Perioperative Care in Cardiac Anesthesia and Surgery

554 Pages·2005·3.141 MB·English

by  Davy C.H. Cheng MD, Tirone E. David MD

CheDavFMv3.qxd 8/31/05 3:49 PM Page i
Perioperative Care
in Cardiac
Anesthesia and
Surgery
CheDavFMv3.qxd 8/31/05 3:49 PM Page ii
CheDavFMv3.qxd 8/31/05 3:49 PM Page iii
Perioperative Care
in Cardiac
Anesthesia and
Surgery
EDITED BY
DAVY C. H. CHENG, MD, MSc, FRCPC
Professor and Chair
Department of Anesthesia & Perioperative Medicine
University of Western Ontario
Chief
Department of Anesthesia & Perioperative Medicine
London Health Sciences Centre and
St. Joseph’s Health Care
Medical Director
Cardiac Surgery Recovery Unit
London Health Sciences Centre
London, Ontario, Canada
TIRONE E. DAVID, MD, FRCSC
Professor
Department of Surgery
University of Toronto
Head
Division of Cardiovascular Surgery
The Peter Munk Cardiac Centre
Toronto General Hospital
Toronto, Ontario, Canada
CheDavFMv3.qxd 8/31/05 3:49 PM Page iv
Acquisitions Editor:Brian Brown
Developmental Editor:Louise Bierig
Project Manager:Dave Murphy
Managing Editor:Franny Murphy
Senior Manufacturing Manager:Ben Rivera
Marketing Manager:Angela Panetta
Design Coordinator:Terry Mallon
Production Services:Laserwords Private Limited
Printer:Edwards Brothers
© 2006 by LippincottWilliams& Wilkins
530 Walnut Street
Philadelphia, PA 19106
All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by
any means, including photocopying, or utilizing by any information storage and retrieval system without written
permission from the copyright owner, except for brief quotations embodied in critical articles and reviews.
Cover: Courtesy of the University of Pennsylvania Art Collection, Philadelphia, Pennsylvania
Printed in the United States
Library of Congress Cataloging-in-Publication Data
Perioperative care in cardiac anesthesia and surgery / edited by Davy C. H. Cheng, Tirone E. David.— 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7817-5774-6
1. Heart—Surgery—Patients—Medical care—Handbooks, manuals, etc. 2. Therapeutics, Surgical—Handbooks,
manuals, etc. 3. Operating room nursing—Handbooks, manuals, etc. 4. Postoperative care—Handbooks, manu-
als, etc. I. Cheng, Davy C. H. II. David, Tirone E. III. Title.
[DNLM: 1. Coronary Disease—surgery—Handbooks. 2. Perioperative Care—methods—Handbooks. 3.
Anesthesia—methods—Handbooks. 4. Cardiac Surgical Procedures—methods—Handbooks. WG 39 P445 2005]
RD598.P45 2005
617.4'12—dc22
2005023363
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted prac-
tices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any conse-
quences from application of the information in this book and make no warranty, expressed or implied, with respect
to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a
particular situation remains the professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth
in this text are in accordance with current recommendations and practice at the time of publication. However, in
view of ongoing research, changes in government regulations, and the constant flow of information relating to
drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in
indications and dosage and for added warnings and precautions. This is particularly important when the recom-
mended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of health care providers to ascertain
the FDA status of each drug or device planned for use in their clinical practice.
The publisher has made every effort to trace copyright holders for borrowed material. If they have inadvertently
overlooked any, they will be pleased to make the necessary arrangements at the first opportunity.
To purchase additional copies of this book, call our customer service department at [phone] or fax orders
to [phone]. International customers should call [phone]. Lippincott Williams & Wilkins customer
service representatives are available from 8:30 am to 6:30 pm, EST, Monday through Friday, for telephone access.
Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com.
10 9 8 76 5 4 3 2 1
CheDavFMv3.qxd 8/31/05 3:49 PM Page v
To our Residents, Fellows, and Students
CheDavFMv3.qxd 8/31/05 3:49 PM Page vi
CheDavFMv3-new.qxd 9/8/05 2:19 PM Page vii
C O N T E N T S
Contributors xi
Preface xvii
Acknowledgments xix
Abbreviations xxi
SECTION I: INTRODUCTION 1
1 Prognostic Risks and Preoperative Assessment 3
Davy C. H. Cheng and Tirone E. David
SECTION II: ANESTHESIA AND CARDIOPULMONARY BYPASS
MANAGEMENT 11
2 Fast-track Cardiac Anesthesia Management in On-pump and Off-pump
Coronary Artery Bypass Surgery 13
Davy C. H. Cheng and Daniel Bainbridge
3 Anesthetic Management in Valvular Heart Surgery 21
Rita Katznelson and Patricia Murphy
4 Anesthetic Management in Robotic Cardiac Surgery 29
Wojciech Dobkowski
5 Circulatory Arrest and Neuroprotection 37
Ivan Iglesias and John M. Murkin
