Perioperative Care in Cardiac Anesthesia and Surgery (Vademecum)

295 Pages·1999·1.37 MB·English

by  Davy C. H.

v a d e m e c u m
Perioperative Care in Cardiac
Anesthesia and Surgery
Davy C.H. Cheng, M.D.
Tirone E. David, M.D.
Toronto General Hospital
Peter Munk Cardiac Centre
.
L A N D E S
B I O S C I E N C E
GEORGETOWN, TEXAS
U.S.A.
v a d e m e c u m
Perioperative Care in Cardiac
Anesthesia and Surgery
Davy C.H. Cheng, M.D.
Tirone E. David, M.D.
Toronto General Hospital
Peter Munk Cardiac Centre
L A N D E S
B I O S C I E N C E
AUSTIN, TEXAS
U.S.A.
VADEMECUM
Perioperative Care in Cardiac Anesthesia and Surgery
LANDES BIOSCIENCE
Austin
Copyright © 1999 Landes Bioscience
All rights reserved.
No part of this book may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopy, recording, or any
information storage and retrieval system, without permission in writing from
the publisher.
Printed in the U.S.A.
Please address all inquiries to the Publisher:
Landes Bioscience, 810 S. Church Street, Georgetown, Texas, U.S.A. 78626
Phone: [phone]; FAX: [phone]
ISBN: 1-57059-527-5
Library of Congress Cataloging-in-Publication Data
Perioperative care in cardiac anesthesia and surgery/ [edited by] Davy C.H.
Cheng, Tirone E. David.
p.cm.
"Vademecum."
Includes bibliographical references and index.
ISBN 1-57059-527-5 (alk. paper)
1. Heart--Surgery--Patients--Medical care--Handbooks, manuals, etc.
2. Therapeutics, Surgical--Handbooks, manuals, etc. 3. Operating room
nursing--Handbooks, manuals, etc. 4. Postoperative care--Handbooks,
manuals, etc. I. Cheng, Davy C. H. II. David, Tirone E.
[DNLM: 1. Perioperative Care--methods. 2. Coronary Disease--surgery.
3. Cardiac Surgical Procedures--methods. WO 178 H2356 1999]
RD598.H286 1999
617.4'12--dc21
DNLM/DLC 98-50222
for Library of Congress CIP
While the authors, editors, sponsor and publisher believe that drug selection and dosage
and the specifications and usage of equipment and devices, as set forth in this book, are in
accord with current recommendations and practice at the time of publication, they make
no warranty, expressed or implied, with respect to material described in this book. In
view of the ongoing research, equipment development, changes in governmental regula-
tions and the rapid accumulation of information relating to the biomedical sciences, the
reader is urged to carefully review and evaluate the information provided herein.
Dedication
To the students, residents, and fellows of cardiac anesthesia and surgery
at Toronto General Hospital, University of Toronto.
Contents
I. Peter Munk Cardiac Centre, Toronto General Hospital
1. The Toronto General Hospital
Cardiac Surgical Program....................................................1
Tirone E. David
2. Fast Track Cardiac Surgical Program..................................3
Davy C.H. Cheng
Introduction..................................................................................................3
Risk Stratification in Fast Track Cardiac Surgery........................................3
Medical and Economic Implications...........................................................4
Fast Track Cardiac Surgery Team.................................................................7
3. Preoperative Assessment......................................................8
Tirone E. David, Susan Kerwin-Lenkei, John Bradley
Basic Evaluation............................................................................................8
Preadmission Tests......................................................................................10
Assessing the Risk and Benefit of Surgery.................................................10
Informed Consent.......................................................................................12
The Pre-admission Clinic...........................................................................12
Preoperative Medication Order..................................................................12
II. Anesthesia and Cardiopulmonary Bypass Management
4. Early Extubation Anesthesia..............................................14
Davy C.H. Cheng
Preoperative.................................................................................................14
Intraoperative..............................................................................................14
Postoperative...............................................................................................15
5. Perioperative Monitoring
and Intraoperative Echocardiography..............................17
Corey Sawchuk, Harry Rakowski
Standard Monitors......................................................................................17
Central Venous Monitoring (CVP)............................................................17
Swan-Ganz Catheterization........................................................................18
Transesophageal Echocardiography (TEE)................................................19
Mitral Valve Repair......................................................................................20
Aortic Valve Repair......................................................................................21
6. Weaning from Cardiopulmonary Bypass.........................23
Annette Vegas
Weaning Techniques...................................................................................23
Theory and Practice....................................................................................25
Individual Agents........................................................................................27
Summary.....................................................................................................30
7. Blood Conservation and Transfusion Requirement........31
Jacek M. Karski
Introduction................................................................................................31
Post-CPB Coagulopathy.............................................................................31
Predictors of Postoperative Bleeding .........................................................31
Prevention of the Postoperative Blood Loss..............................................32
Antifibrinolytics..........................................................................................33
Blood Product Administration...................................................................35
Summary.....................................................................................................36
8. Anesthesia for Special Cardiac Surgical Procedures........38
Annette Vegas
Anesthesia for Minimally Invasive Coronary Artery Bypass....................38
Anesthesia for Partial Left Ventriculectomy (PLV)....................................41
9. Anesthetic Management of Diseases
Affecting Cardiopulmonary Bypass..................................44
Ramiro Arellano
Diabetes Mellitus.........................................................................................44
Renal Insufficiency......................................................................................44
Sickle Cell Trait and Disease.......................................................................46
Cryoproteins................................................................................................47
10. Malignant Hyperthermia...................................................50
Jane E. Heggie
Introduction................................................................................................50
Malignant Hyperthermia Crisis.................................................................50
Postcrisis Management...............................................................................51
Elective Management of Malignant Hyperthermia
Susceptible Patients.....................................................................................52
