Postoperative care of the patient

Post-operative care of the cardiac surgery patient

Martinette FerreiraConsultant in cardiovascular and aortovascular anaesthesia

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Coagulation

Kidney

Standard post-operative course

D 0

All patients

Stabilise Warm, wean, wake Wean vasopressors Extubate Mobilise Analgesia Prevent/treat N & V

D 1

Wean inotropes to OFF Remove chest drains (CXR) Remove urine catheter (FB) Disconnect pacing Mobilise Analgesia Oral intake ERACS: Level 1

D 2 - 4

Continue with previous goals Remove pacing wires D 4 checks: CXR, weight ERACS: D/C home

Location: ITU

Location: level 1

Location: Level 2 or 1

Oral intake: promote oral intake vs IV administrationN&V: treat aggressively. If persistent, investigate (CT)Abd distension: ileus vs iatrogenic vs perforationNBM: Poor absorption/ Hypophosphataemia Poor absorption: convert medication to IV, consider TPN Insulin: BM < 10 mmol/l Type 1 DM: continue with longacting insulin periopBNO: Senna/Docusate/Macrogol/Lactulose/Enema

GIT system

pO2: FiO2 & PEEP Aim: pO2 > 8 kPa pCO2: RR, Vt & I:E Permissive hypercapnoea (Not in pulm HTN, ICP) CXR: daily, if slow weaning/increasing vent requirements Fluid balance: Restrictive if high ventilatory requirements HAP: All patients are at risk after 72 hours in ACCU Treat according to Trust/regional guidelines Practice antibiotic stewardship

Respiratory assessment

Urine output: > 0.5 ml/kg/h Co-amilofruse/Furosemide K+: Target > 4.5 mmol/l Fluid balance: D0: +1000 to +1500 ml (baseline + 5 - 8 kg extra) D1: - 500 to -1000 ml (until baseline) except: high temp/complicated surgery/TAAA RRT: Conventional vs citrate Increased morbidity & mortality Uraemia: GCS/confusion/GIT/N&V/pruritis

Renal function/ electrolytes

• CKD
• Nephrotoxic agents
• Low CO/hypotensive
• Perioperative ischaemia
• Long/complicated procedure

Renal system

High risk patients

VTE: Pneumatic vs pharmacological High BMI Renal-adjusted dosis Mechanical valves: Warfarin AVR: 2.0 - 2.5 MVR: 2.5 - 3.5 AF: 20% of all cardiac patients Therapeutic anticoagulation after 48 h

Coagulation

Atrial fibrillation

• Type of surgery
• Length of surgery
• Pre-existing cardiorespiratory comorbidities
• Older patient (enlarged atria)
• High BMI
• CHAD2S2-VASc

Treatment: Beta-blockers Amiodarone DCCV

High-risk patients

GCS: E 4 M 5 S 6 Orientation / obeying commands Daily sedation wean Pupils: size, reactivity Mobility: localising signs Strength: critical illness neuropathy CVA: thrombectomy rarely indicated haemorrhagic transformation (serial imaging) Delirium: High prevalence; often missed/underdiagnosed LOS, morbidity, mortality Treatment difficult Prevention advised

CNS

HR: sinus rhythm vs paced rhythm vs arrhythmia Beta-blockers OK if spontaneous HR > 60 bpm Daily 12-lead ECGBP: are we achieving set target (Noradrenaline/Vasopressin) Targets: >65; 80 - 110; syst < 120 CO: are we achieving an adequate output Warm, well perfused CO monitoring: SvO2, CI, SVR, PVR, PCWP Milrinone vs Adrenaline vs Levosimendan Monitor weaning (CO, lactate, peripheral perfusion)

Cardiovascular

• Poor LV/RV ventricular function
• MV repair/replacement
• TV replacement
• Pulmonary hypertension
• Long CPB & DHCA
• Complicated procedure
• Less optimal myocardial protection
• Irreversible pathology

CVS

High-risk patients

Acute Pain Management Team: Chronic pain/pain medication Mental health history Catastrophising History/current substance abuse Expected difficult pain control

Analgesia

• COPD/Emphysema
• Poor cough
• High secretion load
• Slow respiratory wean
• Community-acquired infection before admission
• Multi-organ failure

Respiratory

High risk patients

Postoperative pain management:Intra-operative: high-dose short-acting agent Loading with longer acting agent Post-operative: PCA (Morphine/Fentanyl/Oxycodone) If not used correctly - convert to regular oral analgesia Codeine 100 mg = Morphine 10 mg (oral) Oxycodone IR 6.6 mg = Morphine 10 mg (oral)

Analgesia

• Increased LOS ($$$)

• Poor mobilisation / postop complications

• Persistent postoperative pain

• Increased morbidity

Poor pain control

Delirium:Older age Disease severity Prior neurological disease Prior mental health history (depression/schizophrenia) Substance abuse CPB time Surgical complexity Perfusion management (flow rates, MAP, haematocrit) ITU admission (early onset and during prolonged admission) Sleep deprivation Immobility/physical restraints Prolonged mechanical ventilation Medications (BZP, steroids)

CNS

High risk patients