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MANUAL of PERIOPERATIVE CARE in ADULT CARDIAC SURGERY, Fourth Edition PDF

642 Pages·2010·7.59 MB·English
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© 2005,Robert M.Bojar,M.D. Blackwell Publishing,Inc.,350 Main Street,Malden,Massachusetts 02148-5018,USA Blackwell Publishing Ltd,9600 Garsington Road,Oxford OX4 2DQ,UK Blackwell Publishing Asia Pty Ltd,550 Swanston Street,Carlton,Victoria 3053,Australia All rights reserved.No part of this publication may be reproduced in any form or by any elec- tronic or mechanical means,including information storage and retrieval systems,without permission in writing from the publisher,except by a reviewer who may quote brief passages in a review. 6 2009 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 A catalogue record for this title is available from the British Library Acquisitions:Nancy Anastasi Duffy Development:Kate Heinle Production:Debra Murphy Cover design:Eve Siegel Interior design:Eve Siegel Illustrations by Electronic Illustrators Group Typesetter:International Typesetting andComposition Printed and bound by Sheridan Books, Inc., Chelsea, MI, USA For further information on Blackwell Publishing,visit our website: www.blackwellmedicine.com The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has been manufactured from pulp processed using acid-free and elementary chlorine-free practices.Furthermore,the publisher ensures that the text paper and cover board used have met accept- able environmental accreditation standards. 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

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Manual of perioperative care in adult cardiac surgery/by Robert M. Bojar. To my wife, Mercedes, for her patience and understanding . minimizing the adverse effects of CPB, although its advantages over traditional on-pump .. The presence of a ventricular septal defect (VSD) is suggested by.
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