CheDavFMv3.qxd 8/31/05 3:49 PM Page i Perioperative Care in Cardiac Anesthesia and Surgery CheDavFMv3.qxd 8/31/05 3:49 PM Page ii CheDavFMv3.qxd 8/31/05 3:49 PM Page iii Perioperative Care in Cardiac Anesthesia and Surgery EDITED BY DAVY C. H. CHENG, MD, MSc, FRCPC Professor and Chair Department of Anesthesia & Perioperative Medicine University of Western Ontario Chief Department of Anesthesia & Perioperative Medicine London Health Sciences Centre and St. Joseph’s Health Care Medical Director Cardiac Surgery Recovery Unit London Health Sciences Centre London, Ontario, Canada TIRONE E. DAVID, MD, FRCSC Professor Department of Surgery University of Toronto Head Division of Cardiovascular Surgery The Peter Munk Cardiac Centre Toronto General Hospital Toronto, Ontario, Canada CheDavFMv3.qxd 8/31/05 3:49 PM Page iv Acquisitions Editor:Brian Brown Developmental Editor:Louise Bierig Project Manager:Dave Murphy Managing Editor:Franny Murphy Senior Manufacturing Manager:Ben Rivera Marketing Manager:Angela Panetta Design Coordinator:Terry Mallon Production Services:Laserwords Private Limited Printer:Edwards Brothers © 2006 by LippincottWilliams& Wilkins 530 Walnut Street Philadelphia, PA 19106 All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilizing by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Cover: Courtesy of the University of Pennsylvania Art Collection, Philadelphia, Pennsylvania Printed in the United States Library of Congress Cataloging-in-Publication Data Perioperative care in cardiac anesthesia and surgery / edited by Davy C. H. Cheng, Tirone E. David.— 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 0-7817-5774-6 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, manu- als, etc. I. Cheng, Davy C. H. II. David, Tirone E. III. Title. [DNLM: 1. Coronary Disease—surgery—Handbooks. 2. Perioperative Care—methods—Handbooks. 3. Anesthesia—methods—Handbooks. 4. Cardiac Surgical Procedures—methods—Handbooks. WG 39 P445 2005] RD598.P45 2005 617.4'12—dc22 2005023363 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted prac- tices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any conse- quences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recom- mended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of health care providers to ascertain the FDA status of each drug or device planned for use in their clinical practice. The publisher has made every effort to trace copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 824-7390. International customers should call (301) 714-2324. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:30 pm, EST, Monday through Friday, for telephone access. Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. 10 9 8 76 5 4 3 2 1 CheDavFMv3.qxd 8/31/05 3:49 PM Page v To our Residents, Fellows, and Students CheDavFMv3.qxd 8/31/05 3:49 PM Page vi CheDavFMv3-new.qxd 9/8/05 2:19 PM Page vii C O N T E N T S Contributors xi Preface xvii Acknowledgments xix Abbreviations xxi SECTION I: INTRODUCTION 1 1 Prognostic Risks and Preoperative Assessment 3 Davy C. H. Cheng and Tirone E. David SECTION II: ANESTHESIA AND CARDIOPULMONARY BYPASS MANAGEMENT 11 2 Fast-track Cardiac Anesthesia Management in On-pump and Off-pump Coronary Artery Bypass Surgery 13 Davy C. H. Cheng and Daniel Bainbridge 3 Anesthetic Management in Valvular Heart Surgery 21 Rita Katznelson and Patricia Murphy 4 Anesthetic Management in Robotic Cardiac Surgery 29 Wojciech Dobkowski 5 Circulatory Arrest and Neuroprotection 37 Ivan Iglesias and John M. Murkin 6 Anesthesia for Combined Cardiac and Thoracic Surgery 43 Peter Slinger 7 Anesthesia for Intrathoracic Transplantation 49 Karen McRae 8 Anesthesia for Patients with Ventricular Assist Devices 65 Jacek M. Karski 9 Anesthesia and Congenital Heart Disease 71 Helen M. K. Holtby 10 Anesthetic Management of Comorbid Diseases Affecting Cardiopulmonary Bypass 85 Neal H. Badner 11 Regional Anesthesia Techniques and Management 91 George N. Djaiani 12 Perioperative Monitoring in Cardiac Anesthesia 99 Daniel Bainbridge vii CheDavFMv3.qxd 8/31/05 3:49 PM Page viii viii Contents 13 Perioperative Transesophageal Echocardiography 105 