leanna r. miller, rn, mn,ccrn-csc, pccn-cmc, cnrn, cen, cmsrn, np education specialist lrm...
TRANSCRIPT
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Leanna R. Miller, RN, MN,CCRN-CSC, PCCN-CMC, CNRN, CEN, CMSRN, NP
Education Specialist
LRM Consulting
Nashville, TN
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Behavioral Objectives 1.Identify common postoperative pulmonary
complications.2.Describe common cardiac complications
of CV surgery.3.Discuss treatment strategies for
complications seen in the postoperative CV surgery patient.
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Report from Anesthesia
• procedure performed• height/weight• infusions• pacing options• blood products given• events/concerns
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In the “Huddle” • details of surgical procedure• patient’s history• patient’s anatomy• BP, MAP, titration goals• reverse sedation/maintain
sedation• airway difficulty
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Assessing Labs • assess K+ - replete according to
protocol• standing order – 2 gm MgSO4
• assess ABG– are we adequately ventilating patient– watch trends with lactate and Hgb
• Glucose– according to SCIP criteria: BG on POD1 and
POD2 must be < 200 mg/dL– should arrive from the OR on an insulin drip– titrate q1h per protocol
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Postoperative Concerns•Instability
– Hypotension vs. Hypertension– goal range (upper and lower)
•Bleeding– Cardiac Tamponade
•Arrhythmias
•Extubation
•Pain/Mobilization
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Instability•Patient can quickly shift from hypertension to hypotension•Know what your goal for tissue perfusion is - as a general rule keep SBP < 120, currently moving towards using MAP as the goal pressure
– KNOW the patient’s goal for tissue perfusion
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Instability•Hypotension
– most likely “dry” due to fluid shifts that have occurred
– consider HCT - would PRBC’s be appropriate?
– What drips are infusing– Are they warming up now and vasodilating?– Use of NEOSYNEPHRINE sticks NO!
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Instability•Hypertension:
– Are they waking up?– Are they experiencing pain?– Which drips are running - should we wean
vasopressors?– GET HOB UP to at least 30 degrees– Might need to start Nipride drip
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Instability•Chest tube output monitoring:
– q15min X 4, q30min until CT output < 100cc/hr then q1h – keep mid-levels/clinicians informed of excessive CT output
– if output > 100cc in any of the 15 min intervals notify MD/clinician
– Order set: if 200ml/hr then order stat platelet, PT/PTT
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Instability•Chest tube output monitoring:
– high rate of bleeding is what your are concerned with more so than a specific amount
– be diligent in declotting chest tubes - no stripping, gentle pinching, twisting
– keep BP down(SBP 120 mmHg or less) - the higher the BP, the more pressure put on graft & they’ll bleed more
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Instability•Consider the use of PEEP on ventilator•Assess the PT/PTT sent to lab•If INR > 1.5, team will most likely order FFP•Consider sending fibrinogen or platelet labs•If bleeding is significant - prepare to give blood products: PRBC’s, FFP, platelets, cryoprecipitate•Consider what medications patient was on pre-operatively Ex: Aspirin, Plavix
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Coagulation Problems • excessive bleeding usually
occurs in the 1st POD• 5/100 require return to the
OR• can occur later with
development of DIC or tamponade with epicardial wire removal
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Screening • CBC
– Hgb/Hct – platelets
• PT/PTT• Bleeding Time
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Symptom INR aPTT Platelet # PlateletFunction
History Diagnosis
Major/minorbleeding
N N N Massive transfusion;
fluids
Dilutional thrombocytopenia
Major/minorbleeding
N Prolonged N N negative Drug induced - heparin
Major/minorbleeding
N N n/a Vitamin K deficiency
Liver disease, warfarin, antibiotics
Major bleeding
prolonged prolonged N DIC
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Postoperative Bleeding
•Vascular integrity disruption–reoperation
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Medical Causes of Bleeding • residual heparin effect• platelet consumption (CPB)• preoperative platelet
inactivation
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Medical Causes of Bleeding • depletion of clotting factors• preoperative coagulopathy• fibrinolysis
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•Thrombocytopenia– platelet destruction
•drug – induced•DIC
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•Thrombocytopenia– Etiology
•abnormal distribution or sequestration in spleen
–portal hypertension
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Definition•serious bleeding
disorder• thrombosis; then
hemorrhage
Disseminated Intravascular Coagulation
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Etiology of DIC
•shock•IIR•cardiac tamponade
•infection
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Laboratory Findings
• platelets• fibrinogen• PT &/or PTT• d - dimer or FSP• ATIII
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Management•Treat underlying cause
–antimicrobials–product replacement–surgery - open chest
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Management•Stop Thrombosis
– IV heparin–AT III–plasmapheresis
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Management•Administer blood
products–pRBCs–platelets–FFP–cryoprecipitate
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Bleeding•Sudden decrease in CT output - be sure your tubes are not clotting, keep them in eyesight at all times.
