Post-Operative Cardiac Admission to the CVICU

Postoperative cardiac surgery requires a team effort. The goals of a patient immediately after surgery are to maximize tissue perfusion which includes the following:

  • Maintain tissue perfusion

  • Stabilize hemodynamics 

  • Stabilize thermoregulation 

  • Stabilize oxygenation 

  • Prompt recognition and treatment of potential complications related to the surgery, comorbidities, and anesthesia 

  • Monitor for hypertension to avoid bleeding myocardial ischemia strokes dysrhythmias or graph rupture (May require the use of opioids sedatives, anti-hypertensives and or vasodilators).

Postoperative Complications include:

  • Dysrhythmias 

  • Bradycardia

  • Atrial fibrillation

  • Ventricular dysrhythmias

  • Mechanical Complications

  • Cardiac Tamponade 

  • Prosthetic valve endocarditis

  • Post Peri cardiotomy syndrome

  • Sudden cardiac arrest and sudden cardiac death

  • Plural effusions 

  • Chest tube related complications

  • Pulmonary hypertension

  • Postoperative bleeding

  • Transfusion-associated circulatory overload

  • Venous thromboembolism

  • Deep vein thrombosis

  • Pulmonary embolism

  • Mediastinitis 

  • Delirium

  • Postoperative cognitive dysfunction

  • Seizures

  • Sleep deprivation

  • Pain

Preparation for admission is extremely important. The room should be set up for the arrival of the patient with items such as:

  • Suction catheters

  • Yankauer

  • Suction gauge and canister set up

  • Bag valve mask device

  • End Tidal CO2

  • Pulse oximeter

  • Oxygen flow meter

  • Oxygen tubing with the appropriate delivery device

  • Blood pressure cuff

  • ECG electrodes & cables

  • Doppler

  • Invasive pressure monitor with cables

  • IV infusion pumps

  • Thermometer

  • IV poles

  • General hygiene supplies

  • Bedside computer or paper admission documentation forms

  • Other supplies such as flushes, gloves, syringes gauze tape, infusion pump tubing, blood specimen tubes, etc.

  • IV fluids such as normal saline

  • Watch/clock

  • Scale (the ICU bed may have a built-in scale, just make sure that it is zeroed before the patient arrives)

  • Tape measure

  • Penlight/flashlight

  • Stethoscope

  • Doppler

  • Warming blanket

  • Bedside table

  • Nasogastric tube

  • Foley catheter

  • Sequential Compression Stockings

  • Anti-skid socks

  • Arterial line set-up

  • Specialized line cart

  • Code cart

  • Defibrillator

  • Intubation kit

  • Ventilator

  • Soft wrist restraints

  • Pacemaker box with leads

Handoff

  • SBAR

  • Medical and surgical history 

  • Preoperative status

    • Information about comorbidities, nutritional state, cardiac disease, tobacco use...

  • Pertinent information about the surgical procedure

  • Complications 

  • Hemodynamics 

  • Ventilatory status

  • Cardiopulmonary bypass time

  • Surgical time

  • IV fluids type and amount 

  • Estimated blood loss

  • Intraoperative intake and output

  • Blood products given

  • Recent laboratory data

  • Reversal of anesthetic agents

  • Reversal of anticoagulants

  • Location of IV lines and invasive catheters 

  • Inotropes and vasopressors used and infusion rates

  • Mechanical cardiac assist devices

  • Pacing wires

  • Drains 

  • Dressings

Assessment 

  • ECG

  • Blood pressure 

  • Pulmonary artery pressure

  • Pulmonary artery occlusion pressure

  • Central venous pressure

  • Cardiac output

  • Cardiac index

  • Systemic vascular resistance

  • Temperature

  • Pulse oximetry

  • Mixed venous oxygen saturation

  • Checking temporary pacing wires

  • Neurologic Assessment (Level of consciousness, degree of orientation, people size and reaction, and ability to move extremities, pain)

