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(BQ) Part 2 book Postoperative critical care for cardiac surgical patients has contents: Noncardiac complications after cardiac surgery, postoperative pain management in cardiac surgery, fluid management and electrolyte balance, risk and outcome assessments,... and other contents.
8 Noncardiac Complications After Cardiac Surgery Antonio Hernandez Conte and Mahnoosh Foroughi Contents 8.1 Respiratory Complications 8.1.1 Prolonged Intubation and Failure to Extubate 8.1.2 Tracheostomy 8.1.3 Pneumonia 8.2 Renal Complications 8.2.1 Acute Kidney Injury 8.3 Infectious Complications 8.3.1 Surgical Site Infections 8.3.2 Bloodstream Infections 8.3.3 Sternal Wound Infections Reference Suggested Reading 214 214 215 216 222 222 224 224 228 230 231 231 Abstract Surgical, technological, and pharmacologic advances during the past 25 years have enabled complex cardiac surgery to become more routine; however, one cannot underestimate the multiple potential complications that can still arise in the postoperative setting The anesthesiologist, physician intensivist, and critical care nurse should be thoroughly familiar with a wide range of issues that can arise in the postoperative course in the intensive care unit after a patient has undergone cardiothoracic surgery A.H Conte, MD, MBA (*) Perioperative Transesophageal Echocardiography Education, Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA e-mail: antonio.conte@cshs.org M Foroughi, MD Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran e-mail: mahnoosh.foroughi@gmail.com, m_foroughi@sbmu.ac.ir A Dabbagh et al (eds.), Postoperative Critical Care for Cardiac Surgical Patients, DOI 10.1007/978-3-642-40418-4_8, © Springer-Verlag Berlin Heidelberg 2014 213 214 A.H Conte and M Foroughi The widespread use of large long-term clinical databases has led to a greater understanding of the most common complications facing cardiothoracic surgical patients and has allowed the delineation of comorbidities or factors associated with significant and commonly occurring postoperative events Although an extremely vast myriad of noncardiac-related postoperative complications may occur after a patient has undergone cardiac surgery, this chapter will focus on the most common noncardiac complications after the patient has left the cardiac surgical operative arena and entered into the postoperative phase of care, typically provided in the intensive care unit 8.1 Respiratory Complications During cardiac surgery, patients experience multiple physiologic and mechanical alterations in respiratory function due to endotracheal intubation, positive-pressure mechanical ventilation, initiation of cardiopulmonary bypass (CPB), and subsequent termination of CPB All of these respiratory insults are coupled with complex cardiac surgical alterations further exacerbating respiratory mechanics Therefore, the respiratory system is prone to multiple complications after cardiac surgery, most notably prolonged intubation and/or potential infectious processes 8.1.1 Prolonged Intubation and Failure to Extubate After cardiac surgery, virtually all patients present to the intensive care unit with an in situ endotracheal tube and require mechanical ventilation for a short period of time before weaning can be initiated In the last 20 years, improved surgical techniques and shorter-acting anesthetic agents have allowed extubation after cardiac surgery to occur in a shorter period of time Early extubation is defined as within h of arrival in the ICU Because of the success of early extubation, anesthesiologists and surgeons have been able to identify preoperative, intraoperative, and postoperative risk factors for prolonged intubation or failure to extubate Prolonged intubation not only extolls additional morbidity and mortality upon patients, but it also creates noteworthy economic costs upon the health-care system Early extubation may result in shorter ICU length of stays and earlier discharge, as well as lower perioperative morbidity and mortality While early extubation is not associated with higher complications, it may be more beneficial in low-risk patients Early extubation can be accelerated by modifying anesthetic agents selected intraoperatively In particular, lower doses of opioid and/or benzodiazepines can be administered and concomitantly receive propofol or dexmedetomidine In the ICU, reversal of neuromuscular blockade and rapidly decreasing levels of sedation can accelerate extubation Early extubation is not impacted by preoperative routine lung function tests such as spirometry, and this does not predict the length of postoperative intubation While patients who have a history of smoking may have increased pulmonary Noncardiac Complications After Cardiac Surgery 215 Table 8.1 Predictors for prolonged intubation and/or respiratory failure after cardiac surgery Patient-related factors Advanced age >70 Endocarditis Gastrointestinal bleeding Hypoalbuminemia Surgical factors Internal mammary artery dissection Increased number of bypass grafts Multiple valve procedures Operative priority (emergent) NYHA Class Pulmonary hypertension Sepsis Reoperation for bleeding Need for intraoperative aortic balloon pump Topical myocardial cooling Other factors Aspiration pneumonia CPB >120 Deep sternal wound infection Inpatient hospitalization prior to surgery Use of inotropes Perioperative cerebrovascular accident (CVA) Pleural effusion Pulmonary edema NYHA New York Heart Association complications, these patients not necessarily have prolonged intubation periods However, if patients with a history who smoke remain intubated for greater than h, respiratory complications will increase There are multiple factors which are predictive of prolonged intubation and respiratory failure post-cardiac surgery Patients with any one or more of the following may have difficulty with early extubation: advanced age >70, higher New York Heart Association (NYHA) classification, patients who undergo multiple valve procedures, need for emergent surgery, or who require an intra-aortic balloon pump (See Table 8.1) Consideration should be given to developing rapid extubation protocols in all patients who undergo cardiac surgery; however, additional protocols should be implemented to identify patients who possess high-risk factors that could prolong the time to extubation or lead to respiratory failure 8.1.2 Tracheostomy Despite decades of experience in ICUs, there is still controversy over the specific indications, techniques, and timing of tracheostomy Not only the optimal timing (i.e., early versus delayed) and the most appropriate technique remain subjects of debate, but also the actual clinical value (benefit/risk