The postoperative course of a patient undergoing cardiac surgery (CS) is dictated by a largely predictable set of interactions between disease-specific and therapeutic factors. ICU personnel need to quickly develop a detailed understanding of the patient’s current status and how critical care resources can be used to promote further recovery and eventual independence from external support. The goal of this article is to describe a typical operative and postoperative course, with emphasis on the latter, and the diagnostic and therapeutic options necessary for the proper care of these patients. This paper will focus on coronary artery bypass grafting as a model for understanding the course of CS patients; however, many of the principles discussed are applicable to most cardiac surgery patients.
DawberTRKannelWBRevotskieNStokesJ3rdKaganAGordonT. Some factors associated with the development of coronary heart disease: six years’ follow-up experience in the Framingham study. Am J Public Health Nations Health. 1959;49:1349-1356.
2.
BiglioliPCannataAAlamanniF. Biological effects of off-pump vs. on-pump coronary artery surgery: focus on inflammation, hemostasis and oxidative stress. Eur J Cardiothorac Surg. 2003;24:260-269.
3.
HaanschotenMCvan StratenAHter WoorstJF. Fast-track practice in cardiac surgery: results and predictors of outcome. Interact Cardiovasc Thorac Surg. 2012;15:989-994.
4.
MaldonadoJRWysongAvan der StarrePJBlockTMillerCReitzBA. Dexmedetomidine and the reduction of postoperative delirium after cardiac surgery. Psychosomatics. 2009;50:206-217.
5.
BarrJFraserGLPuntilloK. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263-306.
6.
WolmanRLNussmeierNAAggarwalA. Cerebral injury after cardiac surgery: identification of a group at extraordinary risk. Multicenter Study of Perioperative Ischemia Research Group (McSPI) and the Ischemia Research Education Foundation (IREF) Investigators. Stroke. 1999;30:514-522.
7.
MollerTPMadsenMDFuhrmannLOstergaardD. Postoperative handover: characteristics and considerations on improvement: a systematic review. Eur J Anaesthesiol. 2013;30:229-242.
8.
SegallNBonifacioASSchroederRA. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg. 2012;115:102-115.
9.
LighthallGKSinghS. Perioperative maintenance of tissue perfusion and cardiac output in cardiac surgery patients. Semin Cardiothorac Vasc Anesth. 2014;18:117-136.
10.
ColsonPHBernardCStruckJMorgenthalerNGAlbatBGuillonG. Post cardiac surgery vasoplegia is associated with high preoperative copeptin plasma concentration. Crit Care. 2011;15:R255.
11.
FischerGWLevinMA. Vasoplegia during cardiac surgery: current concepts and management. Semin Thorac Cardiovasc Surg. 2010;22:140-144.
AndoMEndoMNishidaHTomiokaHSodenagaYKoyanagiH. Phrenic nerve injury following coronary artery bypass surgery: its clinical implication and management. Rinsho Kyobu Geka. 1994;14:501-505.
14.
TrippHFBoltonJW. Phrenic nerve injury following cardiac surgery: a review. J Card Surg. 1998;13:218-223.
15.
BainbridgeDChengD. Initial perioperative care of the cardiac surgery patient. Semin Cardiothorac Vasc Anesth. 2002;6:229-236.
16.
KochCGLiLSesslerDI. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med. 2008;358:1229-1239.
17.
ManganoDTMiaoYVuylstekeA. Mortality associated with aprotinin during 5 years following coronary artery bypass graft surgery. JAMA. 2007;297:471-479.
18.
CollardCDBodySCShernanSKWangSManganoDT. Preoperative statin therapy is associated with reduced cardiac mortality after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg. 2006;132:392-400.
19.
MartinPHorkayFGuptaNKGebitekinCWalkerDR. Heparin rebound phenomenon—much ado about nothing?Blood Coagul Fibrinolysis. 1992;3:187-191.
20.
SubramaniamPSkillingtonPTatoulisJ. Heparin-rebound in the early postoperative phase following cardiopulmonary bypass. Aust N Z J Surg. 1995;65:331-333.
21.
BiancariFMikkolaRHeikkinenJLahtinenJAiraksinenKEJuvonenT. Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 2012;41:50-55.
22.
AuerJWeberTBerentRNgCKLammGEberB. Risk factors of postoperative atrial fibrillation after cardiac surgery. J Card Surg. 2005;20:425-431.
