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: 512/ 863 7762; FAX: 512/ 863 0081 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. Preface The Peter Munk Cardiac Centre at Toronto General Hospital and Uni- versity of Toronto is the largest cardiac center in Canada. Over 2,500 pa- tients undergo open-heart operations each year. The cardiac surgical pro- gram has gained an international reputation for its academic productivity and attracts fellows and visitors from all parts of the world. The nineties were characterized by cost containment, accountability, and value-based health care. We have responded to these obligations and have been able to provide the highest quality of care at the lowest possible cost. Surgery on the same day of admission, early tracheal extubation, improved operative techniques, and earlier rehabilitation have reduced the median intensive care stay and hospital stay. In addition less than 10% of our patients are transferred to a convalescence center. This handbook describes the perioperative management of adult pa- tients who undergo cardiac surgery at our centre. Although it was written by numerous authors, each chapter was carefully edited to reflect the col- lective view of our health care team. The purpose of this handbook is to provide a succinct, problem oriented source of practical information on cardiac surgical patients based on the clinical and research experience of our fast track cardiac surgery program. It was written for physicians, nurses and other allied health care personnel who are involved in the manage- ment of patients undergoing open-heart surgery. Davy C.H. Cheng, MD Tirone E. David, MD Abbreviations 2,3-DPG 2,3-Diphosphoglyceraldehyde AAA Abdominal Aortic Aneurysm ABG Arterial Blood Gases ACB Aorto-Coronary Bypass ACE Angiotensin Converting Enzyme ACT Activated Clotting Time AF Atrial Fibrillation AI Aortic Insufficiency AICD Automatic Implantable Cardioverion Defibrillator APS Acute Physiology Score ARDS Adult Respiratory Distress Syndrome ASA Acetylsalicylic Acid ASD Atrial Septal Defect AT Anti-thrombin AV Atrio-ventricular BCPS Bi-directional Cavo-pulmonary Shunt BID Twice A Day BP Blood Pressure BUN Blood Urea Nitrogen CABG Coronary Artery Bypass Grafting CAD Coronary Artery Disease cAMP Cyclic Adenosine Monophosphate CAPD Continuous Abdominal Peritoneal Dialysis CAVHD Continuous Arterial-Venous Hemodialysis CBC Complete Blood Count CBF Cerebral Blood Flow cGMP Cyclic Guanine Monophosphate CHF Congestive Heart Failure CI Cardiac Index CK Creatine Kinase CK-MB Creatine Kinase Isoenzyme Fraction CNS Central Nervous System CO Cardiac Output COPD Chronic Obstructive Pulmonary Disease CPAP Continuous Positive Airway Pressure CPB Cardiopulmonary Bypass CSF Cerebral Spinal Fluid CT Computed Tomography CVA Cerebral Vascular Accident CVICU Cardiovascular Intensive Care Unit CVP Central Venous Pressure CVVHD Continuous Venous-Venous Hemodialysis CXR Chest X-Ray DFT Defibrillator Thresholds DLCO Diffusion Coefficient DVT Deep Vein Thrombosis ECG Electrocardiogram ECMO Extracorporeal Membrane Oxygenation EDP End Diastolic Pressure EEA Early Extubation Anesthesia EF Ejection Fraction ETVC Endotracheal Ventilation Catheter FEV Forced Expiratory Volume FFP Fresh Frozen Plasma HAT Heparin Associated Thrombocytopenia HATT Heparin Associated Thrombocytopenia Thrombosis Hb Hemoglobin HIPA Heparin Induced Platelet Activation HIT Heparin Induced Thrombocytopenia HOCM Hypertrophic Obstructive Cardiomyopathy HR Heart Rate HTN Hypertension IABP Intra-aortic Balloon Pump ICU Intensive Care Unit ID Infectious Disease IDDM Insulin Dependent Diabetes Mellitus IHSS Idiopathic Hypertrophic Subaortic Stenosis INR International Normalized Ratio ITA Internal Thoracic Artery IVC Inferior Vena Cava KIU Kallikrein Inhibitor Units LAP Left Arterial Pressure LBBB Left Bundle Branch Block LITA Left Internal Thoracic Artery LM Left Main LMWH Low Molecular Weight Heparin LOS Length of Stay LSVC Left Superior Vena Cava LVAD Left Ventricular Assist Device LVF Left Ventricular Function