❤️ Chapter 56: General Care of a Postoperative Cardiac Surgical Patient

CPB · Ventilator Strategies · VIS Score · Delayed Sternal Closure · LCOS · Pacing · Pulmonary Hypertension · Nutrition · Bleeding · Open Chest Management

❤️ Postoperative Cardiac Surgical Care: Multidisciplinary Approach

📊 Preoperative Considerations
Stabilise prior to surgery: PGE1 for duct-dependent lesions, correct acidosis/electrolytes. Delay elective surgery 2-3 weeks after respiratory infection.
🫁 Ventilator Strategies (Disease-Specific)
• Glenn/Fontan: low PEEP, spontaneous breathing improves CO
• PHT: avoid hypoxia/acidosis, iNO, SpO2 >95%
• BT shunt: target SpO2 82-88% (avoid >90% = pulmonary flooding)
• Norwood: SpO2 70-80%, avoid high FiO2
💊 Vasoactive-Inotropic Score (VIS)
VIS = dopamine + dobutamine + 100×epinephrine + 100×norepinephrine + 100×milrinone + 10,000×vasopressin (units/kg/min). Higher score = sicker patient.
🩸 Bleeding Management
• Chest drain >10 mL/kg in 1 hour or >4 mL/kg/h ×4h → re-explore
• TEG guides component therapy
• Protamine for residual heparin
• rFVIIa for exsanguinating haemorrhage
⚡ Arrhythmias & Pacing
JET (common post-VSD/TOF repair): cooling, amiodarone, overdrive pacing. Atrial/ventricular pacing wires — check threshold daily.
🩺 Delayed Sternal Closure (Open Chest)
Deep sedation + paralysis. Avoid suctioning (vagal). Do not change position. Flat palm CPR if arrest. Close when haemodynamically stable (48-72h).
📌 Key Pearls: Early extubation (<24h) in uncomplicated repairs. Monitor LA/PA lines for preload. NEC risk in univentricular physiology — advance feeds slowly. Antibiotic prophylaxis for 48h only.

🩺 Step-by-Step: Postoperative Cardiac Surgical Care

1
Immediate post-op assessment (handover from OT)
Airway (ETT position, breath sounds), breathing (ventilator settings, SpO2), circulation (BP, CVP, inotropes, chest drain output), lines (LA, PA, pacing wires, PD catheter), sedation.
2
Ventilator management (disease-specific)
• Glenn/Fontan: low PEEP, maintain PCO2 40-45, extubate early
• PHT: avoid hypoxia/acidosis, use iNO, deep sedation
• BT shunt: SpO2 82-88% (avoid >90% = pulmonary flooding)
3
Haemodynamic optimisation
Calculate VIS score. Target age-appropriate MAP, CVP 8-12, UOP >1 mL/kg/h, lactate decreasing, ScvO2 >70%. Use LA/PA lines to guide fluids and inotropes.
4
Bleeding management
Measure chest drain output hourly. If >10 mL/kg in 1 hour or >4 mL/kg/h for 4 hours → re-explore. ACT, PT, PTT, platelets. TEG to guide product replacement.
5
Arrhythmia recognition and treatment
Monitor for JET (narrow QRS, AV dissociation). Cooling to 34-35°C, amiodarone, reduce inotropes, overdrive pacing. Pacing wires: check thresholds daily.
6
Fluid balance & renal support
Restrict fluids to 50% maintenance initially. Furosemide infusion for diuresis (after capillary leak resolves). Peritoneal dialysis or CRRT for fluid overload/renal failure.
7
Delayed sternal closure management
Deep sedation + paralysis. Avoid routine suctioning. Flat palm CPR if arrest. Monitor for bleeding. Close when haemodynamically stable (usually 48-72h).
8
Nutrition, infection control, extubation readiness
Start enteral feeds when stable (avoid NEC in univentricular). Remove lines early to prevent infection. Extubate when haemodynamically stable on minimal inotropes.