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Perioperative Cardiac Management

 • Author: Davinder Jassal, MD, FACC, FRCPC; Chief Editor: William A Schwer, MD
more...

Updated: May 18, 2011

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• Background
• Perioperative Cardiac Physiology
• Patient- and Procedure-Related Factors
• Preoperative Risk Assessment
• Noninvasive Cardiac Evaluation
• Cardiac Management Perioperatively
• Endocarditis Prophylaxis
• Show All
Background
The worldwide elderly population with its associated health concerns is expanding rapidly.
Globally, the proportion of individuals older than 80 years currently averages 5%. In the
developed world, almost 15% of individuals will be older than 80 years in 2020; the
proportion is expected to increase to 25% by 2050. This aging population has associated
comorbidities; consequently, clinicians are often asked to evaluate the preoperative risk status
of this high-risk population.
See algorithm for preoperative cardiac assessment below.

Perioperative cardiac management. Algorithm for

preoperative cardiac assessment.
The cardiovascular systems of patients who undergo general anesthesia and noncardiac
surgical procedures are subject to multiple stresses and complications. A previously stable
patient may decompensate postoperatively, leading to significant postoperative morbidity and
mortality. A substantial number of all deaths among patients undergoing noncardiac surgery
are caused by cardiovascular complications.
Each year, approximately 30 million individuals in the United States undergo noncardiac
surgery. Approximately one third have cardiac disease or major cardiac risk factors. Current
estimated rates of serious perioperative cardiac morbidity vary from 1-10%. The incidence of
perioperative myocardial infarction (MI) is increased 10- to 50-fold in patients who have had
previous coronary events.
Cardiac risk stratification allows clinicians to group patients into various risk categories;
therefore, low-risk patients can be spared further testing, whereas intermediate- and high-risk
patients should undergo preoperative investigations and treatment to reduce overall cardiac
perioperative morbidity and mortality.
Next Section: Perioperative Cardiac Physiology
Perioperative Cardiac Physiology
Cardiac effects of general anesthesia
The cardiovascular effects of general anesthesia include changes in the arterial and central
venous pressures, cardiac output, and varying heart rhythms, which occur by the following
mechanisms: decreased systemic vascular resistance, decreased myocardial contractility,
decreased stroke volume, and increased myocardial irritability.
Induction of general anesthesia lowers systemic arterial pressures by 20-30%, tracheal
intubation increases the blood pressure by 20-30 mm Hg, and agents such as nitric oxide
lower cardiac output by 15%.
The use of fentanyl, sufentanil, or alfentanil results in less myocardial depression compared
to inhaled anesthetics. Yet, these intravenous agents still cause venodilation, thus reducing
preload and, hence, depressing cardiac output. Patients with congestive heart failure (CHF)
are particularly sensitive to these hemodynamic changes. By increasing the preoperative
volume status and applying the Frank-Starling principle, this decrease in cardiac output can
be offset. Additionally, inhalational and intravenous anesthetics along with muscle relaxants
can be detrimental by sensitizing the myocardium to circulating catecholamines. As a result
of the stress of the surgical procedure, circulating catecholamine levels are elevated, thereby
increasing the risk of ventricular ectopy.
Cardiac effects of regional anesthesia
Both epidural and spinal anesthetics cause arteriodilation and venodilation by blocking
sympathetic outflow, decreasing preload, and, ultimately, reducing cardiac output. To offset
this deleterious effect, the clinician may volume load the patient preoperatively. However,
this intervention increases the risk of postoperative CHF by 10-15%.
Although many clinicians believe that regional anesthesia is safer than general anesthesia,
randomized studies comparing the 2 modalities have shown no difference in cardiopulmonary
complications or mortality. Combined epidural and general anesthesia with analgesia for pain
control may attenuate sympathetic hyperactivity, reduce the need for additional parenteral
analgesia postoperatively, improve postoperative pulmonary function, and reduce the
duration of stay in the intensive care unit following surgery.
Previous
Next Section: Perioperative Cardiac Physiology
Patient- and Procedure-Related Factors
Patient-related Factors
Hypertension
Approximately 50% of patients in the United States who are aware they have hypertension
are either not treated or inadequately treated with pharmacological therapy.
In the perioperative period, poorly controlled hypertension is associated with an increased
incidence of ischemia, left ventricular dysfunction, arrhythmia, and stroke. Patients with
hypertension are at a higher risk for labile blood pressure and for hypertensive emergencies
during surgery and immediately following extubation. Patients should continue taking
preoperative antihypertensive medications throughout the entire perioperative period. The
goal should be a systolic blood pressure less than 140 mm Hg and a diastolic blood pressure
lower than 90 mm Hg before proceeding with elective surgery in the ideal situation. In any
patient with stage 3 hypertension (ie, >180/110 mm Hg), blood pressure should be well
controlled prior to surgery. Intravenous esmolol, labetalol, nitroprusside, or nitroglycerin may
be used for acute episodes of hypertension, whereas calcium channel blockers or angiotensin-
converting enzyme (ACE) inhibitors may be used in less acute situations.
Congestive heart failure
The mortality rate following noncardiac surgery increases with advancing New York Heart
stage. The perioperative mortality rate appears to be more dependent on the patient's
condition at the time of surgery rather than on the myocardial depressant effects of the
anesthesia. CHF should be aggressively and adequately treated before the patient undergoes
major elective surgery. Therapy is aimed at reducing ventricular filling pressures in addition
to improving cardiac output. Medications proven to show a morbidity and mortality benefit
include ACE inhibitors, beta-blockers, spironolactone, and angiotensin receptor blockers.
Digoxin and diuretics have been shown to improve morbidity rates without reducing
