Management of Cardiac Surgery Patients and role of PA's

Management of Cardiac Management of Cardiac Surgery Patients and role of Surgery Patients and role of

PA’sPA’s

Bharti Daswani MS,PA-CBharti Daswani MS,PA-C

Stanford University Medical CenterStanford University Medical Center

December 4, 2008December 4, 2008

A Day in the life of…A Day in the life of…

1. Rounds (vital signs, overnight 1. Rounds (vital signs, overnight events, order tests, events, order tests, medications, plan)medications, plan)

2. Progress Notes (S.O.A.P. format)2. Progress Notes (S.O.A.P. format)

3. OR (vein harvest, second assist, 3. OR (vein harvest, second assist, remove chest tubes, pacing remove chest tubes, pacing wires, CVP’s etc)wires, CVP’s etc)

A Day in the life of…..A Day in the life of…..

A Day in the life of…A Day in the life of…

4. Pre-op patients (H&P, admits)4. Pre-op patients (H&P, admits)

5. Discharge patients5. Discharge patients

6. Afternoon rounds6. Afternoon rounds

7. Sign-out to fellow, cross cover 7. Sign-out to fellow, cross cover PA,MDPA,MD

Surgical Progress NoteSurgical Progress Note

Typical SOAP formatTypical SOAP format ””S” (Subjective): S” (Subjective):

O/N events, pt complaintsO/N events, pt complaints ””O” (Objective): O” (Objective):

VS, Labs, I/O, Pain!, VS, Labs, I/O, Pain!, CXR/EKG/ECHO/CTA results, medCXR/EKG/ECHO/CTA results, med

””A”/”P” (Assessment/Plan): A”/”P” (Assessment/Plan): ex. S/P AVR POD #3-Stable, ex. S/P AVR POD #3-Stable, increase ambulation, etc…..increase ambulation, etc…..

The surgical process…..The surgical process…..

Admission (pre-op, peri-op, post-op Admission (pre-op, peri-op, post-op care)care)

Surgical Assessment and Surgical Assessment and PreparationPreparation

Common ComplicationsCommon Complications

Discharge (disposition, PT/OT, etc)Discharge (disposition, PT/OT, etc)

Admission ProcessAdmission Process

H&P, ConsentH&P, Consent

Vein harvest, first/second assist Vein harvest, first/second assist

ICU stayICU stay

Step-down unit / telemetry floor (D/C Step-down unit / telemetry floor (D/C drains, pacing wires, central lines)drains, pacing wires, central lines)

..

Wires are in pairs and can be connected into Medtronic pacemaker in 2 ways. Always check your connections

Temporary PacemakerTemporary Pacemaker

Surgical AssessmentSurgical Assessmentand Preparationand Preparation

H&P- thorough, H&P- thorough, Surgical historySurgical history Prior cardiac surgery! Prior cardiac surgery! Previous exposure to blood Previous exposure to blood

transfusion productstransfusion products Previous cardiac operative notePrevious cardiac operative note Dental history (w/ valve surgery)Dental history (w/ valve surgery)

Surgical Assessment and Surgical Assessment and Preparation cont.Preparation cont.

PhysicalPhysical Check BP in both arms- detect Check BP in both arms- detect

SC/innominate a. stenosisSC/innominate a. stenosis Presence of carotid bruits, esp bilat.- ?Presence of carotid bruits, esp bilat.- ?

CVA vs TIACVA vs TIA Pulmonary and cardiac examPulmonary and cardiac exam Peripheral exam with regards to pulses Peripheral exam with regards to pulses Inspect legs for saphenous vein Inspect legs for saphenous vein

LabsLabs CBC,CMP, UA, T&C 4-6U (for re-op may CBC,CMP, UA, T&C 4-6U (for re-op may

need more)need more) Check EKG, Cardiac Cath, CTA, MRA, CXRCheck EKG, Cardiac Cath, CTA, MRA, CXR

Surgical Assessment and Surgical Assessment and PreparationPreparation

Patient EducationPatient Education Hold ASA 7-10dHold ASA 7-10d Hold Coumadin 7-10dHold Coumadin 7-10d INR of <1.5 OK INR of <1.5 OK Special case: CoumadinSpecial case: Coumadin Antimicrobial shower/bath x2 Antimicrobial shower/bath x2

