Book reading

Presenter: R3 薛成巽
2021/09/07
 CARDIOVASCULAR CARE

• Hemodynamic Assessment
• Hemodynamic Management
• Heart Rate and Rhythm Management
• Postoperative Ischemia and Infarction
• Right Ventricular Failure and Pulmonary Hypertension
• Valve Diseases: Special Postoperative Considerations
• Cardiac Arrest and Cardiopulmonary Resuscitation
 Hemodynamic assessment
• Review of current medications
• heart rate and rhythm
• mean arterial pressure (MAP)
• central venous pressure (CVP)
• ECG analysis to exclude ischemia and conduction abnormalities

presence of a pulmonary artery catheter

• pulmonary artery pressures
• left-sided filling pressures (pulmonary capillary wedge pressure
(PCWP))
• mixed venous oxygen saturation (MVO2) (SVO2)
• Cardiac output (CO)
• pulmonary and systemic vascular resistances (SVRs)
Hemodynamic assessment
 Hemodynamic assessment
Reasonable minimum goals for most patients include
• SVO2 : about 60%
• MAP > 65 mm Hg
• cardiac index (CI) > 2 L/min/m2

Goals should be individualized.

• Patients with a history of hypertension or significant peripheral
vascular disease will benefit from higher BP;
• patients who are bleeding or who have suture lines in fragile
tissue are best served with tighter control.
• Strategies designed to produce a supra normal CI or SVO2 have
failed to demonstrate a survival advantage.
 Hemodynamic assessment
Failure to achieve adequate CO and end-organ oxygen
delivery can be caused by many co-dependent
factors.
1. volume status (preload)
2. peripheral vascular tone (afterload)
3. cardiac pump function
4. heart rate and rhythm
5. blood oxygen carrying capacity
 Hemodynamic assessment
Volume status
elevated CVP
• volume overload, right heart failure, tricuspid and mitral
regurgitation, pulmonary hypertension, cardiac tamponade,
tension pneumothorax, and pulmonary embolism

PCWP (or left atrial pressure if this is being directly measured)

provides the most accurate assessment of left-sided filling
pressures in the absence of significant mitral stenosis,
correlation with pulmonary artery diastolic pressure should be
noted to enable a more continuous assessment of left-sided
pressures.
• A wedge pressure of 15 mmHg is generally adequate
 Hemodynamic assessment
Volume status

• Most patients arrive from the operating room with a significant

net fluid gain, but much of this excess volume is extravascular
due to third space and pleural cavity accumulation.
• Many patients are intravascularly underfilled and have on going
volume requirements in the immediate postoperative period.
 Hemodynamic assessment
Volume status
Postoperative vasoplegia is common. Contributors include
• a systemic inflammatory response to CPB
• the stress of surgery
• preoperative and perioperative medications including ACEI,
CCB and sedatives.
• Urine output and bleeding are common sources of ongoing
fluid loss.
• Hypothermia promotes vasoconstriction. As patients rewarm,
changes in peripheral vascular tone contribute to labile
hemodynamics which are often best treated with volume
replacement
 Hemodynamic assessment
Peripheral vascular tone

• Provide the patient with adequate BP

• excess vasoconstriction can increase SVR and create dangerous
levels of hypertension and decreased CO.
• Increases in afterload can be caused by medications,
hypothermia, increased sympathetic output (including pain and
anxiety) or may be secondary to hypovolemia or pump failure.
 Hemodynamic assessment
Left ventricular pump function
can be influenced by
• levels of exogenous or endogenous inotropes
• Postoperative ischemic stunning or infarction
• valve function
• Acidosis
• electrolyte abnormalities
• Hypoxia
• Cardiac tamponade
• Bradycardia, arrhythmias, and conduction defects can also
adversely affect CO.
 Hemodynamic assessment
oxygen carrying capacity of blood
• a function of hematocrit and oxygenation.
• A hematocrit of 21% and oxygen saturation greater
than 90% is adequate for a stable postoperative
patient.
 Hemodynamic assessment
• It is important not to allow the evaluation of the patient to
become obscured by too many numbers or theories, and an
overall assessment of the patient is always more important than
any single parameter.
• Trends in hemodynamic parameters are usually more important
than isolated values.
• Patients generally do well if they have warm, well-perfused
extremities, a normal mental status and good urine output (>0.5
cc/kg/min).
• Acute changes in hemodynamic status are common
postoperatively, and vigilant monitoring should enable care to be
more preemptive than reactive.
 Hemodynamic Management

