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Cardiac complications
Low
cardiac output
Cardiac arrest
Arrhythmias
MI
Coronary artery spasm
Cardiac Tamponade
Respiratory complications
Atelectasis
Bronchospasm
Phrenic nerve injury
Prolonged respiratory insufficiency
ARDS
Pneumothorax
Pleural effusion
PE
Renal complications
Acute
Renal Failure
Infectious complications
Pneumonia
Wound
infection
Mediastinitis
Catheter sepsis
GI complications
Ileus
Upper
GI bleeding
Intestinal ischemia
Acute Cholecystitis
Acute Pancreatitis
Acute Hepatic Failure
Nausea, Dysphagia, Hiccups
Neurological complications
Stroke
Neurobehavioral
disturbances
Peripheral Nerve Injury
of IABP
Significant dose of inotropic agent for more than
30 min
Incidence 10-20%
Causes
of LVEF
Hemodynamic problems
BP
PCW
CO
SVR
Plan
Volume
Venodilator or diuretic
Inotrope
Vasodilator
Inotrope/Vasodilator/IABP
-agent
hypertension
Inadvertent trauma to RCA
RV hypoperfusion
Intrinsic pulmonary disease, ARDS, PE
Optimize LV function
RVAD
Dobutamine
Dopamine
Ephedrine
Epinephrine
Isoproterenol (rarely used)
Milrinone
Norepinephrine
Phenylephrine
Mechanism of action
Rapid
Indications
Contraindications
Aortic
insufficiency
Aortic dissection
Severe aortic and peripheral vascular
arteriosclerosis
Insertion
Percutaneous
Surgical
Complications
Causes of bleeding
Causes of bleeding
Medical causes:
Platelet depletion
Platelet dysfunction
Clotting Factor Deficiency
Residual Heparin Effect
Excessive Protamine Administration
Hypothermia
Increased Fibrinolytic Activity
Consumptive Coagulopathy
? Genetic factors
Genetic factors
Seven genetic polymorphisms associated with bleeding after cardiac surgery. Genetic
factors appear primarily independent of, and explain at least as much variation in
bleeding as clinical covariates; combining genetic and clinical factors double our
ability to predict bleeding after cardiac surgery. Accounting for genotype may be
necessary when stratifying risk of bleeding after cardiac surgery
GPIaIIa-52C>T and 807C>T,
GPIb alpha 524C>T,
tissue factor-603A>G,
prothrombin 20210G>A,
tissue factor pathway inhibitor-399C>T, and
angiotensin converting enzyme (ACE) deletion/insertion
PEGASUS investigative team
Department of Anesthesiology, Duke University Medical Center, Durham
Prevention of bleeding
Assessment
Cessation of medications
Warfarin: 4 days
Heparin: no need to be stopped
LMWH: 12 hours
Aspirin: 3 days
Clopidogril(Plavix): 5-7 days
Ticlopidine(Ticlid): 7 days
Tirofiban: 4 hours
Abciximab: 12-24 hours
Thrombolytic therapy: 12-24 hours
Antifibrinolytic therapy
Aprotinin
-aminocaproic
acid
Tranexamic acid
CPB considerations
Heparin-coated
circuits
Retrograde autologous priming
Avoidance of cardiotomy suction
Balachandran S, Cross MH, Ann Thorac Surg 2002;73:1912-8
Johnell M, Larrson R, J Thorac Cardiovasc Surg 2002;124:321-32
Assessment of bleeding
Documentation
Management of bleeding
if Hct <26
Platelets 1 unit/10 kg
FFP 2-4 units
Cryoprecipitate 1 unit/10 kg
Drugs
Protamine
Aprotinin
Useful
Desmopressin
Desmopressin
Factor VIIa
Management of bleeding
Cardiac Tamponade
Should be suspected when the patient has hemodynamic
compromise with rising filling pressures
Suspicion increases if:
Sudden cessation of significant mediastinal bleeding
low cardiac output and hypotension with respiratory variation and narrow
pulse pressure
Widened mediastinum or displaced cardiac right shadow
Equalization of intracardiac pressures
Tachycardia
Arrythmias, decreased ECG voltage, EMD
Cardiac tamponade
Diagnosis
is confirmed by echo
Management is by early exploration