SMACC Gold 2014 Michaela Cartner MBBS FACEM FCICM PG Dip Echo Crit Care

Cardiac Surgery …

then Cardiac Arrest….

OR• The Approach to the Deteriorating Cardiac

Surgical Patient

My Aim:• To give you a safe systematic way to treat and assess

the post op cardiac patient

• To show you the subtle differences in this subgroup that

are practice altering

• And yeah Yeah YEAH!!!!!

Emergency

Resternotomy

My Aim:• To give you a safe systematic way to treat and assess

the post op cardiac patient

• To show you the subtle differences in this subgroup that

are practice altering

• To make you safer when you leave the room than when

you entered it

Shock is still Shock.

A and B still come first

But C is the key

= SV x HR

run thru twice as the body has two pumps

C o

Co = SV x HR is easy to manipulate

Rate

Rhythm

Rate

Rhythm

Uppers

Adrenaline

Isoprenaline

Atropine

PacingDowners

BB

Ca CB

cardioversion

Overdrive pacing

ALL PURPOSE

DETERGENT

Amiodarone

HR is easy to manipulate

Co = SV x HR

run thru twice as the body has two pumps

Rate

Rhythm

Co = SV x HR

run thru twice as the body has two pumps

Rate

Rhythm

Preload

Contractility

Afterload

SV AfterloadRight Heart

•

hypoxia/hypercarbia/acid

osis

• atelectasis (PEEP ?)

• Pulm Vasodilators

-Nox

- PC

- SNP

- Phosphodiesterase IIIi

Left Heart

SV AfterloadLeft Heart

• Uppers-

– Adrenaline

– Norad

• PEEP

• Downers– Db

– Milrinone

– GTN

– SNP

Left Heart

SV Contractility

Muscle

Pipes

Valves

Milieu

Cardiogenic Shock..pump broken..

Muscle

Pipes

Valves

Augment the Muscle

Adrenaline

Milrinone

Dobutamine

Dopamine

iABP

VAD L, R, Bi

ECMO

Unblock the pipe

Return to theatre

Cath lab

Replace the valve

Return to theatre

Echo/TOE

Milieu

Ph

Ca++

Stop Shivering

Temperature

BSL

Co = SV x HR

run thru twice as the body has two pumps

Rate

Rhythm

Preload

Contractility

Afterload

Preload: Hemorrhage

3-8% return to theatre for reopen.

SV PRELOAD

Definition:

• >500ml/hr for first hours

• > 800ml in first 2 hours

• > 900ml in first 3 hours

> 100 in first 4

Or cardiac tamponadeKristensen KL, Rauer LJ Reoperation for bleeding in cardiac surgery

Interactive Vascular and Cardiac Surgery 14 (2012) 709-713

Risk factors• Patient

– Low BMI

– Co-morbidities DM,

low EF, CRF

• Operation

• Long pump time

• Multiple grafts

• Failed off pump

Medical or Surgical?

Kristensen KL, Rauer LJ Reoperation for bleeding in cardiac surgery Interactive Vascular and Cardiac Surgery 14 (2012) 709-713

Your approach is fine….

Cardiac arrest post surgery

Guideline for resusitation in cardiac arrest after cardiac surgery European Journal of cardiothoracc surgery 2009

Survival rate

• 17-79%

50% survival if reopen

within 24 hours surgery and

within 10 mins of arrest

time.

VF most common

Bleeding/tamponade

• ERC 2009 Guidelines

When to think about ICM and reopen?

- before 10 mins of CPR

- Aim for s60 mmHg

Gown and glove

Don’t worry about hand washing

ERC guidelines 2009

Mackay JH, et al Six Year prospective audit of chest reopening after cardia arrest. European Journal of Cardio-thoracic Surgery 22 ( 2002) 421-425

Video

My Aim:• To give you a safe systematic way to treat and assess

the post op cardiac patient

• To show you the subtle differences in this subgroup that

are practice altering

• To make you safer when you leave the room than when

you entered it

Thank you.