mortality rates. In a 1986 report, Detsky et al suggest that patients with decompensated CHF
should be stabilized for at least 1 week before undergoing elective surgery.[1]
Ischemic heart disease
Ischemic heart disease (IHD) is a major determinant of perioperative morbidity and mortality.
During the 1970s, several studies reported a 30% risk of reinfarction or cardiac death for
patients undergoing surgery within 3 months of an MI, 15% when surgery was performed 3-6
months after an infarction, and 5% when the operation was performed 6 months later.
However, this traditional definition has been replaced by the consensus of the American
College of Cardiology (ACC) Cardiovascular Database Committee. In particular, an acute MI
is now defined as occurring within 7 days, a recent MI is defined as occurring within 7 days
to 1 month, and a history of prior MI refers to an event occurring more than 1 month
previously.
True lifesaving procedures should be performed regardless of cardiac risk, but consideration
should be given to performing elective surgery 4-6 weeks following an MI. In patients
requiring semi-urgent surgery, the patient's risk should be evaluated with prognostic studies
(see Preoperative Risk Assessment). In a 1990 report, Shah et al revealed that 25% of patients
with unstable angina had an MI after noncardiac procedures.[2] Medical therapy and/or
revascularization are necessary to ameliorate this risk factor.
No evidence-based trials compare perioperative cardiac outcome after noncardiac surgery for
individuals treated with preoperative percutaneous coronary intervention (PCI) versus
medical therapy. Indications for PCI in the perioperative setting should adhere to the
ACC/American Heart Association (AHA) guidelines established for PCI in general. In the
setting of PCI without stenting, wait 1 week prior to surgery. In the setting of PCI with a
coronary stent, wait 4-6 weeks prior to noncardiac surgery.
Aortic stenosis
Aortic stenosis (AS) is associated with a 13% risk of perioperative death. Risk varies based
on the severity of AS. The death rate associated with critical AS is approximately 50%.
While taking a history, the clinician should inquire about symptoms of syncope, angina, and
dyspnea. During the examination, assess for a crescendo-decrescendo murmur in the right
intercostal space radiating to the carotids. Pulsus parvus et pulsus tardus, a soft second heart
sound (S2), a late peaking murmur, brachioradial delay, and an apical-carotid delay should
raise the suggestion of AS. Critical AS is often characterized by an absent S2 and pulsus
parvus et tardus. Echocardiography revealing an aortic valve area less than 0.7 cm2 and/or a
mean gradient of 50 mm Hg/peak gradient of 80 mm Hg is deemed critical stenosis. The
clinician should delay surgery, except for emergencies, and should consider preoperative
valve replacement in these selected patients.
Anticoagulation
The clinician must remember that patients with atrial fibrillation and prosthetic heart valves
are on anticoagulation therapy. Coumadin therapy should be discontinued 4-5 days before
elective surgery, given its half-life. Patients at high risk for thromboembolic events include
those with prosthetic valves in the mitral position, atrial fibrillation associated with mitral
valve disease, and a history of thromboembolism. Such patients should be admitted for
intravenous heparin treatment. Outpatient therapy with preoperative low molecular weight
heparin instead of conventional unfractionated intravenous heparin is often used, although no
randomized controlled trials have validated this protocol. Patients with highly thrombotic
valves (eg, Star-Edwards valve), 2 prosthetic valves, or recent arterial embolism should be
considered for standard intravenous heparin therapy perioperatively.
Procedure-related Factors
The clinician must consider 2 factors when assessing the patient's cardiovascular risk: (1) the
type of surgery, and (2) the hemodynamic stress associated with the procedure. Generally, the
more extensive the surgical procedure, the greater the physiological stress, the more
significant the postoperative pain, and the greater the incidence of cardiac complications.
Surgical operations may be classified as follows:
• High risk (>5% rate of perioperative death or MI) - Emergent major operations
(particularly in elderly patients), peripheral vascular or aortic surgery, and prolonged
procedures with large amounts of blood loss involving the abdomen, thorax, head, and
neck
• Intermediate risk (1-5% rate of perioperative death or MI) - Carotid endarectomy and
urologic, orthopedic, uncomplicated abdominal, head, neck, and thoracic operations
• Low risk (< 1%) - Cataract removal, endoscopy, superficial procedure, and breast
surgery
Previous
Next Section: Perioperative Cardiac Physiology
Preoperative Risk Assessment
A preoperative cardiac risk assessment involves obtaining a thorough history and physical
examination, along with a baseline electrocardiogram. Established cardiac diseases, including
IHD, hypertension, arrhythmia, valvular heart disease, CHF, and the presence of a pacemaker
or implantable defibrillator should be sought as part of the patient's history.
A number of studies pertaining to cardiac risk stratification have been published over the past
3 decades, including the Goldman, Detsky, and Eagle indices. In 2002, the ACC/AHA
updated guidelines for the perioperative cardiovascular evaluation for noncardiac surgery.
(See also New ACC/AHA Guidelines on Perioperative CV Evaluation for Noncardiac
Surgery.) A stepwise strategy that includes the assessment of clinical markers, prior cardiac
evaluation and management, functional capacity in mets, and surgery specific risk is
followed.
• Clinical markers
○ Major clinical predictors - Unstable coronary syndrome, decompensated CHF,
significant arrhythmia, and severe valvular disease
 ○ Intermediate clinical predictors - Mild angina, prior MI, compensated or prior
CHF, diabetes mellitus, and renal insufficiency
○ Minor clinical predictors - Advanced age, abnormal findings on
echocardiography, rhythm other than sinus, history of stroke, low function
capacity, and uncontrolled hypertension
• Functional capacity
○ Poor functional class (< 4 mets) - Energy expended during activities, including
dressing, eating, and walking around the house
○ Adequate functional class (>4 mets) - Energy expended during activities,
including walking up a flight of stairs, scrubbing floors, and swimming
• Surgery-specific risk
○ See Patient- and Procedure-Related Factors.
○ See the algorithm presented in the image shown below.

