Cardiac Complications

1
Cardiac Complications

• Lynn McGugan Clark ACNP
• Duke University

2
Tamponade

• Heart too large for pericardial space
• Apparent immediately after chest closure
• Related to edema
• Fluid accumulation
• Pericardium or anterior mediastinum
• Undrained blood and clots
• Correcting coagulopathy -gt pericardial clot
• Chest tubes unable to drain

3

• Delayed
• Occurs up to several weeks after operation
• May occur after pacing wire or LA catheter
  removal
• More common in anticoagulated patients
• Not associated with postpericardiotomy syndrome
• May be caused by chylopericardium
• Not prevented by prolonged drainage of
  pericardial space

4
Signs and Symptoms

• Widened mediastinal silhouette
• Rapid increase in right and left atrial pressures
• Narrow pulse pressure
• Increased diastolic pressure an attempt to
  compensate for decreased CO by sending blood back
  to the heart
• Decreased CO
• Tachycardia

5

• Electrical alternans
• Pulsus paradoxus
• Drop in BP on inspiration by at least 10 mmHg
• Becks triad
• Hypotension r/t decreased CO
• Muffled heart sounds r/t insulating fluid
• JVD r/t blood not flowing forward and
  accumulating in venous system

6
Diagnostic Tests

• Echocardiogram
• CXR
• Fluroscopy
• Hamid et al (2006) found only 20 of patients
  with tamponade met radiographic criteria for
  tamponade, while 100 of patients showed
  pericardial effusions on echo

7
Management

• Maintain perfusion give fluid and inotropes
• Reduce positive pressure ventilation
• Monitor for PEA

8
EMERGENT OPENING OF THE CHEST
9
VF Post Cardiac Surgery

• Best Evidence Topic
• 15 papers reviewed
• Chance of successful defibrillation
• 1st attempt 75-78
• 2nd attempt 35
• 3rd attempt 14

10

• Conclusions Three shocks should be quickly
  delivered. If these do not succeed the chance of
  a 4th shock succeeding is likely to be less than
  10 and immediate chest reopening should be
  performed.
• Richardson, L., Dissanayake, A. Dunning, J.
  (2007). What cardioversion protocol for
  ventricular fibrillation should be followed for
  patients who arrest shortly post-cardiac surgery?
  Interactive Cardiovascular and Thoracic Surgery,
  6(6), pp 799-805. Retrieved January 7, 2008 from
  http//www.ncbi.nlm.nih.gov/pubmed/17693437?ordina
  lpos1itoolEntrezSystem2.PEntrez.Pubmed.Pubmed_R
  esultsPanel.Pubmed_RVDocSum

11
Which Patients Benefit?

• 6-year prospective study of post-op adult cardiac
  surgery patients (not in OR or for reasons other
  than cardiac arrest)
• Evaluated location of arrest, type of arrest,
  specialty, time since surgery, time to chest
  reopening, location of chest opening, surgical
  findings upon reopening, time to CPB if used, and
  outcomes
• Results 25 survival to discharge

12
Favorable determinants of outcome

• Arrest within 24 hours of surgery
• 38 survived compared with 13 of those greater
  than 24h post surgery
• Reopening within 10 minutes of arrest
• 48 survived compared to 12 when longer than 10
  minutes to reopening
• Arrest in intensive care unit (ICU)
• 33 survived to discharge compared with 5 of
  those who arrested outside the ICU
• All patients who were reopened outside the ICU
  died
• Mackay, J. H., Powell, S. J., Osgathorp, J.
  Rozario, C. J. (2002). Six year prospective
  audit of chest reopening after cardiac arrest.
  European Journal of Cardiothoracic Surgery,
  22(3), pp. 421-425.