ratio) of tracheostomy is unknown Typically, the most common indication for tracheostomy in the intensive care unit (ICU) setting has been the need for prolonged mechanical ventilation However, this is also a controversial indication because of the potential complications and costs associated with the performance of a tracheostomy in this patient population In addition to the need for prolonged ventilation, ICU patients may require a tracheostomy due to development of nosocomial pneumonia, the administration of aerosol treatments, having a witnessed aspiration event, and after requiring reintubation Benefits attributed to tracheotomy versus prolonged translaryngeal intubation include improved patient comfort, more effective airway suctioning, decreased airway resistance, enhanced patient mobility, increased potential for speech, ability 216 A.H Conte and M Foroughi to eat orally, a more secure airway, accelerated ventilator weaning, reduced ventilator-associated pneumonia, and the ability to transfer ventilator-dependent patients from the ICU However, none of these benefits have been demonstrated in large-scale, prospective, randomized studies Patients requiring a tracheostomy usually have significantly longer lengths of stay in the ICU and hospital, a longer duration of mechanical ventilation, and more acquired organ-system derangements compared with patients without a tracheostomy The duration of mechanical ventilation before tracheostomy was also significantly longer than the overall duration of mechanical ventilation for patients without a tracheostomy However, mechanically ventilated patients in the ICU setting who received a tracheostomy have a higher hospital survival rate compared with mechanically ventilated patients without a tracheostomy This difference in hospital survival usually occurs during the first weeks of intensive care and does not appear to be attributable to the tracheostomy procedure The optimal timing for tracheostomy and the impact of tracheostomy on patient outcomes in the ICU setting are controversial and very important in optimally managing this subset of patients Patient-specific variables that were independently associated with subsequent tracheostomy may allow earlier identification of individuals who are at increased risk for prolonged ventilatory support These variables or risk factors offer clinicians the opportunity to identify more objectively patients who may benefit from earlier placement of a tracheostomy to improve potentially their outcomes (e.g., reduction of pain associated with the prolonged presence of an oral endotracheal tube) and to reduce the use of ICU beds Earlier placement of a tracheostomy may be justified if it improves patient tolerance of prolonged ventilatory support, even if it does not reduce the total duration of mechanical ventilation compared with translaryngeal intubation 8.1.3 Pneumonia 8.1.3.1 Aspiration Pneumonia Most patients with depressed consciousness may experience pharyngeal aspiration, which, in the presence of underlying diseases that impair host defense mechanisms and alterations in oropharyngeal flora, may manifest as aspiration pneumonia Patients having undergone cardiac surgery may have residual effects from sedation or may be receiving opioids that may depress protective reflexes Additionally, cardiac surgical patients may sustain a neurologic injury that could also predispose them to an aspiration event Concomitantly, patients with diabetes or morbid obesity are prone to delayed gastric emptying, thereby also increasing the risk for aspiration of gastric contents K pneumoniae is frequently implicated in aspiration pneumonia Clinical manifestations of pulmonary aspiration depend in large part on the nature and volume of aspirated material Aspiration of large volumes of acidic gastric fluid (Mendelson’s syndrome) produces fulminating pneumonia and arterial hypoxemia Aspiration of particulate material may result in airway obstruction, and Noncardiac Complications After Cardiac Surgery 217 smaller particles may produce atelectasis Radiographically, infiltrates are most common in dependent areas of the patient’s lungs Penicillin-sensitive anaerobes are the most likely cause of aspiration pneumonia Clindamycin is an alternative to penicillin and may be superior for treating necrotizing aspiration pneumonia and lung abscess Hospitalization or antibiotic therapy alters the usual oropharyngeal flora such that aspiration pneumonia in hospitalized patients often involves pathogens that are uncommon in community-acquired pneumonias There are limited data to suggest that treatment of aspiration pneumonia with antibiotics improves outcome 8.1.3.2 Lung Abscess Lung abscess may develop after bacterial pneumonia Alcohol abuse and poor dental hygiene are important risk factors Septic pulmonary embolization, which is most common in intravenous drug abusers, may also result in formation of a lung abscess A finding of an air–fluid level on the chest radiograph signifies rupture of the abscess into the bronchial tree, and foul-smelling sputum is characteristic Antibiotics are the mainstay of treatment of a lung abscess Surgery is indicated only when complications such as empyema occur Thoracentesis is necessary to establish the diagnosis of empyema, and treatment requires chest tube drainage and antibiotics Surgical drainage is necessary to treat chronic empyema 8.1.3.3 General Postoperative Pneumonia Postoperative pneumonia occurs in approximately 20 % of patients undergoing major thoracic, esophageal, or major upper abdominal surgery but is rare in other procedures in previously fit patients Chronic respiratory disease increases the incidence of postoperative pneumonia threefold Other risk factors include obesity, age older than 70 years, and operations lasting more than h Diagnosis An initial chill, followed by abrupt onset of fever, chest pain, dyspnea, fatigue, rigors, cough, and copious sputum production often characterize bacterial pneumonia, although symptoms vary Nonproductive cough is a feature of atypical pneumonias A detailed history may suggest possible causative organisms Hotels and whirlpools are associated with Legionnaires’ disease (L pneumoniae) outbreaks Fungal pneumonia may occur with cave exploration (Histoplasma capsulatum) and diving (Scedosporium angiospermum) Chlamydia psittaci pneumonia may follow contact with birds and Q fever (Coxiella burnetii) contact with sheep Alcoholism may increase the risk of bacterial aspiration such as K pneumoniae Patients who are immunocompromised, such as those with AIDS, are at risk of fungal pneumonia, such as Pneumocystis jiroveci pneumonia (PCP) Posteroanterior and lateral chest radiographs may be extremely diagnostic in