• FLUID MANAGEMENT
• PHARMACOLOGIC SUPPORT
 Hemodynamic Management
Fluid management

• Goal
maintenance of adequate end-organ perfusion
without taxing the heart necessarily.
 Hemodynamic Management
Fluid management
• Patients with ventricular hypertrophy (eg, those with a history of
hypertension or aortic stenosis) diastolic dysfunction or systolic
anterior motion of the mitral valve usually need higher filling
pressures (preload).
• Patients with persistently low filling pressures despite
aggressive fluid administration are usually either bleeding or
vasodilated.
• Calculation of CO and SVR can often help sort this out.
 Hemodynamic Management
Fluid management
Hypovolemia
• In the case of significant vasodilation, judicious use
of a pressor agent can help to decrease fluid
requirements.
• Inotropic agents should not be administered for the
treatment of hypovolemia.
• Fluid requirements can often be reduced following
extubation; as decreased intrathoracic pressures will
improve venous return
 Hemodynamic Management
Fluid management
Volume overload
• Unusual in the immediate postoperative period, but a common
problem in the days following surgery.
• Normal cardiac function: diuresis appropriately without
intervention.
• A common cause of postoperative heart failure. Diuretics and
vasodilators are frequently required in patients with impaired
pump function before or following surgery, or in those who
receive large volumes of fluid perioperatively.
• Rapid diuresis accompanied by inadequate electrolyte repletion
is frequently arrhythmogenic.
 Hemodynamic Management
Pharmacologic support
1. Pressors are indicated for vasodilated patients who have
normal pump function and are unresponsive to volume.
2. Vasodilators are indicated for hypertensive patients and for
patients who are normotensive with poor pump function.
3. Inotropic agents are indicated when low CO persists despite
optimization of fluid status (preload), vascular tone (afterload),
and heart rate and rhythm
 Hemodynamic Management
Pharmacologic support
Nitroglycerin and sodium nitroprusside
• short acting and easy to titrate.
• cause hypoxia by inhibiting pulmonary arterial hypoxic vasoconstriction and
increasing blood flow through poorly oxygenated lung
• Nitroglycerin is a stronger venodilator than an arterial dilator, and can increase
intercoronary collateral blood flow, but patients can quickly become
tachyphylactic.
• Prolonged nitroprusside use can lead to cyanide toxicity, and methemaglobin
levels must be monitored.

Nicardipine: calcium channel blocker

• minimal effects on contractility or trioventricular (AV) nodal conduction
• the efficacy of nipride without its toxicity.
• control BP with less variability than nitroglycerine or nitroprusside
• been found to correlate with improved outcomes.
 Hemodynamic Management
Pharmacologic support

beta adrenergic agents (dobutamine) and cyclic nucleotide

phosphodiesterase inhibitors (milrinone)
• increase CO by increasing myocardial contractility and by
reducing afterload through peripheral vasodilation.
• Dobutamine is shorter acting and easier to titrate
• Milrinone achieves increases in CO with lower myocardial
oxygen consumption.
• Both are arrhythmogenic and can exacerbate coronary ischemia.
 Hemodynamic Management
Pharmacologic support
• Both epinephrine and norepinephrine combine β and α
adrenergic agonist effects; they are pressors in addition to
positive inotropes. Relative α effects increase with dose.
• Dopamine in low doses causes splanchnic and renal
vasodilation; α and β effects dominate at higher doses.

• Since perioperative beta blockade has been shown to improve

mortality and morbidity following cardiac surgery, it seems
reasonable to avoid the gratuitous use of inotropes, and efforts
should be made to rapidly wean these agents when they are no
longer required.