Endoscopic Vein Endoscopic Vein Harvest VideoHarvest Video

Common Common ComplicationsComplications

Mediastinal Bleeding and HemorrhageMediastinal Bleeding and Hemorrhage

ArrhythmiasArrhythmias

Other organ system complications Other organ system complications (Neurologic, Pulmonary,GI, Renal)(Neurologic, Pulmonary,GI, Renal)

Myocardial infarctionMyocardial infarction

InfectionInfection

Mediastinal BleedingMediastinal Bleeding

CPB and systemic heparinizationCPB and systemic heparinization significant disruption of coagulation significant disruption of coagulation systemsystem

Use of anticoagulants (ASA, ASA Use of anticoagulants (ASA, ASA containing compounds,NSAIDs), containing compounds,NSAIDs), altered platelet function, low platelet altered platelet function, low platelet count- count- most common causemost common cause!!

Activation of fibrinolysis and dilution Activation of fibrinolysis and dilution of clotting factors also causesof clotting factors also causes


Labs: PT/INR, PTT, ACT, platelet countLabs: PT/INR, PTT, ACT, platelet count TreatmentTreatment

-Starts in OR- meticulous technique and -Starts in OR- meticulous technique and hemostatic controlhemostatic control

--Typical sites- Typical sites- sternal sternal periosteum,sternal notch, mammary bed, periosteum,sternal notch, mammary bed, mammary pedicle, superior mediastinal mammary pedicle, superior mediastinal fat pad, pericardium, diaphragmatic fat pad, pericardium, diaphragmatic surface, anastomoses, cannulation and surface, anastomoses, cannulation and vent sites, incision in heart and great vent sites, incision in heart and great vessels, vein, IMA branches.vessels, vein, IMA branches.


Treatment cont.Treatment cont. Chest tubesChest tubes CT to suction at 20 cm HCT to suction at 20 cm H22OO Blood/blood products (RBC’s, FFP, Blood/blood products (RBC’s, FFP,

platelets)platelets) Severe bleeding- Protamine sulfate (25-Severe bleeding- Protamine sulfate (25-

50 mg IV)50 mg IV) Prolonged PT/PTT- 2-4 U FFPProlonged PT/PTT- 2-4 U FFP Platelets <100,000-platelets (1U/10kg Platelets <100,000-platelets (1U/10kg

body wt)body wt) Persistent bleeding- test for fibrinogen Persistent bleeding- test for fibrinogen

defect, ?cryoprecipitatedefect, ?cryoprecipitate


Indications for surgical re-Indications for surgical re-exploration:exploration:

Bleeding rate >200 ml/hr x 4-6 hrsBleeding rate >200 ml/hr x 4-6 hrs >1500 ml of blood loss in 12h >1500 ml of blood loss in 12h

periodperiod Sudden increase (300-500 ml) in Sudden increase (300-500 ml) in

CT outputCT output Evidence of pericardial tamponadeEvidence of pericardial tamponade


Common post-opCommon post-op 2 categories: ventricular (early, most 2 categories: ventricular (early, most

common) and supraventricular (24h-5d common) and supraventricular (24h-5d post-op)post-op)

Diagnosed via ECG strip or 12 Lead ECGDiagnosed via ECG strip or 12 Lead ECG Common causesCommon causes: : Ca, Ca, K, K, Mg Mg Other causes: acidosis, uremia, Other causes: acidosis, uremia,

hyperthyroidism, reversible surgical hyperthyroidism, reversible surgical trauma, hemorrhage, ischemia, edematrauma, hemorrhage, ischemia, edema


Irreversible: conduction tissue Irreversible: conduction tissue traumatrauma

Suture placement/valve Suture placement/valve debridement debridement BBBBBB

Temporary epicardial pacing Temporary epicardial pacing usefuluseful

Sinus tachycardiaSinus tachycardia

CommonCommon Sinus tachycardiaSinus tachycardia

HR>100HR>100 Vagal blockade or beta-adrenergic Vagal blockade or beta-adrenergic

stimulationstimulation Appropriate response to underlying Appropriate response to underlying

stimuli (pain, fever, hypovolemia, stimuli (pain, fever, hypovolemia, hypoxia)hypoxia)