– Need to be out on top of sheets/bair hugger
•Signs & Symptoms of cardiac tamponade:– Beck’s triad: muffled heart sounds, distended neck
veins, hypotension– rule of 20’s: CVP > 20, SBP decreased by 20, HR
increased by 20– equalization of cardiac pressures, narrowed pulse
press, sudden cessation of CT drainage
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Bleeding•Possibly return trip to OR•Worse case scenario – OPEN chest in unit
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Postoperative Arrhythmias
• Atrial Fibrillation– most common dysrhythmia in
the postoperative period– incidence 30% to 50% – consequences include:
• hemodynamic instability• thromboembolism
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• Predictors of Atrial Fibrillation post CABG– advanced age,– history of AF– enlarged left atrial size– history of CHF– elevated BNP levels
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• Prophylactic -blocker Use– 35 of 122 (28.6%) developed AF while on
beta blocker whereas only 18 of 109 (16.5%) developed AF in the absence of prophylactic beta blockers.
– predisposing effect was not significant with Multivariate analysis
– based on this analysis, BB did not show protection against post CABG AF
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Arrhythmias•Consider electrolyte assessment•VT/Vfib –
– SHOCK FIRST!!!– Then CPR/ACLS
•treat it according to ACLS protocol, but look further because it’s not common in the post op setting
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Arrhythmias•Bradycardia/Asystole: use your pacing wires immediately - pace before CPR & drugs if possible. Emergency pacer kept in supply room•Don’t hold back with CPR if pulseless
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Arrhythmias•Atrial Fibrillation/Aflutter:
– In immediate post-op period drug of choice will be Metoprolol or Amiodarone
– Peak incidence in post-op setting is Day 2 & 3– Are they mobilizing fluids now & need Lasix (right
atrium distended)– Consider ABG - check their oxygenation
status(low 02 makes heart irritable)
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Arrhythmias•Atrial Fibrillation/Aflutter:
– Are they hypovolemic - what’s their HCT?– Is their SVR too high - heart pushing against
narrow opening makes it more irritable, might need to get SVR down with Nipride
– Valve patients have higher incidence – Common time is when they’re getting ready to
transfer to floor
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Pulmonary Problems • pulmonary function
– 13% to 64% decrease in VC, FEV1, & FRC
•diaphragmatic dysfunction
•atelectasis•chest wall instability
– hypoxemia is exacerbated– usually lowest within 2 to 3
days postoperative
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Pulmonary Problems • Atelectasis
– 80% of patients post-CABG– risk factors for atelectasis
• phrenic nerve palsy• intra-operative compression
of lung• ischemia during CPB• endothelial damage• cardiomegaly/supine
positioning
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Pulmonary Problems • Diaphragmatic Dysfunction
– decline in inspiratory/expiratory pressures as much as 17% to 47%
– uncoordinated rib cage expansion– muscle strength improves over 6
weeks following surgery– diaphragmatic flutter
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Pulmonary Problems • Pleural Effusions
– develop in 50% to 89% of patients
– less likely post valve surgery– usually left – sided (bilateral in
10%)– causes include:
• hemorrhage or contusion• pulmonary emboli• postcardiotomy syndrome
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Pulmonary Problems • Pulmonary Edema
– most common cause is pre-existing LV dysfunction
– noncardiogenic – “pump lung”• inflammatory process leading
to direct lung injury
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Extubation
•Goal is typically 4-6 hours from being “stable”
– Strike a balance between letting patient wake up and over-breathe vent and giving pain medicine
– Patient preferably needs to have paralytic reversed
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Extubation•Once to minimal vent settings (40% fio2, simv rate 4, ps 5, peep 5)
– perform 30 min cpap trial• In some instances this can be skipped
– draw ABG– can patient lift their head– patient not bleeding– Hemodynamically stable– ectopy
•Notify clinician of all findings and obtain order for extubation (be sure to chart extubation in HED)
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Post - Extubation•Goal is to have patient sitting up within 1-2 hours after extubation
•Patient may begin PO intake 2-4 hours after extubation - begin with ice chips
•Be careful with carbonated drinks/juice– Be mindful of diabetics– ½ strength juice
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Pain Management•Contrary to popular belief, pain is not intense for all - some have very little, while others it is extremely difficult to manage
– Fentanyl: commonly used IV analgesic• Short half-life
– Dilaudid: IV• Longer half-life
– Percocet: PO pain med, better pain relief than Fentanyl (Percocet lasts longer)
