ReviewInnovative Approaches in the Perioperative Care of the Cardiac Surgical Patient in the Operating Room and Intensive Care Unit
Section snippets
Cerebral and Somatic Near-Infrared Spectroscopy
Postoperative neurological complications will significantly alter postoperative recovery after cardiac surgery.6 Delirium is also very common after cardiac surgery particularly in the elderly patients.7 The use of near-infrared spectroscopy (NIRS) has been developed to identify and prevent these complications. The association between preoperative and intraoperative reduction in NIRS value with postoperative mortality, renal failure, and delirium has been established.8, 9, 10, 11 In 2011,
NIRS Technology
NIRS technology is available with multiple Health Canada-approved devices (Supplemental Fig. S2). The physics underlying these monitoring instruments is based on the principle that each tissue substance has a characteristic light absorbance. In the near-infrared wavelength range, hemoglobin and cytochrome c oxidase are the main chromophores (light-absorbing substances at a specific frequency). Therefore, their light absorption will be proportional to the oxygenation content of the tissue.21 The
TEE and Bedside Focused Ultrasound
Technical complications such as malfunctioning valves and the evaluation of mitral valve repair has led to recommendation of the use of TEE routinely in cardiac surgery as currently recommended by the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.52 Intraoperative TEE monitoring was first described by Matsumoto in 1980.53 Its use by the Department of Anesthesiology at the MHI started in 1999 and 20,480 examinations have been performed since (
Ultrasound-Guided Vascular Access
Every cardiac surgical patient requires central venous access and peripheral or central arterial monitoring. Recent guidelines have been published on the indication of ultrasound-guided vascular access.99 Complications such as hematoma, pneumothorax, or inadvertent arterial complications can occur.100 The ability to visualize the true anatomy, to reduce the number of useless punctures and complications, to identify thrombus or arterial occlusion, and to see the arterial vessel in situations in
Point-of-Care Coagulation Monitoring: ROTEM
Bleeding and transfusion of blood products is common after cardiac surgery. Rotational thromboelastometry (ROTEM, Tem International GmbH, Munich, Germany) is a whole-blood, point of care, hemostasis monitor that evaluates the viscoelastic properties of blood. This technology was developed in the late 1940s in Germany by Hartert102 and is also used in the TEG device (Haemonetics, Braintree, MA). A review of the effect of point-of-care coagulation has been published by Thiele and Raphael.103 A
RV Pressure Monitoring
RV dysfunction has been associated with increased mortality in cardiac surgical patients,70, 107 noncardiac surgery, and in the ICU.108, 109 RV failure can be present before, during, or after cardiac surgery. It might also complicate any cardiac or noncardiac surgical procedure. RV failure occurring after cardiac surgery will be associated with difficult separation from CPB. The latter has been demonstrated to be an independent predictor of mortality in high-risk cardiac surgical patients.2
Hemodynamic Diagnosis of RV Dysfunction
Continuous RV pressure waveform monitoring was described several years ago in the diagnosis of RV ischemia,121, 122 but not as a continuous monitoring modality. Our group started using continuous RV pressure waveform monitoring in 2002 to detect changes in RV function during cardiac surgery.67, 68, 115 For detailed review on RV pressure waveform, consult the article by Denault et al.71 The diagnosis of RV systolic dysfunction, diastolic dysfunction, and RV outflow tract obstruction (RVOTO) can
Inhalation Therapy for RV Failure
A common contributor to RV failure after cardiac surgery is pulmonary hypertension, which can be exacerbated by intraoperative pulmonary reperfusion syndrome, postoperative systemic inflammatory syndrome, and red blood cell transfusions.112, 130 The mechanism of pulmonary injury during extracorporeal circulation is thought to be mainly triggered by: (1) release of cytokines131 through endotoxin production; (2) complement activation; and (3) ischemia reperfusion injury.132, 133 All of these can
Acute Postoperative Pain Service
Patients experience pain after cardiac surgery to varying degrees145 and between 30% and 50% of patients experience moderate to severe pain for an average of 5 to 12 days after sternotomy.146 Unfortunately, many patients are unwilling to complain or do not want to disturb their caregivers about their painful experience. In fact, many try not to use pain medication, and they often wait until pain is unbearable to do so.147 The foundation of optimal and efficient postsurgical pain treatment is a
Intra- and Postoperative Medical Record Acquisition Systems
Critical information from the OR regarding patient's hemodynamic condition, intraoperative TEE, coagulation status, and numerous laboratory tests are transferred to the ICU team at the end of the procedure. To facilitate this process, communication between intraoperative and postoperative medical record acquisition systems allows complete transfer of critical information and a reduction in the time required for data recovery. All patient information is collected and stored as database-compliant
Simulation in Postoperative Cardiac Arrest After Cardiac Surgery
After many years of research and initiatives on standardization of the care of the patients suffering from postoperative cardiac arrest, guidelines have been published in 2009149 and applied in many countries. Most surgeons agree that perioperative arrest in the cardiac surgical ICU should be managed differently than in all other patients because of the immediate identification of the arrest, the proximity of a defibrillator or pacemaker, and the ability to promptly reopen the chest. After
Conclusion
In summary, many new innovative approaches have been developed in the MHI OR and, more recently, in the perioperative ICU. A combination of these modalities which include noninvasive perfusion monitoring of the brain and the periphery using NIRS, RV pressure monitoring, and bedside ultrasound and a more algorithmic approach to postoperative hemorrhage using the ROTEM might improve postoperative care in the cardiac surgical patient. Electronic data management is essential in quality control and
Acknowledgements
The authors thank Denis Babin, MSc, and Antoinette Paolitto for their help with the manuscript.
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2019, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Unilateral somatic desaturation can result from arterial compromise, venous congestion, or limb compartment syndrome.67–69 Identification of unexpected hypoperfusion detected by somatic NIRS in the perfused area is particularly useful in vascular surgery13 and trauma70 and also in procedures involving arterial cannulation, such as intra-aortic balloon pump, Impella device (Fig 3),30 ventricular assist device, and extracorporeal membrane oxygenation (ECMO). Venous thrombosis can occur in a significant number of patients undergoing ECMO.71
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