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KEY POINTS
Every postcardiac patient should be evaluated for fast tracking, and the decision to proceed with this strategy should be assessed on a case-by-case basis and may be modified by patient comorbidities or situational factors.
Subsequent administration of sedatives and analgesics should be done judiciously to keep the patient comfortable while intubated, but to avoid oversedation and respiratory depression that may delay extubation.
To conceptualize the hemodynamic changes in the postoperative period is to consider whether the myocardium is pressure overloaded of volume overloaded or particularly with the various valvular surgeries.
Viscoelastic whole blood tests such as the thromboelastography (TEG) may pinpoint the hemostatic defect and provide more targeted transfusion therapy.
Atrial fibrillation after cardiac surgery is a common phenomenon occurring in 10% to 65% of postoperative patients with a peak incidence occurring 2 to 3 days after surgery.
Renal dysfunction is not uncommon after surgery with an incidence of 1.4% for overt renal failure, risk factors being age, New York Heart Association (NYHA) class 3 or 4 heart failure, chronic renal disease, type I diabetes mellitus (DM), prolonged operative time, and poor cardiac performance.
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The care of patients after cardiac surgery, particularly in the immediate postoperative period, frequently involves a period of physiologic volatility as the body adapts to the cardiac intervention and recovers from the effects of cardiopulmonary bypass (CPB) and anesthesia. The successful management of this patient population can be facilitated by addressing common issues such as fast-track eligibility and extubation, hypotension and low cardiac output (CO), postoperative bleeding, dysrhythmias, renal function, and glucose control. This chapter aims to provide an overview of these topics as well as a framework for approaching problems in these areas.
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When the postcardiac surgery patient arrives in the intensive care unit (ICU), the optimal transition of care is achieved by direct communication between the ICU team and the surgeons and anesthesiologists involved in the case. If a coronary artery bypass graft (CABG) was performed, the report from the surgeons should include the number of bypasses, the locations of the grafts, and whether the quality of the targets were good, as this has implications for the degree of protection achieved against future myocardial ischemia. Patients very commonly will have had coronary stents placed prior to their CABG. If the grafts did not bypass these stents, then antiplatelet agents such as clopidogrel may need to reinstated as soon as hemostasis is assured. When radial artery or bilateral internal mammary grafts are utilized, some institutions utilize low-dose nitroglycerin or nicardipine to protect against vasospasm, and the need for these agents should be communicated to the ICU team. If a valvular procedure has been performed, the differentiation the surgeon's report should include the valve of interest, whether it was repaired or replaced, and it was replaced, the type of valve that was implanted, that is, bioprosthetic or ...