Preoperative.................................................................................................52
Intraoperative..............................................................................................53
Postoperative...............................................................................................53
11. Combined Cardiac and Thoracic Surgery ........................54
Peter Slinger
Controversies...............................................................................................54
Presentation.................................................................................................55
Preoperative Evaluation..............................................................................55
Anesthetic Technique..................................................................................57
Combined Procedures.................................................................................58
Postoperative Analgesia...............................................................................59
12. Anesthesia for Intrathoracic Transplantation..................60
Karen M. McRae
Introduction................................................................................................60
Lung Transplantation..................................................................................61
Heart Transplant.........................................................................................65
Heart-Lung Transplant...............................................................................69
Nitric Oxide.................................................................................................69
13. Heparin Associated Thrombocytopenia
and Alternatives to Heparin...............................................71
Patricia McNama, Annette Vegas
Introduction................................................................................................71
Heparin........................................................................................................71
Heparin Associated Thrombocytopenia....................................................72
Diagnosis.....................................................................................................73
Management................................................................................................73
Alternatives to Heparin for CPB................................................................74
14. Cardiopulmonary Bypass Technique................................78
TTH Perfusionists
Introduction................................................................................................78
Circuit..........................................................................................................78
Circulatory Changes During CPB..............................................................79
Methods of Adjusting BP............................................................................80
Pump Flow vs. Pressure (MAP)..................................................................80
Pulsatile vs. Nonpulsatile Flow...................................................................81
Hypothermia vs. Normothermia Bypass...................................................81
ABG Analysis Alpha (α) vs. pH Stat...........................................................83
15. Circulatory Arrest and Neuroprotection..........................84
Christopher M.S. Feindel, Ludwig Fedorko
Introduction................................................................................................84
Indications...................................................................................................84
Technique of Circulatory Arrest.................................................................85
Retrograde Cerebral Perfusion...................................................................86
Pharmaceutical and Other Neuroprotective Adjuncts..............................86
Acid/Base Control.......................................................................................87
Glucose Control..........................................................................................87
Temperature Monitoring and Rewarming Phase......................................87
Pharmacotherapy........................................................................................87
16. Hemoconcentration and Hemodialysis During CPB ......89
Teraze McDougall, Mary Scholz
Hemoconcentration (Ultra-filtration).......................................................89
Hemodialysis...............................................................................................91
17. Intra-Aortic Balloon Pump................................................93
Arthur Melo, Mindy Madonik, Annette Vegas
Mechanism of Action and Role..................................................................93
Monitoring..................................................................................................94
Weaning and Removal................................................................................94
Balloon Operation ......................................................................................95
Conventional Timing..................................................................................95
Trouble Shooting IABP...............................................................................97
III. Surgical Technique and Postoperative Consideration
18. Aortocoronary Bypass: Surgical Technique
Including Cannulation Techniques...................................99
Anthony Ralph-Edwards
Aortocoronary Bypass Surgery...................................................................99
Cannulation Techniques...........................................................................102
19. Myocardial Protection......................................................106
Michael A. Borger, Richard D. Weisel
Introduction..............................................................................................106
Cardioplegia Composition.......................................................................106
Cardioplegia Temperature........................................................................107
Cardioplegia Delivery...............................................................................108
Future Directions......................................................................................110
20. Surgery of Heart Valve, the Aortic Root,
Ascending Thoracic Aorta and Transverse Arch ............111
Tirone E. David
Aortic Valve Repair....................................................................................112
Aortic Valve Replacement.........................................................................112
Mitral Valve Repair....................................................................................116
Mitral Valve Replacement.........................................................................117
Tricuspid Valve Repair...............................................................................118
Tricuspid Valve Replacement....................................................................118
Maze Procedure for Atrial Fibrillation.....................................................119
Surgery for Chronic Ascending Aortic Aneurysm...................................119
Surgery for Mega-Aorta Syndrome..........................................................120
Surgery for Acute Type A Aortic Dissection............................................120
21. Heart Transplantation......................................................122
Christopher M.S. Feindel, Heather Ross, Annette Vegas
Recipient....................................................................................................122