Sinus tachycardiaSinus tachycardia

May precipitate myocardial ischemiaMay precipitate myocardial ischemia Treatment: correct underlying cause- normalize volume Treatment: correct underlying cause- normalize volume

status, correct hypoxia, provide adequate pain controlstatus, correct hypoxia, provide adequate pain control Meds: Metoprolol 12.5-50 mg BID, 5 mg IV Q6Meds: Metoprolol 12.5-50 mg BID, 5 mg IV Q6

Sinus BradycardiaSinus Bradycardia

HR <60HR <60 Due to drugs (narcotics or BB) / intrinsic sinus node Due to drugs (narcotics or BB) / intrinsic sinus node

diseasedisease Treatment: temporary atrial pacing at 90-110 Treatment: temporary atrial pacing at 90-110

beats/minbeats/min Severe bradycardia-Atropine 0.5 mg -2.0 mg IV Severe bradycardia-Atropine 0.5 mg -2.0 mg IV ?placement of temp/PPM?placement of temp/PPM

Atrial Flutter/FibrillationAtrial Flutter/Fibrillation

MOST COMMON!!!!!!MOST COMMON!!!!!! Disorganized atrial Disorganized atrial

depolarizationsdepolarizations ““irregularly irregular” irregularly irregular”

rhythm- AF, “saw rhythm- AF, “saw tooth”- A. Fluttertooth”- A. Flutter

Urgency of therapy Urgency of therapy dictated by ventricular dictated by ventricular response rate, pt’s response rate, pt’s hemodynamic tolerancehemodynamic tolerance

Atrial Fibrillation/FlutterAtrial Fibrillation/Flutter

Treatment: Amiodarone bolus Treatment: Amiodarone bolus 150 mg IV, drip at 1 mg/min. Re-150 mg IV, drip at 1 mg/min. Re-bolus prnbolus prn

0.5 mg/min 6 hrs post conversion.0.5 mg/min 6 hrs post conversion. PO Amio 400 mg TID once in SR. PO Amio 400 mg TID once in SR.

Maintenance dose200 mg BID or Maintenance dose200 mg BID or QD. Taper dose over 30 days or 3 QD. Taper dose over 30 days or 3 monthsmonths


Treatment cont.Treatment cont. Digoxin as an alternative Digoxin as an alternative

Loading dose- 0.5 mg IV, 0.25 mg IV Q4h x 2 Loading dose- 0.5 mg IV, 0.25 mg IV Q4h x 2 dosesdoses

Onset IV Digoxin 30 min, peak at 3 hrs. Onset IV Digoxin 30 min, peak at 3 hrs. Maintenance dose 0.125 mg-0.5 mg QPMMaintenance dose 0.125 mg-0.5 mg QPM Check serum K levels! Check serum K levels! Check serum Digoxin once steady state (4hrs Check serum Digoxin once steady state (4hrs

post IV, 6-7 hrs after PO)post IV, 6-7 hrs after PO) Great for poor LV fxn, asthmaGreat for poor LV fxn, asthma

Replete serum electrolytes (K, Mg, Ca)Replete serum electrolytes (K, Mg, Ca)


Recent studies no difference Recent studies no difference between rate/rhythm between rate/rhythm

Anticoagulation key if no Anticoagulation key if no conversion in 48 hrs!conversion in 48 hrs!

Give Warfarin, goal INR 2.0-2.5Give Warfarin, goal INR 2.0-2.5 DC cardioversion, anticoagulate DC cardioversion, anticoagulate

priorprior

Premature Atrial Premature Atrial ContractionsContractions

Atrial impulse discharges prematurely!Atrial impulse discharges prematurely! P wave premature, may be buried in preceding T P wave premature, may be buried in preceding T

wavewave QRS usually normal and short pause before next QRS usually normal and short pause before next

beatbeat Common, may be precursor to AFCommon, may be precursor to AF Treatment: none, replete lytes, BB, Amio helps Treatment: none, replete lytes, BB, Amio helps

prevent progression of rhythm to AFprevent progression of rhythm to AF

Ventricular arrhythmiasVentricular arrhythmias

Primarily ectopicPrimarily ectopic Potential for fatal VT or VFPotential for fatal VT or VF May be improved post-op by May be improved post-op by

revascularization of ischemic revascularization of ischemic areas of the myocardiumareas of the myocardium

