REDUCING MORTALITY AND MORBIDITY IN CARDIAC SURGICAL PRACTICE

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REDUCING MORTALITY AND MORBIDITY IN CARDIAC
SURGICAL PRACTICE STANDARDIZED BEST PRACTICES
SUMMARY OF RECOMMENDATIONS
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STANDARDIZED BEST PRACTICES CARDIAC SURGERY

• Prevention Stroke
• Prevention Renal Failure/Insufficiency
• Transfusion Practice
• Prompt Extubation Protocol
• Prevention/Treatment of LV failure
• Perioperative Atrial Fibrillation
• Perioperative Glucose Control
• Cardiac Surgical Practice
• Cardiothoracic Intensive Care Operation and
  Administration

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STANDARDIZED BEST PRACTICESOPTIMIZING
NEUROLOGICAL OUTCOMES

• Risk Stratification
• Perfusion Practices
• CNS Monitoring
• Atheroma Management
• Pharmacological Neuroprotection
• Glucose Management

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ALGORITHM FOR NEUROLOGICAL RISK REDUCTION
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RECOMMENDATIONS FOR NEUROLOGICAL RISK REDUCTION

• Routine use of carotid imaging in high risk
  patients
• Routine use of full dose aprotinin
• Routine use of intraoperative TEE and Epiaortic
  Scanning
• Algorithm directed strategy for management
  atherosclerotic aorta
• Selective use of OPCAB in high risk patient
• Routine use of diffusion tip arterial cannula
• For open procedures use of CO2 on the field
• Avoidance of aortic cross clamp
• High Flow-high pressure cardiopulmonary bypass
• Hct on CPB gt 25lt30
• Alpha Stat pH management
• Avoid reinfusion of unprocessed cardiotomy blood
• Maintenance of normal perioperative blood
  pressure
• Avoidance of introperative and post operative
  hyperthermia
• Maintenance of Blood glucose lt 150
• Prompt treatment of perioperative arrhythmias

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STANDARDIZED BEST PRACTICESOPTIMIZING RENAL
OUTCOMES

• Risk Stratification
• Perfusion Practice
• Pharmacologic Renal Preservation
• Perioperative Treatment of Renal Failure

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RECOMMENDATIONS FOR PATIENTS AT RISK FOR
PERIOPERATIVE RENAL FAILURE

• Avoidance of nephrotoxic drugs in the
  perioperative period (aminoglycosides, toradol,
  etc)
• Consideration for OPCAB in patients with severe
  atherosclerosis of aorta
• Avoidance of prolonged CPB
• No evidence for the use of low dose dopamine as a
  renoprotective agent
• Avoidance of inotropes with alpha effects (high
  dose dopamine, norepinephrine)
• Avoidance of acidosis
• Use of nesiritide in patients with low cardiac
  output and /or renal insufficiency
• Early treatment of LCOS by goal directed protocol

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STANDARDIZED BEST PRACTICESTRANSFUSION PRACTICE

• Transfusion Practice
• POC Testing
• Heparin/Protamine Administration
• Pharmacologic Interventions
• Antifibrinolytics
• DDAVP
• Algorithm based Transfusion Practice
• Approach to Patients on GP IIb/IIIa agents

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RECOMMENDATIONS FOR ALLOGENIC RBC TRANSFUSION IN
CARDIAC SURGERY

• Preoperative Treatment of Anemia in Stable
  Cardiac Surgical Patients with HCTlt35
• EPO
• Iron
• Lowest HCT on CPB
• HCT gt 22 men
• HCT gt 25 women
• Postoperatively in Patients with LV dysfunction,
  Acute MI ,High Risk CVA or who exhibit
  hemodynamic instability
• HCT gt 30
• HCT gt 33 not justified and may increase mortality
• Postoperatively in low risk patients without MI
• HCT gt 25 lt 30
• Directed Efforts to minimize operative blood loss
  

Preautologous donation of PRBC has been found not
to be cost effective or reduce the incidence of
RBC Transfusions in cardiac surgery
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BLOOD CONSERVATION MULTIMODALITY ALGORITHM FOR
CARDIAC SURGERY PREOPERATIVE
INTRAOPERATIVE
POSTOPERATIVE Yes EPO
YES Aprotinin Minimize Cyrstal Inf No
reinfusion CT Blood Pump Prime lt
1000 Transfusion Algorithm
Heparin
RAP Transfusion
Trigger ASAlt 5days
Ultrafiltration
1. HRP Hct gt 30lt34 HCT lt 35
GP IIB/ IIIa Cell Saver
Use 2. LRP Hct gt24
Stroke Risk
Optimal Surgical
BP Control Age gt 65
Techn/Hemostasis PEEP lt 10

Adeq Rewarming DDAVP CRF
No No Amicar HCTgt25
on CPB Minimize Labs
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RECOMMENDATIONS FOR PATIENT MANAGEMENT