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Pain Management•Toradol: for musculoskeletal pain, not routinely ordered, must have good kidney function & no bleeding
•Demerol – used for post-op shivering only
•Dilaudid – IV or SQ, watch your orders
•Morphine SQ
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Mobilization•Patient will still get up with pacemaker in place
– DO NOT AMBULATE WITH pacemaker
•Be diligent with coaching patient to use incentive spirometer ( keep it handy for them to reach)
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Neurologic Complications
• Stroke– most common neurologic
complication of revascularization
– go undetected within the 1st 24 hours
– incidence 2% to 9%– most occur within the 1st 48
hours postoperative
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Neurologic Complications • possible complications
– delirium– transient or permanent cognitive
deficits– seizures– anterior spinal artery infarction– transient focal cerebral ischemia– stroke
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Neurologic Complications
• Location of strokes– cerebral hemispheres– less common
• brainstem• cerebellum• deep white and gray matter
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Neurologic Complications
• Mechanism of stroke in CABG– embolization from atheromatous
plaque– fat embolism– air embolism– atrial fibrillation– hypotension– intra-operative hypotension
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Neurologic Complications • Predictors of post – CABG
stroke– age– diabetes– hypertension– elevated serum creatinine– recent MI– low EF– atrial fibrillation
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Neurologic Complications • Predictors of post – CABG
stroke– on pump procedure– multiple blood transfusions– IABP– duration of bypass– emergency surgery– combined procedure
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Postoperative Infections • Common postoperative
infections– superficial sternal wound infections– deep sternal wound infections– donor site infections– pulmonary infections
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Postoperative Infections • Mediastinitis
– 0.4% to 5% incidence– 2.5% to 7.5% in heart transplant– higher is patients with cardiac
assist devices– generally noted within 14 days
of surgery
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Postoperative Infections • Mediastinitis risk factors:
– diabetes/perioperative hyperglycemia– obesity– peripheral artery disease– tobacco use– prior cardiac surgery– mobilization of IMA– procedure > 5 hours– return to OR within 4 days postop– prolonged postoperative intensive care
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Postoperative Infections • Mediastinitis – clinical
features– fever– tachycardia– chest pain or sternal instability– purulent discharge from site– crepitus & edema of chest wall– Hamman’s sign
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Case Study #1
•65 yo F, S/P CABG X 3
•Patient history– CAD– Atrial fibrillation– Ejection Fraction 45%– HTN– previous MI’s in past with stents placed– on Plavix pre-op
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Case Study #1
•Pt arrives from OR:
•VS’s:– BP 130/70, HR 112, CVP = 4, 02 sat 98%
– Chest tube output: 200cc in 1st 30 minutes– Initial ABG results:
• PO2 – 178 (60% FiO2), pH 7.34, pCO2 46, BE -2.2
• Vent settings:– TV 600, SIMV 12, PEEP 5, PS 5
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Case Study #1
•Patient’s Drips and Labs:– Propofol 30 mcg/kg/min– Norepinephrine @ 2mcg/min– Amicar 1gm/hr– Carrier fluids running at 150cc/hr
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Case Study #1•What needs some work?
– BP too high – get their head up, get Norepinphrine gtt off, maybe Nipride gtt to be started, high BP will cause more CT OP
– HR too high – is the patient dry and that is why HR is too high, does the patient need blood
– CT OP is too high – make sure MD is aware, do we need to send COAGS to lab, does the patient need FFP or cryoprecipitate, could use extra PEEP, field trip to OR?
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Case Study #2•Patient arrives from OR:•Vital Signs
– Temp: 34.2 (Core)– HR 65– BP 95/52– CO/CI: 3.2/2.0– CT OP: Currently 50cc/q15 min– PAP: 22/15– CVP: 8
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Case Study #2
•Patient’s Drips:– Levophed @ 15mcg/min– Epinephrine @ 2mg/min– Propofol @ 20 mcg/kg/min
•What interventions are needed?
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Case Study #2
Interventions
•WARM the patient up!!– Heat to the vent– Bair hugger– Cover head with blankets/plastic
•Possibly send COAGS/Plt count
•Will need fluids/blood products– If giving platelets: premedicate
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Case Study #2Interventions
•Watch VS/BP as patient warms up
•Go ahead and hook patient to pacemaker in back-up rate.
•Won’t reverse patient– might need more than/something
different from Propofol
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IN CONCLUSION
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