Perioperative cardiac management. Algorithm

for preoperative cardiac assessment.
Previous
Next Section: Perioperative Cardiac Physiology
Noninvasive Cardiac Evaluation
Tests for Risk Stratification
Dobutamine stress echocardiography
Dobutamine is a beta-receptor agonist that increases both heart rate and contractility. In
combination with echocardiography, regional wall abnormalities and, thus, ischemia may be
assessed. The negative and positive likelihood ratios of dobutamine stress echocardiography
for detecting coronary artery disease are 0 and 4.5, respectively. Of note, avoid dobutamine
stress echocardiography testing in patients with a history of ventricular tachyarrhythmia (see
image below).

Perioperative cardiac management. The transthoracic

echocardiogram illustrates a parasternal long axis view of the left ventricle with preserved
cardiac function.
Dipyridamole thallium imaging
Intravenous dipyridamole (Persantine) increases coronary blood flow to the myocardium 2-
to 3-fold. Viable myocardial cells take up thallium-201, a radionucleotide tracer, in
proportion to blood flow. Hence, delayed thallium redistribution following dipyridamole
helps identify areas of ischemia (see image below). The test has a negative predictive value
(NPV) of 95-100% for coronary artery disease in patients having vascular surgery; negative
results have a likelihood ratio (LR) of 0.12, whereas positive results have an LR of 3.02.