detecting pneumonia Diffuse infiltrates are suggestive of an atypical pneumonia, whereas a lobar radiographic opacification is suggestive of a typical pneumonia Atypical pneumonia occurs more frequently in young adults Radiography is useful A.H Conte and M Foroughi 218 Table 8.2 Clinical pulmonary infection score calculation Parameter Temperature (°C) Blood leukocytes (mm3) Tracheal secretions Oxygenation: PaO2/ FIO2 (mm Hg) Pulmonary radiography Progression of pulmonary infiltrate Culture of tracheal aspirate Options ≥36.5 and ≤38.4:0 ≥38.5 and ≤38.9:1 ≥39 or ≤36:2 ≥4,000 and ≤11,000:0 11,000:1 + band forms ≥50 %, add Absence of tracheal secretions: Presence of non-purulent tracheal secretions: Presence of purulent tracheal secretions: >240 or ARDS: ≤240 and no ARDS: No infiltrate: Diffuse (or patchy) infiltrate: Localized infiltrate: No radiographic progression: Radiographic progression (after cardiac failure and ARDS excluded): Pathogenic bacteria cultured in rare or light quantity Pathogenic bacteria cultured in moderate or heavy quantity Same pathogenic bacteria seen on Gram stain Score Add 1 2 2 Add Data from Luyt (2004) ARDS acute respiratory distress syndrome for detecting pleural effusions and multilobar involvement Polymorphonuclear leukocytosis is typical, and arterial hypoxemia may occur in severe cases of bacterial pneumonia Arterial hypoxemia reflects intrapulmonary shunting of blood owing to perfusion of alveoli filled with inflammatory exudates Microscopic examination of sputum plus culture and sensitivity testing may be helpful in suggesting the etiologic diagnosis of pneumonia and in guiding the selection of appropriate antibiotic treatment S pneumoniae and gram-negative organisms, such as H influenzae, may be seen on sputum stain or culture Unfortunately, sputum specimens are frequently inadequate, and organisms not invariably grow from sputum Interpretation of sputum culture may be challenging, as there is frequent normal nasopharyngeal carriage of S pneumoniae If there is suspicion, sputum specimens should be sent for acid-fast bacilli (M tuberculosis) Antigen detection in urine is a good test for L pneumophila, whereas blood antibody titers are helpful in diagnosing M pneumoniae Sputum polymerase chain reaction is useful for chlamydia Blood cultures are usually negative but are important to rule out bacteremia Table 8.2 displays a useful clinical pulmonary infection score calculator Treatment For severe pneumonia, empirical therapy is typically a combination such as a cephalosporin (e.g., cefuroxime or ceftriaxone) plus a macrolide Noncardiac Complications After Cardiac Surgery 219 (e.g., azithromycin or clarithromycin) antibiotic However, local patterns of antibiotic resistance should always be considered prior to initiating therapy There may be an increasing role for newer quinolones such as moxifloxacin in the treatment of community-acquired pneumonia, especially as “atypical” bacteria are becoming increasingly responsible for community-acquired pneumonia Therapy is advised for 10 days for S pneumoniae and for 14 days for M pneumoniae and C pneumoniae Therapy should be narrowed and targeted when the pathogen is identified When symptoms resolve, therapy can be switched from intravenous to oral The inappropriate prescription of antibiotics for nonbacterial respiratory tract infections is common and promotes antibiotic resistance It has recently been demonstrated that even brief administration of macrolide antibiotics to healthy subjects promotes resistance of oral streptococcal flora that lasts for months Resistance of S pneumoniae is becoming a major problem Prognosis The Pneumonia Severity Index (http://www.mdcalc.com/psi-port-score-pneumoniaseverity-index-adult-cap/) is a useful tool for aiding clinical judgment, guiding appropriate management, and suggesting prognosis Old age and coexisting organ dysfunction have a negative impact Physical examination findings associated with worse outcome are: T temperature >40 °C or 30/min A altered mental status S systolic blood pressure 125/min Laboratory findings and special investigations that are consistent with poorer prognosis include: H hypoxia (PO2 < 60 mmHg or saturation 250 mg/dL (14 mmol/L) A acidosis (pH 14 days), and short postoperative length of stay (Shroyer et al 2003) Definitions for each endpoint and the variables used for the calculations have been previously described by the STS (Shahian et al 2009) The risk calculators for specific outcomes can be accessed at http://riskcalc.sts.org/STSWebRiskCalc273/ 15.4.2 The European System for Cardiac Operative Risk Evaluation (EuroSCORE) The EuroSCORE was developed in 1999 from nearly 20,000 patients and 128 European centers as a simplified tool to calculate the operative mortality risk in cardiac surgery The initial version was developed as an additive system with scores for each risk factor derived from coefficients obtained in a multivariable regression model (Roques et al 1999) The total score was calculated as the sum of the scores of 17 participating variables, and it was correlated to a specific predicted mortality risk In 2003 a second iteration was developed, the logistic EuroSCORE, as a multivariable logistic regression formula; similar to the additive system, coefficients were determined for each participating variable, and the categorical or continuous values of each variable were entered in a logistic regression formula that calculated the predicted mortality risk as described under 2.2 (Michel et al 2003) The additive system seemed to underestimate the outcomes in high-risk patients (EuroSCORE >6) and the logistic EuroSCORE was developed to bridge this gap in the calculations A third iteration was developed in 2011, the EuroSCORE II, as a logistic regression formula similar to the logistic EuroSCORE, with several modifications to the participating variables (http://www.euroscore.org/calc.html) 426 M Caceres Unlike the STS risk calculator, the EuroSCORE does not include calculations for morbidity endpoints and does not provide separate risk models for each type of cardiac surgical procedure; however, it adjusts for the number of surgical interventions, e.g., CABG with mitral valve surgery counts as two procedures, CABG with mitral and tricuspid valve surgery counts as three procedures The EuroSCORE risk calculator can be accessed at http://www.euroscore.org/ 15.5 Limitations of Current Databases Clinical databases have been successful in presenting early outcomes following cardiac surgery; however, longitudinal follow-up including midterm or long-term outcomes has been limited At present, only early outcome data is available in clinical databases, while administrative databases, although with lower