MANUAL of PERIOPERATIVE CARE in ADULT CARDIAC SURGERY, Fourth Edition

642 Pages·2010·7.59 MB·English

by  Robert M. Bojar

© 2005,Robert M.Bojar,M.D.
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ISBN 978-1-4051-0439-5
Library of Congress Cataloging-in-Publication Data
Bojar,Robert M.,1951–
Manual of perioperative care in adult cardiac surgery/by Robert M.Bojar.—4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-0439-5 (pbk.)
1.Heart—Surgery—Handbooks,manuals,etc. 2.Therapeuticsm Surgical—
Handbooks,manuals,etc.
[DNLM:1.Cardiac Surgical Procedures—Outlines. 2.Perioperative Care—
methods—Outlines. WG 18.2 B685m 2005] I.Bojar,Robert M.,1951–.Manual of
perioperative care in cardiac surgery. II.Title.
RD598.B64 2005
617.4'12—dc22
2004019487
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MANUAL of
PERIOPERATIVE CARE in
ADULT CARDIAC SURGERY
Fourth Edition

MANUAL of
PERIOPERATIVE CARE in
ADULT CARDIAC SURGERY
Fourth Edition
By
Robert M.Bojar,M.D.
Associate Professor ofCardiothoracic Surgery
Tufts University School ofMedicine
ChiefofCardiothoracic Surgery
St.Vincent Hospital,Worcester,Massachusetts
Senior Cardiothoracic Surgeon
Tufts-New England Medical Center,Boston,Massachusetts
Dedication
To my wife, Mercedes, for her patience and understanding
as I deprived Alana and Rebecca of their bedtime
stories—but not any longer!

Table of Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
1.Synopsis of Adult Cardiac Surgical Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2.Diagnostic Techniques in Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.Preoperative Considerations and Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . 91
4.Cardiac Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
5.Cardiopulmonary Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
6.Myocardial Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
7.Admission to the ICU and Monitoring Techniques . . . . . . . . . . . . . . . . . . . . . . . 217
8.Early Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
9.Mediastinal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
10.Respiratory Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
11.Cardiovascular Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
12.Fluid Management,Renal and Metabolic Problems . . . . . . . . . . . . . . . . . . . . . . 467
13.Post-ICU Care and Other Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
Appendix 1 Typical Preoperative Order Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . 573
Appendix 2 Typical Orders for Admission to the ICU . . . . . . . . . . . . . . . . . . . 574
Appendix 3 Transfer Orders from the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
Appendix 4 Typical ICU Flowsheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
Appendix 5 Heparinization Protocol for Cardiac Surgery Patients . . . . . . . . . . . 581
Appendix 6 Hyperglycemia Protocol for Cardiac Surgery Patients . . . . . . . . . . . 582
Appendix 7 Doses of Parenteral Medications Commonly Used in the ICU
and Their Modifications in Renal Failure . . . . . . . . . . . . . . . . . . . . 583
Appendix 8 Doses of Nonparenteral Medications Commonly Used After
Heart Surgery and Their Modifications in Renal Failure . . . . . . . . . 587
Appendix 9 Drug and Food Interactions with Warfarin (Coumadin) . . . . . . . . . 596
Appendix 10 Definitions from the STS Data Specifications (2004) . . . . . . . . . . . 597
Appendix 11Technique of Thoracentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600
Appendix 12Technique for Tube Thoracostomy . . . . . . . . . . . . . . . . . . . . . . . . . 601
Appendix 13Technique for Insertion of Percutaneous Tracheostomy Tube . . . . . . 603
Appendix 14 Body Surface Area Nomogram for Adults . . . . . . . . . . . . . . . . . . . . 606
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 607
vii
Preface
Technological advances in cardiovascular care have changed the patient population
referred to cardiac surgeons.At a time when off-pump surgery and robotics are being uti-
lized to offer the patient a less invasive and potentially more benign procedure,the advent of
drug-eluting stents has dramatically decreased referrals for coronary bypass surgery.
Saphenous vein graft disease,multivessel disease,and at times,left main disease have become
“endovascular”problems to be approached by percutaneous coronary interventions (PCI) in
the cath lab.Seemingly,coronary artery bypass surgery (CABG) has become reserved for
patients with failed stents,unstentable disease,or such diffuse disease that even the most
aggressive cardiologist admits defeat and refers the patient to surgery.The percentage of
patients requiring valve or combined surgery has increased,although isolated coronary sur-
gery still remains the most common procedure.Yet,despite these trends,surgical results,as
tracked by the Society of Thoracic Surgeons database,continue to improve.So,we must be
doing something right!
Improvements in intraoperative management have contributed to better patient out-
comes.Excellence in cardiac anesthesia with protocols to achieve early extubation and rou-
tine use of intraoperative transesophageal echocardiography play a major role in optimizing
surgical outcome.Surgeons have also become more technically proficient and recognize the
importance of excellent myocardial protection.Despite improvements in cardiopulmonary
bypass (CPB) technology,off-pump surgery (OPCAB) has been promoted as a means of
minimizing the adverse effects of CPB,although its advantages over traditional on-pump
CABG are somewhat controversial.Some surgeons reserve its use for patients with advanced
comorbidities that might otherwise contraindicate on-pump CABG.However,no matter
which technique of surgery is used and how well it is performed,excellence in perioperative
care will affect the outcome in critically ill patients.That is why an update of the manual is
timely,now 6 years since the last edition.
In an attempt to keep this manual at a reasonable length and not weigh down the pocket
of the user,the decision was made to retain only the Adult Cardiac Surgery section of the
book.Each chapter has been extensively updated and rereferenced to include the latest infor-
mation on perioperative care. The outline format, which most readers have found quite
beneficial in providing easy access to information,has been retained.It should be noted that
the book is written in a chronological fashion from Chapters 2 to 8,covering diagnostic tests,
then preoperative,intraoperative,and early postoperative care issues.Chapters 9–12 discuss
bleeding,and the respiratory,cardiac,and renal subsystems in depth,and the final chapter
covers additional problems and issues on the postoperative floor.Thus,there is no chapter
devoted specifically to off-pump surgery, which is discussed primarily in the chapters on
intraoperative and postoperative management (Chapters 4 and 8).
I am hopeful that this 4th edition will provide a timely update on perioperative care that
will allow its readers to provide the best possible care to their adult cardiac surgical patients.
Robert M.Bojar,M.D.
December 2004
viii