ABG’s, serum K, ECGABG’s, serum K, ECG

Premature Ventricular Premature Ventricular Contractions (PVCs)Contractions (PVCs)

Impulse occurs earlier than next normal Impulse occurs earlier than next normal sinus beatsinus beat

Wide QRS complex: much wider, taller and Wide QRS complex: much wider, taller and deeper than normal QRS (>0.12 sec)deeper than normal QRS (>0.12 sec)

Occurs after T wave of normal cycleOccurs after T wave of normal cycle Followed by compensatory pauseFollowed by compensatory pause


Unifocal or multifocalUnifocal or multifocal Many unifocal PVCs Many unifocal PVCs poor oxygenation. poor oxygenation.

Treat if > Treat if > 66 PVCs per minute! PVCs per minute! Many multifocal PVCs Many multifocal PVCs severe cardiac severe cardiac

hypoxia! Dangerous, needs intervention! hypoxia! Dangerous, needs intervention!


Treatment:Treatment: Replete serum K to 4.5 mEq/L. Give Replete serum K to 4.5 mEq/L. Give

IV or PO.IV or PO. Order K sliding scale!Order K sliding scale! Replete Magnesium sulfate for Replete Magnesium sulfate for

levels <2.0 mEq/L. Give 1-4 g IV levels <2.0 mEq/L. Give 1-4 g IV

Ventricular tachycardiaVentricular tachycardia

3 successive runs >100 bpm3 successive runs >100 bpm Wide bizarre QRS occurring regularlyWide bizarre QRS occurring regularly Precursor of VFPrecursor of VF Occurs in underlying structural heart Occurs in underlying structural heart

disease w/ damage to ventriclesdisease w/ damage to ventricles

Ventricular tachycardiaVentricular tachycardia

Sustained VT dangerous!Sustained VT dangerous! Treatment: initiate CPR, emergent Treatment: initiate CPR, emergent

defibrillation, antiarrhythmic drugs. defibrillation, antiarrhythmic drugs. CALL CODE TEAM!!!!! CALL CODE TEAM!!!!!

Consider ICD in pts with resolved VTConsider ICD in pts with resolved VT

Ventricular FibrillationVentricular Fibrillation

Dangerous, LETHAL if not treated emergently!!!!!Dangerous, LETHAL if not treated emergently!!!!! Call CODE team!Call CODE team! Start CPR ASAP!, Defibrillate!!!Start CPR ASAP!, Defibrillate!!! Antiarrhythmics to maintain normal rhythmAntiarrhythmics to maintain normal rhythm ICD if successful conversionICD if successful conversion

Other organ system Other organ system complicationscomplications

Neurologic DysfunctionNeurologic Dysfunction CVACVA if >24hr deficit persists and if >24hr deficit persists and

confirmed on Head CTconfirmed on Head CT Hypoperfusion or embolic event commonlyHypoperfusion or embolic event commonly Focal motor/sensory deficits or cognitive Focal motor/sensory deficits or cognitive

deficitsdeficits Prognosis variable (age, degree of initial Prognosis variable (age, degree of initial

impairment, mechanism of injury, area of impairment, mechanism of injury, area of brain involved). brain involved).

Obtain neuro consult, vigorous PT/OT Obtain neuro consult, vigorous PT/OT optimizes recoveryoptimizes recovery


Neurologic cont.Neurologic cont. SeizuresSeizures

Structural brain injury or metabolic Structural brain injury or metabolic encephalopathyencephalopathy

Look for contributing cause if Look for contributing cause if metabolic process if suspectedmetabolic process if suspected

EEG helpful, treat with phenytoin, EEG helpful, treat with phenytoin, BZD, call neurologist!BZD, call neurologist!