data accuracy, have the potential to retrieve long-term data through payer claims records The difficulty to assign patient identifiers that could serve as relational links among databases has prevented the integration of early- and long-term outcome data Likewise, the difficulty in merging clinical databases from different specialties has restricted the assessment of cardiac care outcomes to either surgical or medical modalities of treatment An attempt to bridge this gap is in effect by standardizing the data definitions between the American College of Cardiology and the Society of Thoracic Surgeons databases 15.6 Summary The last two decades have witnessed the origin and expansion of a variety of multi- institutional registries, essential tools in the assessment of outcomes and the implementation of quality improvement initiatives The analysis of risk-adjusted results has been useful in identifying institutions with outlier results and implementing specific strategies to address gaps in the quality of care The data analysis of early outcomes in cardiac surgery has been satisfactory through clinical databases, but there are still limitations in assessing the continuity of cardiac care, necessary in the modeling of mid- and long-term outcomes In the current landscape of scrutiny by consumers and payer organizations, quality improvement remains at the forefront agenda of organized medicine; thus, proper risk adjustment through reliable regional and nationwide registries is essential for the accurate assessment of the quality of cardiac care References Anderson RP (1994) First publications from the Society of Thoracic Surgeons National Database Ann Thorac Surg 57:6–7 Bewick V, Cheek L, Ball J (2004) Statistics review 13: receiver operating characteristic curves Crit Care 8:508–512 Bewick V, Cheek L, Ball J (2005) Statistics review 14: logistic regression Crit Care 9:112–118 15 Risk and Outcome Assessments 427 Caceres M, Braud RL, Garrett HE Jr (2010) A short history of the Society of Thoracic Surgeons national cardiac database: perceptions of a practicing surgeon Ann Thorac Surg 89:332–339 Ellis H (2008) Florence Nightingale: creator of modern nursing and public health pioneer J Perioper Pract 18:404–406 Grover FL, Shroyer AL, Hammermeister K, Edwards FH, Ferguson TB Jr, Dziuban SW Jr, Cleveland JC Jr, Clark RE, McDonald G (2001) A decade’s experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases Ann Surg 234:464–472 Hannan EL, Cozzens K, King SB III, Walford G, Shah NR (2012) The New York State cardiac registries: history, contributions, limitations, and lessons for future efforts to assess and publicly report healthcare outcomes J Am Coll Cardiol 59:2309–2316 Hosmer DW, Lemeshow S (2000) Applied logistic regression, 2nd edn Wiley, New York Michel P, Roques F, Nashef SA, EuroSCORE Project Group (2003) Logistic or additive EuroSCORE for high-risk patients? Eur J Cardiothorac Surg 23:684–687 O’Connor GT, Plume SK, Olmstead EM, Coffin LH, Morton JR, Maloney CT, Nowicki ER, Tryzelaar JF, Hernandez F, Adrian L et al (1991) A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting The Northern New England Cardiovascular Disease Study Group JAMA 266:803–809 Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR (1996) A simulation study of the number of events per variable in logistic regression analysis J Clin Epidemiol 49:1373–1379 Roques F, Nashef SA, Michel P, Gauducheau E, de Vincentiis C, Baudet E, Cortina J, David M, Faichney A, Gabrielle F, Gams E, Harjula A, Jones MT, Pintor PP, Salamon R, Thulin L (1999) Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients Eur J Cardiothorac Surg 15:816–822 Shahian DM, O’Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB, Normand S-LT, DeLong ER, Shewan CM, Dokholyan RS, Peterson ED, Edwards FH, Anderson RP (2009) The Society of Thoracic Surgeons 2008 cardiac surgery risk models: Part Coronary artery bypass grafting surgery Ann Thorac Surg 88:2–22 Shroyer LW, Coombs LP, Peterson ED, Eiken MC, Delong ER, Chen AY, Ferguson TB, Grover FL (2003) The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models Ann Thorac Surg 75:1856–1864 Weiss ES, Chang DD, Joyce DL, Nwakanma LU, Yuh DD (2008) Optimal timing of coronary artery bypass after acute myocardial infarction: a review of California discharge data J Thorac Cardiovasc Surg 135:503–511 Welke KF, Peterson ED, Vaughan-Sarrazin MS, O’Brien SM, Rosenthal GE, Shook GJ, Dokholyan RS, Haan CK, Ferguson TB Jr (2007) Comparison of cardiac surgery volumes and mortality rates between the Society of Thoracic Surgeons and Medicare databases from 1993 through 2001 Ann Thorac Surg 84:1538–1546 Index A Aaslid, R., 147 Abciximab, 170, 171, 177 ABG See Arterial blood gases (ABG) analysis Acid–base balance anion gap (AG), 389, 402 arterial blood gases analysis (ABG), 398–400 arterial pH, pCO2 and bicarbonate measurements, 387–388 base excess, 401–402 blood buffer systems, 386 body compensatory system and action time, 386 Boston rules, 400–401 buffer base, 388–389 fluid administration, 393–394 fluid and electrolyte management colloids, 398 crystalloids, 397–398 dilution acidosis, 396 hyperchloremic acidosis, 395 metabolizable anions and base excess, 396–397 SID, 396 homeostasis, 392 hydro-electrolytic, 392 kidneys and lungs, 387 metabolic acidosis, 404–407 metabolic alkalosis, 407–409 osmolar and hydro-electrolytic balances, 392 pathophysiology of, 394–395 phosphate ions, 387 plasma proteins, 387 respiratory acidosis, 409–411 respiratory alkalosis, 411 standard base excess (SBE), 389, 401–402 standard bicarbonate, 388 Stewart’s approach, 391, 403–404 strong ion difference (SID), 390–391, 403–404 Acute kidney injury (AKI) cardiopulmonary bypass, 302–303 hydroxyethyl starches, 347 noncardiac complications acute renal failure, 222 diagnosis, 223 etiology for, 222 management, 223–224 risk factors for, 222, 223 Acute postoperative pain management analgesic methods, 264–265 chronic pain CABG, 262 chest pain, 262–264 etiologic mechanisms, 263 leg pain, 262, 264 potential risk factors, 263 etiologic risk factors, 261–262 fast-track anesthesia approach, 259–260 multimodal analgesic methods, 260 pain-related health-care costs, 258 pathophysiology, 260–261 patient satisfaction and expectations, 260 perioperative surgical stress response, 259 pharmacologic methods alpha agonists, 273 NSAIDs (see Nonsteroidal antiinflammatory drugs (NSAIDs)) opioids (see Opioids) progressive biopsychosocial epiphenomena, 258 regional anesthetic techniques intercostals nerve block, 278 intrapleural infiltration, 278 neuraxial blocks (see Neuraxial blocks) surgical wound, 277 stress response, 259 Adaptation to the Intensive Care Environment (ATICE), 132 Agrò, F.E., 73–76, 313–372, 385–412 