Donors.......................................................................................................124
Surgical Technique for Donor Harvest....................................................125
Surgical Technique for Orthotopic Heart Transplant.............................125
Immediate Postoperative Management...................................................127
Immunosuppression.................................................................................127
Complications...........................................................................................128
22. Adult Congenital Heart Surgery......................................130
Nancy C. Poirier, Glen S. Van Arsdell, William G. Williams
Atrial Septal Defect (ASD)........................................................................131
Ventricular Septal Defects (VSD).............................................................133
Patent Ductus Arteriosis (PDA)...............................................................135
Coarctation................................................................................................136
Tetralogy of Fallot (TOF)..........................................................................138
Single Ventricle (Fontan Operation)........................................................140
Hypertrophic Obstructive Cardiomyopathy (HOCM)...........................143
23. Ventricular Aneurysm Resection.....................................146
Lynda L. Mickleborough
Left Ventricular Aneurysm........................................................................146
Ventricular Arrhythmias, Mapping,
Ventricular Tachycardia Ablation.............................................................147
24. Combined Cardiac and Vascular Surgery.......................148
Charles M. Peniston
Carotid Artery Surgery and Cardiac Surgery...........................................148
Combined Coronary Artery Bypass
with Abdominal Aortic Aneurysm Repair...............................................149
25. Minimally Invasive Cardiac Surgery...............................151
Robert J. Cusimano
Indications.................................................................................................151
Operative Technique.................................................................................152
Stabilization of the Heart..........................................................................153
Heart Rate Control....................................................................................153
Postoperative Care.....................................................................................154
26. Partial Left Ventriculectomy (PLV).................................155
Robert J. Cusimano
Indications.................................................................................................155
Operative Technique.................................................................................156
Postoperative Care.....................................................................................156
27. AICD and Pacemakers Insertion.....................................158
Charles M. Peniston
Automatic Implantable Cardioverter Defibrillator (AICD)...................158
Pacemakers................................................................................................159
28. Ventricular Assist Devices (VAD)....................................163
Gideon I. Cohen
Commonly Utilized Ventricular Assist Devices (VAD)...........................163
Indications for Left Ventricular Assist Device (LVAD) Implantation.....163
Absolute and Relative Contraindications to LVAD Implantation..........164
Biventricular VAD Indications.................................................................165
Semi-Implantable/Pericorporeal VAD.....................................................165
Perioperative Considerations...................................................................166
LVAD Complications................................................................................168
Myocardial Recovery after LVAD Placement...........................................168
Total Artificial Heart.................................................................................169
29. Lung and Heart-Lung Transplantation...........................170
Shaf H. Keshavjee
Introduction..............................................................................................170
Surgical Technique....................................................................................170
Postoperative Care.....................................................................................173
IV. Post-cardiac Surgical Unit Management
30. Routine CVICU Care: Early Extubation to Discharge...176
Annette Vegas, Davy C. H. Cheng
Early Tracheal Extubation and Process of Care.......................................176
CVICU—A Variable Care Unit ................................................................177
Admissions................................................................................................177
Routine Postoperative Course..................................................................179
Common Management Strategies............................................................179
Unstable Patients and Chest Re-openings...............................................181
Medical Rounds.........................................................................................181
Discharges..................................................................................................182
Delegated Acts and Procedures ................................................................182
31. Analgesia Techniques.......................................................184
Gerald O’Leary, Alan N. Sandler
Introduction..............................................................................................184
Modalities..................................................................................................184
Common Problems...................................................................................186
32. Common Problems in the CVICU ..................................188
Annette Vegas
Central Nervous System (CNS)................................................................188
Respiratory................................................................................................189
Cardiovascular...........................................................................................190
Gastrointestinal.........................................................................................193
Renal..........................................................................................................194
Hematologic..............................................................................................195
Metabolic...................................................................................................195
Infectious Disease......................................................................................200
V. Postoperative Complications Management
33. Chest Reopening...............................................................201
Terrence M. Yau
Introduction..............................................................................................201
Incidence....................................................................................................201
Indications.................................................................................................201
Technique of Emergency Chest Reopening.............................................203
Outcomes...................................................................................................205
Summary...................................................................................................206