• Heparin 4mg/kg or ACT gt 480 on CPB
• Quantitative Heparin Monitoring (HMS, Hepcon)
• Avoid excessive use Protamine
• Heparin bonded circuits high risk patients
• Avoidance of infusion of large volume crystalloid
  intraoperatively
• Use of Low pump primes
• Routine use of albumen in pump prime
• Use of centrifugal pump
• HCT above 25 for women 22 for men on CPB
• Moderate hypothermia
• Avoid reinfusion of unprocessed cardiotomy blood
• Full dose aprotinin on High risk patients/Redo
  and Valves
• All other patients amicar
• Routine use Hemofiltration
• Routine use of Goal Directed Transfusion
  Algorithm

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SIMPLIFIED INTRAOPERATIVE TRANSFUSION ALGORITHM
Celite TEG w/wout Heparinase
Platelet Count
Fibrinogen
Plt Count lt 100K MA lt 45 mm
TEG Rgt2X hTEG R
hTEG R gt20 mm
TEG LY30gt7.5
Fib lt 140mg/dl
Protamine
Platelets
FFP
EACA
CRYO
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GUIDELINES FOR THE USE OF PLATELET INHIBITORS IN
CARDIAC SURGERYGENERAL RECOMMENDATIONS

• Preoperative aspirin use is associated with
  reduced mortality and does not increased post
  operative bleeding
• GP IIB/IIIA inhibitors/ASA provides significant
  reduction in acute ischemic events relative to
  conventional treatment in both patients
  undergoing PCI and in those with ACS
• Emergency CABG in patients receiving abciximab
  and clopidogrel is associated with increased risk
  of hemorrhage
• Emergency CABG in patients receiving tirofiban
  and eptifibatide is not associated with increased
  risk of hemmorrhage

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RECOMMENDED STRATEGIES FOR MANAGEMENT OF POST
OPERATIVE BLEEDING IN PATIENTS ON ABCIXIMAB

• Delay surgery gt 12 hours since last dose in the
  urgent but stable patient
• In high risk PCI patients do not use abciximab
• Delay in surgical intervention balanced against
  severity and instability of CAD
• Ensure adequate heparinization
• Full heparin dose 3 mg/kg
• Titrate heparin to ACT gt 480 or Heparin
  concentration gt 2.7 U/cc
• Full dose Aprotinin
• Hemoconcentrator (50kD) to eliminate abciximab
  during CPB
• Post CPB platelet transfusion based on algorithm

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RECOMMENDED STRATEGIES FOR MANAGEMENT OF POST
OPERATIVE BLEEDING IN PATIENTS ON CLOPIDOGREL

• Delay surgery gt 5 days in stable patients
• Do not pre-load with clopidogrel before high risk
  PCI
• PFA to assess platelet function lt 5 days
• Ensure adequate heparinization
• Full heparin dose 3 mg/kg
• Titrate heparin to ACT gt 480 or Heparin
  concentration gt 2.7 U/cc
• Full dose Aprotinin
• Hemoconcentrator to eliminate clopidogrel during
  CPB
• Post CPB platelet transfusion based on algorithm

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RECOMMENDED STRATEGIES FOR MANAGEMENT OF POST
OPERATIVE BLEEDING IN PATIENTS ON TIROFIBAN and
EPTIFIBATIDE

• No delay in emergent/urgent CABG necessary
• Preferred agents for patients likely to need CABG
  due to short half life
• Ensure adequate heparinization
• Full heparin dose 3 mg/kg
• Titrate heparin to ACT gt 480 or Heparin
  concentration gt 2.7 U/cc
• Full dose Aprotinin
• Post CPB platelet transfusion based on algorithm

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STANDARDIZED BEST PRACTICESPROMPT EXTUBATION
PROTOCOL

• Risk Stratification
• Anesthetic Technique
• ICU Sedation
• ICU Pain Management
• Ventilator Management Protocol

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CRITERIA FOR WEANING AND EARLY EXTUBATION
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Wean to CPAP Over 30 minutes Check ABG
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RECOMMENDATIONS FOR FAST TRACK EXTUBATION AND ICU
SEDATION

• Appropriate selection of patients for FTCA
• Use of low dose narcotic anesthesia
• Fentanyl lt 10 mcg/kg or sufenta lt 2 mcg/kg
• Midazolam lt 5 mg
• Background inhalational agents
• Use of simplified mechanical ventilation protocol
• Use of dexmedetomidine on patients for FTCA
• Use of propofol for non FTCA patients (gt24 hrs
  intubation)
• Multimodal approach to post operative pain
  management
• Narcotics
• Acetaminophen
• NSAIDS
• Dexmedetomidine

