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
References and Links
Introduction to ICU Series
Introduction to ICU Series Landing Page
DAY TO DAY ICU: FASTHUG, ICU Ward Round, Clinical Examination, Communication in a Crisis, Documenting the ward round in ICU, Human Factors
AIRWAY: Bag Valve Mask Ventilation, Oropharyngeal Airway, Nasopharyngeal Airway, Endotracheal Tube (ETT), Tracheostomy Tubes
BREATHING: Positive End Expiratory Pressure (PEEP), High Flow Nasal Prongs (HFNP), Intubation and Mechanical Ventilation, Mechanical Ventilation Overview, Non-invasive Ventilation (NIV)
CIRCULATION: Arrhythmias, Atrial Fibrillation, ICU after Cardiac Surgery, Pacing Modes, ECMO, Shock
CNS: Brain Death, Delirium in the ICU, Examination of the Unconscious Patient, External-ventricular Drain (EVD), Sedation in the ICU
GASTROINTESTINAL: Enteral Nutrition vs Parenteral Nutrition, Intolerance to EN, Prokinetics, Stress Ulcer Prophylaxis (SUP), Ileus
GENITOURINARY: Acute Kidney Injury (AKI), CRRT Indications
HAEMATOLOGICAL: Anaemia, Blood Products, Massive Transfusion Protocol (MTP)
INFECTIOUS DISEASE: Antimicrobial Stewardship, Antimicrobial Quick Reference, Central Line Associated Bacterial Infection (CLABSI), Handwashing in ICU, Neutropenic Sepsis, Nosocomial Infections, Sepsis Overview
SPECIAL GROUPS IN ICU: Early Management of the Critically Ill Child, Paediatric Formulas, Paediatric Vital Signs, Pregnancy and ICU, Obesity, Elderly
FLUIDS AND ELECTROLYTES: Albumin vs 0.9% Saline, Assessing Fluid Status, Electrolyte Abnormalities, Hypertonic Saline
PHARMACOLOGY: Drug Infusion Doses, Summary of Vasopressors, Prokinetics, Steroid Conversion, GI Drug Absorption in Critical Illness
PROCEDURES: Arterial line, CVC, Intercostal Catheter (ICC), Intraosseous Needle, Underwater seal drain, Naso- and Orogastric Tubes (NGT/OGT), Rapid Infusion Catheter (RIC)
INVESTIGATIONS: ABG Interpretation, Echo in ICU, CXR in ICU, Routine daily CXR, FBC, TEG/ROTEM, US in Critical Care
ICU MONITORING: NIBP vs Arterial line, Arterial Line Pressure Transduction, Cardiac Output, Central Venous Pressure (CVP), CO2 / Capnography, Pulmonary Artery Catheter (PAC / Swan-Ganz), Pulse Oximeter
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC