Intern Survival Guide Part 3

CARDIAC SURGERY
Intern "Survival" Guide

Kirk J. Fleischer, M.D.
 

POSTOPERATIVE MANAGEMENT
OF THE CARDIAC SURGERY PATIENT

  Discharges

1. Review all meds for discharge with fellow the morning of discharge
2. Give the MAR with the final discharge medication list to the case managers
3. ** If wires have not been removed, do so early » patient must be observed for 4 hours!!
4. Make sure physical therapy has cleared patient for discharge (may need home PT or rehab)
5. Contact fellow early if problems arise threatening patient's discharge
6. Activity limitations: No lifting of objects > 5 lbs and no driving until follow-up with surgical attending in 1 month. (Climbing of stairs in moderation is permitted.)

EKG

1. Routine EKG performed on POD 3; others performed prn for chest pain, arrhythmias, and evaluation of EKG evidence of pericarditis
2. Check:
   
   1. Rhythm
   2. PR interval: Should be ( 0.20 sec (see "AV Conduction Abnormalities")
   3. ST segments: Look for evidence of ischemia vs. pericarditis (see "ST Segment Elevation")
   4. QTc interval (in patients on Procainamide or Amiodarone): Should be < 0.45 -0.50 sec
   5. Note: Many patients have baseline EKG abnormalities. Compare with preop EKG.

1. Repeat STAT K+ (from 7th floor STAT lab) » Don't wait for routine SMA-7 result!!
2. 12 lead EKG » Look for peaked T waves/widening of QRS complex (indicate that the hyperkalemic is clinically significant)
3. If > 6.0 and/or with EKG changes, treat aggressively with Lasix (20 - 40 mg IV), insulin (10 - 15 U IV)/glucose (1/2 amp 50% Dextrose » give before insulin) and NaHCO3 (1 amp IV). Check K+ Q4hrs until NL.
4. Don't forget to discontinue supplemental potassium !

Hypokalemia 

1. Due to aggressive diuresis in early postop period, most patients are hypokalemic. Close monitoring of K+ (Q6 - 12hr) and appropriate repletion of this electrolyte will reduce risk of cardiac irritability
2. Target K+ = 4.0 - 4.5 mEq/dl
3. If patient having difficulty with K-Dur tablets, order Micro-K tablets (8 - 10 mEq / tablet) which are smaller and usually better tolerated (or administer IV through central line)

Operating Room Experience

1. The demands of the cardiac surgery service often keep the interns quite busy on the ward; however, every house-officer should come to observe at least one CABG and one aortic valve replacement. Best view is from the head of the table ("anesthesia territory", but the anesthesiologists are quite friendly and readily willing to teach...)
2. The intern may also scrub in to assist on the saphenous vein harvest as well as the thoracic portion of the procedure. Palpation of the diabetic heart with diffuse calcification of the coronaries is a must for the "complete cardiac experience".
3. Before scrubbing in for a case:
   
   1. Please talk with the fellow » Some cases will be better to just observe
   2. Leave your pager with your intern partner. Provide him/her with a brief sign-out of active issues.
   3. Tell the service's case manager that you will be in the O.R.

1. Refer all outside calls from physicians or discharged patients as well as in-house consults directly to the fellow (410-955-1109). It's usually best not to take any information.
2. Realize that some thoracic consults will be referred to the Halsted surgery service.

Pacemakers 

1. The wires in the right subcostal region are atrial (present in less than 25% of patients) and in the left subcostal region are ventricular.
2. Typically, a single ventricular wire (pacing lead) and a skin wire (ground) are placed. The ventricular wire is the shorter one. Occasionally, 2 ventriclar wires are placed (will be equal length)» either one can be used as the ground lead.
3. The ventricular wire is inserted into the negative pole of the temporary external pacemaker. The skin wire is inserted in the positive pole.
4. For V-pacing, set the sensitivity on "demand", the rate at 70 - 90 bpm, and the output at several mA higher than where it captures the ventricle (dial it up and watch for the wide QRS complex following pacer spikes on telemetry).
5. If pacer "misfiring", turn it off and notify fellow