A Dabbagh et al (eds.), Postoperative Critical Care for Cardiac Surgical Patients, DOI 10.1007/978-3-642-40418-4, © Springer-Verlag Berlin Heidelberg 2014 429 430 AKI See Acute kidney injury (AKI) Albumin (HA) calcium, 318, 369 clinical use, 334–336 composition and concentration, 334 hypovolemia treatment, 334 pharmacokinetics, 334 potential risks and side effects, 336 Alfentanil, 270, 272 Allison, K.P., 352 Alpha agonists, 265, 273 American Society of Neurophysiological Monitoring (ASNM), 134 Analgesic agents, 50, 59–61, 139, 140 Antiarrhythmic therapy, 50, 56–58, 238, 241 Anticoagulants, 299 apixaban, 164, 165 dabigatran, 163–165 DTIs, 164, 168, 169 fondaparinux, 164, 168 LMWH, 164, 167 rivaroxaban, 164, 165 UFH, 164, 167 warfarin, 163, 166 Antifibrinolytics, 178–179 Antihypertensive agents, 49–55 Antimicrobial prophylaxis, 42–43 Antiplatelet therapy, 169–171 Apixaban, 164, 165 Aranki, S.F., 182–192 Arrhythmias CVC insertion, 97 diagnosis of, 202–203 magnesium supplementation, 371 management, 203 mean arterial pressure, 79 metabolic alkalosis, 408 oculocardiac reflex, 31 Arterial blood gases (ABG) analysis, 398–400 metabolic acidosis, 404–407 metabolic alkalosis, 407–409 respiratory acidosis, 409–411 respiratory alkalosis, 411 Arterial-jugular vein oxygen gradient (AjvDO2), 146–147 Arterial line cannulation, IBP monitoring See Invasive blood pressure (IBP) monitoring Aspiration pneumonia, 216–217 Aspirin, 86, 169, 171, 177 Astrup, P., 388 Index Auditory-evoked potential (AEP), 131, 141 Automated blood pressure monitoring compartment syndrome, 79–80 oscillometric technique, 79 Axillary artery cannulation, 84, 299 B Bainbrid, F., 26 Bainbridge reflex, 28 Baker, A., 146, 147 Baroreceptors reflex, 28–29 Benedetto, M., 73–76, 313–372, 385–412 Benes, J., 363 Berger, H., 133 Bernard, C., 314 Bezold-Jarisch reflex, 29–30 Bispectral analysis index, 140 Bivalirudin, 164, 168, 169, 189, 194 Blasco, V., 346 Bloodstream infections (BSIs) central venous catheter insertion strategies, 229–230 diagnosis, 228 nosocomial infections, 228 signs and symptoms, 228 treatment, 228–229 Brachial artery cannulation, 84 Bradyarrhythmias, 241–242 Brainstem auditory-evoked response (BAEP), 141 BSIs See Bloodstream infections (BSIs) Bunn, F., 332 Byrne, J.G., 182–192 C Caceres, M., 417–426 Ca2+ homeostasis, 5, 7, 15–16 California discharge database, 423 Calmodulin (CaM), 14, 16–18 Camm, A.J., 237 Cardiac electrical system cells, 2, 4, Cardiac output monitoring bioimpedance and bioreactance, 110–111 EDM, 108–109 Fick principle, 105 indicator dilution techniques, 105–107 partial carbon dioxide (CO2) rebreathing, 107–108 pulse contour analysis, 109–110 selection of, 112–113 USCOM, 111–112 Index Cardiac physiology cardiac reflexes Bainbridge reflex, 28 baroreceptors reflex, 28–29 Bezold-Jarisch reflex, 29–30 chemoreceptor reflex, 31 Cushing reflex, 30 oculocardiac reflex, 31 Valsalva maneuver, 30 cardiac work cardiac output, 26 ejection fraction, 26 stroke volume, 25–26 cellular physiology action potential, 11–13 atrial and ventricular syncytium, 11 contractile mechanisms, 18–24 excitation-contraction coupling, 14–18 coronary arteries, anatomy of, 8–10 Frank-Starling relationship, 26–27 heart, anatomy of atrioventricular valve, atrium and ventricles, 2–3 cardiac connective tissue cells, cardiac contractile tissue cells, 4–8 conductive tissue cells, 8, endocardium, fibrous and parietal pericardium, tricuspid valve, visceral pericardium, normal cardiac cycle, 24–25 Cardiac reflexes Bainbridge reflex, 28 baroreceptors reflex, 28–29 Bezold-Jarisch reflex, 29–30 chemoreceptor reflex, 31 Cushing reflex, 30 oculocardiac reflex, 31 Valsalva maneuver, 30 Cardiac surgery registries administrative databases California discharge database, 423 MEDPAR registry, 422 NIS, 423 clinical databases New York State Cardiac Registry, 423–424 Northern New England Cardiovascular Disease Study Group, 424 STS, 424 Veterans Administration Cardiac Database, 424 431 Cardiac surgery risk calculators EuroSCORE, 425–426 STS database, 425 Cardiopulmonary bypass (CPB) CABG, 200 circuit structure anticoagulation, 299 arterial and venous cannulation, 299 arterial filter, 300 blood circuit, 297 cardioplegia, 299–300 cardiotomy, 298 centrifugal pump, 298 heat exchanger, 300 history, 296–297 MECC, 300–301 membrane oxygenator, 298–299 roller pump, 297 ultrafiltration, 301 complications AKI, 302–303 cognitive disorder, 305 hematologic effect, 302 hypoperfusion, 305 inflammation, 301 lung, 303–304 OPCAB, 305–306 stroke, 304 hemodilution, 135 mean arterial pressure, 80 postoperative hyperthermia, 131 Cardiopulmonary resuscitation (CPR), 46, 205–207 Cardiovascular complications and management assist devices ECMO, 208–209 IABP, 207–208 VAD, 208 cardiac monitoring, 198–199 complications arrhythmias, 202–203 hemodynamic instability, 200–202 PMI, 199–200 CPR, 205–207 POCT, 204–205 vasoplegic syndrome, 203–204 Cardiovascular monitoring cardiac output monitoring (see Cardiac output monitoring) CVP monitoring (see Central venous catheters (CVCs)) hemodynamic parameters, 113–114 432 Cardiovascular monitoring (cont.) IBP monitoring (see Invasive blood pressure (IBP) monitoring) noninvasive blood pressure monitoring automated blood pressure monitoring, 79–80 Riva-Rocci/Korotkoff technique, 78–79 pulmonary artery pressure monitoring (see Pulmonary artery catheter (PAC)) TEE, 114 Carotid sinus reflex, 28–29 Central nervous system (CNS) dysfunction after cardiac surgery, 246 postoperative injuries CPB-related equipment, 253 mechanisms and potential etiologies of, 248–252 pharmacologic neuroprotection, 252 risk factors, 248 time-based classification, 247–248 type I and type II injuries, 246, 247 postoperative monitoring bispectral analysis index, sedation/ analgesia level, 140 of cardiac surgery patients, 130–131 cerebral oximetry, 141–144 dynamic CT scanning, 150 EEG (see Electroencephalography (EEG)) evoked potentials, 140–141 fMRI, 150 ICP monitoring, 151 laser Doppler flowmetry, 150–151 magnetic resonance angiography, 150 neurologic monitoring, 253 positron emission tomography, 150 sedation assessment scales, 132–133 SjvO2 catheter insertion (see Jugular venous oxygen saturation (SjvO2)) thermal diffusion flowmetry, 151 transcranial Doppler, 147–150 Central venous catheters (CVCs) complications of arrhythmia, 97 bleeding and air emboli, 97 infection, 97 mechanical, 94–95 misinterpretation of data, 97–98 thromboembolic, 96 CVP curve, 89–90 indications and contraindications for, 89 insertion of external jugular vein, 94 femoral vein, 94 Index LIJV approach, 93 peripheral CVCs, 94 right internal jugular vein approach, 90–93 subclavian approach, 93–94 ultrasound-guided CVC insertion, 94–95 Central venous pressure (CVP) monitoring See Central venous catheters (CVCs) Cerebral oximetry, 141–144, 249, 305 Chemoreceptor reflex, 31 Chronic pain CABG, 262 chest pain, 262–264 etiologic mechanisms, 263 leg pain, 262, 264 risk factors, 263 Chytra, I., 362 Clopidogrel, 169, 171 Clotting disorders, 331, 339 CNS See Central nervous system (CNS) Coagulopathies, 81, 89, 175–176 Cole, D.J., 146, 147 Colloids and acid–base status, 398 balanced and unbalanced colloids, 333 vs crystalloids, 348–350 vs HES, 350–353 high molecular weight molecules, 332 isotonic and hypertonic colloids, 333 natural colloids (see Albumin (HA)) pharmacokinetics, 333, 334 physiological properties, 333 plasma-adapted and non-plasma-adapted colloids, 333 synthetic (see Synthetic/artificial colloids) Compartment syndrome, 81, 83 brachial artery cannulation, 84 noninvasive blood pressure monitoring, 79–80 Constant, I., 134 Constat, 137 Conte, A.H., 213–231 Context-sensitive half-life (CSHL), 270 Continuous wave Doppler (CWD) technology, 111 Coronary arteries, 8–10, 44, 281 Cost–benefit analysis, 74–76 Cost-effectiveness analysis (CEA), 74 Cost minimization analysis (CMA), 74 Cost–utility analysis (CUA), 74 CPB See Cardiopulmonary bypass (CPB) CPR See Cardiopulmonary resuscitation (CPR) Index Crystalloids and acid–base status, 397–398 classification, 328 vs colloids, 348–350 HCS, 332 latest-generation crystalloids, 330–331 low molecular weight salts, 327 pharmacokinetics, 328 potential risks and side effects clotting disorders, 331 electrolyte modifications, 331 water distribution modification, 331 properties of, 329, 330 Ringer lactate and Ringer acetate, 330 saline solution, 329–330 Cushing reflex, 30 Cushin, H., 30 CVCs See Central venous catheters (CVCs) D Dabbagh, A., 1–39, 77–114, 129–151, 245–253, 257–283 Dabigatran, 163–165 Daily, P.O., 91 Datsur, D.K., 144 Delirium, 66–67, 247, 366 Denault, A., 143 Desmopressin, 179 Dexmedetomidine, 62, 214, 252, 273 Dextrans, 337–338 Dietrich, G., 336 Direct blood pressure monitoring See Invasive blood pressure (IBP) monitoring Direct thrombin inhibitors (DTIs), 164, 168, 169, 188 Disseminated intravascular coagulopathy (DIC), 175–176 Dobutamine, 48, 49, 364 Dopamine, 44–47 Drug-induced thrombocytopenia, 176–177 See also Heparin-induced thrombocytopenia (HIT) Duke Clinical Research Institute, 424 E Eason, M.J., 279 ECMO See Extracorporeal membrane oxygenation (ECMO) ECS See Extracellular space (ECS) EDM See Esophageal Doppler monitoring (EDM) 433 Electroencephalography (EEG), 132 cardiac surgery patients, 134–135, 138–139 electrodes, 136–138 evoked potentials, 140–141 normal and abnormal EEG, 137–138 time epochs, 137 wakefulness, sleep, and anesthesia, 137 waves and electrical characteristics, 135–136 Electrolyte management magnesium, 371 potassium, 369–370 sodium, 364–368 End diastolic volume (EDV), 25, 26 End systolic volume (ESV), 25, 26 English, I.C., 90 Epinephrine, 46, 47, 57, 199 Epsilon-aminocaproic acid (EACA), 178–179 Eptifibatide, 170, 171, 177 Esophageal Doppler monitoring (EDM), 106, 108–109 European System for Cardiac Operative Risk Evaluation (EuroSCORE), 425–426 Excitation-contraction coupling (ECC), 13–14 Ca2+ homeostasis, 15–16 controllers of, 16–18 functioning organelles of, 14–15 External jugular vein, 94 Extracellular space (ECS) chemical properties, 317, 319 chloride, anion, 319 fluid and electrolyte balance, 315 hypertonic solutions, 327, 328 interstitial space (ISS), 315 intravascular space, 315 osmotic pressure, 319–320 potassium, cation, 318 sodium, cation, 318 transcellular space (TCS), 315 Extracorporeal membrane oxygenation (ECMO), 131, 208–209 F Fellin, R., 41–70 Femoral artery cannulation, 84, 299 Femoral vein, 94, 99, 299 Fentanyl, 59, 60, 270–271 Fick, A.E., 105 Fick principle, 105 Fish oil, 170 Fluid management and electrolyte balance balanced vs unbalanced solutions, 353 clinical management, 325–327 434 Fluid management and electrolyte balance (cont.) colloids (see Colloids) crystalloids (see Crystalloids) dextrans, 337–338 extracellular space (ECS) (see Extracellular space (ECS)) fluid movement, capillary membranes, 321–323 GDT (see Goal-directed therapy (GDT)) gelatins., 338–339 hydroxyethyl starches (see Hydroxyethyl starches (HES)) hypertonic colloid solutions, 347–348 ICS (see Intracellular space (ICS)) ionic balance bicarbonate, 319 body fluids properties, 317 calcium, 318 chloride, 319 electric neutrality, 317 Gamble gram, 317 magnesium, 318 potassium, 318 sodium, 318 liberal vs restricted approach, 354–356 osmolar balance, 319–321 postoperative ICU electrolyte modifications, 325 water distribution modification, 323 Fondaparinux, 164, 168, 184, 189, 194 Foroughi, M., 213–231, 295–306 Forssman, W., 88 Frank, O., 26, 109 Frank-Starling relationship, 23, 26–27 Franz, A., 345 Functional magnetic resonance imaging (fMRI), 150 Fuster, V., 237 G Gabapentin, 258, 265, 276 Gallandat Huet, R.C.G., 345 Gamble gram, 317, 392 Ganz, W., 98 Gelatins, 338–339 Gibbon, J., 296 Gibbs, E.L., 144 Girbes, R., 325 Global end-diastolic volume (GEDV), 106, 361 Glycocalyx, 324–325, 372 Goal-directed therapy (GDT) Index clinical impact, 363–364 DO2 physiologically, 356–358 fluid infusions, 356 hemodynamic variables, 358–361 inotropic/vasoactive drugs, 356 monitoring systems, 362–363 Gugino, L.D., 134, 137 H HA See Albumin (HA) Haghjoo, M., 233–242 Haloperidol, 66, 67, 177 Hasselbalch, K.A., 388 Hastings, 388 H2 blockers, 69 Hemopericardium, 96 Henderson–Hasselbalch equation, 318, 388, 392, 393 Heparin-induced thrombocytopenia (HIT), 182–183, 194 aortic stenosis, 190, 191 argatroban, 189 bivalirudin, 189 consequences of, 184–186 coronary artery disease, 190 danaparoid, 188 diagnosis, 186–187 heparin-induced antibodies, 182 incidence of, 184, 185 laboratory test interpretation, 177–178 lepirudin, 188 management, 187–188 pathophysiology, 183–184 4-T score, 177–178 Herbal supplements, 170 HES See Hydroxyethyl starches (HES) Hirt, L., 29 HIT See Heparin-induced thrombocytopenia (HIT) Hosmer–Lemeshow test, 420, 421 Hydromorphone, 59, 60 Hydroxyethyl starches (HES) α-amylases, 340 black boxed, 352 classification, 340–342 clinical role of, 352 clinical use, 343–344 CPB-induced inflammatory process, 350 endothelial activation, 350 enzymatic degradation of, 351 gelatins, 352 hemodynamic effects, 351 isolated renal perfusion model, 352 Index natural polysaccharides, 339 pharmacokinetics, 341–343 plasma-expanding effect, 350 potential risks and side effects anaphylaxis, 347 coagulation and platelet function, 344–345 kidney dysfunction, 345–347 storing and itching, 347 Hyperchloremia, 331, 353, 393, 395, 398, 411 Hyperglycemia, 366 epinephrine, 46 hypovolemic shock, 327 intensive care units, 67–68 Hypertonic colloid solutions, 347–348 Hypertonic crystalloid