Perioperative cardiac management. The sestamibi perfusion

scan illustrates reversible ischemia in the anterior wall of the myocardium, comparing rest
and stress images.
Of note, be cautious when performing Persantine thallium scanning in patients with an
underlying history of reactive airway disease, including asthma and severe chronic
obstructive pulmonary disease (COPD).
Coronary angiography
Studies to date have not evaluated the role of coronary angiography as a risk predictor.
Coronary angiography should not be performed routinely in all vascular patients, but it is
generally recommended for those individuals with clinical or noninvasive evidence of
coronary artery disease, as determined by dobutamine echocardiography results or Persantine
methoxyisobutyl isonitrile testing. Furthermore, indications for coronary artery bypass
grafting (CABG) before noncardiac surgery are identical to those established by the
ACC/AHA guidelines for CABG, in particular left main disease and critical 3 vessel disease
with a reduced ejection fraction (see the following image).

Perioperative cardiac management. Coronary angiogram

revealing severe left circumflex and left anterior descending disease.
Tests Not Recommended for Risk Stratification
Transthoracic echocardiography
Noninvasive measurement of left ventricular systolic dysfunction was once considered
predictive of increased perioperative cardiac complications because the noninvasive
measurement was considered an indirect measurement of left heart failure. This finding no
longer holds true because transthoracic echocardiography does not provide any further data
over the clinical cardiac examination for predicting perioperative cardiac complications.
Although a high ejection fraction is associated with a low perioperative cardiac risk, even a
normal ejection fraction cannot exclude severe coronary artery disease. Transthoracic
echocardiography does play an important role in evaluating the severity of stenotic and
regurgitant valvular lesions.
Exercise treadmill testing
Exercise stress testing is useful in patients who are able to exercise, but a significant
percentage of patients undergoing noncardiac surgery are unable to reach the maximal
predicted heart rate, given the magnitude of their concomitant vascular disease. In those
individuals able to walk the treadmill, the sensitivity and specificity for predicting coronary
artery disease are 65% and 85%, respectively.
Studies have confirmed that exercise stress testing does not provide a high NPV.
Physiologically, exercise increases the heart rate and systemic vascular resistance, thus
increasing oxygen consumption by the myocardium. Therefore, a positive test result indicates
a high risk of developing ischemia perioperatively. However, many ischemic events
occurring intraoperatively are not associated with changes in the heart rate or blood pressure;
therefore, the minimal threshold of myocardial oxygen utilization to evoke ischemia is not
reached, and the significance of a negative stress test result is misleading.
Ambulatory electrocardiographic monitoring
Although preliminary data suggested that the absence of ST depression had an NPV of 99%,
this finding no longer holds true.
Previous
Next Section: Perioperative Cardiac Physiology
Cardiac Management Perioperatively
Preoperative and intraoperative cardiac management
The stress of surgery results in the release of catecholamines. Increasing the rate-pressure
product may predispose the patient to a cardiac event. In 1996, Mangano et al evaluated the
role of atenolol perioperatively in reducing long-term cardiac morbidity and mortality.[3]
Patients received a beta-blocker if they had known coronary artery disease or met 2 of the
following criteria: older than 65 years, hypertension, total cholesterol level higher than 6.2
mmol/L, smoking history, or diabetes mellitus.
Atenolol produced a 15% absolute risk reduction in the end points of MI, unstable angina,
CHF requiring hospitalization, or death at 6 months and reduced mortality at 6 months and 2
years in noncardiac surgery.
Similarly, another randomized controlled trial evaluating the cardioprotective effects of
bisoprolol in high-risk patients undergoing vascular surgery was performed. The study was
stopped early because of the dramatic results. In 1999, Poldermans et al screened 1351
patients awaiting vascular surgery and included those who had one or more cardiac risk
factors and positive results on a dobutamine echocardiography study.[4] The 112 patients
remaining were randomized to receive either standard care or standard care plus bisoprolol.
Bisoprolol, at a dose of 10 mg PO qd given 1 week preoperatively and continued for 1 month
postoperatively, reduced the incidence of perioperative death from cardiac causes and
nonfatal MI. Consequently, when possible, beta-blockers should be started 1 week before
elective surgery, with the dose titrated to a resting heart rate of 50-60. As for the use of
nitrates, digitalis, and calcium blockers, no studies have evaluated their use in the
perioperative state.
Postoperative management
Historically, postoperative MI carried a grave prognosis (ie, >50% mortality rate).
Postoperative ischemia is well characterized, with its peak incidence within 48 hours of
surgery. Postoperative ischemia is clinically silent in more than 90% of cases. The
Perioperative Ischemia Research Group evaluated the use of continuous echocardiographic
monitoring perioperatively and found that ischemia occurred most frequently on
postoperative days 1 and 2 (ie, 20% preoperative, 25% intraoperative, 55% postoperative).
Because postoperative ischemia can be more deleterious than ischemia detected at other
times, interventions, including the perioperative use of beta-blockers and high-dose narcotic
analgesia to reduce postoperative pain, are recommended.
The PeriOperative Ischemic Evaluation (POISE) trial was a cohort study of 8351 patients
undergoing noncardiac surgery who had troponin levels routinely checked 3 days after
surgery. Myocardial infarction was defined as elevated troponin with clinical, ECG, or
imaging evidence of myocardial ischemia. The 30-day mortality rate was 5-fold higher in
patients with postoperative MI (11.6% vs 2.2%) and was similar between those with and
without ischemic symptoms.[5]
Previous
Next Section: Perioperative Cardiac Physiology
Endocarditis Prophylaxis
According to the revised guidelines of the AHA published in 1997, cardiac conditions in
which antimicrobial prophylaxis is indicated prior to invasive dental or surgical procedures
include the following:
• Prosthetic heart valve
• Prior history of infective endocarditis
• Cyanotic congenital heart defect
• Surgically constructed systemic or pulmonary conduit
• Hypertrophic cardiomyopathy
• Mitral valve prolapse with regurgitation, valve thickening, or both
Endocarditis prophylaxis is not recommended for the following:
• Atrial septal defect
• Surgically repaired ventricular septal defect
• Patent ductus arteriosus
• Isolated mitral valve prolapse
• Mild tricuspid regurgitation
• Previous rheumatic fever or Kawasaki disease without valvular dysfunction
• Cardiac pacemaker
• Implantable defibrillator
The following antimicrobial regimen is suggested for prophylaxis:
• Dental, oral, or upper respiratory tract procedures - Amoxicillin 2 g PO 1 hour prior to
the procedure; if allergic to penicillin, alternatives include clindamycin 600 mg PO,
cephalexin 2 g PO, or azithromycin 500 mg PO 1 hour prior to the procedure
• Genitourinary or gastrointestinal procedures - Ampicillin 2 g IV and gentamicin 1.5
mg/kg 30 min prior to procedure, followed by amoxicillin 1 g PO/IV/IM 8 hours later;
 if allergic to penicillin, alternatives include vancomycin 1 g IV and gentamicin 1.5
mg/kg 1-2 hours prior to the procedure
Previous

