Post Cardiac Surgery Patient Hot Case

GENERAL APPROACH

• Type of surgery
• Emergency or Elective
• Post-operative complications (bleeding, tamponade, graft occlusion, CVA)
• Shock assessment
• Causes and type of heart disease

INTRODUCTION

CUBICLE

• short or long term patient
• tracheostomy
• organ support

INFUSIONS

• vasoactives
• haemostatic agents (tranexamic acid, blood products, DDAVP, rFVIIa)
• fluid boluses

VENTILATOR

• mode
• level of support
• level of oxygenation (FiO2, PEEP: APO, atelectasis, ARDS, nosocomial pneumonia)
• disease specific questions

MONITOR

• temperature: SIRS/sepsis
• ECG: rate, rhythm, pacing spikes, conduction defects
• CVP: number, waveform
• arterial trace: MAP, swing, pulsus paradoxus, pulse pressure

EQUIPMENT

• IABP: position, efficiency, complications
• PAC or PiCCO: ask for a recent set of output data
• pacing: box, wires, settings
• drains: drainage, pneumothorax
• rapid infusion lines
• dialysis
• surgical scars

QUESTION SPECIFIC EXAMINATION

• hands/arms -> head -> chest -> abdo -> legs/feet -> back

-> general: habitus
-> cardiovascular: sternal stability, pace maker, cardiac failure, graft sites, endocarditis stigmata, femorals
-> respiratory: effusion
-> abdominal: distension, mesenteric embolism, pancreatitis

• neurological

-> paralysed
-> quick examination
-> unconscious: hemiparesis -> CVA
-> conscious: analgesia adequate

• urine output: oliguria, polyuria (cold diuresis), methylene blue

• surgical details
• drain losses since OT
• preoperative anti-platelets and anticoagulation
• clarify position of surgical drains
• recent 12 lead ECG
• ECHO findings
• IABP: CXR, check pulses clinically and with Doppler
• PAC: position on CXR
• pacemaker: pacing thresholds and sensitivities, underlying rhythm
• transfusion in OT

RELEVANT INVESTIGATIONS

• CXR
• TEG
• FBC: Hb, platelets
• coag’s:
• ABG: gas exchange

OPENING STATEMENT

=

• Type of surgery
• Shock and volume status
• Complications – bleeding, tamponade, low output state, vasoplegia
• Current issues
• Management

DISCUSSION

• Hypotension Post Cardiac Surgery
• Phrenic Nerve Palsy Post-Cardiac Surgery
• Hypoxaemia post Cardiac Surgery
• Haemorrhage Post Cardiac Surgery
• Hypertension Post Cardiac Surgery
• Cardiac Arrest Management After Cardiac Surgery
• Hypothermia Post Cardiac Surgery
• Infectious Endocarditis
• Acute Aortic Dissection
• Indications for Adult Cardiac Surgery
• Congenital Heart Disease
• ICU after Cardiac Surgery
• Arrhythmias
• Cardiac Output Measurement
• Off Pump vs On Pump CABG
• Murmurs and Valve Lesions
• Cardiac Lesions and Severe Clinical Signs