View
67
Download
3
Category
Tags:
Preview:
Citation preview
GUIDELIN
ES FOR
MANAGEMENT OF
LEFT HEART F
AILURE
IN C
ARDIAC S
URGERY
PATIE
NTS
BY- DR. A
RMAAN SIN
GH
POSTOPERATIVE CARDIO-CIRCULATORY DYSFUNCTION
Indicators of cardiocirculatory failure:
• Cardiac index < 2.0 L/min/m2
• SvO2 < 60%
• Mean arterial pressure < 60 mmHg
• Urine output < 0.5 ml/h, existing for longer than an hour
• Plasma lactate > 2.0 mmol/L
• Peripheral vasoconstriction with delayed capillary refill and cool extremities
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.
POSTOPERATIVE CARDIO-CIRCULATORY DYSFUNCTION
When LAP/PAD/CVP decrease :
• Evaluate response to an increase in preload. • Autotransfusion by means of passive leg raising. • Administration of colloid or crystalloid solution
(maximum of 10 ml/kg body weight).
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.
GUIDELINES FOR MANAGEMENT OF LEFT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
• If a preload increase does not lead to hemodynamic stabilization, an echocardiogram is indicated.
• In unstable patients, a 12-lead ECG to rule out acute ischemia, and lactate level should be obtained.
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.
GUIDELINES FOR MANAGEMENT OF LEFT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
No history of pre-existing cardiac failure:
1. Normalization of preload 2. Afterload reduction (NTG, nicardipine)3. Choice of pharmacological inotropes:
• DOBUTAMINE should be regarded as being of medium efficacy • EPINEPHRINE is highly effective
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.
GUIDELINES FOR MANAGEMENT OF LEFT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Patients with dilated or ischemic cardiomyopathy:
1. Down-regulation of cardiac ß receptors 2. Reduced response to endogenous & exogenous catecholamines 3. Catecholamines with α-mimetic effects may decrease cardiac output
Carl M, et al: S3 guidelines for intensive care in cardiac surgery patients. GMS 2010;8:1-25.
GUIDELINES FOR MANAGEMENT OF LEFT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Goal directed therapy:
• Increase preload
• Optimize heart rate & rhythm (avoid tachycardia & arrhythmias)
• Vasodilating agents (NTG, nicardipine, nesiritide)
• Inotropic agents (milrinone or dobutamine)
• Mixed vasoactive agents (epinephrine, norepinephrine)
• Drug combinations (inotropic + vasopressor agents)
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.
GUIDELINES FOR MANAGEMENT OF LEFT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Drug combinations:
• Dobutamine + norepinephrine
• Milrinone + norepinephrine
• Milrinone + ephinephrine
• Milrinone + vasopressin or phenylephrine (if diastolic dysfunction)
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.
GUIDELINES FOR DIAGNOSIS AND TREATMENT OF ACUTE AND CHRONIC HEART FAILURE
Decompensated congestive heart failure:
Dickstein K, et al: ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur Heart J. 2008;29:2388-2442.
GUIDELINES FOR DIAGNOSIS AND TREATMENT OF ACUTE AND CHRONIC HEART FAILURE
Immediate goals of treatment:
•Improve hemodynamics •Improve organ perfusion •Restore oxygenation •Limit cardiac & renal damage •Treating the cause of heart failure
Dickstein K, et al: ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur Heart J. 2008;29:2388-2442.
GUIDELINES FOR DIAGNOSIS AND TREATMENT OF ACUTE AND CHRONIC HEART FAILURE
Treatment:
•Vasodilators (class of recommendation I, level of evidence B)
•Dobutamine / milrinone (class of recommendation IIa, level of evidence B)
•Levosimendan (class of recommendation IIa, level of evidence B)
•Dopamine (class of recommendation IIb, level of evidence C)
•Vasopressors (class of recommendation IIb, level of evidence C)
Dickstein K, et al: ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur Heart J. 2008;29:2388-2442.
