Pre-op Management
NSTEMI management
Heparin gtt
Double Product Control
ASA
Morphine
Oxygen
What STS stands for
Society of Thoracic Surgeons
Most common arrhythmia postoperatively and what postoperative days are most susceptible
Atrial Fibrillation
POD#2-3
5 sources of postoperative fever (>38.5)
Wind
Water
Walking
Wound
Wonder drugs
Platelet counts go (up / down / no change) postoperatively and why.
Platelet activation >> sticks to circuit
Damage and elimination by spleen
Hemodilution
Decrease in surface receptors: GP1B, GP2b-3a
Percentage of coronary vessel required for surgical bypass
70%
50% (LM)
Percent mortality for average CABG
1-2%
Type of Myocardial Infarction related to postoperative CABG
5
cTN >10× 99th percentile URL in the first 48 hours with either: (a) new pathological Q waves or new LBBB, or (b) angiographic occlusion, or (c) WMA
Describe sternal precautions
No lifting >10#
No raising objects over head
Keep elbows at the side of chest
Splint for cough/sneeze
Treatment of choice for postoperative Atrial Fibrillation and give appropriate doses
Beta-blocker
Amiodarone (gtt and oral load)
Typical Cardiac Surgery Workup (Hint: there's a lot!)
Chemistry: bmp/cbc/coags/lfts/tsh/hgba1c/ua/t&c
Imaging: TTE/TEE/carotids/cxr/ct chest
Extra: PFTs/dentalNumber of Variables that can be inputted on the STS Online Risk Calculator
68
70yoM with STEMI undergoes emergent CABG for dissection of LAD during stent where a LIMA was placed. Postop he is having numerous PVCs, ~20/min. HDS on norepinephrine. What is the medication of choice for ventricular arrhythmia.
Lidocaine gtt
Amiodarone gtt
Cardiac rehab duration and start date after cardiac surgery
Class I indication
8-12 weeks duration (twice / week)
4 weeks after surgery
Plavix usage before 5 days of washout leads to increased CABG mortality.
False
Device used for 80% LM stenosis in a patient with 35% EF and mild angina
IABP
Name 4 of the 9 calculations obtained from the Online Risk Calculator (i.e. Mortality %)
Risk of Mortality
Renal Failure
Permanent Stroke
Prolonged Ventilation
DSW Infection
Re-operation
Morbidity or Mortality
Short Length of Stay
Long Length of Stay
82yoM undergoes TAVR for Aortic Stenosis. Postoperatively, he is slow to arouse but coherent. Later that night his speech is slurred and left grip is weaker. What is the most common etiology, arterial distribution affected and how do you manage.
Embolic - valve, aorta, CPB, hypotension
M2
Code Stroke, CTH, CTA H/N, Neurointerventionalist. Supportive Care
You're seeing LTC Smith for his first visit after his 3vCABG ~3 weeks postop. What are the five main things you need to accomplish during your visit.
Review vitals
Medication update
CXR
Cardiac rehab
Encouragement/Show you care...
Three items mandatory for discharge after cardiac surgery for CABG (one more for EF<30%)
BB
ASA
STATIN
(ACE-i)
Medication held due to concern for postoperative vasoplegia
ACE-i
ARB
Name 5 variables that significantly increase risk for surgery
Age
LVEF
Prior Stroke
IDDM
CKD
64yoM undergoes aortic root replacement/hemiarch under DHCA. Postop, he is on Epi 2/NE 5/vaso 0.02. CT output for first 4 hours: 200/100/150/20. RN is on 4th bottle of 250ml 5% albumin. RN calls due to CI dropping to 1.5 despite increases in Epi, now at 8. CVP 20, PAP 35/25. What is the likely cause.
Tamponade
Postoperative Day that patients are walking around ICU after cardiac surgery
One!
CXR shows elevated R hemidiaphragm on CXR on the morning of POD#1. Wasn't noticed on immediate postoperative CXR when intubated in the ICU. What is the etiology of a finding.
1. Right phrenic injury during LIMA takedown
2. Right phrenic injury during creation of pericardial slit for LIMA
3. Freezing of nerve after topical slush applied to heart during CABG
All of the above are possible etiologies!