Date post: | 12-Jul-2015 |
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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.