Postoperative complications among patients undergoing cardiac surgery
- Frank E Silvestry, MD
Frank E Silvestry, MD
- Associate Professor of Medicine
- Hospital of the University of Pennsylvania
- Section Editors
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Talmadge E King, Jr, MD
Talmadge E King, Jr, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Interstitial Lung Disease
- Dean, School of Medicine
- Vice Chancellor, Medical Affairs
- University of California San Francisco
The use of cardiopulmonary bypass distinguishes cardiac surgery from other types of surgery. It also introduces a unique set of potential postoperative complications. These include vasospasm, altered platelet-endothelial cell interactions, and a generalized inflammatory response due to blood contacting the synthetic surfaces of the bypass equipment. The result is low flow in the microcirculation of the heart, brain, and other organs, which may lead to organ dysfunction [1,2].
The postoperative management of patients following cardiac surgery is reviewed here. Preoperative pulmonary assessment and potential complications of coronary artery bypass grafting are discussed separately. (See "Evaluation of preoperative pulmonary risk" and "Medical therapy to prevent complications after coronary artery bypass graft surgery" and "Early noncardiac complications of coronary artery bypass graft surgery".)
Routine monitoring following cardiac surgery typically includes continuous telemetry, measurement of the arterial blood pressure via an arterial catheter, measurement of the cardiac filling pressures via a pulmonary artery catheter (ie, right heart catheter, Swan Ganz catheter), continuous assessment of the arterial oxygen saturation via pulse oximetry, and continuous measurement of the mixed venous oxygen saturation via an oximetric pulmonary artery catheter. Such monitoring allows instantaneous assessment of cardiopulmonary physiology. The expected postoperative values are listed in the table (table 1).
Although pulmonary artery catheters are used routinely in most centers, there is a paucity of empirical evidence to support this practice [3,4]. In a trial that randomly assigned 1094 patients undergoing coronary artery bypass grafting (CABG) to receive either a central venous catheter or a pulmonary artery catheter to assist in perioperative management, there were no significant differences in the length of intensive care unit stay, occurrence of postoperative myocardial infarction, in-hospital death, major hemodynamic aberrations, or major noncardiac complications . Most pulmonary artery catheters are removed within 12 to 24 hours of surgery if significant vasopressor, vasodilator, or inotropic therapy is no longer required. (See "Pulmonary artery catheterization: Indications, contraindications, and complications in adults" and "Pulmonary artery catheterization: Interpretation of hemodynamic values and waveforms in adults" and "Pulmonary artery catheters: Insertion technique in adults".)
Fluid shifts should be closely monitored by frequent assessment of the central venous pressure and/or pulmonary artery occlusion pressure (ie, pulmonary capillary wedge pressure), chest and mediastinal tube drainage, urine output, and patient weight. Measurement of arterial blood gases, hemoglobin concentration, platelet count, coagulation parameters, serum electrolytes, and serum creatinine is routinely performed on a daily basis.
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- CARDIAC DYSFUNCTION
- Mechanical complications
- Physiologic complications
- - Inadequate preload
- - Excessive afterload
- - Poor inotropy
- Myocardial infarction
- VASODILATORY SHOCK
- HEMATOLOGIC DYSFUNCTION
- PULMONARY DYSFUNCTION
- NEUROLOGIC DYSFUNCTION
- RENAL DYSFUNCTION
- SUMMARY AND RECOMMENDATIONS