Chapter 26

### Key Concepts

• Cardiac surgery involves unique anatomic and physiologic stresses that tax the reserve of every organ system. Continuous postoperative surveillance is required for early recognition of pathology and for rapid institution of organ and life-preserving therapies.

• Cardiac surgery causes transient (lasting 12–24 h) myocardial injury, sympathetic hyperreactivity, and the systemic inflammatory response syndrome (SIRS) in nearly all patients. As a result, hemodynamic instability requiring transient pressor and/or vasodilator infusions and intravascular volume expansion should be expected in all patents during the first 6 to 24 postoperative hours.

• Atrial fibrillation/flutter occurs in 30 percent of patients after cardiac surgery, and its incidence can be reduced by half through prophylactic administration of β-blockers, amiodarone, or sotalol.

• Significant pulmonary compromise should be expected in all cardiac surgical patients postoperatively, with 5 percent of patients experiencing overt respiratory failure. Diuresis should be instituted as soon as SIRS abates to limit fluid accumulation in the injured post-CPB lung.

• Liberation from mechanical ventilation should be sought at the earliest possible time in all patients. Extubation in most patients can be achieved as soon as they are awake enough to maintain airway patency and achieve adequate spontaneous gas exchange. In patients with significant respiratory compromise, daily assessment of a spontaneous breathing trial is the best method to assess readiness for extubation.

• Aggressive glucose control with a goal of 100 to 140 mg/dL within 24 h of ICU arrival reduces the incidence of death, sepsis, and renal failure after cardiac surgery.

### Introduction

Over the past 20 years, the cardiac surgery patient has become more acute, with sicker patients being operated upon. As an example, at Johns Hopkins, just in the past several years, the portion of elective cases for coronary artery disease (CAD) has decreased from 75 percent to approximately 40 percent, while urgent cases have increased from 25 percent to over 50 percent. Nevertheless, despite this increase in acuity of disease, the expected mortality for this same population has remained constant, at approximately 2 percent. It is more than possible that these similar outcomes in the face of sicker patients are the result of improvements in intra- and postoperative management strategies. It goes without saying that prevention of complications requires a thorough understanding of the pathophysiologic basis for the development of organ dysfunction after cardiac surgery, the ability to identify high-risk patients, and the ability to execute therapeutic strategies that prevent complications from developing. In many of those patients who develop complications, early diagnosis and treatment prevent further deterioration and limit subsequent morbidity and mortality.

The early management of the postoperative open heart surgery patient can be viewed as an extension of the intraoperative care the patient received, with a focus on recovery from hypothermia, restoring hemostatic capability, recognition and support during the inflammatory condition provoked by cardiopulmonary bypass (CPB) itself, and optimization of cardiac function as the heart recovers from the transient ischemic injury sustained while undergoing surgery. ...

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