ICU after Cardiac Surgery
OVERVIEW
- 3% risk of death
ORGANISATION
- MDT
- those involved in pre and post op care
- patient selection
- preoperative optimisation
- intra-operative and post operative haemodynamic monitoring
- patient flow from OT -> ICU
HANDOVER
- Preoperative and Intraoperative Events
- A, B, C
- haemostasis and haemotherapy
- infusions
- haemodynamic parameters
- fluids
- CXR
CARDIOVASCULAR MANAGEMENT
- monitoring: art line, CVP, +/- PAC (Q and SvO2), TOE
- fluids: crystalloids, colloids, albumin (it doesn’t matter)
- K+: keep high for antiarrhythmia
- Mg2+: keep high for antiarrhythmia
- Ca2+: generally maintained but may be low post massive transfusion
- haemorrhage: reverse heparin, correct coagulopathy, controlled tamponade
- hypotension: multi-factorial – hypovolaemia, vasodilation, tamponade, heart failure
- hypertension: can cause – bleeding, heart failure, aortic bleeding, myocardial ischaemia -> analgesia, sedation, GTN, beta-blockers
- low Q state: intravascular volume depletion, systolic heart failure, tamponade -> ECHO, inotropes, IABC, VAD, delayed sternal closure, bypass
- intra-aortic balloon counterpulsation: see IABP notes for details
- ischaemia: graft failure -> angiography or re-operation
- diastolic dysfunction and right ventricular dysfunction: ventricular hypertrophy, poor myocardial protection, ischaemia, RV dilation, tamponade -> fluid, SR, atrial pacing, inotropes
- dysrhythmias: electrolytes, pacing, anti-arrhythmics, debibrillation
- AF: prevention = beta-blockers, amiodarone, sotolol, diltiazem, atrial pacing, dexamethasone, treatment =
- rate control – beta-blockers, Ca2+ channel blockers, amiodarone, sotolol, digoxin
- cardioversion – ibuletide, amiodarone, Mg2+, DC
- anticoagulation – if > 48 hours
- emergency reoperation: need to be done when haemodynamics can’t be supported by other means
OTHER
- renal failure: haemodynamic augmentation and avoidance of nephrotoxic agents
- shivering: bad -> dexamethasone, clonidine, morphine, warming, pethidine, paralysis
- sternal infection: 0.5-2.5%, sugar control and preoperative nasal and oropharyngeal decontamination
- neurological: delirium, peripheral neuropathies, CVA’s
- gastrointestinal: (<1%) peptic ulcers, pancreatitis, cholecystitis, gut ischaemia, ileus, hepatic dysfunction
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC