Post Op Cardiac Care

8/2/2019 Post Op Cardiac Care

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Postoperative Care in thePostoperative Care in thePatient With CongenitalPatient With CongenitalHeart DiseaseHeart Disease

UTHSCSA Pediatric Resident Curriculum for the PICUUTHSCSA Pediatric Resident Curriculum for the PICU


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General PrinciplesGeneral Principles

Patient homeostasisPatient homeostasis Early declining trends do not correctEarly declining trends do not correct

themselvesthemselves Late time can be important diagnostic toolLate time can be important diagnostic tool

The enemy of good is betterThe enemy of good is better


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Specific ApproachesSpecific Approaches

Cardiovascular principlesCardiovascular principles

Approach to respiratory managementApproach to respiratory management

Pain control/sedationPain control/sedation

Metabolic/electrolytesMetabolic/electrolytes

InfectionInfection

Effects of surgical interventions on theseEffects of surgical interventions on theseparametersparameters

NO PARAMETER EXISTS IN ISOLATIONNO PARAMETER EXISTS IN ISOLATION


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Cardiovascular PrinciplesCardiovascular Principles

Maximize OMaximize O22 delivery/ Odelivery/ O22consumption ratioconsumption ratio

Oxygen delivery:Oxygen delivery:Cardiac OutputCardiac Output

Ventilation/OxygenationVentilation/Oxygenation

HemoglobinHemoglobin


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Maximizing Oxygen DeliveryMaximizing Oxygen Delivery

Metabolic acidosis isMetabolic acidosis is

the hallmark of poorthe hallmark of poor

oxygen deliveryoxygen delivery


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Maximizing Oxygen DeliveryMaximizing Oxygen Delivery

OXYGENOXYGENDELIVERYDELIVERY OXYGENOXYGENCONTENTCONTENTCARDIACCARDIACOUTPUTOUTPUTXX==


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OO22 Content =Content =

Saturation(OSaturation(O22 Capacity)+(PaOCapacity)+(PaO22)0.003)0.003

Oxygen Capacity = Hgb (10) (1.34)Oxygen Capacity = Hgb (10) (1.34)

So . .So . .

Hemoglobin and saturations are determinantsHemoglobin and saturations are determinants

of Oof O22 deliverydelivery

Maximizing Oxygen DeliveryMaximizing Oxygen DeliveryCardiac OutputCardiac Output


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Gidding SS et al 198Gidding SS et al 198

y=-0.26(x)+3y=-0.26(x)+3

R=0.7R=0.7

S.E.E.=1.S.E.E.=1.


13

15

17

19

21

23

65 70 75 80 85 90

Saturation(%)


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Stroke VolumeStroke Volume ContractilityContractility

Diastolic FillingDiastolic Filling

AfterloadAfterload

Heart rateHeart rate Physiologic ResponsePhysiologic Response Non-physiologicNon-physiologic

ResponseResponse Sinus vs. junctional vs.Sinus vs. junctional vs.

paced ventricular rhythmpaced ventricular rhythm

CardiacCardiacOutputOutput

StrokeStrokeVolumeVolume

HeartHeartRateRate== X

X


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Maximizing OxygenMaximizing Oxygen

Oxygen consumptionOxygen consumption Decreasing metabolic demandsDecreasing metabolic demands

Sedation/ paralysisSedation/ paralysisThermoregulationThermoregulation


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Ventilator StrategiesVentilator Strategies

Respiratory acidosis/hypercarbiaRespiratory acidosis/hypercarbia

OxygenationOxygenation

Physiology of single ventricle/shunt lesionsPhysiology of single ventricle/shunt lesions

Oxygen delivery!Oxygen delivery!

Atelectasis 15-20 cc/kg tidal volumes.Atelectasis 15-20 cc/kg tidal volumes.

PEEP, inspiratory timesPEEP, inspiratory times


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Ventilator Strategies:Ventilator Strategies:Pulmonary HypertensionPulmonary Hypertension

Sedation/neuromuscular blockadeSedation/neuromuscular blockade

High FiO2 no less than 60% FiO2High FiO2 no less than 60% FiO2

Mild respiratory alkalosisMild respiratory alkalosis pH 7.50-7.60pH 7.50-7.60

pCOpCO22 30-35 mm Hg 30-35 mm Hg

Nitric OxideNitric Oxide


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Ventilator Strategies:Ventilator Strategies:Pulmonary HypertensionPulmonary Hypertension