13
Indications

• 5 of post cardiac surgery patients
• Indications
• Bleeding
• Cardiac arrest
• Clinical suspicion of Tamponade
• Hemodynamic instability
• Disadvantages No positive pressure ventilation
  systems, laminar air flow or restricted personnel
  entry

14
Patient Population

• Older (p0.02)
• Procedure other than CABG (plt0.001)
• Urgent/emergent initial operation (p0.007)
• Reoperation (p0.05)
• Chronic renal insufficiency (pgt0.0001)
• Longer CPB and aortic cross clamp time
• ? Pre-op ASA and prolonged bleeding times
• Pre-op myocardial infarction

15
Preparation

• Decision made by surgeon/senior resident
• Sterile attire and field
• Drapes
• Caps, gowns, masks
• Prepped with betadine
• Hallway partitioned off
• OR nurse if available
• Light source
• Set up and get blood products to bedside
• Sterile suction tubing and catheters

16
Procedure

• Incision made beside staples/suture line
• Wires cut and removed
• Soft tissues and sternal edges inspected
• Clots evacuated
• Inspect all operative sites
• Sutures, clips, thrombostatic material applied to
  bleeding sites

17

• Drainage tubes cleared of blood and clots
• Internal cardiac massage if needed
• Chest closed or packed and left open
• Open chest antibiotics
• Vancomycin, pip-tazo, fluconazole

18
Outcomes

• Median amount of blood removed 1L
• Chest bleeding found in greater than 90
• Focal bleeding greater than 55
• Diffuse ooze approximately 33
• Initiation of CPB possible
• 48 of patients with cardiac arrest responded to
  open chest CPR (Anthi et al. 1998) and survived
  to discharge
• Survival approximately 50

19
Complications

• Sternal wound infection
• Increased mortality
• Renal failure
• Respiratory failure
• ARDS
• Sepsis
• Atrial arrhythmias
• Stroke
• Chest infection
• Longer ICU and hospital LOS

20
References

• Anthi, A., Tzelepis, G. E., Alivizatos, P.,
  Michalis, A., Palatianos, G. M., Geroulanos, S.
  (1998). Unexpected cardiac arrest after cardiac
  surgery incidence, predisposing causes, and
  outcome of open chest cardiopulmonary
  resuscitation. Chest, 113(1), pp. 15-19.
• Charalambous, C. P., Zipitis, C. S. Keenan, D.
  J. (2006). Chest reexploration in the intensive
  care unit after cardiac surgery a safe
  alternative to returning to the operating
  theatre. Annals of Thoracic Surgery, 81(1), pp.
  191-4.
• Dulak, S. B. (2005). Hands-on help. Cardiac
  tamponade. RN, 68(4), pp 32ac1-4.
• Hamid, M., Khan, M. U. Bashour, A. C. (2006).
  Diagnostic value of chest X-ray and
  echocardiography for cardiac tamponade in post
  cardiac surgery patients. Journal of the Pakistan
  Medical Association, 56(3), pp. 104-107.
• Lewis, A. M. (1999). Cardiovascular emergency!
  Nursing, 29(6), pp. 49-51.
• Moulton, M. J., Creswell, L. L., Mackey, M. E.,
  Cox, J. L. Rosenbloom, M. (1996).
  Reexploration for bleeding is a risk factor for
  adverse outcomes after cardiac operations.
  Journal of Thoracic and Cardiovasc Surgery, 111,
  pp. 10371046.
• Mackay, J. H., Powell, S. J., Osgathorp, J.
  Rozario, C. J. (2002). Six year prospective
  audit of chest reopening after cardiac arrest.
  European Journal of Cardiothoracic Surgery,
  22(3), pp. 421-425.
• Richardson, L., Dissanayake, A. Dunning, J.
  (2007). What cardioversion protocol for
  ventricular fibrillation should be followed for
  patients who arrest shortly post-cardiac surgery?
  Interactive Cardiovascular and Thoracic Surgery,
  6(6), pp 799-805. Retrieved January 7, 2008 from
  http//www.ncbi.nlm.nih.gov/pubmed/17693437?ordina
  lpos1itoolEntrezSystem2.PEntrez.Pubmed.Pubmed_R
  esultsPanel.Pubmed_RVDocSum
• Wahba, A., Gotz, W. Birnbaum, D. E. (1997).
  Outcome of cardiopulmonary resuscitation
  following open heart surgery. Scandinavian
  Cardiovascular Journal, 31(3), pp. 147-149.