23.
MartinezEABassEBZimetbaumP; American College of Chest Physicians. Pharmacologic control of rhythm: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest. 2005;128:48S-55S.
24.
MitchellLB; CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention and treatment of atrial fibrillation following cardiac surgery. Can J Cardiol. 2011;27:91-97.
25.
SteinbergBAZhaoYHeX. Management of postoperative atrial fibrillation and subsequent outcomes in contemporary patients undergoing cardiac surgery: insights from the Society of Thoracic Surgeons CAPS-Care Atrial Fibrillation Registry. Clin Cardiol. 2014;37:7-13.
26.
HogueCWJrCreswellLLGuttermanDDFleisherLA; American College of Chest Physicians. Epidemiology, mechanisms, and risks: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest. 2005;128:9S-16S.
27.
EpsteinAEAlexanderJCGuttermanDDMaiselWWhartonJM; American College of Chest Physicians. Anticoagulation: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest. 2005;128:24S-27S.
28.
CiminoJJKoganAD. Constrictive pericarditis after cardiac surgery: report of three cases and review of the literature. Am Heart J. 1989;118:1292-1301.
29.
KutcherMAKingSB3rdAlimurungBNCraverJMLogueRB. Constrictive pericarditis as a complication of cardiac surgery: recognition of an entity. Am J Cardiol. 1982;50:742-748.
30.
MarinellaMA. Electrocardiographic manifestations and differential diagnosis of acute pericarditis. Am Fam Physician. 1998;57:699-704.
31.
EdwardsFHEngelmanRMHouckPShahianDMBridgesCR; Society of Thoracic Surgeons. The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery, part I: duration. Ann Thorac Surg. 2006;81:397-404.
32.
FinkelsteinRRabinoGMashiahT. Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methicillin-resistant staphylococcal infections. J Thorac Cardiovasc Surg. 2002;123:326-332.
33.
EggimannPHarbarthSConstantinMNTouveneauSChevroletJCPittetD. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet. 2000;355:1864-1868.
34.
van den BergheGWoutersPWeekersF. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359-1367.
35.
LipshutzAKGropperMA. Perioperative glycemic control: an evidence-based review. Anesthesiology. 2009;110:408-421.
36.
FrenchCMcGainF. Understanding low sugar from NICE-SUGAR. N Engl J Med. 2012;367:2449.
37.
JacobiJBircherNKrinsleyJ. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012;40:3251-3276.
38.
KavanaghBPMcCowenKC. Clinical practice. Glycemic control in the ICU. N Engl J Med. 2010;363:2540-2546.
39.
DeRisoAJ2ndLadowskiJSDillonTAJusticeJWPetersonAC. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use in patients undergoing heart surgery. Chest. 1996;109:1556-1561.
40.
TorresASerra-BatllesJRosE. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med. 1992;116:540-543.
41.
FreitasERSoaresBGCardosoJRAtallahAN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database Syst Rev. 2012;(9):CD004466.
42.
CooperWAO’BrienSMThouraniVH. Impact of renal dysfunction on outcomes of coronary artery bypass surgery: results from the Society of Thoracic Surgeons National Adult Cardiac Database. Circulation. 2006;113:1063-1070.
43.
ThakarCVWorleySArrigainSYaredJPPaganiniEP. Influence of renal dysfunction on mortality after cardiac surgery: modifying effect of preoperative renal function. Kidney Int. 2005;67:1112-1119.
44.
BellomoRAuriemmaSFabbriA. The pathophysiology of cardiac surgery-associated acute kidney injury (CSA-AKI). Int J Artif Organs. 2008;31:166-178.
45.
ManganoDT; Multicenter Study of Perioperative Ischemia Research Group. Aspirin and mortality from coronary bypass surgery. N Engl J Med. 2002;347:1309-1317.
46.
BadenesRLozanoABeldaFJ. Postoperative pulmonary dysfunction and mechanical ventilation in cardiac surgery. Crit Care Res Pract. 2015;2015:420513.
47.
RiceTWMoganSHaysMABernardGRJensenGLWheelerAP. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Crit Care Med. 2011;39:967-974.
48.
WellsDL. Provision of enteral nutrition during vasopressor therapy for hemodynamic instability: an evidence-based review. Nutr Clin Pract. 2012;27:521-526.
49.
CasaerMPMesottenDHermansG. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506-517.
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