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Contributor Information and Disclosures
Author
Davinder Jassal, MD, FACC, FRCPC Clinical and Research Cardiac Echocardiography
Fellow, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School

Davinder Jassal, MD, FACC, FRCPC is a member of the following medical societies:
American College of Cardiology, American College of Physicians-American Society of
Internal Medicine, American Heart Association, and Canadian Medical Association
Disclosure: Nothing to disclose.
Coauthor(s)
Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine,
Department of Internal Medicine, University of Manitoba; Site Director, Respiratory
Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American
Academy of Sleep Medicine, American College of Chest Physicians, American College of
Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian
Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of
Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.
Specialty Editor Board
George A Stouffer III, MD Henry A Foscue Distinguished Professor of Medicine and
Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief
of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center
George A Stouffer III, MD is a member of the following medical societies: Alpha Omega
Alpha, American College of Cardiology, American College of Physicians, American Heart
Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska
Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: eMedicine Salary Employment
Donna Leco Mercado, MD Director of Medical Consultation, Department of Internal
Medicine, Baystate Medical Center; Assistant Professor, Tufts University School of Medicine

Donna Leco Mercado, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.
Amer Suleman, MD Private Practice
Amer Suleman, MD is a member of the following medical societies: American College of
Physicians, American Heart Association, American Institute of Stress, American Society of
Hypertension, Federation of American Societies for Experimental Biology, Royal Society of
Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.
Chief Editor
William A Schwer, MD Professor, Department of Family Medicine, Rush Medical College;
Chairman, Department of Family Medicine, Rush-Presbyterian-St Luke's Medical Center
William A Schwer, MD is a member of the following medical societies: American Academy
of Family Physicians
Disclosure: Nothing to disclose.
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References
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patients undergoing non-cardiac surgery. J Gen Intern Med. 1(4):211-9. [Medline].
2. Shah KB, Kleinman BS, Rao TL, et al. Angina and other risk factors in patients with
cardiac diseases undergoing noncardiac operations. Anesth Analg. 70(3):240-7.
[Medline].
3. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and
cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative
Ischemia Research Group. N Engl J Med. 335(23):1713-20. [Medline].
4. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative
mortality and myocardial infarction in high-risk patients undergoing vascular surgery.
Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography
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5. Devereaux PJ, Xavier D, Pogue J, Guyatt G, Sigamani A, Garutti I, et al.
Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in
Patients Undergoing Noncardiac Surgery: A Cohort Study. Ann Intern Med. Apr 19
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Image 1 of 4
Perioperative cardiac management. Algorithm for preoperative cardiac assessment.
Perioperative cardiac management. The transthoracic echocardiogram illustrates a parasternal
long axis view of the left ventricle with preserved cardiac function.
Perioperative cardiac management. The sestamibi perfusion scan illustrates reversible
ischemia in the anterior wall of the myocardium, comparing rest and stress images.
Perioperative cardiac management. Coronary angiogram revealing severe left circumflex and
left anterior descending disease.
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Perioperative Cardiac Management

