Manual of Perioperative Care in Adult Cardiac Surgery,Fifth Edition PDF
Preview Manual of Perioperative Care in Adult Cardiac Surgery,Fifth Edition
MANUAL of PERIOPERATIVE CARE in ADULT CARDIAC SURGERY Fifth Edition Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition Robert M. Bojar © 2011 Robert M. Bojar. ISBN: 978-1-444-33143-1 MANUAL of PERIOPERATIVE CARE in ADULT CARDIAC SURGERY Fifth Edition By Robert M. Bojar, MD Chief of Cardiothoracic Surgery Saint Vincent Hospital Worcester, Massachusetts, USA Thiseditionfirstpublished2011(cid:1)2011byRobertM.Bojar BlackwellPublishingwasacquiredbyJohnWiley&SonsinFebruary2007.Blackwell’spublishing programhasbeenmergedwithWiley’sglobalScientific,TechnicalandMedicalbusinesstoform Wiley-Blackwell. Registeredoffice:JohnWiley SonsLtd,TheAtrium,SouthernGate,Chichester, WestSussex,PO198SQ,UK Editorialoffices: 9600GarsingtonRoad,Oxford,OX42DQ,UK TheAtrium,SouthernGate,Chichester,WestSussex,PO198SQ,UK 111RiverStreet,Hoboken,NJ07030-5774,USA Fordetailsofourglobaleditorialoffices,forcustomerservicesandforinformationabouthowto applyforpermissiontoreusethecopyrightmaterialinthisbookpleaseseeourwebsiteat www .wiley.com/wile y-blackwell TherightoftheauthortobeidentifiedastheauthorofthisworkhasbeenassertedinaccordancewiththeUKCopyright, DesignsandPatentsAct1988. Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,ortransmitted,inanyform orbyanymeans,electronic,mechanical,photocopying,recordingorotherwise,exceptaspermittedbytheUKCopyright, DesignsandPatentsAct1988,withoutthepriorpermissionofthepublisher. 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Thecontentsofthisworkareintendedtofurthergeneralscientificresearch,understanding,anddiscussiononlyandarenot intendedandshouldnotberelieduponasrecommendingorpromotingaspecificmethod,diagnosis,ortreatmentby physiciansforanyparticularpatient.Thepublisherandtheauthormakenorepresentationsorwarrantieswithrespectto theaccuracyorcompletenessofthecontentsofthisworkandspecificallydisclaimallwarranties,includingwithout limitationanyimpliedwarrantiesoffitnessforaparticularpurpose.Inviewofongoingresearch,equipmentmodifications, changesingovernmentalregulations,andtheconstantflowofinformationrelatingtotheuseofmedicines,equipment,and devices,thereaderisurgedtoreviewandevaluatetheinformationprovidedinthepackageinsertorinstructionsforeach medicine,equipment,ordevicefor,amongotherthings,anychangesintheinstructionsorindicationofusageandfor addedwarningsandprecautions.Readersshouldconsultwithaspecialistwhereappropriate.Thefactthatanorganization orWebsiteisreferredtointhisworkasacitationand/orapotentialsourceoffurtherinformationdoesnotmeanthatthe authororthepublisherendorsestheinformationtheorganizationorWebsitemayprovideorrecommendationsitmay make. Further,readersshouldbeawarethatInternetWebsiteslistedinthisworkmayhavechangedordisappeared betweenwhenthisworkwaswrittenandwhenitisread. Nowarrantymaybecreatedorextendedbyanypromotional statementsforthiswork. Neitherthepublishernortheauthorshallbeliableforanydamagesarisingherefrom. LibraryofCongressCataloging-in-PublicationData Bojar,RobertM.,1951- Manualofperioperativecareinadultcardiacsurgery/byRobertM.Bojar.–5thed. p.;cm. Includesbibliographicalreferencesandindex. ISBN978-1-4443-3143-1 1. Heart–Surgery–Handbooks,manuals,etc.2. Therapeutics,Surgical–Handbooks,manuals,etc. I.Title. [DNLM:1.CardiacSurgicalProcedures–Outlines.2.PerioperativeCare–methods–Outlines.WG18.2B685m2011] RD598.B642011 6170.412–dc22 2010010689 AcataloguerecordforthisbookisavailablefromtheBritishLibrary. Thisbookispublishedinthefollowingelectronicformats:ePDF9781444325294;WileyOnlineLibrary9781444325287 Setin9/11pt,CaslonbyThomsonDigital,Noida,India 1 2011 Dedication To my parents, Leah and Samuel Bojar, who instilled in me a lifelong desire for learning, the importance of sharing knowledge, and a dedication to provide all patients with the best possible care. Table of Contents Preface.......................................................................................................................................ix Acknowledgments.......................................................................................................................xi 1. SynopsisofAdultCardiacSurgicalDisease...................................................................1 2. DiagnosticTechniquesinCardiacSurgery..................................................................85 3. GeneralPreoperativeConsiderationsandPreparationofthe PatientforSurgery......................................................................................................129 4. CardiacAnesthesia......................................................................................................173 5. CardiopulmonaryBypass.............................................................................................227 6. MyocardialProtection.................................................................................................263 7. AdmissiontotheICUandMonitoringTechniques.................................................279 8. EarlyPostoperativeCare.............................................................................................301 9. MediastinalBleeding...................................................................................................345 10. RespiratoryManagement............................................................................................383 11. CardiovascularManagement.......................................................................................437 12. FluidManagement,Renal,Metabolic,andEndocrineProblems..............................581 13. Post-ICUCareandOtherComplications.................................................................641 Appendices............................................................................................................................727 Appendix1A AmericanCollegeofCardiologyClassesofRecommendation andLevelsofEvidence.........................................................................729 