6 Anesthesia for Combined Cardiac and Thoracic Surgery 43
Peter Slinger
7 Anesthesia for Intrathoracic Transplantation 49
Karen McRae
8 Anesthesia for Patients with Ventricular Assist Devices 65
Jacek M. Karski
9 Anesthesia and Congenital Heart Disease 71
Helen M. K. Holtby
10 Anesthetic Management of Comorbid Diseases Affecting
Cardiopulmonary Bypass 85
Neal H. Badner
11 Regional Anesthesia Techniques and Management 91
George N. Djaiani
12 Perioperative Monitoring in Cardiac Anesthesia 99
Daniel Bainbridge
vii
CheDavFMv3.qxd 8/31/05 3:49 PM Page viii
viii Contents
13 Perioperative Transesophageal Echocardiography 105
Annette Vegas
14 Essence of Cardiopulmonary Bypass Circuit and Intra-aortic Balloon
Pump 117
Peter Allen
15 Weaning from Cardiopulmonary Bypass and Low Output
Syndrome 135
Annette Vegas
16 Pulmonary Hypertension and Right Ventricular Dysfunction
Postcardiopulmonary Bypass 145
Achal K. Dhir and Fiona E. Ralley
17 Perioperative Blood Conservation in Cardiac Surgery 153
Bruce D. Spiess
18 Antifibrinolytics and Coagulation Management 165
Jacek M. Karski and Keyvan Karkouti
19 Heparin-Induced Thrombocytopenia and Alternatives to Heparin 173
Fiona E. Ralley
20 Management of the Cardiac Surgical Emergency 185
Ravi Taneja
SECTION III: SURGICAL TECHNIQUE AND POSTOPERATIVE
CONSIDERATION 193
21 Myocardial Protection During Cardiac Surgery 195
Shafie Fazel and Richard D. Weisel
22 On-pump Coronary Artery Bypass Surgery 201
Terrence M. Yau
23 Off-pump Coronary Revascularization Surgery 209
Richard J. Novick
24 Robotic Coronary Artery Revascularization Surgery 215
Bob Kiaii, R. Scott McClure, and W. Douglas Boyd
25 Surgery of the Aortic Valve 227
Tirone E. David
26 Surgery of the Mitral Valve 241
Tirone E. David
27 Tricuspid Valve Surgery 253
Tirone E. David
28 Robotic Cardiac Valvular Surgery 257
Alan H. Menkis
CheDavFMv3.qxd 8/31/05 3:49 PM Page ix
Contents ix
29 Surgery of the Ascending Aorta 261
Tirone E. David
30 Surgery of the Transverse Aortic Arch and Cerebral Protection 267
Christopher M. Feindel
31 Surgery of the Descending Thoracic Aorta 273
Steve K. Singh and Michael A. Borger
32 Combined Cardiac and Vascular Surgery 279
Michael A. Borger
33 Surgery for Mechanical Complications of Myocardial Infarction 285
Tirone E. David
34 Surgery for End-stage Heart Disease and Heart Transplantation 289
Vivek Rao and Christopher M. Feindel
35 Lung and Heart–Lung Transplantation 295
Shaf Keshavjee and Stefan Fischer
36 Ventricular Assist Devices 301
Vivek Rao
37 Adult Congenital Heart Surgery 307
Glen S. Van Arsdell, Igor E. Konstantinov, and William G. Williams
38 Ventricular Reconstruction or Aneurysm Resection for Ischemic
Cardiomyopathy 323
Lynda L. Mickleborough
39 Implantable Cardioverter Defibrillator and Pacemaker Insertion 327
Raymond Yee and Jonathan Prychitko
SECTION IV: CARDIAC SURGICAL RECOVERY UNIT 339
40 Routine Cardiac Surgery Recovery Care: Extubation to Discharge 341
Daniel Bainbridge and Davy C. H. Cheng
41 Common Problems in the Cardiac Surgery Recovery Unit 347
Annette Vegas
42 Atrial and Ventricular Arrhythmia Management 359
Christopher A. Palin and Charles W. Hogue, Jr.
43 Postcardiac Surgery Pacing Therapy 369
Douglas A. Cameron
44 Tamponade and Chest Reopening 375
Terrence M. Yau
CheDavFMv3.qxd 8/31/05 3:49 PM Page x
x Contents
45 Infection, Sternal Debridement, and Septic Shock 381
Lois K. Champion
46 Difficult Weaning from Mechanical Ventilation and Tracheotomy
Care 387
Thomas L. Higgins and Patrick C. Lee
47 Renal Failure and Dialysis 401
Atilio Barbeito and Mark Stafford-Smith
48 Neurologic Complications and Management 415
Ronald J. Butler
SECTION V: SURGICAL WARD MANAGEMENT 421
49 Routine Surgical Ward Care 423
Susan C. M. Lenkei-Kerwin and Stephanie J. Brister
50 Common Ward Complications and Management 429
Stephanie J. Brister and Susan C. M. Lenkei-Kerwin
SECTION VI: APPENDICES 435
Appendix A: Postoperative TGH/CVICU Medical Admission Form 437
Appendix B: Postcardiac Surgery Medical Admission Orders
(TGH/CVICU) 439
Appendix C: Postcardiac Surgery Medical Admission Orders
(LHSC/CSRU) 441
Appendix D: TGH/CVICU Medical Discharge Forms 443
Appendix E: TGH/CVICU Medical Discharge Orders 445
Appendix F: LHSC Ventilation Weaning and Extubation Protocol 447
Appendix G: Patient Control Analgesia Order 449
Appendix H: Anticoagulation Guideline Postcardiac Surgery 451
Appendix I: Insulin Protocol for Glucose Control 453
Appendix J: Pharmacology in Cardiovascular Anesthesia and Surgery 455
Janet Martin
Appendix K: Modified ACLS Protocols 493
Appendix L: Preoperative Cardiac Transplant Medical Order 505
Appendix M: Medical Transfer Orders Post Heart Transplant 507
Appendix N: Medical Orders for Care of Spinal Drains 509
Appendix O: Hospital Discharge Instructions Postcardiac Surgery 511