Precipitating

Event-Cold stress

-Suctioning

-Acidosis

Metabolic Acidosis

Hypercapnia

Increased

PVR

Decreased Pulmonary Blood FlowDecreased LV preload

RV dysfunction

Central Venous Hypertension

HypoxemiaLow output

Ischemia


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Pain Control/SedationPain Control/Sedation

Stress response attenuationStress response attenuation

Limited myocardial reserve decreasingLimited myocardial reserve decreasing

metabolic demandsmetabolic demands

Labile pulmonary hypertensionLabile pulmonary hypertension

Analgesia/anxiolysisAnalgesia/anxiolysis


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OpioidsOpioids MSO4 Gold standard: better sedative effectsMSO4 Gold standard: better sedative effects

than synthetic opioidsthan synthetic opioids Cardioactive histamine release and limits endogenousCardioactive histamine release and limits endogenous

catecholaminescatecholamines

Fentanyl/sufentanylFentanyl/sufentanyl Less histamine releaseLess histamine release

More lipid soluble better CNS penetrationMore lipid soluble better CNS penetration


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SedativesSedatives

Chloral hydrateChloral hydrate

Can be myocardial depressantCan be myocardial depressant Metabolites include trichloroethanol and trichloroaceticMetabolites include trichloroethanol and trichloroacetic

acidacid

BenzodiazepinesBenzodiazepines

Valium/Versed/AtivanValium/Versed/Ativan


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Muscle relaxantsMuscle relaxants Depolarizing SuccinylcholineDepolarizing Succinylcholine

Bradycardia ( ACH)Bradycardia ( ACH)

Non-depolarizingNon-depolarizing Pancuronium tachycardiaPancuronium tachycardia Vecuronium shorter durationVecuronium shorter duration AtracuriumAtracurium

spontaneously metabolizedspontaneously metabolized Histamine releaseHistamine release


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Others:Others:

Barbiturates vasodilation, cardiac depressionBarbiturates vasodilation, cardiac depression

Propofol myocardial depression, metabolicPropofol myocardial depression, metabolic

acidosisacidosis

Ketamine increases SVRKetamine increases SVR

Etomidate No cardiovascular effectsEtomidate No cardiovascular effects


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Fluid and ElectrolytesFluid and Electrolytes

Effects of underlying cardiac diseaseEffects of underlying cardiac disease

Effects of treatment of that diseaseEffects of treatment of that disease


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Cardiopulmonary BypassCardiopulmonary Bypass

Controlled shockControlled shock

Loss of pulsatile blood flowLoss of pulsatile blood flow Capillary leakCapillary leak

VasoconstrictionVasoconstriction

Renovascular effectsRenovascular effects Renin/angiotensinRenin/angiotensin

Cytokine releaseCytokine release

Endothelial damage and sheer injuryEndothelial damage and sheer injury


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Cardiopulmonary BypassCardiopulmonary Bypass

StressResponse SIRS

MicroembolicEvents

RenalInsufficiency

FluidAdministration Hemorrhage

Capillary Leak SyndromeFeltes, 1998

Lung Fluid

Filtration= [( )-( )]

Microvascular

Hydrostatic Pressure

Microvascular

Oncotic Pressure


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Circulatory ArrestCirculatory Arrest

Hypothermic protection of brain and otherHypothermic protection of brain and other

tissuestissues

Access to surgical repair not accessible by CPBAccess to surgical repair not accessible by CPB

alonealone

Further activation of SIRS/ worsened capillaryFurther activation of SIRS/ worsened capillary

leak.leak.


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Fluid and ElectrolyteFluid and ElectrolytePrinciplesPrinciples

CrystalloidCrystalloid Total body fluid overloadTotal body fluid overload Maintenance fluid = 1500-1700 cc/mMaintenance fluid = 1500-1700 cc/m22/day/day

Fluid advancement:Fluid advancement: POD 0 : 50-75% of maintenancePOD 0 : 50-75% of maintenance POD 1 : 75% of maintenancePOD 1 : 75% of maintenance Increase by 10% each day thereafterIncrease by 10% each day thereafter


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Flushes and Cardiotonic DripsFlushes and Cardiotonic Drips Remember: Flushes and Antibiotics = VolumeRemember: Flushes and Antibiotics = Volume

UTHSCSA protocol to minimize crystalloid: Standard Drip ConcentrationUTHSCSA protocol to minimize crystalloid: Standard Drip Concentration

Mix in dextrose or saline containing fluid to optimize serum glucose & electrolytesMix in dextrose or saline containing fluid to optimize serum glucose & electrolytes

