificantchallengeswiththewidespreadapplicationof
transcatheter technologies, including coronary stenting, percutaneous valves, endovascular
approaches to thoracic aortic disease, and ablation of arrhythmias in the electrophysiology
laboratory.Mostofthesetechnologiesevolvedfromtheconceptthatalessinvasiveapproachto
structural heart disease is preferred by patients to reduce trauma, minimize complications,
expediterecovery,andimprovethequalityoflife.
Although these approaches may be applicable to patients at both ends of the clinical
spectrum,surgerywillstillremainthebestapproachformanypatients–especiallythosewith
advancedcardiacdiseaseandsignificantnoncardiacissues.Althoughlessinvasivesurgeryis
seeingwiderapplicability,mostsurgicalproceduresrequireuseofcardiopulmonarybypasswith
itsinherentmorbidity.Thereislittledoubtthatsurgicalpatientacuitycontinuestoincrease,
and excellence in perioperative care will remain essential to optimizing surgical results, no
matter which surgical technique is used. This has become especially important with the
increasingdemandfortransparency,withtheperceptionthatoutcomesaredirectlyrelatedto
thequalityofcare.Thus,ithasbecomeessentialthatsurgicalprogramsmaintainthehighest
levelofcaretoremaincompetitive.
The5theditionoftheManualhasbeencompletelyupdatedtoprovidecurrentapproachesto
patientcare.Thereferencelistshavealsobeenextensivelyupdatedtodirectthereadertosome
ofthebestresourcesavailableonmosttopics.Iamhopefulthatthis5theditionwillprovidea
comprehensive up-to-date review that will assist healthcare providers in delivering the best
possiblecaretotheircardiacsurgicalpatients.
RobertM.Bojar,MD
Worcester,MA
December2010
ix
Acknowledgments
Cardiacsurgeryrequiresmeticulousattentiontodetailtoensurethebestpossiblesurgicalresult.
Decision-makingintheperioperativeperiodinvolvesclosecooperationandcommunication
among all members of the healthcare team, including cardiac surgeons, anesthesiologists,
physicianassistants,nursepractitioners,andcriticalcareandfloornurses.Identifyingproblems
andseekingconsultationswithexpertsinotherfieldsisimportanttoensureoptimaloutcomes.I
amgreatlyappreciativeoftheeffortsofmanyindividualswhosetasidevaluabletimetoreview
sectionsofthemanuscriptintheirareasofexpertise.Iwouldliketoacknowledgetheassistance
ofDavidLiu,MD,GaryNoroian,MD,TimothyHastings,CRNA,BettinaAlpert,CCP,
Kathi O’Leary, CCP, and Wanda Reynolds, CCRT, for their review and comments. I am
especially indebted to George Gordon, MD, whose vast knowledge of anesthesiology,
echocardiography,pharmacology,andphysiologyallowedhimtoprovideinsightandsugges-
tionsonmultipleareasofclinicalmanagement.Lastly,IamindebtedtomyChiefPhysician
Assistant,TheresaPhillips,PA,whohelpscoordinatethecaremypatientsreceive,andwho
reviewedmanysectionsofthemanuscripttoensuretheiraccuracy.
xi
Notice:Theindicationsanddosagesofalldrugsinthisbookhavebeenrecommended
in the medical literature and conform to the practices of the general community.
ThemedicationsdescribeddonotnecessarilyhavespecificapprovalbytheFoodand
DrugAdministrationforuseinthediseasesanddosagesforwhichtheyarerecom-
mended.Thepackageinsertforeachdrugshouldbeconsultedforuseanddosageas
approved by the FDA. Because standards for usage change, it is advisable to keep
abreast of revised recommendations, particularly those concerning new drugs.
Althoughtheauthorhasmadeeveryattempttoensuretheaccuracyofdrugdosages,
itistheobligationofthereadertoconfirmdrugdosagespriortoprescribinganydrug.
Abbreviationsusedthroughthisbookaretypesetandeasytoread.However,many
hospitalshavelistsofapprovedabbreviationsdesignedtopreventmedicationerrors,
whichareoftencausedbyinabilitytointerprethandwriting.Itisthereforeadvisable
thatallordersbewrittenaccordingtoindividualhospitalregulationstoensurethat
accuratemedicationdosesandintervalsareprovidedtopatients.