Review
Innovative Approaches in the Perioperative Care of the Cardiac Surgical Patient in the Operating Room and Intensive Care Unit

https://doi.org/10.1016/j.cjca.2014.09.029Get rights and content

Abstract

Perioperative care for cardiac surgery is undergoing rapid evolution. Many of the changes involve the application of novel technologies to tackle common challenges in optimizing perioperative management. Herein, we illustrate recent advances in perioperative management by focusing on a number of novel components that we judge to be particularly important. These include: the introduction of brain and somatic oximetry; transesophageal echocardiographic hemodynamic monitoring and bedside focused ultrasound; ultrasound-guided vascular access; point-of-care coagulation surveillance; right ventricular pressure monitoring; novel inhaled treatment for right ventricular failure; new approaches for postoperative pain management; novel approaches in specialized care procedures to ensure quality control; and specific approaches to optimize the management for postoperative cardiac arrest. Herein, we discuss the reasons that each of these components are particularly important in improving perioperative care, describe how they can be addressed, and their impact in the care of patients who undergo cardiac surgery.

Résumé

Les soins périopératoires de la chirurgie cardiaque connaissent une évolution rapide. Plusieurs des changements exigent l’application de nouvelles technologies pour faire face aux défis communs de l’optimisation de la prise en charge périopératoire. Dans cet article, nous illustrons les récentes avancées de la prise en charge périopératoire en nous concentrant sur les nouvelles composantes que nous jugeons particulièrement importantes. Parmi celles-ci, notons : 1) l’introduction de l’oxymétrie cérébrale et somatique; 2) la surveillance hémodynamique par l’échocardiographie transœsophagienne et remplacer focalisée par échographie ciblée au chevet du patient; 3) l’accès vasculaire guidé par échographie; 5) la surveillance de la pression du ventricule droit; 6) le nouveau traitement par inhalation de l’insuffisance ventriculaire droite; 7) les nouvelles approches de la prise en charge de la douleur postopératoire; 8) les nouvelles approches dans les interventions de soins spécialisés pour assurer le contrôle de la qualité; 9) les approches particulières pour optimiser la prise en charge de l’arrêt cardiaque postopératoire. De plus, nous examinons les raisons pour lesquelles chacune de ces composantes est particulièrement importante pour l’amélioration des soins périopératoires, et décrivons comment elles peuvent être abordées et quelles sont leurs répercussions sur les soins offerts aux patients qui subissent la chirurgie cardiaque.

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.

References (153)

  • G.M. Hoffman

    Pro: near-infrared spectroscopy should be used for all cardiopulmonary bypass

    J Cardiothorac Vasc Anesth

    (2006)
  • H.L. Edmonds

    Pro: all cardiac surgical patients should have intraoperative cerebral oxygenation monitoring

    J Cardiothorac Vasc Anesth

    (2006)
  • S. Muehlschlegel et al.

    Con: all cardiac surgical patients should not have intraoperative cerebral oxygenation monitoring

    J Cardiothorac Vasc Anesth

    (2006)
  • L.K. Davies et al.

    Con: all cardiac surgical patients should not have intraoperative cerebral oxygenation monitoring

    J Cardiothorac Vasc Anesth

    (2006)
  • J.C. Diephuis et al.

    Jugular bulb desaturation during coronary artery surgery: a comparison of off-pump and on-pump procedures

    Br J Anaesth

    (2005)
  • L.J. Caruso et al.

    Detection of oxygen delivery failure during cardiopulmonary bypass: an even earlier warning technique

    J Cardiothorac Vasc Anesth

    (2002)
  • J.C. Kolb et al.

    Protocol to measure acute cerebrovascular and ventilatory responses to isocapnic hypoxia in humans

    Respir Physiol Neurobiol

    (2004)
  • A. Koike et al.

    Cerebral oxygenation during exercise in cardiac patients

    Chest

    (2004)
  • R.T. Hahn et al.

    Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

    J Am Soc Echocardiogr

    (2013)
  • M. Matsumoto et al.

    Application of transesophageal echocardiography to continuous intraoperative monitoring of left ventricular performance

    Am J Cardiol

    (1980)
  • R. Salem et al.

    Left ventricular end-diastolic pressure is a predictor of mortality in cardiac surgery independently of left ventricular ejection fraction

    Br J Anaesth

    (2006)
  • M. Carricart et al.

    Incidence and significance of abnormal hepatic venous Doppler flow velocities before cardiac surgery

    J Cardiothorac Vasc Anesth

    (2005)
  • A.Y. Denault et al.