Sedation: (Used currently as carrier for drips)Sedation: (Used currently as carrier for drips)MSO4MSO4 2cc/hr = 0.1 mg/kg/hr2cc/hr = 0.1 mg/kg/hr

FentanylFentanyl 2 cc/hr = 3 mcg(micrograms)/kg/hr2 cc/hr = 3 mcg(micrograms)/kg/hr

Cardiotonic medications:Cardiotonic medications:

Dopamine/DobutamineDopamine/Dobutamine 50 mg/50 cc50 mg/50 cc

Epi/NorepinephrineEpi/Norepinephrine 0.5 mg/50 cc0.5 mg/50 cc

MilrinoneMilrinone 5 mg/50 cc5 mg/50 cc

Nipride (Nitroprusside)Nipride (Nitroprusside) 0.5 mg/50 cc0.5 mg/50 cc

NitroglycerinNitroglycerin 50 mg/50 cc50 mg/50 cc

PGEIPGEI 500 mcg/50 cc500 mcg/50 cc


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Intravascular volume expansion/ Fluid challengesIntravascular volume expansion/ Fluid challenges Colloid osmotically activeColloid osmotically active

FFPFFP

5% albumin/25% albumin5% albumin/25% albumin PRBCsPRBCs

HCT adequate: 5% albumin (HR, LAP, CVP)HCT adequate: 5% albumin (HR, LAP, CVP) HCT inadequate: 5-10 cc/kg PRBCHCT inadequate: 5-10 cc/kg PRBC Coagulopathic: FFP/ CryoprecipitateCoagulopathic: FFP/ Cryoprecipitate

Ongoing losses: CT and Peritoneal frequently = 5%Ongoing losses: CT and Peritoneal frequently = 5%albuminalbumin


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Metabolic EffectsMetabolic Effects

GlucoseGlucose Neonates vs. children/adultsNeonates vs. children/adults Hyperglycemia in the early post-op periodHyperglycemia in the early post-op period


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CalciumCalcium Myocardial requirementsMyocardial requirements

RhythmRhythm

ContractilityContractility Vascular resistanceVascular resistance

NEVER UNDERESTIMATE THE POWER OFNEVER UNDERESTIMATE THE POWER OF

CALCIUM!CALCIUM!


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Calcium/inotropesCalcium/inotropes

SarcoplasmicReticulum

cAMP-Dependent PK

Ca

Ca

CaCa

Ca

PhosphodiesterasePhosphodiesteraseAdenylateAdenylateCyclaseCyclase

RegulatoryG Protein

Na

Alpha 1Alpha 1

Beta 1

DAG

IP3

Na

KSR


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PotassiumPotassium Metabolic acidosisMetabolic acidosis Rhythm disturbancesRhythm disturbances


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Thermal RegulationThermal Regulation

As a sign to watch, and an item toAs a sign to watch, and an item to

manipulatemanipulate

PerfusionPerfusion Junctional ectopic tachycardiaJunctional ectopic tachycardia

Metabolic demandsMetabolic demands

Oxygen consumptionOxygen consumption

InfectionInfection


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InfectionInfection

Routine anti-staphylococcal treatmentRoutine anti-staphylococcal treatment


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Effects of SurgicalEffects of SurgicalInterventionsInterventions

Cardiopulmonary Bypass vs. Non-BypassCardiopulmonary Bypass vs. Non-Bypass Fluids and electrolytesFluids and electrolytes

Modified ultrafiltrationModified ultrafiltration

Types of anatomic defectsTypes of anatomic defects Overcirculated increased blood volumesOvercirculated increased blood volumes

preoperativelypreoperatively

Undercirculated reperfusion of area previouslyUndercirculated reperfusion of area previously

experiencing much reduced flow volumes.experiencing much reduced flow volumes.


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SummarySummary

Optimize oxygen delivery by manipulation of cardiacOptimize oxygen delivery by manipulation of cardiac

output and hemoglobinoutput and hemoglobin

Sedation and pain control can aid in the recoverySedation and pain control can aid in the recovery

Appreciate effects of cardiopulmonary bypass andAppreciate effects of cardiopulmonary bypass and

circulatory arrest on fluid and electrolyte managementcirculatory arrest on fluid and electrolyte management

Tight control of all parameters within the first 12 hours;Tight control of all parameters within the first 12 hours;

after that time, patients may be better able to declareafter that time, patients may be better able to declare

trends that can guide your interventions.trends that can guide your interventions.

Post Op Cardiac Care

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