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STANDARDIZED BEST PRACTICES MANGEMENT OF
PERIOPERATIVE LV DYSFUNCTION

• Risk Stratification
• Monitoring
• Goal Directed Hemodynamic Management
• Pharmacologic Support
• Surgical Approach
• IABP
• Assist Devices

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MANAGEMENT OF POST OPERATIVE LV
DYSFUNCTION
GENERAL PRINCIPLES
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GENERAL GUIDELINES FOR HEMODYNAMIC MANAGEMENT
No Inotropes Indicated Unless C.I. lt 2.2 PAWP gt
18 MAP lt 50 And/or Signs of Inadequate Tissue
Perfusion SV02 lt 70 Lactate gt 3 Base Deficit gt
-3.0 UO lt 50 cc/hr
Hx CHF And/Or Renal Dysfunction Preop Serum
Creatinine gt 1.4
NISERITIDE
YES
NO
NORMAL PVR/SVR Hx CHF/ Beta Blockers
Low SVR
Increased PVR
hyperventilation
Dopamine Epinephrine Norepinephrine
YES
NO
RV Failure
No RV Failure
Pulmonary Vasodilators NTG/SNP Milrinone Niseritid
e Alprostadol NO
Dobutamine Milrinone Pulmonary Vasodilators
Milrinone Epinephrine
Dobutamine Dopamine Milrinone Epinephrine
Vasodilatory Shock NL CI Low SVR
NL SVR Low C.I.
IABP
Milrinone
PA BCP RVAD
AVP
VAD
IABP
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RECOMMENDATIONS FOR MANAGEMENT OF PERIOPERATIVE
LV DYSFUNCTIONHEMODYNAMIC MANAGEMENT

• Risk Stratification
• Monitoring CVP Low Risk Patients
• Monitoring PA CCO/Sv02 and TEE High Risk Patients
• Prophylactic IABP High Risk Patients
• Consideration For OPCAB
• Limit CPB time (lt180 minutes)
• Combination Beta agonist/PDI
• Nesiritide for patients with low EF and renal
  insufficiency (Creat gt 1.4)
• Goal Directed Hemodynamic Management

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STANDARDIZED BEST PRACTICESPERIOPERATIVE ATRIAL
FIBRILLATION

• Risk Factors
• Antiarrhythmia Treatment
• Perioperative Beta Blockade

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GENERAL ALGORITHM FOR MANAGEMENT OF POSTOPERATIVE
ATRIAL FIBRILLATION
NL EF
LOW EF
AMIODARONE
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UCSF PERIOPERATIVE BETA BLOCKADE PROTOCOL
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Recommendations

• Postoperative AF should be aggressively treated.
• Prophylactic beta blockade reduces postoperative
  AF by more than 75 and should be administered
  in all patients without contraindications
• Amiodarone as prophylactic agent should be
  considered in the preoperative setting in high
  risk patients
• Unstable AF patients should be promptly
  cardioverted.
• Ibutilide should be used in patients who need
  repeat cardio versions
• Amiodarone should be used in all low EF patients
  in postoperative AF
• All postoperative patients in AF for more than 48
  hours should be anticoagulated.
• High risk patients in AF for more than 24 hours
  should be anticoagulated.

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PERIOPERATIVE GLYCEMIC CONTROL

• Intraoperative Glucose Management
• ICU Glucose Management

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RECOMMENDATIONS FOR GYCLEMIC CONTROL

• Intraoperative management with insulin infusions
  to maintain blood glucose lt 150
• ICU management by current established protocol

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STANDARDIZED BEST PRACTICESCARDIAC SURGICAL
PRACTICE

• Timing of surgery after acute MI
• CABG in the emergent situation
• CABG in LVA
• CABG in post MI VSD
• CABG in post MI rupture
• Surgical approaches to mitral valve disease
• Degenerative
• Ischemic
• rheumatic
• Considerations For AVR and Treatment of the
  Dilated Ascending Aorta
• Valve Considerations For Endocarditis
• Perioperative Strategy For The High Risk patient

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Emergency CABG

• Cardiogenic shock complicates 7-10 of MIs and
  is associated with a 70-80 mortality
• Leading cause of death in pts. with AMI
• CABG has extremely high and protracted
  periprocedural risk

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RECOMMENDATIONS FOR EMERGENT CABG

• Unstable patients in the cardiac catheterization
  lab must be stabilized prior to transfer to
  surgery
• Intubation/ventilation
• IABP
• Perfusion catheters
• Pacemaker
• Cardiogenic drugs
• If patient does not respond but continues to
  deteriorate in spite of all supportive measures
  surgical risk is prohibitive
• Patients not candidates for surgery
• Questionable reversible ischemia
• Age gt 75 with multiple comorbidities
• CPR with pH lt 7.1
• No arterial pressure without IABP
• No or minimal wall motion on TEE