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


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and 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 two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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