PulmonaryPulmonary

AtelectasisAtelectasis Most common Most common Resultant of mucous plugging and mechanical Resultant of mucous plugging and mechanical

ventilationventilation Tx- incentive spirometry, bronchodilators, Tx- incentive spirometry, bronchodilators,

pulmonary toiletpulmonary toilet

PleuralPleural effusion effusion Post-op bleed, interstitial edema, excess fluid Post-op bleed, interstitial edema, excess fluid

not absorbed by bodynot absorbed by body Tx- thoracentesis/chest tube for large Tx- thoracentesis/chest tube for large

effusions, diuretics (IV and PO)effusions, diuretics (IV and PO)


Pulmonary contPulmonary cont..PneumoniaPneumonia Prolonged ventilation, immunocompromised Prolonged ventilation, immunocompromised

patient, emergent operation, age, preexisting patient, emergent operation, age, preexisting lung diseaselung disease

Tx: antibiotics, good pulmonary hygiene, Tx: antibiotics, good pulmonary hygiene, mobilization of secretionsmobilization of secretions

Pulmonary EmbolismPulmonary Embolism Prolonged hospitalization/bed rest, recent groin Prolonged hospitalization/bed rest, recent groin

catherization, or hypercoagulable statecatherization, or hypercoagulable state Not seen much since use of heparin and Not seen much since use of heparin and

hemodilution during surgeryhemodilution during surgery Tx: Heparin/Warfarin, INR goal ~2.0, IVC filterTx: Heparin/Warfarin, INR goal ~2.0, IVC filter


GIGI

IleusIleus Due to anesthesia/narcotics commonlyDue to anesthesia/narcotics commonly Usually self limitingUsually self limiting Usually resolved with DC of narcotics, Usually resolved with DC of narcotics,

restriction of PO intake, IV fluids, and restriction of PO intake, IV fluids, and ambulationambulation

Severe cases may need gastric Severe cases may need gastric decompression with NG tube, or surgical decompression with NG tube, or surgical evaluation if SBO or peritonitis, initiate TPN evaluation if SBO or peritonitis, initiate TPN


RenalRenal 1-5% of patients 1-5% of patients Age, history of DM,prior renal insufficiency, CPBAge, history of DM,prior renal insufficiency, CPB Perioperative hypotension, atheroembolism, Perioperative hypotension, atheroembolism,

sepsis or nephrotoxic drugssepsis or nephrotoxic drugs Major mechanismsMajor mechanisms: prerenal azotemia, ATN. : prerenal azotemia, ATN. Others: acute interstitial nephritis, acute Others: acute interstitial nephritis, acute

glomerulonephritis, obstructive uropathyglomerulonephritis, obstructive uropathy Tx: high arterial perfusion pressure, renal dose Tx: high arterial perfusion pressure, renal dose

Dopamine (1-3 mcg) drip, free water hydration, Dopamine (1-3 mcg) drip, free water hydration, Lasix/ MannitolLasix/ Mannitol

Monitor I/O carefully, and check electrolytes, Monitor I/O carefully, and check electrolytes, esp. Kesp. K++!!!!

Temporary HD vs permanentTemporary HD vs permanent

Myocardial infarctionMyocardial infarction

1-2 % of patients1-2 % of patients Common causes: inadequate Common causes: inadequate

myocardial protection, incomplete myocardial protection, incomplete revascularization, premature graft revascularization, premature graft closureclosure

Sx: angina, diaphoresisSx: angina, diaphoresis ST elevation, high troponin and CK ST elevation, high troponin and CK Medical therapy (ASA,Plavix) when Medical therapy (ASA,Plavix) when

appropriate, ? angioplasty, ? CCB for appropriate, ? angioplasty, ? CCB for vasospasm of arterial graftsvasospasm of arterial grafts

Wound infectionWound infection

Fever, leukocytosis, wound drainage, Fever, leukocytosis, wound drainage, sternal instabilitysternal instability

Superficial subcutaneous infectionSuperficial subcutaneous infection isolated sternal wound infection (w/ isolated sternal wound infection (w/ no mediastinal involvement) no mediastinal involvement) severe severe cases mediastinitis with sepsiscases mediastinitis with sepsis