18 May 2011... to those established by the ACC/AHA guidelines for CABG, .... Practice
Advisory for the Perioperative Management of Patients with ...
emedicine.medscape.com/article/285328-overview - Cached - Similar

Overview of the postoperative management

of patients undergoing cardiac surgery
AuthorFrank E Section EditorsScott Manaker, MD, Deputy EditorKevin C
Silvestry, MD PhDTalmadge E King, Jr, MD Wilson, MD
As a subscriber you will have access to the full contents of this article
• INTRODUCTION
• MONITORING
• CARDIAC DYSFUNCTION
• Mechanical complications
• Inadequate preload
• Excessive afterload
• Dysrhythmias
• - Atrial fibrillation
• - Ventricular arrhythmias
• - Bradyarrhythmias
• Poor inotropy
• Myocardial infarction
• Pulmonary hypertension
• Management
• - Pharmacologic
• - Mechanical
• VASODILATORY SHOCK
• HEMATOLOGIC DYSFUNCTION
 • Bleeding
• Thrombosis
• PULMONARY DYSFUNCTION
• NEUROLOGIC DYSFUNCTION
• RENAL DYSFUNCTION
• DIABETES
• REFERENCES

GRAPHICS
• FIGURES
• Cerebral outcomes after CABG
• TABLES
• Physiologic values in postop
• Inotropic agents in postop
• Postcardiac surgery pl effusion
INTRODUCTION
The use of cardiopulmonary bypass distinguishes conventional cardiac surgery from other
types of surgery. Blood contact with the synthetic surfaces of bypass equipment results in a
generalized inflammatory response, altered platelet-endothelial cell interactions, and
vasospasm, which may in combination produce low flow states in the microcirculation of the
heart, brain, or other organs. Transient left ventricular dysfunction and myocardial infarction,
as well as disruption of normal physiology in a number of organ systems, may ensue [1,2].
Early postoperative complications may result from preexisting comorbidities or as
consequences of cardiac surgery and cardiopulmonary bypass. In addition to mechanical
injuries due to surgery, postoperative organ dysfunction may occur secondary to other
processes, such as:
• Transient left ventricular dysfunction
• Increased capillary permeability
• Hypothermia and rewarming
• Mediastinal bleeding and infection
• Emergence from anesthesia
The immediate postoperative management of patients following cardiac surgery will be
presented here. Issues related to preoperative pulmonary assessment and potential
complications of coronary artery bypass grafting (CABG) are discussed separately. (See
"Evaluation of preoperative pulmonary risk" and "Medical therapy to prevent perioperative
complications after coronary artery bypass graft surgery" and "Early noncardiac
complications of coronary artery bypass graft surgery".)
MONITORING
Routine postoperative monitoring typically includes continuous telemetry, measurement of
arterial blood pressure via an arterial catheter, measurement of cardiac filling pressures via a
flow-directed pulmonary artery catheter, and continuous assessment of arterial and mixed
venous oxygen saturation (typically via pulse oximetry and an oximetric pulmonary artery
catheter). This allows instantaneous, moment to moment monitoring of cardiopulmonary
physiology. The table gives the range of expected physiologic values in the postoperative
patient (table 1).

