ICU Management Following Cardiac Surgery

First Things First

• Get report from surgery/anesthesia team and assess for the following:

Airway

• Security and depth of ETT upon arrival
• Difficulties with intubation

Oxygenation

• Oximetric saturation and PaO2 for a given amount of FiO2 and PEEP

Ventilation

• pH and pCO2 for a given tidal volume, respiratory rate and peak inspiratory pressure

Hemodynamics

• MAP, SBP and DBP, as supported by
  • CO, SVR, CVP, PAOP/PAD, rhythm
  • Hemodynamically active drug infusions

• Correlation of filling pressures with ventricular dimensions on 2D TEE
• Intraoperative segmental wall motion abnormalities
• Intraoperative TEE assessment of native valves, replaced/repaired valves
• ASD or VSD?
• IABP timing and adequacy of both systolic and diastolic augmentation
• General function of LVAD, RVAD or BIVAD

Temperature

• Bladder and core (intravascular) temperature
• Degree to which patient was cooled and subsequently warmed intraoperatively

Fluids, electrolytes and renal function

• Intraoperative measures of electrolytes (most notably last values for potassium)

• Total fluids and blood products
• Intraoperative urine output

Hematological (oxygen carrying capacity)

• Estimates of blood loss
• Salvaged blood returned
• Total PRBC products administered

Hematological (capacity to clot)

• ACT
  • Prebypass
  • Post heparin
  • Postbypass
  • Post protamine

• Amount of heparin administered in total, types and amounts of non-PRBC blood products (platelets, FFP, cryoprecipitate)
• Hematologically active drugs administered (aminocaproic acid, tranexemic acid, DDAVP)

Nutrition

• Intraoperative blood glucoses
• Amount and route of insulin given

• Infectious disease defenses

• Timing and dose of perioperative antibiotics

Anesthesia

• Type, timing and doses of:
  • Narcotics, benzodiazepines
  • Neuromuscular blocking agents,
  • Volatile anesthetics, intravenous anesthetics

Surgical specifics

• Bypass grafts
  • Number
  • Location
  • Types performed (vein, radial, mammary, etc.)

• Any portion of diseased coronary circulation not amenable to bypass
• Type and location of valvular replacement/repair
• Total CPB time, total cross-clamp time