  • Respiratory assessment (auscultation of Breath Sounds, oxygen delivery mode, symmetry of chest expansion, respiratory rate, depth, effort, rhythm, mechanical ventilation, Ventilator settings, FiO2, rate, tidal volume, positive and expiratory pressure, and title carbon dioxide levels, arterial blood gas results, chest x-ray, chest tubes, wall suction)

  • Types and number of drainage catheters

    • Bleeding (~200ml or more per 2 hours)

  • Cardiac tamponade 

    • Dyspnea 

    • Sudden decrease or cessation of mediastinal bleeding

    • Decreased cardiac output

    • Hypotension

    • Tachycardia

    • Increased CVP

    • Low-voltage QRS on ECG

    • Anxiety

    • Pallor

Hemodynamic Management

  • The goal is to achieve a balance between oxygen supply and oxygen demand by maintaining adequate cardiac output

  • Optimal hemodynamic Values 

    • CI 2L/min/m2

    • PAOP 10-15

    • CVP 5-15 mmHg

    • SBP 90-140 mmHg

    • DBP 60-90 mmHg

    • MAP 60-100 mmHg

    • SVR 1400-2800 dyne/sec/cm/m2

  • Alterations in heart rate and rhythm

    • Post-operative dysrhythmias can be anticipated the most common dysrhythmias are atrial in origin but ventricular dysrhythmias and bradycardic rhythms are possible. Dysrhythmias may cause hemodynamic instability

    • Can be controlled pharmacologically and/or with pacing

  • Postoperative nausea and vomiting

    • Usually caused by agents given intraoperatively 

    • May cause dehydration aspiration hypokalemia hyponatremia and disruption of surgical incisions. 

  • Hypothermia

    • Patients are considered hypothermic at less than 36°C 

    • Hypothermia can cause the patient to have prolonged mechanical ventilation, shivering, and increased oxygen consumption, and a greater likelihood of developing dysrhythmias, hypertension, tachycardia, a decreased preload, impaired contractility, or coronary graft spasm. Risk is also for the development of coagulopathy, impaired healing,  wound infection myocardial infarction, need for blood transfusions, and death. Hypothermia alters drug metabolism and delays emergence from anesthesia causing a disruption of the coagulation pathway. Shivering can also cause vasoconstriction, which can result in renal and mesenteric ischemia.

Medication Tips

Anesthetic Agents [Induction Agents]

  • Barbiturates (thiopental sodium)

    • Can cause hypotension, decreased cardiac output, decreased peripheral vascular resistance, respiratory depression, loss of laryngeal reflexes, nausea (can persist for 36 hours)

  • Non-barbiturates (propofol, etomidate)

    • Etomidate can cause nausea, hiccups, involuntary tremors, and suppressed adrenal function

    • Propofol can cause hypotension 

  • Benzodiazepines (midazolam, lorazepam)

    • Can cause respiratory depression bradycardia vasodilation

    • Reversed by giving flumazenil

Anesthetic Agents [Inhalation Agents]

  • Sevoflurane, Halothane

    • Have depressant effects on the respiratory system decreased responsiveness to oxygenation and ventilation and elevated carbon dioxide levels increase the risk for atelectasis and pneumonia it can also cause myocardial depression and peripheral vasodilation they have a low incidence of postoperative nausea and vomiting and they have a bronchodilator property. 

  • Enflurane, Isoflurane

    • Can cause laryngeal spasms, coughing, and predispose to non-cardiogenic pulmonary edema, decreased blood pressure stroke volume and systemic vascular resistance, and increased heart rate, mild coronary vasodilation

Neuromuscular blocking agents

  • Rocuronium, Vecuronium

    • Can cause returned paralysis early postoperative period by inadequate reversal

    • They have no amnesia or analgesic properties so must be administered with an analgesic whether or not the patient can quantify their pain levels

Opioids 

  • Fentanyl 

    • The most frequently used opioid in cardiac surgery. Can cause bradycardia, nausea, and vomiting

Summary

Assessment and communication are essential to the patient’s postoperative recovery. If you are not sure of an assessment finding always communicate with the provider. Remember to ask questions, and after the patient is hemodynamically stable review and document your findings.

Cheryl