Annette Vegas 14 Essence of Cardiopulmonary Bypass Circuit and Intra-aortic Balloon Pump 117 Peter Allen 15 Weaning from Cardiopulmonary Bypass and Low Output Syndrome 135 Annette Vegas 16 Pulmonary Hypertension and Right Ventricular Dysfunction Postcardiopulmonary Bypass 145 Achal K. Dhir and Fiona E. Ralley 17 Perioperative Blood Conservation in Cardiac Surgery 153 Bruce D. Spiess 18 Antifibrinolytics and Coagulation Management 165 Jacek M. Karski and Keyvan Karkouti 19 Heparin-Induced Thrombocytopenia and Alternatives to Heparin 173 Fiona E. Ralley 20 Management of the Cardiac Surgical Emergency 185 Ravi Taneja SECTION III: SURGICAL TECHNIQUE AND POSTOPERATIVE CONSIDERATION 193 21 Myocardial Protection During Cardiac Surgery 195 Shafie Fazel and Richard D. Weisel 22 On-pump Coronary Artery Bypass Surgery 201 Terrence M. Yau 23 Off-pump Coronary Revascularization Surgery 209 Richard J. Novick 24 Robotic Coronary Artery Revascularization Surgery 215 Bob Kiaii, R. Scott McClure, and W. Douglas Boyd 25 Surgery of the Aortic Valve 227 Tirone E. David 26 Surgery of the Mitral Valve 241 Tirone E. David 27 Tricuspid Valve Surgery 253 Tirone E. David 28 Robotic Cardiac Valvular Surgery 257 Alan H. Menkis CheDavFMv3.qxd 8/31/05 3:49 PM Page ix Contents ix 29 Surgery of the Ascending Aorta 261 Tirone E. David 30 Surgery of the Transverse Aortic Arch and Cerebral Protection 267 Christopher M. Feindel 31 Surgery of the Descending Thoracic Aorta 273 Steve K. Singh and Michael A. Borger 32 Combined Cardiac and Vascular Surgery 279 Michael A. Borger 33 Surgery for Mechanical Complications of Myocardial Infarction 285 Tirone E. David 34 Surgery for End-stage Heart Disease and Heart Transplantation 289 Vivek Rao and Christopher M. Feindel 35 Lung and Heart–Lung Transplantation 295 Shaf Keshavjee and Stefan Fischer 36 Ventricular Assist Devices 301 Vivek Rao 37 Adult Congenital Heart Surgery 307 Glen S. Van Arsdell, Igor E. Konstantinov, and William G. Williams 38 Ventricular Reconstruction or Aneurysm Resection for Ischemic Cardiomyopathy 323 Lynda L. Mickleborough 39 Implantable Cardioverter Defibrillator and Pacemaker Insertion 327 Raymond Yee and Jonathan Prychitko SECTION IV: CARDIAC SURGICAL RECOVERY UNIT 339 40 Routine Cardiac Surgery Recovery Care: Extubation to Discharge 341 Daniel Bainbridge and Davy C. H. Cheng 41 Common Problems in the Cardiac Surgery Recovery Unit 347 Annette Vegas 42 Atrial and Ventricular Arrhythmia Management 359 Christopher A. Palin and Charles W. Hogue, Jr. 43 Postcardiac Surgery Pacing Therapy 369 Douglas A. Cameron 44 Tamponade and Chest Reopening 375 Terrence M. Yau CheDavFMv3.qxd 8/31/05 3:49 PM Page x x Contents 45 Infection, Sternal Debridement, and Septic Shock 381 Lois K. Champion 46 Difficult Weaning from Mechanical Ventilation and Tracheotomy Care 387 Thomas L. Higgins and Patrick C. Lee 47 Renal Failure and Dialysis 401 Atilio Barbeito and Mark Stafford-Smith 48 Neurologic Complications and Management 415 Ronald J. Butler SECTION V: SURGICAL WARD MANAGEMENT 421 49 Routine Surgical Ward Care 423 Susan C. M. Lenkei-Kerwin and Stephanie J. Brister 50 Common Ward Complications and Management 429 Stephanie J. Brister and Susan C. M. Lenkei-Kerwin SECTION VI: APPENDICES 435 Appendix A: Postoperative TGH/CVICU Medical Admission Form 437 Appendix B: Postcardiac Surgery Medical Admission Orders (TGH/CVICU) 439 Appendix C: Postcardiac Surgery Medical Admission Orders (LHSC/CSRU) 441 Appendix D: TGH/CVICU Medical Discharge Forms 443 Appendix E: TGH/CVICU Medical Discharge Orders 445 Appendix F: LHSC Ventilation Weaning and Extubation Protocol 447 Appendix G: Patient Control Analgesia Order 449 Appendix H: Anticoagulation Guideline Postcardiac Surgery 451 Appendix I: Insulin Protocol for Glucose Control 453 Appendix J: Pharmacology in Cardiovascular Anesthesia and Surgery 455 Janet Martin Appendix K: Modified ACLS Protocols 493 Appendix L: Preoperative Cardiac Transplant Medical Order 505 Appendix M: Medical Transfer Orders Post Heart Transplant 507 Appendix N: Medical Orders for Care of Spinal Drains 509 Appendix O: Hospital Discharge Instructions Postcardiac Surgery 511