Appendix1B NewYorkHeartAssociationFunctionalClassification......................729 Appendix2 TypicalPreoperativeOrderSheet.........................................................730 Appendix3 TypicalOrdersforAdmissiontotheICU...........................................731 Appendix4 TypicalTransferOrdersfromtheICU................................................734 Appendix5 TypicalICUFlowsheet.........................................................................737 Appendix6 HyperglycemiaProtocolforCardiacSurgeryPatients.........................738 Appendix7 HeparinizationProtocolforCardiacSurgeryPatients.........................739 Appendix8 ProtocolforInitiatingWarfarin...........................................................740 Appendix9 INRReversalProtocol..........................................................................741 Appendix10 Drug,Food,andDietarySupplementInteractions withWarfarin.........................................................................................742 Appendix11 DosesofParenteralMedicationsCommonlyUsedin theICUandTheirModificationinRenalFailure...............................743 vii viii TABLEOFCONTENTS Appendix12 DosesofNonparenteralDrugsCommonlyUsed AfterHeartSurgeryandTheirModificationsin RenalFailure..........................................................................................747 Appendix13 DefinitionsfromtheSTSDataSpecifications(Version2.72011)......753 Appendix14 BodySurfaceAreaNomogram..............................................................756 Appendix15 BodyMassIndexChart.........................................................................757 Appendix16 TechniqueofThoracentesis...................................................................758 Appendix17 TechniqueforTubeThoracostomy.......................................................759 Appendix18 TechniqueofInsertionofPercutaneousTracheostomyTube..............761 Index......................................................................................................................................765 Preface Thefutureofcardiacsurgeryfacessignificantchallengeswiththewidespreadapplicationof transcatheter technologies, including coronary stenting, percutaneous valves, endovascular approaches to thoracic aortic disease, and ablation of arrhythmias in the electrophysiology laboratory.Mostofthesetechnologiesevolvedfromtheconceptthatalessinvasiveapproachto structural heart disease is preferred by patients to reduce trauma, minimize complications, expediterecovery,andimprovethequalityoflife. Although these approaches may be applicable to patients at both ends of the clinical spectrum,surgerywillstillremainthebestapproachformanypatients–especiallythosewith advancedcardiacdiseaseandsignificantnoncardiacissues.Althoughlessinvasivesurgeryis seeingwiderapplicability,mostsurgicalproceduresrequireuseofcardiopulmonarybypasswith itsinherentmorbidity.Thereislittledoubtthatsurgicalpatientacuitycontinuestoincrease, and excellence in perioperative care will remain essential to optimizing surgical results, no matter which surgical technique is used. This has become especially important with the increasingdemandfortransparency,withtheperceptionthatoutcomesaredirectlyrelatedto thequalityofcare.Thus,ithasbecomeessentialthatsurgicalprogramsmaintainthehighest levelofcaretoremaincompetitive. The5theditionoftheManualhasbeencompletelyupdatedtoprovidecurrentapproachesto patientcare.Thereferencelistshavealsobeenextensivelyupdatedtodirectthereadertosome ofthebestresourcesavailableonmosttopics.Iamhopefulthatthis5theditionwillprovidea comprehensive up-to-date review that will assist healthcare providers in delivering the best possiblecaretotheircardiacsurgicalpatients. RobertM.Bojar,MD Worcester,MA December2010 ix Acknowledgments Cardiacsurgeryrequiresmeticulousattentiontodetailtoensurethebestpossiblesurgicalresult. Decision-makingintheperioperativeperiodinvolvesclosecooperationandcommunication among all members of the healthcare team, including cardiac surgeons, anesthesiologists, physicianassistants,nursepractitioners,andcriticalcareandfloornurses.Identifyingproblems andseekingconsultationswithexpertsinotherfieldsisimportanttoensureoptimaloutcomes.I amgreatlyappreciativeoftheeffortsofmanyindividualswhosetasidevaluabletimetoreview sectionsofthemanuscriptintheirareasofexpertise.Iwouldliketoacknowledgetheassistance ofDavidLiu,MD,GaryNoroian,MD,TimothyHastings,CRNA,BettinaAlpert,CCP, Kathi O’Leary, CCP, and Wanda Reynolds, CCRT, for their review and comments. I am especially indebted to George Gordon, MD, whose vast knowledge of anesthesiology, echocardiography,pharmacology,andphysiologyallowedhimtoprovideinsightandsugges- tionsonmultipleareasofclinicalmanagement.Lastly,IamindebtedtomyChiefPhysician Assistant,TheresaPhillips,PA,whohelpscoordinatethecaremypatientsreceive,andwho reviewedmanysectionsofthemanuscripttoensuretheiraccuracy. xi Notice:Theindicationsanddosagesofalldrugsinthisbookhavebeenrecommended in the medical literature and conform to the practices of the general community. ThemedicationsdescribeddonotnecessarilyhavespecificapprovalbytheFoodand DrugAdministrationforuseinthediseasesanddosagesforwhichtheyarerecom- mended.Thepackageinsertforeachdrugshouldbeconsultedforuseanddosageas approved by the FDA. Because standards for usage change, it is advisable to keep abreast of revised recommendations, particularly those concerning new drugs. Althoughtheauthorhasmadeeveryattempttoensuretheaccuracyofdrugdosages, itistheobligationofthereadertoconfirmdrugdosagespriortoprescribinganydrug. Abbreviationsusedthroughthisbookaretypesetandeasytoread.However,many hospitalshavelistsofapprovedabbreviationsdesignedtopreventmedicationerrors, whichareoftencausedbyinabilitytointerprethandwriting.Itisthereforeadvisable thatallordersbewrittenaccordingtoindividualhospitalregulationstoensurethat accuratemedicationdosesandintervalsareprovidedtopatients.
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