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Last literature review version 19.1: January 2011
This topic last updated: September 22, 2010
Overview of the postoperative management of patients undergoing ...
22 Sep 2010 ... The immediate postoperative management of patients following cardiac ... of
coronary artery bypass grafting (CABG) are discussed separately. ...
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CARDIAC Student Nurse Resources - Cardiac
GENERAL INFO
NURSING

ASSESSMENT TITLE: Bypass, Cardiopulmonary: Post-

Operative Care (Initial 24 Hours) (Adult
Patient)
PATIENT CARE
PURPOSE: To outline the nursing
management of the adult patient who has
DISORDERS undergone surgery requiring
cardiopulmonary bypass.
Aortic Aneurysms
LEVEL: Interdependent (*requires MD
Aortic Dissections
order)
Arrhythmia
Cardiomyopathy SUPPORTIVE DATA: Many patients
Congenital Heart experiencing cardiac and thoracic surgery
Disease require cardiopulmonary bypass (CPB).
Congestive Heart CPB is used to facilitate tissue oxygenation
Failure during surgical procedures, such as
coronary artery bypass grafting, cardiac
Coronary Artery
valve replacement or repair, thoracic
Disease aortic aneurysm repair, and heart or
Endocarditis heart/lung transplantation. CPB and its
Long QT Syndrome concomitant therapies of hemodilution,
Myocardial Ischemia hypothermia, anticoagulation, and
Myocarditis cardioplegia can result in dramatic fluid
Pericarditis and electrolyte imbalances, catecholamine
storm, and hemorrhage. Immediate
Valvular Disease
postoperative nursing care focuses on
recovering the patient from the effects of
CPB and anesthesia.

ASSESSMENT:
1. Assess upon arrival to the CT-ICU:
•blood pressure
•heart rate and rhythm
•O2 saturation by pulse oximeter (SpO2)
•temperature
•pulses in all 4 extremities
•respiratory rate
•pain level
•CVP, PA pressures, CO, CI, SVR
•SvO2 (if oximetric PA catheter used) or
ScO2 (if continuous cardiac output
catheter used)
•vasoactive/inotropic drip concentrations
•urine output
•chest tube output
• JP output
•epicardial pacing wires/generator settings
NOTE: Provide care according to Nursing
Protocol Pacing, Epicardial: Wires &
Pacemaker (Post-op) [Adult] Protocol.
•surgical dressings
2. Assess on post-op admission, every 15
minutes x 4, every 30 minutes x 2, then
every 1 hour and prn while titrating
vasoactive and inotropic medications:
•blood pressure
•heart rate
•heart rhythm
•respiratory rate
•oxygen saturation
3. Assess every hour while titrating
vasoactive and inotropic medication, then
every 4 hours and p.r.n.:
•CVP, PA pressures, CO/CI, SVR
•SvO2 (if oximetric PA catheter used), or
ScO2 (if continuous cardiac output
catheter used)

4. Assess every hour, then change to

every 2 hours and prn when patient is
without pharmacological or mechanical
ventilatory support:
•respiratory rate
•heart rate and rhythm
•blood pressure
•temperature
•O2 saturation by pulse oximeter
•urine output
ASSESSMENT: •chest tube drainage
•mediastinal tube drainage
•JP drainage
• Pain score (either verbal or NAPS)
*5. Draw mixed venous gas on admission,
every 24 hrs, and p.r.n. for calibration if
oximetric PA catheter in place.
LABS/DIAGNOSTIC
STUDIES:
*6. Obtain within 30 minutes of
admission:
•ABG with ionized calcium
•SvO2 (measured by Blood Gas Lab),
oximetric PA catheter only
•Na, K, Cl, BUN, Cr, CO2, glucose,
magnesium, phosporus
•CBC
•PT/PTT/INR for chest tube output
>200mL/hr
•chest X-ray
•12 lead ECG
*7. Obtain 6 hours after admission:
• Na, K, Cl, BUN, Cr, CO2, glucose,
magnesium, phosporus
•CBC
*8. Obtain on post-op Day 1:
•Na, K, Cl, BUN, Cr, CO2, glucose
•CBC
•PT, INR, PTT if patient had valve
replacement
•chest x-ray every morning until chest
tubes are removed
REPORTABLE CONDITIONS/ NOTIFY M.D.:
9. Notify M.D. of the following
hemodynamic parameters:
•cardiac index <2 L/min/m2
•MAP <60 or >90 mmHg.
•SBP >140 mmHg of < 90mmHg.
•SvO2 <60%
10. Notify M.D. of:
•cardiac dysrhythmias
•changes in sensorium
•temperature =35° or >38.5° C
•urine output <30mL/hr x 2 hours (since
last void or foley removed)
•chest tube & JP drainage >100 mL/hr. x
2 hours
11. Notify M.D. of laboratory values when:
•hematocrit <28%
•PaO2 <70 mmHg
•SaO2 = 90%
•PaCO2 <30 or >50 mmHg.
•pH <7.35 or >7.5
•ionized Ca++ <4.5 mEq/L
REPORTABLE CONDITIONS/ NOTIFY M.D.
12. Notify M.D. STAT of signs of cardiac
tamponade as evidenced by:
•cardiac index <2 L/min/m2
•heart rate >130 bpm
•muffled/distant heart tones
•pulsus paradoxus >15mm Hg during
inspiration
•elevated PAD >20 mmHg, CVP >20
mmHg.
•narrowing pulse pressure--systolic blood
pressure <90mm Hg with diastolic blood
pressure >70 mmHg
•distended neck veins
•SvO2 < 60 % or changed by 10%
CARE:
13. Receive report from OR
Anesthesiology staff to include:
•vital signs including most recent
temperature
•location of lines and drains
•PA pressures
•history (to include all abnormal physical
findings)
•allergies
•surgical procedures
•duration of cardiopulmonary bypass and
aortic cross clamp
•hemodynamic profile in OR, current
vasoactive/inotropic drips
•crystalloid/colloid infusion totals
•urine output in OR
•most recent potassium, magnesium and
glucose
•most recent hemoglobin
•anesthetic agents/ volume administrated
•pre-op baseline data
•last antibiotic dose
*14. Institute ventilator weaning protocol
when patient is awake and initiating
own breaths.
*15. Apply warming blanket for core
temperature <36°C.
NOTE: Provide care according to UNC
Hospitals Nursing Procedure Warming
Blanket: Warm Touch® or Warming
Blanket: Bair Hugger® and remove
blanket when patient’s temperature
reaches 36.5° C.
16. Observe airstrips for drainage every
shift.
17. Turn every 2 hours. Head of bed 30-
40 degrees unless medically
contraindicated.