GUIDELINES FOR MANAGEMENT OF DECOMPENSATED LEFT HEART FAILURE
Levosimendan (Simdax):
• Standard Dilution:
[12.5 mg/5 ml] [500 ml D5W]
• Loading dose:
6-12 mcg/kg over 10 min
• Followed by 0.1 mcg/kg/min
• Continuous infusion x 24-48 hours
• In US: REVIVE 2 trial
GUIDELINES FOR MANAGEMENT OF DECOMPENSATED LEFT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
•Supportive care of the heart & lungs •Obtain ABG, CXR, EKG, TTE or TEE •IV loop diuretics, morphine •Agents with positive inotropic activity can increase mortality despite acute hemodynamic improvement •Vasodilating agents (NTG > 1 mcg/kg/min, Nesiritide) •Levosimendan •± Ventilatory support
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;19:278-292.
Young JB. Intravenous Nesiritide vs Nitroglycerin for Treatment of Decompensated Congestive Heart Failure. A Randomized Controlled Trial. JAMA 2002;287:1531-1540.
GUIDELINES FOR MANAGEMENT OF LEFT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Treatment of LV diastolic dysfunction:
• Optimize preload (LAP 14-18 mmHg) • Avoid tachycardia• Optimize heart rate (80/min) & increase AV delay (180 ms) • Aggressive treatment of atrial fib & tachyarrhythmias • Milrinone (0.5 mcg/kg/min) ± Vasopressin (0.04 units/min)
or phenylephrine (1-2 mcg/kg/min) [avoid tachycardia] • Levosimendan (if MAP > 60 mmHg) • IABP
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:296-308.
MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide:
Hemodynamic benefits: ↓ PAP, ↓ CVP, ↑ CO Improves postop renal function Decreases respiratory failure and AF Decreases LOS Decreases mortality
Blais DM. Nesiritide Compared with Milrinone for Cardiac Surgery. Ann Pharmacother 2007;41:502-504.
Mentzer RM, et al: Effects of Perioperative Nesiritide in Patients With Left Ventricular Dysfunction Undergoing Cardiac Surgery. The NAPA Trial. J Am Coll Cardiol 2007;49:716-726.
MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide:
Pulmonary, coronary, and renal arterial vasodilation Lusitropic effects on ventricular myocardium Improves echocardiographic indices of diastolic function Increases cardiac output without direct inotropic effects Not pro-arrhythmic
Young JB. Intravenous Nesiritide vs Nitroglycerin for Treatment of Decompensated Congestive Heart Failure. A Randomized Controlled Trial. JAMA 2002;287:1531-1540
Gordon GR, et al: Nesiritide for treatment of perioperative low cardiac output syndromes in cardiac surgical patients: an initial experience. J Anesth 2006; 20:307-311.
MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Nesiritide :
Perioperative management of patients with severe MR, severe LV dysfunction and secondary pulmonary hypertension
Expected mortality by EuroSCORE 26% Preoperative treatment with Nesiritide for 13-55 hr (mean=24 hr) Postoperative treatment with Nesiritide for 2-80 hr (mean=22 hr) Improves postop renal function and survival
Salzberg SP, et al: High-Risk mitral valve surgery. Perioperative hemodynamic optimization with Nesiritide (BNP). Ann Thorac Surg 2005;80:502-506.
MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
Salzberg SP, et al: High-Risk mitral valve surgery. Perioperative hemodynamic optimization with Nesiritide (BNP). Ann Thorac Surg 2005;80:502-506.
MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
NAPA (Nesiritide Administered Peri-Anesthesia in Patients Undergoing Cardiac Surgery) Trial:
Perioperative management of CABG patients with LV systolic & diastolic dysfunction
Patients received Nesiritide vs placebo for 24 to 96 h after induction of anesthesia
Decreases preload, afterload and PVR Improves postop renal function and survival
Mentzer RM, et al: Effects of Perioperative Nesiritide in Patients With Left Ventricular Dysfunction Undergoing Cardiac Surgery. The NAPA Trial. J Am Coll Cardiol 2007;49:716-726.
MANAGEMENT OF LEFT HEART FAILURE WITH SECONDARY PULMONARY HYPERTENSION
IN CARDIAC SURGERY PATIENTS
NAPA (Nesiritide Administered Peri-Anesthesia in Patients Undergoing Cardiac Surgery) Trial:
Mentzer RM, et al: Effects of Perioperative Nesiritide in Patients With Left Ventricular Dysfunction Undergoing Cardiac Surgery. The NAPA Trial. J Am Coll Cardiol 2007;49:716-726.
Recommended