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CARDIAC SURGERY- WHAT CAN GO WRONG….
DEIRDRE MURPHY
WHAT CAN GO WRONG WILL GO WRONG
Murphy’s Law
.. AND AT THE WORST POSSIBLE MOMENT
Finagle’s corollary
ORIGINS OF MURPHY’S LAW REVISITED
"ANYTHING THAT CAN POSSIBLY GO WRONG, DOES. -- Ancient mountaineering adage" John Sack, _The Butcher: The Ascent of Yerupaja_ (1952), epigram, page 2 “
Fred Shapiro EDYale Dictionary of Quotations
CARDIAC SURGERY IS LOW RISK….
SOCIETY OF CARDIOTHORACIC SURGERY DATABASE 2.73
CABG 1.9 %
Valve alone 2.1 %
CABG + Valve 3.8 %
CABG AND RISK BENEFIT
CABG offers long term morbidity and mortality benefit for a range of conditions
The risks are mainly during and shortly after the operation
Coronary Artery Bypass Grafting , Alexander J and Smith P NEJM 2016; 374: 1954-64
COMMON COMPLICATIONS PREVENTION/RX
UNCOMMON COMPLICATIONS IMPORTANT TO KNOW ABOUT
AVALANCHES
Pneumonia
Mediastinitis
GI haemorrhage
Ischaemic bowel
(IABP, A fib)
AKI 20-30%
RRT 2-3% (40% mortality)
No difference in hospital length of stay or mortality in rate vs. rhythm control
NEJM 2016
A Fib 30-50%
Increased hospital LOS
Stroke risk x 5
Stroke 1-2%
Air embolism
(open chamber)
role for HBO
Delirium
Pumphead
Neurologic deficits ascribed to “pump” but no difference vs CABG vs PCI
BLEEDING
Time post surgery
Blood loss expected
30 mins 100mls
1 hour 200 mls/hr
2 hours 100/hr
3 hours 50 mls/hr
Useful to look at rate/pattern of bleeding
medical bleeding
vs. surgical bleeding
medical bleeding
vs.
surgical bleeding
Fix Coagulation Deficit (POC tests)
Ensure adequate reversal of heparin (“Pump Blood”)
Platelets/ Fibrinogen/FFP
Prothrombinex
Tranexamic acid (ATACAS)
Temperature, Ca, pH
Operation
WHAT HAPPENS WHEN PATIENTS STOP BLEEDING??
TAMPONADE….
RA
LA
SVCIVC
LA
RA
RV
PREVENTING TAMPONADE
Correct significant coagulopathy (but don't overdo it!!)
Keep drains patent……
fan-folding milking rolling
TAMPONADE
Recognise and treat urgently!!
Low cardiac index, rising filling pressures, increasing inotrope/vasopressor requirement
Be aware of MIMICS
Cardiorespiratory interactions- waking and “bearing down”
CONDITIONS MIMICKING TAMPONADE
CONDITIONS MIMICKING TAMPONADE
Pneumothorax-lung point Haemothorax- TOE
LATE TAMPONADE
often recognised late also
mortality high
may follow therapeutic anticoagulation or pacing wire removal
62 y.o F 3 weeks post CAGS and AVR. PEA arrest with peaked t waves
TOE shows late tamponade
MURPHY’S LAW AMENDMENT…THERE CAN BE MORE THAN ONE CAUSE OF AN ARREST
Murphy
HAEMODYNAMICS
LOW OUTPUT STATES- PUMP FAILURE
Pre-existing poor LV
Graft spasm
Mitral valve surgery often “unmasks” poorly performing LV
Perioperative MI
KNOW YOUR PATIENT’S SURGERY
Normal coronary arteries pre-op doesn't mean there can’t be a problem post operatively
From File Titled“Things I Wish I had Known”
CORONARY INJURY POST OPERATIVELY
L Main stenosis / R coronary injury 2nd aortic valve surgery- (immediate or months )
Circumflex injury post mitral prosthesis, annuloplasty
JACC Standardized Imaging for Aortic Annulus Sizing. Kasel et al 2013
Visualisation of the Circumflex in The Perioperative Setting with Transesophageal Echocardiography Ender et al. Anesth Analg 2012
RV DYSFUNCTION
Some degree of RV dysfunction expected
RV protection on bypass (esp RCA stenosis)
Associated with longer bypass time
KEEP THE RV HAPPY
Maintain perfusion pressure
Adequate preload
Low PVR (ventilator settings)
Inodilator (Milrinone)
Selective pulmonary vasodilators e.g iNO
Maintain sinus rhythm
COMBINATIONS OF VENTRICULAR DYSFUNCTION CAN BE TRICKY TO MANAGE
POST PUMP SYNDROME
High output , low SVR. Up to 5%
Valve>>CABG
? inflammatory mediators secondary to CPB
vasopressors, methylene blue
(Sepsis may be a cause )
CARDIAC ARREST AFTER CARDIAC SURGERY
Multifactorial
EACTS guidelines
Important differences in ALS approach
ALWAYS DO CPR !
!
Dunning J, et al. Guideline for resuscitation in cardiac arrest after cardiac surgery. European Journal of Cardio-Thoracic Surgery. 2009
50-60%
!
“Between living and dying
is the calmest place I’ve ever been
He stood opposite me and smiled.
I smiled too, I think, because this was the first time
I’d seen a man made of rain
though once or twice
my heart was chilled by men of ice.”
Prevent complicationsRecognise complications early
Train for avalanches