Postoperative Critical Care for Cardiac Surgical Patients Ali Dabbagh Fardad Esmailian Sary F Aranki Editors Postoperative Critical Care for Cardiac Surgical Patients Ali Dabbagh • Fardad Esmailian • Sary F Aranki Editors Postoperative Critical Care for Cardiac Surgical Patients Editors Ali Dabbagh, MD Department of Anesthesiology and Anesthesiology Research Center Faculty of Medicine Shahid Beheshti University of Medical Sciences Tehran Iran Sary F Aranki, MD Divisions of Cardiac Surgery Brigham and Women’s Hospital Boston, MA USA Fardad Esmailian Heart Transplant and Mechanical Circulatory Support Cedars-Sinai Heart Institute Los Angeles, CA USA ISBN 978-3-642-40417-7 ISBN 978-3-642-40418-4 DOI 10.1007/978-3-642-40418-4 Springer Heidelberg New York Dordrecht London (eBook) Library of Congress Control Number: 2013955229 © Springer-Verlag Berlin Heidelberg 2014 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer Permissions for use may be obtained through RightsLink at the Copyright Clearance Center Violations are liable to prosecution under the respective Copyright Law The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) To my wife Samira and to my Parents Ali Dabbagh To my family: Yvonne, Gabriel and Aaron and to my parents Fardad Esmailian To Nadia, Alex, Heather and Abla Sary F Aranki Foreword The Handbook of Postoperative Critical Care for Cardiac Surgeries is a superb amalgamation of a wide variety of clinical expertise in the perioperative and postoperative care of cardiac surgical patients edited by three very fine academicians from three outstanding medical centers and who are in the position of being able to judge the best perioperative and postoperative cardiac surgical care The three editors have a wide variety of cardiac surgical interest Dr Dabbagh is a cardiac anesthesiologist, who is intimately involved in the intraoperative and postoperative care of cardiac surgery patients; Dr Esmailian is an expert in the care of patients receiving cardiac assist devices and cardiac transplantation, which are some of the most challenging postoperative patients; and Dr Aranki is an extremely talented surgeon in all aspects of cardiac surgery, especially coronary artery bypass grafting and valve repair and replacement This book brings the entire spectrum of cardiac surgical perioperative treatment and postoperative care under one cover Postoperative critical care in cardiac surgery is extremely important and I believe this book has the potential to be the gold standard in postoperative care for cardiac surgical patients The key to good surgical results is the combination of an excellent operation and meticulous perioperative and postoperative care, the essence of this book The authors are to be complimented for providing up-to-date, accurate, and intellectual contributions for this most important area of cardiac surgery This book is an excellent effort in advancing the art and science of perioperative and postoperative surgical care Lawrence H Cohn, MD Brigham and Women’s Hospital Harvard Medical School, Boston, MA, USA vii Preface Cardiac surgery is a process, not an event Due to the prevalence of cardiac diseases and conditions within society, cardiac surgeries now rank among the most common of all surgical procedures But they are also the most challenging and complicated, all of which imposes a burden of instructive issues upon students and faculty alike The following is a handbook encompassing the entire period of postoperative cardiac surgical care, including the basic physiologic and pharmacologic knowledge to clinical aspects of clinical care in different major body organs This book stresses on this point that during postoperative period, the patient commences upon a highly complex set of postoperative challenges and will often require lifelong monitoring to ensure that the management of all potential morbidities has been achieved Surgery is not, therefore, an end, but rather a beginning In the often long-term postoperative era, a patient embarks upon a new set of needs for recovery and lifelong follow-up Towards this end of perioperative care, it is most crucial not to view the surgery and anesthesia as the climax of a patient’s experience, but rather as a bridge between a former and a new life for the patient While postoperative care plays a crucial role in determining the clinical result for the patient, the success of postoperative care is also directly affected by the quality of the pre- and intraoperative experiences The chapters of this book, therefore, also survey these seminal periods for the patient, with particular attention given to cardiopulmonary bypass Other chapters assume an organ-oriented perspective in addressing critical care This broad, intersystemic approach creates a holistic view of the cardiac domain not only in its functions within itself but also within the entire body, enabling this to become a reliable guidebook for cardiac intensive care This book can then be used by cardiac surgeons, cardiac anesthesiologists, intensivists, and cardiac intensive care nurses, as well as the students, interns, and residents learning in such environments, in the successful management of the process of cardiac surgery This book could not have been come to fruition without the very committed and compassionate teamwork of Springer Company, especially Springer-Verlag Berlin Heidelberg The authors should acknowledge among a long list of people especially to the following people: Dr Ute Heilmann, Meike Stock, Martina Himberger, Dörthe Mennecke-Bühler, Sally Ellyson, Margaret Zuccarini, Megan Hughes, Karthikeyan Gurunathan and Palanisamy Dhanapal ix 15  Risk and Outcome Assessments 425 15.4 Cardiac Surgery Risk Calculators In an era of increasing emphasis on the quality of medical care, benchmarking of cardiac surgical outcomes is essential to allow proper risk-adjusted comparisons Cardiac surgery risk calculators represent the cornerstone in the prediction of surgical outcomes, allowing for the comparison of observed-to-expected rates and risk-­ adjusted event rates Furthermore, risk calculators are useful tools for proper patient selection and informed patient consent Multiple risk calculators in cardiac surgery have been developed, but only two systems have been thoroughly validated: 15.4.1 The STS Cardiac Surgery Risk Calculator The STS database has served as the source of patient data to develop the STS cardiac surgery risk calculators Although initially intended for CABG, iterations have been created for aortic, mitral, or tricuspid valve surgery Risk models are developed through multivariable logistic regression, and predicted risks are calculated for specific outcome variables Initial calculators focused on operative mortality, but in 2003 specific risk calculators were developed for nine endpoints: operative mortality, permanent stroke, renal failure, prolonged ventilation, deep sternal wound infection, major morbidity or mortality, prolonged postoperative length of stay (> 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 .. .Postoperative Critical Care for Cardiac Surgical Patients Ali Dabbagh • Fardad Esmailian • Sary F Aranki Editors Postoperative Critical Care for Cardiac Surgical Patients Editors... Aranki Foreword The Handbook of Postoperative Critical Care for Cardiac Surgeries is a superb amalgamation of a wide variety of clinical expertise in the perioperative and postoperative care of cardiac. .. standard in postoperative care for cardiac surgical patients The key to good surgical results is the combination of an excellent operation and meticulous perioperative and postoperative care, the