LVOT Left Ventricular Outflow Track MAO Monamine Oxidase MAP Mean Arterial Pressure MAPCA Major Aorto-Pulmonary Collateral Arteries MH Malignant Hyperthermia MI Myocardial Infarction MIDCAB Minimally Invasive Direct Coronary Artery Bypass MR Mitral Regurgitation MRI Magnetic Resonance Imaging MVV Maximal Voluntary Ventilation NG Nasogastric NIDDM Non-insulin Dependent Diabetes Mellitus NIF Negative Inspiratory Force NO Nitric Oxide NSAID Non-steroidal Antiinflammatory Drug NTG Nitroglycerin OLV One Lung Ventilation OR Operating Room PAP Pulmonary Artery Pressure PAPVD Partial Anomalous Pulmonary Venous Drainage PCA Patient Controlled Analgesia PCSU Post Cardiac Surgical Unit PCWP Pulmonary Capillary Wedge Pressure PDA Patent Ductus Arteriosis PE Pulmonary Embolism PEEP Positive End-Expiratory Pressure PGE Prostaglandin PI Pulmonary Insufficiency PLV Partial Left Ventriculectomy POD Postoperative Day PR Per Rectum PRBC Packed Red Blood Cell PS Pulmonary Stenosis PSV Pressure Support Ventilation PT Prothrombin Time PTCA Percutaneous Transluminal Coronary Angioplasty PTT Partial Thromboplastin Time PVC Premature Ventricular Contraction PVR Pulmonary Vascular Resistance Qp:Qs Pulmonary to Systemic Blood Flow Ratio RAP Right Arterial Pressure RATS Rabbit Anti-thymocyte Serum RBC Red Blood Cells RCA Right Coronary Artery RT Respiratory Therapist RVOT Right Ventricular Outflow Tract RVOTO Right Ventricular Outflow Tract Obstruction SAM Systolic Anterior Motion SAP Systemic Arterial Pressure SDA Same Day Admission SNP Sodium Nitroprusside TA Tranexamic Acid TCCCA Toronto Congenital Cardiac Centre for Adults TEE Transesophageal Echocardiography TEF Transesophagel Fistula TGA Transposition of Great Arteries TIA Transient Ischemic Attack TIF Tracheoinnominate Fistula TLC Total Lung Capacity TOF Tetralogy of Fallot TPN Total Parenteral Nutrition TR Tricuspid Regurgitation TGH Toronto General Hospital VC Vital Capacity VSD Ventricular Septal Defect WBC White Blood Cell Toronto General Hospital Cardiac Surgical Program 1 Toronto General Hospital 1 Cardiac Surgical Program Tirone E. David Toronto General Hospital cardiac surgical program was created in 1990 after the merger of the Toronto General and Toronto Western Hospitals. Since then, the number of open-heart procedures increased from approximately 2,000 to 2,700 per year. Nine heart surgeons perform these operations plus 500 pacemaker and defibrillator implantations each year. Our cardiac surgical program is a provincial and national referral center for cardiovascular diseases. In addition to a large number of cases of coronary artery and heart valve disease, we also treat numerous patients with complex and un- usual cardiovascular problems. This variety of cases offers an unique opportunity to learn and investigate new surgical approaches. This is an academic program but the primary emphasis is patient care. Educa- tion and research are important components of our mission but they come sec- ond to our responsibilities to our patients. A detailed database form containing numerous clinical, hemodynamic, opera- tive and postoperative variables is completed for every patient who undergoes heart surgery and is entered into a computer. This database is indispensable to monitor clinical outcomes, utilization trends, indirect costs, and individual surgeon’s performance. It is also used for clinical research. Patients’ satisfaction surveys are conducted twice yearly. Problems identified during these assessments of quality are discussed among caregivers and recommended changes are imple- mented and the outcome reassessed. From 1993 to 1997, 11,112 patients underwent cardiovascular operations with cardiopulmonary bypass. The overall operative mortality was 3.4%. Table 1.1 gives a summary of operations performed and the operative mortality rates. Postoperative complications are serious and expensive problems in cardiovas- cular surgery. Table 1.2 shows our complications rates from 1993 to 1997. Approximately 90% of our patients are discharged within 7 days from surgery. The