    Dynamic right ventricular outflow tract obstruction in cardiac surgery

    J Thorac Cardiovasc Surg

    (2006)
  • F. Haddad et al.

    Right ventricular myocardial performance index predicts perioperative mortality or circulatory failure in high-risk valvular surgery

    J Am Soc Echocardiogr

    (2007)
  • P. St-Pierre et al.

    Inhaled milrinone and epoprostenol in a patient with severe pulmonary hypertension, right ventricular failure and reduced baseline brain saturation value from a left atrial myxoma

    J Cardiothorac Vasc Anesth

    (2014)
  • A.Y. Denault et al.

    Tezosentan and Right Ventricular Failure in Patients with Pulmonary Hypertension Undergoing Cardiac Surgery: the TACTICS Trial

    J Cardiothorac Vasc Anesth

    (2013)
  • H.K. Eltzschig et al.

    Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery

    Ann Thorac Surg

    (2008)
  • T. Schachner et al.

    Factors associated with presence of ascending aortic atherosclerosis in CABG patients

    Ann Thorac Surg

    (2004)
  • G. Bolotin et al.

    Use of intraoperative epiaortic ultrasonography to delineate aortic atheroma

    Chest

    (2005)
  • S. Suvarna et al.

    An intraoperative assessment of the ascending aorta: a comparison of digital palpation, transesophageal echocardiography, and epiaortic ultrasonography

    J Cardiothorac Vasc Anesth

    (2007)
  • K.S. Ibrahim et al.

    Enhanced intra-operative grading of ascending aorta atheroma by epiaortic ultrasound vs echocardiography

    Int J Cardiol

    (2008)
  • K.T. Spencer et al.

    Focused cardiac ultrasound: recommendations from the American Society of Echocardiography

    J Am Soc Echocardiogr

    (2013)
  • J.G. Faris et al.

    Limited transthoracic echocardiography assessment in anaesthesia and critical care

    Best Pract Res Clin Anaesthesiol

    (2009)
  • H.D. Kanji et al.

    Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes

    J Crit Care

    (2014)
  • P.H. Mayo et al.

    American College of Chest Physicians/La Société de Réanimation de Langue Francaise statement on competence in critical care ultrasonography

    Chest

    (2009)
  • G. Via et al.

    International evidence-based recommendations for focused cardiac ultrasound

    J Am Soc Echocardiogr

    (2014)
  • S.T. Reeves et al.

    Basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

    J Am Soc Echocardiogr

    (2013)
  • C.A. Troianos et al.

    Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

    J Am Soc Echocardiogr

    (2011)
  • S.A. Nashef et al.

    EuroSCORE II

    Eur J Cardiothorac Surg

    (2012)
  • Denault AY. Difficult separation from cardiopulmonary bypass:importance, mechanism and prevention. PhD Thesis....
  • G.M. Janelle et al.

    Unilateral cerebral oxygen desaturation during emergent repair of a DeBakey type 1 aortic dissection: potential aversion of a major catastrophe

    Anesthesiology

    (2002)
  • F. Harel et al.

    Near-infrared spectroscopy to monitor peripheral blood flow perfusion

    J Clin Monit Comput

    (2008)
  • S. Koster et al.

    Risk factors of delirium after cardiac surgery: a systematic review

    Eur J Cardiovasc Nurs

    (2011)
  • M. Heringlake et al.

    Preoperative cerebral oxygen saturation and clinical outcomes in cardiac surgery

    Anesthesiology

    (2011)
  • J. Schoen et al.

    Preoperative regional cerebral oxygen saturation is a predictor of postoperative delirium in on-pump cardiac surgery patients: a prospective observational trial

    Crit Care

    (2011)
  • W.A. Palmbergen et al.

    Improved perioperative neurological monitoring of coronary artery bypass graft patients reduces the incidence of postoperative delirium: the Haga Brain Care Strategy

    Interact Cardiovasc Thorac Surg

    (2012)
  • F.F. Jobsis

    Noninvasive, infrared monitoring of cerebral and myocardial oxygen sufficiency and circulatory parameters

    Science

    (1977)
  • H.L. Edmonds et al.

    Cerebral oximetry for cardiac and vascular surgery

    Semin Cardiothorac Vasc Anesth

    (2004)
  • V.H. Gracias et al.

    Cerebral cortical oxygenation: a pilot study

    J Trauma

    (2004)
  • F. Vernieri et al.

    Transcranial Doppler and near-infrared spectroscopy can evaluate the hemodynamic effect of carotid artery occlusion

    Stroke

    (2004)
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