Tx: broad spectrum antibiotics, blood Tx: broad spectrum antibiotics, blood cultures, wound debridement, VAC, or cultures, wound debridement, VAC, or pectoral or omental muscle flapspectoral or omental muscle flaps

DM, bilateral IMA harvest, DM, bilateral IMA harvest, immunocompromised predisposedimmunocompromised predisposed

DischargeDischarge

Mobilize patients quickly (within 1-2 days)Mobilize patients quickly (within 1-2 days)

Ambulation most common form of endurance activityAmbulation most common form of endurance activity

Order PT/OT evaluation when ready Order PT/OT evaluation when ready

Cardiac rehab RN, dietician and case manager see Cardiac rehab RN, dietician and case manager see patients prior to discharge. patients prior to discharge.

Sternal precautions (no heavy lifting >5lbs x 6 Sternal precautions (no heavy lifting >5lbs x 6 weeks), heart pillowweeks), heart pillow

Case mgt: SNF v Acute Rehab, Home PT/OT, IV Case mgt: SNF v Acute Rehab, Home PT/OT, IV antibiotics, wound care, INR checksantibiotics, wound care, INR checks

QUESTIONS?????QUESTIONS?????

AppendixAppendix

Monitoring- ICU/ORMonitoring- ICU/OR

ECG leads- 3 electrode system, aVR- ECG leads- 3 electrode system, aVR- right arm, aVL- left arm, aVF- left legright arm, aVL- left arm, aVF- left leg

Arterial line/BP cuffArterial line/BP cuff Central venous pressure (CVP)- Central venous pressure (CVP)-

vasoactive drugs,venous access, vasoactive drugs,venous access, parenteral nutritionparenteral nutrition

Pulmonary artery pressure: RA Pulmonary artery pressure: RA pressure, PA pressure, PCW, CO, pressure, PA pressure, PCW, CO, blood temp.blood temp. assess volume status, ventricular fxn, assess volume status, ventricular fxn,

presence of pulm. HTNpresence of pulm. HTN

Monitoring cont.Monitoring cont.

Transesophageal Echo (TEE)- eval Transesophageal Echo (TEE)- eval LV fxn, WMA, native and prosthetic LV fxn, WMA, native and prosthetic valve dysfunction, aortic valve dysfunction, aortic aneurysms, masses, vegetations.aneurysms, masses, vegetations.

Pulse oximetry- measure Pulse oximetry- measure oxygenationoxygenation

Temperature- initiating/ Temperature- initiating/ terminating CPBterminating CPB

Urine output- adequate blood Urine output- adequate blood volume, CO, peripheral perfusionvolume, CO, peripheral perfusion

Common MedicationsCommon Medications

Beta Blockers- HR/BP controlBeta Blockers- HR/BP control-Metoprolol-Metoprolol-Esmolol- Type B dissections -Esmolol- Type B dissections

Antiarrhythmics- Afib,etcAntiarrhythmics- Afib,etc Amiodarone Amiodarone DigoxinDigoxin CCB CCB

ACE-Inhibitors- LV dysfunction, ventricular ACE-Inhibitors- LV dysfunction, ventricular remodeling, afterload reductionremodeling, afterload reduction LisinoprilLisinopril

Lipid lowering agents- post-CABG,HLDLipid lowering agents- post-CABG,HLD LipitorLipitor Zetia Zetia

Common MedicationsCommon Medications

Pain medicationsPain medications IV: fentanyl, Morphine, Dilaudid. Also use PCA IV: fentanyl, Morphine, Dilaudid. Also use PCA

versionsversions PO: Vicodin, Percocet, Oxycodone, Tylenol #3PO: Vicodin, Percocet, Oxycodone, Tylenol #3

DiureticsDiuretics-Lasix IV and PO, drip (ICU)-Lasix IV and PO, drip (ICU)-HCTZ-HCTZ-Spironolactone-Spironolactone

AnticoagulantsAnticoagulants-Heparin/Warfarin- AF, mechanical valves-Heparin/Warfarin- AF, mechanical valves-ASA- all patients unless contraindicated! -ASA- all patients unless contraindicated!

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Management of Cardiac Surgery Patients and role of PA's

Health & Medicine