EMERGENCY MEASURES:
18. CARDIAC TAMPONADE, HEMORRHAGE
(MEDIASTINAL DRAINAGE > 200mL/HR x
1 hrs)
•STAT page M.D.
•prepare for emergency sternotomy/
return to O.R.
19. SYMPTOMATIC DYSRHYTHMIAS:
•STAT page M.D.
•Provide care according to Guidelines for
Handling Specific Emergency Situations
located in Critical Care Policy manual
online.
PATIENT/CAREGIVER
TEACHING:
20. Orient to purpose of monitoring and
supportive equipment and devices.
21. Review visitation policies and unit
routine for patient/ caregiver.
22. Evaluate family/caregiver’s knowledge
 and level of understanding of instructions.
DOCUMENTATION:
23. Document on Progress Notes, Patient
Care Record/flowsheet, Patient Education
Index or electronic record:
•implementation of Post-Operative Care
(Initial 24 hours) of the Adult Patient
Requiring Cardiopulmonary Bypass
protocol
•implementation of Oral Care for
Ventilated and Cardiac Surgery Patients
(Adult) protocol.
•implementation of Epicardial Pacing
protocol (if pacing wires in place).
•assessment findings
•interventions and patient
responses/outcomes
•reported conditions
•patient/caregiver teaching and level of
understanding

REFERENCES: Bojar RM. (1999). Manual

of perioperative care in cardiac surgery.
Malden, Massachusetts: Blackwell
Publishing.
Finkelmeier BA. (2000). Cardiothoracic
surgical nursing. Philadelphia,
Pennsylvannia: Lippincott Company.
Margereson, C. & Riley, J. (2003).
Cardiothoracic surgical nursing: Current
trends in adult care. Malden,
Massachusetts: Blackwell Publishing.
APPROVAL: Standards Committee DATE:
08/06/91
REVISED: DATE: 12/12/94
02/17/98
02/20/01
04/13/04
04/09/07
Distribution: Critical Care Service

SNJourney - CABG Care Plan

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Your doctor will help you determine the schedule for resuming normal activities
but general post-operative care routine guidelines include:

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• If you develop problems such as difficulty breathing, or a swollen and

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• Strictly avoid lifting, pulling or pushing heavy objects for at least six to
eight weeks following your surgery.

• Eat a wide variety of fresh fruit and vegetables, wholegrain cereals and
cold-water fish (such as salmon, tuna, sardines, mackerel, swordfish and
sea mullet) while avoid consuming saturated fats such as those found in
animal products and dairy foods.

• All activities that do not cause fatigue are permitted. You must follow
your surgeon`s advise on exercise and physical fitness.

• You may resume sexual activities 4 weeks after surgery.

• Quit smoking.

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