Chapter 14

• Upon completion of surgery, the cardiac patient is transported to the intensive care unit (ICU) for postoperative management. The role of the anesthesiologist or the anesthesiology department in postoperative care depends on institutional policies and procedures. Anesthesiologists trained in intensive care, non-anesthesiologist intensivists or surgical physician assistants, and nurse practitioners in consultation with the patient's attending cardiac surgeon might manage the ICU care. In other settings, the patient's anesthesiologist will manage some elements of postoperative care (eg, ventilation) while the surgeon attends to issues regarding chest tube management. What must be emphasized for the practitioner new to cardiac anesthesiology is the need to be aware of the operating paradigm used in one's individual institution. Moreover, it is critically important that the anesthesiologist carefully documents their report and the time of transfer of care to the ICU team. Unfortunately, sometimes patients survive the intraoperative period only to succumb minutes, hours, or days following arrival in the intensive care unit.
• This chapter reviews common problems encountered in the postoperative care of the cardiac surgery patient. It is by no means a comprehensive text on critical care but rather highlights some of the particular problems that appear in routine postoperative cardiac surgery recovery and ICU.

Following cardiac surgery patients are transported fully monitored (ECG, arterial pressure, oxygen saturation) from the operating room to the ICU. As the transport of an unstable patient to the ICU carries in itself significant morbidity, every effort toward hemodynamic stability should be undertaken in the operating room prior to moving the patient. Anesthesiologists must be aware of the possibility of inadvertent extubation of the patient or the loss of a central venous line that can occur during routine patient transport and be prepared accordingly. Similarly, they must be prepared to treat hemodynamic instability. Blood pressure variations are common as patients begin to regain sympathetic tone once anesthetics are withdrawn. Propofol infusions, when hemodynamically tolerated, can be used to mitigate the increases in blood pressure often seen in postoperative patients. In particular, patients with a noncompliant vasculature (common among cardiac surgery patients) will frequently develop severe hypertension during emergence requiring the administration of propofol, narcotics, and vasodilators postoperatively. At the same time, because these patients may be hypovolemic, when hypertension is treated there is often a tendency to overshoot transforming hypertension into severe hypotension. Avoidance of hypertension is particularly desirous in the perioperative period to avoid ensuing pressure-related postoperative bleeding. Efforts are likewise undertaken to avoid hypotension during patient transport and transfer to ICU care.

Patients are routinely brought from the operating room to the ICU with any one of many vasoactive infusions running. Care must be taken to be sure that during transport all expected infusions are flowing at the desired rate and that these can be adjusted. At times, as patients awaken and their vascular tone increases, there is less need for vasoconstrictors such as vasopressin and norepinephrine. Inotropic medications are continued and hemodynamic measurements as described in ...

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