1. Pacing wires are removed ("pulled") on POD 3 - 5. Decision on when to pull depends on:
   
   1. Attending and fellow preference
   2. Anticoagulation
   3. Postop arrhythmia or AV block history If patient has had recent arrhythmias, confirm plan for removal with fellow !
2. Slow steady continuous pulling will permit removal of virtually all pacing wires. If unsuccessful, ask fellow or case managers for assistance.
3. Hold heparin for 2 hours prior to removal and at least 1 hour after removal
4. INR must be less than 2.0 - 3.0 (depending on attending). Check with fellow.
5. **Remove before 3PM » call fellow if pulling wires later. (Note: Need a team available to take patient to OR emergently if bleeding and tamponade occurs!)
6. There is a greater risk of bleeding with atrial wire removal.

1. Occasionally, patients who have nonfunctioning pacing wires or those who have had their pacing wires removed experience AV block or symptomatic bradycardia.
2. Transcutaneous pacing pads (i.e. Zoll pads) may be placed prophylactically in these patients +/- connect with pacer (depending on patient condition). Realize that transcutaneous pacing can be rather painful and sedation/intubation may be necessary until a transvenous pacing catheter in place.

PACING WIRES: Use for pacing:

PACING WIRES: Removal:

 

Physical Therapy

1. PT automatically consults on all patients.
2. Periodically ask the therapists if there any problem patients that may require home PT or transfer to rehabilitation center so that arrangements can be made early (insurance companies continue to make our lives difficult...)

Premature Atrial Contractions

1. Frequent PAC's often herald the onset of atrial fibrillation
2. Although it is unclear how best to avoid the development of Afib, the following steps should be taken once PACs are noted on telemetry:
   
   1. Check K+ and replete as necessary
   2. MgSO4 4 gm IV over 4 hours (if Cr < 1.5 mg/dl)
   3. If patient's condition permits, reduce diuresis until PACs resolve
   4. If patient receiving metoprolol/dilitiazem, administer a dose early (provides additional rate control should Afib develop)

1. Common postoperatively and almost always benign » However, do not ignore PVCs as they may herald myocardial ischemia or ventricular arrhythmias.
2. Management:
   
   1. Check K+ and replete as necessary
   2. MgSO4 4 gm IV over 4 hours (if Cr < 1.5 mg/dl)
   3. 12 lead EKG to rule out ischemia
   4. Check oxygen saturation (+/- ABG)
3. When should consideration be given to the treatment of PVCs with lidocaine or other antiarrhythmic agent?
   
   1. Frequent couplets or runs of ventricular tachycardia (VT, 3 or more consecutive PVCs)
   2. Multifocal PVCs (Note: Bigeminy and trigeminy rhythms are not associated with an increased risk of VT.)

ST Segment Elevation

1. The first step in the work-up of new ST elevation on telemetry is a 12 lead EKG.
2. The primary concern is whether these EKG changes represent myocardial ischemia. The three key questions are:
   
   1. Is the patient symptomatic and/or hemodynamically unstable?
   2. Are the ST elevations confined to a single EKG territory?
   3. Is patient having increased ventricular ectopy?
3. Myocardial ischemia in the postop cardiac surgery patient is usually not subtle. If the patient is asymptomatic and stable, it is unlikely that these EKG changes represent ischemia. Furthermore, if the elevations are noted in > 1 territory, the most likely diagnosis is pericarditis. (Note: Even if localized to one territory, focal pericarditis is still often the etiology.)
4. Pericarditis (the post-pericardiotomy syndrome):
   
   1. Most common cause of postop ST elevation
   2. Some attendings feel that EKG evidence of pericarditis is sufficient reason to treat, while others await clinical evidence of pericardial inflammation (rub, chest pain, fever,etc.). Treatment: Motrin x 7 days (or occasionally, a Medrol taper pack). Remember to stop ASA and give a course of Zantac during the period of treatment.
   3. The most concerning sequela of pericarditis is inflammatory- mediated occlusion of the bypass grafts (uncommon); the most frequent sequela is Afib.

 Staples 

1. Routinely removed on POD 5
2. Exceptions:
   
   1. Obese patients
   2. Wounds draining serous fluid (usually SVG harvest site)
   3. Patients on steriods (usually leave in until POD 14)
   4. Patients with tissues that appear to heal slowly (i.e. diabetics, heavy tobacco abuse, etc.)
3. If patient leaves before POD 5 or if he/she falls into one of the aforementioned groups, home care nursing can remove staples at a later date. Make sure to leave order in chart mentioning on which POD the staples should be removed

1. Almost all heart transplant patients are on cyclosporine. Order as "Neoral ___ mg Q 8AM/Q8PM" (do not order "cyclosporine" » Less bioavailable form!)
2. Make sure Cyclosporine (CYA) level drawn before AM dose of Neoral » Remind patient each day not to take Neoral before AM blood drawn. Levels are usually back by mid-afternoon. The fellow will speak with the attending surgeon every day to decide on the PM Neoral dose. We are currently targeting a level of 250 -350.
3. Review the surgical attending's and the cardiology (cardiomyopathy/transplant or CM/TX) service's notes every morning and evening, respectively, for plans/recommendations
4. Mask/hand-washing precautions as required
5. Pacing wires are usually removed just prior to discharge.
6. Review critical pathway outline for guidance in ordering labs, etc

Transports from CSICU (for Diagnostic studies, etc.) 

1. The beloved "road trips" of internship
2. During the day, the intern will be called to transport his/her service's patients from the CSICU to radiology, etc.
3. At night and on weekends after sign-out, the on-call intern makes all road trips.
4. Notify the ward charge RN when you are going on a road trip » In case a floor emergency arises, reinforcements (i.e. fellow, etc.) will be summoned earlier since you will be unavailable
5. Make sure that you have the following:
   
   1. Code bag
   2. Monitor and extra battery (or 2) » Unfortunately, it is not uncommon to lose electronic monitoring capabilities due to power loss. Keep your finger on the groin pulse until you reach your destination. Plug in the monitor immediately on arrival and call to the CSICU for a replacement battery for the trip back.
   3. * Radiology requisition (for diagnostic study) » often forgotten
6. Determine the best IV for administration of drugs and have the stopcock of this line easily accessible prior ro leaving on transport

Unstable Patients on the Floor (and Urgent Transfers to the CSICU) 

1. Stay in patient's room. Until senior assistance arrives, the patient's care is under your focused direction. Stay calm.....or at least look calm » your appearance will set the tone of the crisis!! Your intern partner and the nurses can assist by obtaining supplies and making calls, etc.
2. Have the fellow paged
3. Have the CSICU notified of the potenial transfer to the unit.
   
   1. Particularly important now that the CSICU is routinely full (must make room for transfer).
   2. The attending and/or resident in the CSICU can provide valuable assistance if necessary
4. If the patient is going to be transferred back to the CSICU:
   
   1. Have security called to hold an elevator (Blalock)
   2. Connect patient to transport monitor
   3. Check that there is sufficient oxygen in tank for transport
   4. Obtain/confirm adequate venous access.
   5. Have sticks of Epinephrine*, Atropine, Lidocaine, and Calcium Chloride available to push (and code bag on bed). (* Remember: For most events only need to give 1 - 2 cc of EPI at a time.)
5. While transporting patient, the physician should have always have a finger on the femoral pulse. Consider fluid bolus, calcium chloride or in some cases a small bolus of epinephrine if the pulse becomes weak. Of course, if pulse is absent, CPR must be initiated (Be sure to confirm the absence of pulse yourself before beginning chest compressions ! Also, an awake patient with "no pulse" does not need CPR.....)

1. It is absolutely imperative that each patient have adequate vascular access!! The vast majority of problems on the ward can be managed without return to the CSICU if treated promptly with parenteral agents.
2. If a central line is not in place, a well-functioning peripheral IV is sufficient. However, if access is difficult and patient has had arrhythmias, etc. on the ward, a second IV should be strongly considered. Femoral cannulation in a "code" setting can actually be quite challenging even for the experienced senior house-officer (particularly in the obese population that frequents our service).
3. ** Consult with fellow prior to removal of any central venous access line.