remaining 10% utilize as much resource as approximately one-half of all others. We audited the problem of re-exploration for bleeding and the utilization of blood transfusion in our program. A multivariate logistic regression analysis iden- tified several variables (the surgeon was one of them) predictive of re-exploration for bleeding and of blood transfusion. In addition, re-exploration for bleeding Perioperative Care in Cardiac Anesthesia and Surgery, edited by Davy C.H. Cheng and Tirone E. David. © 1999 Landes Bioscience 2 Perioperative Care in Cardiac Anesthesia and Surgery Table 1.1. Operations performed from 1993-1997 1 Number Mean age Timing mortality (mean +/-S.D.) Urgent Emergent rate Coronary 7,371 62 ± 10 44% 3% 2.3% artery bypass Aortic valve surgery 1,070 63 ± 15 32% 2% 2.5% Mitral valve surgery 704 59 ± 14 27% 6% 4.3% Double/triple 381 57 ± 16 23% 3% 9.0% valve surgery Ascending aorta ± arch ± aortic valve surgery 475 57 ± 16 26% 16% 6.6% Congenital heart 473 42 ± 15 11% 1% 3.2% surgery in adults Miscellaneous* 638 57 ± 14 33% 23% 10.2% *Left ventricular aneurysms (254), heart transplantation (99), myectomy (94), mapping+ablation (44), postinfarction rupture of the septum (37), atrial myxoma (29), others (82). Table 1.2. Complications rates from 1993-1997 CABG Valves AA/A CHD Miscellaneous Re-exploration for bleeding 1.5% 4.0% 6.5% 4.2% 4.2% Perioperative stroke 1.4% 2.5% 6.6% 0.0% 2.2% Perioperative myocardial infarction 2.4% 1.3% 1.7% 0.6% 1.6% Deep sternal infection 0.8% 0.7% 1.1% 0.6% 0.2% Superficial wound infection 1.7% 0.8% 1.7% 1.9% 1.4% Sternal dehiscence 0.3% 0.1% 0.6% 0.0% 0.2% Renal failure 0.3% 0.3% 0.6% 0.0% 1.6% Mean ICU stay (days) 1.9 2.5 3.3 2.4 3.4 Abbreviations: CABG = coronary artery bypass graft; AA/A = ascending aorta +/-arch; CHD = congenital heart disease was associated with a significant increase in operative mortality (12.2% vs. 2.7%), and hospital stay (14.8 vs. 9.4 days). The awareness of the problem alone resulted in an improvement of this type of complication. Careful reviews of perioperative complications and their implications in the clinical outcomes and costs frequently allow for changes that have a positive effect in the quality of care. Fast Track Cardiac Surgical Program 3 Fast Track Cardiac Surgical Program 2 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 INTRODUCTION In this era of cost containment and physician report cards, we are being held accountable for patients’ outcome in terms of mortality, morbidity, quality of life, length of stay (LOS) and costs of care. Intensive care unit (ICU) costs rank second only to operating room costs, thus it is economically appealing for early extuba- tion to facilitate earlier ICU and hospital discharge of cardiac surgical patients. FAST TRACK CARDIAC ANESTHESIA Fast track or early tracheal extubation anesthesia is a perioperative anesthetic plan which aims to facilitate tracheal extubation of patients within 1-6 h post cardiac surgery. Most centers consider fast track extubation up to 8-10 h postop- eratively. FAST TRACK CARDIAC SURGERY This clinical pathway is a process of care including a multi-disciplinary ap- proach aimed to improve the efficiency of care in cardiac surgical patients. Early extubation anesthesia is a key to the success of the fast track cardiac surgery pathways. It is now feasible to accomplish early extubation because of improved anes- thetic management, coupled with advancements in surgical, myocardial protec- tion and normothermic cardiopulmonary bypass (CPB) techniques. Postopera- tive hemostasis is better controlled. We have demonstrated that early tracheal ex- tubation anesthesia is safe, cost beneficial and can improve resource utilization in cardiac surgery. RISK STRATIFICATION IN FAST TRACK CARDIAC SURGERY Perioperative morbidity and mortality in cardiac surgery are strongly influ- enced by the severity of the patients’ cardiac and non-cardiac illness. The Perioperative Care in Cardiac Anesthesia and Surgery, edited by Davy C.H. Cheng and Tirone E. David. © 1999 Landes Bioscience