POST OPERATIVE MANAGEMENT

OF ON PUMP AND OFF PUMP CABG

DR P ADARSH
 CASE 1
• 55 year old Female,underwent emergency
on pump CABG
• HTN+,DM-,Mod LV Dysfunction
• Grafts:RSVG->LAD,D1,OM1
• Shifted to ICU on Adr=0.2 mcg/kg/min
NorAdr=0.2 mcg/kg/min,
NTG=0.5mcg/kg/min, Dopamine=7.5
mcg/kg/min with IABP
• Extubated on POD2
 CASE 2
• 46 year male underwent Off Pump CABG
• LIMA->D1,RSVG->LAD,OM,RADIAL->PDA
• Smoker,HTN+,DM+,Mod LV dysfunction
• Shifted to ICU on NorAdr=0.1mcg/kg/min,
NTG=0.2 mcg/kg/min,Adr=0.1 mcg/kg/min
with IABP
• On POD 0 he had a run of VT with fall in BP for
which external shock was given
• 250 mg of Xylocard was added in 500 ml of iv
fluid
• Cordarone infusion started at 15 mcg/kg/min
• Cordarone tapered off after 48 hrs after event
free period
• Adr tapered off by POD 4 and NAdr by POD 7
• IABP removed on POD 5
CHARACTERISTIC ON PUMP OFF PUMP

ARRYTHMIAS LESS FREQUENT MORE FREQUENT

HEMODYNAMIC LESS VARIATION WIDE FLUCTUATION

INSTABILITY

IABP LESS COMMONLY MORE CHANCES FOR

REQUIRED INSERTION

MYOCARDIAL ISCHEMIA LESSER DEGREE GREATER ISCHEMIA

INOTROPES LESS REQUIREMENT MORE REQUIREMENT

PROTAMINE REVERSAL ALWAYS GIVEN MOSTLY NOT GIVEN

MYOCARDIAL EDEMA MORE PROMINENT LESS EDEMA

 GOALS OF MANAGEMENT
• Adequate cardiac output
• Tissue oxygenation
• Ensuring balance between myocardial oxygen
supply and demand
 DURING TRANSFER TO ICU

• Watch for
Arrythmias
Hypotension
Hypertension
 SUPPORTS
• Preferred combination is of Nor Adrenaline
and Nitroglycerine
• If required
Dopamine
Adrenaline
SNP
Metoprolol/Esmolol i.v
 IN THE ICU
• Avoid Brady/Tachycardia
• Target MAP of 90 mm Hg
• Optimise inotropes/dilators/pressors
• Active rewarming of patient
• Check for drain output
• Check placement of ECG electrodes
• Regularly assess the ABG
• Switch on ST mapping in the monitor
• i.v fluid @2ml/kg/hr
• Avoid boluses
• Replace blood with blood
• In case of massive transfusion consider use of
FFP,Platelets,Cryo
• Ca may also be given
• i.v Mg in case of VPCs
• Insulin infusion preferred in diabetics
 RED FLAG SIGNS
• Development of new Q waves(>1 small square
in width and 2 small squares in depth)
• New ST elevation(>1 mm)
• Persistence of ST depression
• T wave inversions
• Ventricular tachyarrythmias
• New bundle branch block
• Poor progression of R wave
 PERIOPERATIVE MI
• As per STS defined as:
• Elevation of cardiac biomarkers >5 UNL within
72 hrs following CABG+new pathological Q
waves/LBBB (or)
• Angiographically demonstrated new
graft/native vessel occlusion (or)
• Imaging evidence of new loss of viable
myocardium
 TREATMENT
Go up on NTG(upto 2 microgram/kg/min)
IABP
If no contraindications Aspirin through RT
i.v Heparin
Inform the operating team
 THE DRAINING PATIENT
• When to intervene?
Any bleeding resulting in hemodynamic
compromise
Cool extremities
Drop in Hb/Hct
Quantitatively=2ml/kg/hr
 BEFORE EXTUBATION
• Stable hemodynamics
• ABG
• No significant drain
• Adequately warmed pt
• Intact neurological status
• Remove packs if any
 POST OP DAY 1
• Gradually taper supports
• Start oral Beta blockers only after all supports are
tapered
• Start anti platelet therapy (DAPT vs Aspirin)
• Statin therapy
• ACE inhibitors in case of LV dysfunction
• Chest physiotherapy and Incentive spirometry
• Amlodipine if radial artery used
• Warfarin if endarterectomy done
 POST OP DAY 2
• Consider drain out
• Check all wounds
• Invasive lines out
• Mobilise the pt
• Pacing wires out on POD 4
• Optimise oral medications
• Plan for discharge
 NITROGLYCERIN
• Initial therapy for myocardial ischemia
• Smooth muscle relaxant
• Nitrate mediated vasodilation occurs with or
without intact vascular endothelium
• Converted to NO which stimulates guanylate
cyclase->cGMP->protein kinase->
dephosphorylation of myosin light chain
kinase and smooth muscle relaxation
• At low doses acts as a venodilator
• At higher doses NTG dilates smaller arterioles
and resistance vessels reducing BP
• Potent epicardial coronary vasodilator in
normal and diseased vessels
• Smaller vessels dilate more than larger vessels
• Intercoronary coronary collaterals vasodilation
results in increased regional blood flow
especially to subendocardium
 RISK FACTOR MODIFICATION
• Cessation of smoking
• Regular exercise
• Control of Blood pressure
• Optimise blood sugars and lipid levels
THANK YOU