solutions (HCS), 332 I IABP See Intra-aortic balloon pump (IABP) ICS See Intracellular space (ICS) IJV See Internal jugular vein (IJV) Incremental cost-effectiveness ratio (ICER), 74 Indicator dilution techniques, 105–107, 109–110 Inotropic agents cardiovascular effects of, 199 dobutamine, 48, 49 hypotensive patient, 48–49 milrinone, 48, 49 Insulin therapy, 68 Intercostals nerve block, 278 Internal jugular vein (IJV), 90–93, 145, 299 International Classification of Diseases (ICD) codes, 418 Intra-aortic balloon pump (IABP), 99, 109, 169, 181, 207–208 Intracellular space (ICS) body water, 315 chemical properties, 317, 319 fluid and electrolyte balance, 315 hypertonic solutions, 327, 328 osmotic pressure, 319–320 Intracranial pressure (ICP) monitoring, 151 Intra-thoracic blood volume (ITBV), 106 Intravenous antiarrhythmic agents, 50, 56–58 Invasive blood pressure (IBP) monitoring arterial line cannulation and, 80 axillary artery, 84 brachial artery, 84 contraindications, 81 dorsalis pedis, 85 femoral artery, 84 435 indications, 81 needle through catheter technique, 82, 83 posterior tibialis, 85 radial artery, 82–83 Seldinger method, 82 superficial temporal artery, 85 technical considerations in, 86–87 ulnar artery, 85 arterial line transducer and coupling system, 87–88 cardiac output and SVR, 80–81 in cardiac surgery patients, 80 complications infectious complications, 86 ischemic complications, 85 thrombus formation, 85–86 features of, 80 MAP, 80 Isley, M.R., 134 J Jarisch, A., 29 Jarvela, K., 332 Jöbsis, F., 142 Jones, S.B., 350 Jörgensen, K.E., 388 Jugular venous oxygen saturation (SjvO2) AjvDO2, 146–147 complications of, 146 contraindications for, 144–145 data collection, 146 technique of, 145 K Ketamine, 252, 265, 275 Ketorolac therapy, 59, 61 Kharasch, E.D., 333 Korotkoff, N.S., 78 Korotkoff sounds, 78–79 L Laser Doppler flowmetry, 150–151 Laxenaire, M., 347 Leacche, M., 182–192 Left anterior descending (LAD) artery, 8–10 Left circumflex coronary artery (LCX), 8–10 Left internal jugular vein (LIJV) approach, 93 Left main coronary artery (LMCA), 8–10 Legendre, C., 346 Ley, S.J., 349, 350 436 Lorazepam, 62 Lowell, J.A., 354 Low-molecular-weight heparin (LMWH), 164, 167, 183, 184, 188 Luyt, C.E., 218 M Magnesium sulfate (MgSO4), 57, 237, 265, 275 Magnetic resonance angiography (MRA), 150 Martin-Stone, S., 161–192 McIlroy, D.R., 333 Mean arterial pressure (MAP), 114, 199, 297 IBP monitoring, 80 oscillometric technique, 79 Medicare Provider Analysis and Review (MEDPAR) Database, 422 Metabolic acidosis, 404–407 Metabolic alkalosis, 407–409 Midazolam, 63 Milrinone, 48, 49, 202 Minimized extracorporeal circulation (MECC), 300–301 Minnesota Sedation Assessment Tool (MSAT), 59, 132 Modified Beer-Lambert Law, 142 Moore, F.D., 355 Motor Activity Assessment Scale (MAAS), 132 Motor-evoked potential (MEP), 141 Murkin, J.M., 143 Myosin-binding protein C (MYBPC), 19, 21, 24 N Nationwide Inpatient Sample (NIS), 423 Natural colloids See Albumin (HA) Near-infrared spectroscopy (NIRS), 131, 142, 253 Needle through catheter technique, 82, 83 Neuraxial blocks spinal (intrathecal) analgesia, 280–281 TEA, 281–283 thoracic paravertebral block, 278–280 Neuromuscular blocking agents (NMBAs), 65 adjunct therapy, 66 TOF monitoring, 64, 66 toxicity of, 64 New Sheffield Sedation Scale (Sheffield), 132 New York State Cardiac Registry, 423–424 Ng, K.F.J., 331 Niemi, T., 350 Index Noncardiac complications AKI (see Acute kidney injury (AKI)) infectious complications BSIs (see Bloodstream infections (BSIs)) SSIs (see Surgical site infections (SSIs)) sternal wound infections, 320–321 respiratory complications pneumonia (see Pneumonia) prolonged intubation and extubation, 214–215 tracheostomy, 215–216 Noninvasive blood pressure (NIBP) monitoring automated blood pressure monitoring compartment syndrome, 79–80 oscillometric technique, 79 Riva-Rocci/Korotkoff technique, 78–79 Nonsteroidal anti-inflammatory drugs (NSAIDs), 265 acute renal ischemia, 274 adjuvant analgesics, 274 gastrointestinal complications, 274 multimodal analgesia, 265, 276 paracetamol, 265, 274–275 PCA, 265, 276–277 pharmaceutical agents gabapentin/pregabalin, 265, 276 ketamine, 265, 275 magnesium sulfate (MgSO4), 265, 275 risk of bleeding, 274 selective COX-2 inhibitors, 273 traditional COX-1 inhibitors, 274 Norepinephrine, 44, 47, 199, 203, 204 Northern New England Cardiovascular Disease Study Group, 424 NSAIDs See Nonsteroidal anti-inflammatory drugs (NSAIDs) Nuevo, F.R., 330 O Observer’s Assessment of Alertness/Sedation Scale (OAA/S), 132 Off-pump coronary artery bypass (OPCAB), 305–306, 364 Olanzapine, 67 Olsson, J., 329 Opioids, 265 body homeostasis cardiovascular system, 268 cell growth and cell death, 269 Index extrahypothalamic brain stress system, 266 gastrointestinal tract, 268 gold standard, 267 HPA, 266 hydrophilic opioids, 267 immune system, 268 morphine, 267 respiratory system, 267–268 side effects of, 269 urinary retention, 269 clinical administration of, 266 compounds morphine, 269 synthetic opioid agents (see Synthetic opioid agents) receptors, 266 Oral anticoagulants apixaban, 164, 165 dabigatran, 163–165 rivaroxaban, 164, 165 warfarin, 163, 166 Oral antihypertensive agents, 53–55 Oscillometric technique, 79 P PAC See Pulmonary artery catheter (PAC) Pain management See Acute postoperative pain management Palumbo, D., 350 Paracetamol, 265, 274–275 Parenteral anticoagulants DTIs, 164, 168, 169 fondaparinux, 164, 168 LMWH, 164, 167 UFH, 164, 167 Partial carbon dioxide (CO2) rebreathing technology, 107–108 Patient-controlled analgesia (PCA), 265, 276–277 Pharmacoeconomics cost-effectiveness analysis, 74 cost minimization analysis, 74 cost–utility analysis, 74 direct costs, 73 fluid therapy, cost–benefit analysis, 74–76 indirect and intangible costs, 74 natural and utility units, 74 Pharmacologic agents analgesic agents, 50, 59–61 antibiotic prophylaxis, 42–43 drug shortages, 69–70 ICU patients 437 delirium, 66–67 hyperglycemia, 67–68 inotropic agents, 48–49 intravenous antiarrhythmic agents, 50, 56–58 medication reconciliation, 68 neuromuscular blocking agents, 64–66 sedating agents, 59, 62–63 stress ulcer prophylaxis, 68–69 vasoactive agents (see Vasopressor agents) vasodilators and antihypertensives, 49–55 Phenylephrine, 45, 47, 199, 204 Phosphodiesterase (PDE) inhibitors, 48 PMI See Postoperative myocardial ischemia (PMI) Pneumonia aspiration, 216–217 lung abscess, 217 postoperative pneumonia diagnosis, 217–218, 220 management, 219 prognosis, 219 treatment, 218–219 VAP, 220–222 Pneumonia Severity Index, 219 Polderman, K., 325 Positron emission tomography (PET), 150 Posterior descending artery (PDA), 8–10 Posterior tibialis artery cannulation, 85 Postoperative bleeding antifibrinolytics, 178–179 antiplatelet therapy, 169–171 coagulation status, 170, 172–174 desmopressin, 179 disseminated intravascular coagulopathy, 175–176 drug-induced thrombocytopenia, 176–177 exogenous blood products and factors, 179, 180 fish oil, 170 hemodilution, 162 herbal supplements, 170 HIT (see Heparin-induced thrombocytopenia (HIT)) oral anticoagulants, 164–166 parenteral anticoagulants, 164, 167–169 protamine, 175 prothrombotic coagulopathies, 175–176 surgical bleeding, 179, 181 Postoperative cardiac tamponade (POCT), 204–205 Postoperative myocardial ischemia (PMI), 199–200 438 Postoperative rhythm disorders bradyarrhythmias, 241–242 supraventricular arrhythmias incidence and prognosis, 234, 235 management, 237–238 pathogenesis, 235–236 prophylaxis, 236–237 ventricular arrhythmias incidence and prognosis, 239, 240 management, 239–241 pathogenesis, 239 prophylaxis, 239 Prasugrel, 170, 171 Propofol, 63, 214, 252 Protamine, 164, 167, 175, 299, 370 Prothrombotic coagulopathies, 175–176 Proton pump inhibitor (PPI), 69, 164, 169, 170 Pulmonary artery catheter (PAC) clinical outcome of, 98 complications, 103–104 contraindications of, 99 indications for, 99 online cardiovascular monitoring, 98 technical considerations for, 99–103 Pulmonary artery occluding pressure (PAOP), 103 Pulmonary artery wedge pressure (PAWP), 103, 113 Pulse contour analysis (PCA), 106, 109–110 Q Quality-adjusted life year (QALY), 74 Quetiapine, 67 R Radial artery cannulation, 82–83 Ramsay Sedation Scale (Ramsay), 59, 132 RASS See Richmond Agitation-Sedation Scale (RASS) Reid, F., 326 Remifentanil, 270, 272–273 Renal-dose dopamine, 44, 45 Renin–angiotensin–aldosterone (RAA) system, 318, 320–322 Respiratory acidosis, 388, 399–401, 404, 409–411 Respiratory alkalosis, 395, 399–401, 404, 411 Reuter, D.A., 361 Richmond Agitation-Sedation Scale (RASS), 59, 132–133 Richter, H., 29 Right atrial pressure (RAP), 90, 113 Index Right coronary artery (RCA), 8–10 Right internal jugular vein approach, 90–93 Risk-adjustment methodology data collection, 418–419 multivariable logistic regression model, 419 over fitting, 420 risk model assessment Hosmer–Lemeshow test, 420, 421 model discrimination, 420, 421 model validation, 421 surgeon-specific outcomes observed-to-expected (O/E) ratio, 422 risk-adjusted rates, 422 Riva-Rocci, S., 78 Rivaroxaban, 164, 165 Russell, J.A., 335 Ruttmann, T.G., 331 S Sarcomere proteins, 24 functional classification of, 19 structural classification of thick filament, 19–22 thin filament, 19, 22–23 Scharbert, G., 345 Schell, R.M., 146, 147 Sedating agents consequences of, 59 dexmedetomidine, 62 lorazepam, 62 midazolam, 63 propofol, 63 validated ICU sedation scales, 59 Sedation-Agitation Scale (SAS), 59, 133 Sedation Intensive Care Score (SEDIC), 132 Seldinger method, 82 Sertürner, F., 266 Sessler, C.N., 132, 133 Shaaban Ali, M., 144 Singer, 388 Society of Thoracic Surgeons (STS), 199, 424, 425 Somatosensory-evoked potential (SSEP), 131, 141 Spinal (intrathecal) analgesia, 280–281 SSIs See Surgical site infections (SSIs) Starling, E., 26 Starling equation, 321, 322, 324 Sternal wound infections, 181, 320–321 Stewart-Hamilton equation, 107 Stewart, P., 389 Stogermuller, B., 345 Index Stress ulcer prophylaxis (SUP), 68–69 Subclavian approach, 93–94, 97 Sufentanil, 270–272 SUP See Stress ulcer prophylaxis (SUP) Superficial temporal artery, 85 Supraventricular arrhythmias incidence and prognosis, 234, 235 management, 237–238 pathogenesis, 235–236 prophylaxis, 236–237 Surgical Care Improvement Project, 43 Surgical site infections (SSIs) diagnosis, 226 intensive care unit, 224 mediastinitis, 225 risk factors for, 225–226 signs and symptoms, 226 treatment, 227 types of, 224, 225 Swan-Ganz catheter See Pulmonary artery catheter (PAC) Swan, H.J., 98 Synthetic/artificial colloids biological, nonhuman molecules, 336 dextrans, 337–338 gelatins, 338–339 hydroxyethyl starches (HES) (see Hydroxyethyl starches (HES)) therapeutic and side effects, 336 Synthetic opioid agents alfentanil, 272 CSHL, 270 fentanyl, 270–271 remifentanil, 272–273 sufentanil, 271–272 Systemic vascular resistance (SVR), 26, 46, 81, 114, 199, 203 T TEA See Thoracic epidural analgesia (TEA) TEE See Transesophageal echocardiography (TEE) Thermal diffusion flowmetry, 151 Thoracic epidural analgesia (TEA), 281–283 Thoracic paravertebral block, 278–280 Thrombocytopenias See Heparin-induced thrombocytopenia (HIT) Thromboelastography, 170, 173, 174 Ticagrelor, 170, 171 Tirofiban, 170, 171, 177 Tissue trauma, 93, 95, 96 Tobias, M.D., 336 Tracheostomy, 215–216, 220 439 Tranexamic acid (TA), 178–179 Transcranial Doppler (TCD), 131, 147–150, 253 Transesophageal echocardiography (TEE), 98, 114, 202, 204, 304 Transverse tubules, 14, 15 Tropomodulin, 19, 23, 24 Tropomyosin (TM), 19, 20, 22–24 Troponin, 19, 23, 200 U Ulnar artery cannulation, 85 Ultrasonic cardiac output monitor (USCOM), 106, 111–112 Ultrasound-guided CVC insertion, 94–95 Unfractionated heparin (UFH), 164, 167, 183, 184, 299 V VA See Ventricular arrhythmias (VA) Valsalva maneuver, 30 Vancomycin, 43, 177, 229 Vancouver Interaction and Calmness Scale (VICS), 59, 132 Van den Berg, B., 325 Van der Linden, P.J., 350 VAP See Ventilator-associated pneumonia (VAP) Vascular injuries, 95–96 Vasodilators, 49–52 Vasoplegic syndrome, 203–204 Vasopressin, 45–47, 58, 204 Vasopressor agents, 47 dopamine, 44–45 epinephrine, 46 hypotension, 46 norepinephrine, 44 phenylephrine, 45 reduced systemic vascular resistance, 46 vasopressin, 45 Vennari, M., 73–76, 313–372, 385–412 Ventilator-associated pneumonia (VAP), 220 diagnosis, 218, 220 nosocomial infection, 220 postoperative management, 221 treatment and prognosis, 220–221 Ventricular arrhythmias (VA) incidence and prognosis, 239, 240 management, 239–241 pathogenesis, 239 prophylaxis, 239 Ventricular assist device (VAD), 208 Verheij, J., 349 440 Index Veterans Administration Database, 424 Visual-evoked potential (VEP), 141 Vitamin E, 170 von Bezold, A., 29 Warkentin, T.E., 187 White, H., 146, 147 Windkessel model, 109 Wyatt, R., 279 W Wade, C.E., 332 Warfarin, 163, 166, 185, 190 Z Zheng, F., 142 Ziprasidone, 67 ... References 23 4 23 4 23 5 23 6 23 7 23 9 23 9 23 9 23 9 23 9 24 1 24 1 24 2 24 2 24 2 24 2 Abstract New-onset arrhythmias are a common complication of cardiac surgery Atrial fibrillation... majid.haghjoo@gmail.com A Dabbagh et al (eds.), Postoperative Critical Care for Cardiac Surgical Patients, DOI 10.1007/978-3-6 42- 40418-4_9, © Springer-Verlag Berlin Heidelberg 20 14 23 3 23 4 M Haghjoo hospitalization,... 79 :24 2 24 7 El-Chami MF, Sawaya FJ, Kilgo P et al (20 12) Ventricular arrhythmia after cardiac surgery: incidence, predictors, and outcomes J Am Coll Cardiol 60 :26 64 26 71 Fan K, Lee K, Lau CP (20 03)