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.
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: Jun 02, 2017.References
- Cameron D. Initiation of white cell activation during cardiopulmonary bypass: cytokines and receptors. J Cardiovasc Pharmacol 1996; 27 Suppl 1:S1.
- Gold JP, Roberts AJ, Hoover EL, et al. Effects of prolonged aortic cross-clamping with potassium cardioplegia on myocardial contractility in man. Surg Forum 1979; 30:252.
- Leibowitz AB, Beilin Y. Pulmonary artery catheters and outcome in the perioperative period. New Horiz 1997; 5:214.
- Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348:5.
- Tuman KJ, McCarthy RJ, Spiess BD, et al. Effect of pulmonary artery catheterization on outcome in patients undergoing coronary artery surgery. Anesthesiology 1989; 70:199.
- Mansur A, Popov AF, Abu Hanna A, et al. Perioperative Blood Glucose Levels <150 mg/dL are Associated With Improved 5-Year Survival in Patients Undergoing On-Pump Cardiac Surgery: A Prospective, Observational Cohort Study. Medicine (Baltimore) 2015; 94:e2035.
- Bláha J, Mráz M, Kopecký P, et al. Perioperative Tight Glucose Control Reduces Postoperative Adverse Events in Nondiabetic Cardiac Surgery Patients. J Clin Endocrinol Metab 2015; 100:3081.
- Ma J, He L, Wang X, et al. Relationship between admission blood glucose level and prognosis in elderly patients without previously known diabetes who undergo emergency non-cardiac surgery. Intern Emerg Med 2015; 10:561.
- Lazar HL, McDonnell M, Chipkin SR, et al. The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg 2009; 87:663.
- Aps C. Fast-tracking in cardiac surgery. Br J Hosp Med 1995; 54:139.
- Appelbaum A, Kouchoukos NT, Blackstone EH, Kirklin JW. Early risks of open heart surgery for mitral valve disease. Am J Cardiol 1976; 37:201.
- Vignon P, Mentec H, Terré S, et al. Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU. Chest 1994; 106:1829.
- Slama MA, Novara A, Van de Putte P, et al. Diagnostic and therapeutic implications of transesophageal echocardiography in medical ICU patients with unexplained shock, hypoxemia, or suspected endocarditis. Intensive Care Med 1996; 22:916.
- Imren Y, Tasoglu I, Oktar GL, et al. The importance of transesophageal echocardiography in diagnosis of pericardial tamponade after cardiac surgery. J Card Surg 2008; 23:450.
- McKenney PA, Apstein CS, Mendes LA, et al. Increased left ventricular diastolic chamber stiffness immediately after coronary artery bypass surgery. J Am Coll Cardiol 1994; 24:1189.
- Fremes SE, Weisel RD, Baird RJ, et al. Effects of postoperative hypertension and its treatment. J Thorac Cardiovasc Surg 1983; 86:47.
- Roberts AJ, Niarchos AP, Subramanian VA, et al. Systemic hypertension associated with coronary artery bypass surgery. Predisposing factors, hemodynamic characteristics, humoral profile, and treatment. J Thorac Cardiovasc Surg 1977; 74:846.
- Estafanous FG, Tarazi RC. Systemic arterial hypertension associated with cardiac surgery. Am J Cardiol 1980; 46:685.
- Kuttila K, Niinikoski J. Peripheral perfusion after cardiac surgery. Crit Care Med 1989; 17:217.
- Downing SW, Edmunds LH Jr. Release of vasoactive substances during cardiopulmonary bypass. Ann Thorac Surg 1992; 54:1236.
- Christakis GT, Fremes SE, Koch JP, et al. Determinants of low systemic vascular resistance during cardiopulmonary bypass. Ann Thorac Surg 1994; 58:1040.
- Birdi I, Regragui I, Izzat MB, et al. Influence of normothermic systemic perfusion during coronary artery bypass operations: a randomized prospective study. J Thorac Cardiovasc Surg 1997; 114:475.
- Steen PA, Tinker JH, Pluth JR, et al. Efficacy of dopamine, dobutamine, and epinephrine during emergence from cardiopulmonary bypass in man. Circulation 1978; 57:378.
- Stephenson LW, Blackstone EH, Kouchoukos NT. Dopamine vs epinephrine in patients following cardiac surgery: randomized study. Surg Forum 1976; 27:272.
- Uretsky BF, Jessup M, Konstam MA, et al. Multicenter trial of oral enoximone in patients with moderate to moderately severe congestive heart failure. Lack of benefit compared with placebo. Enoximone Multicenter Trial Group. Circulation 1990; 82:774.
- Packer M, Carver JR, Rodeheffer RJ, et al. Effect of oral milrinone on mortality in severe chronic heart failure. The PROMISE Study Research Group. N Engl J Med 1991; 325:1468.
- Landoni G, Lomivorotov VV, Alvaro G, et al. Levosimendan for Hemodynamic Support after Cardiac Surgery. N Engl J Med 2017.
- Mehta RH, Leimberger JD, van Diepen S, et al. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery. N Engl J Med 2017.
- Creswell LL, Schuessler RB, Rosenbloom M, Cox JL. Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 1993; 56:539.
- Kotter GS, Kotrly KJ, Kalbfleisch JH, et al. Myocardial ischemia during cardiovascular surgery as detected by an ST segment trend monitoring system. J Cardiothorac Anesth 1987; 1:190.
- Yokoyama Y, Chaitman BR, Hardison RM, et al. Association between new electrocardiographic abnormalities after coronary revascularization and five-year cardiac mortality in BARI randomized and registry patients. Am J Cardiol 2000; 86:819.
- Chaitman BR, Alderman EL, Sheffield LT, et al. Use of survival analysis to determine the clinical significance of new Q waves after coronary bypass surgery. Circulation 1983; 67:302.
- Argenziano M, Chen JM, Choudhri AF, et al. Management of vasodilatory shock after cardiac surgery: identification of predisposing factors and use of a novel pressor agent. J Thorac Cardiovasc Surg 1998; 116:973.
- Leyh RG, Kofidis T, Strüber M, et al. Methylene blue: the drug of choice for catecholamine-refractory vasoplegia after cardiopulmonary bypass? J Thorac Cardiovasc Surg 2003; 125:1426.
- Argenziano M, Choudhri AF, Oz MC, et al. A prospective randomized trial of arginine vasopressin in the treatment of vasodilatory shock after left ventricular assist device placement. Circulation 1997; 96:II.
- Kristof AS, Magder S. Low systemic vascular resistance state in patients undergoing cardiopulmonary bypass. Crit Care Med 1999; 27:1121.
- Cremer J, Martin M, Redl H, et al. Systemic inflammatory response syndrome after cardiac operations. Ann Thorac Surg 1996; 61:1714.
- Wan S, LeClerc JL, Vincent JL. Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies. Chest 1997; 112:676.
- Osawa EA, Rhodes A, Landoni G, et al. Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review. Crit Care Med 2016; 44:724.
- Hajjar LA, Vincent JL, Barbosa Gomes Galas FR, et al. Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: The VANCS Randomized Controlled Trial. Anesthesiology 2017; 126:85.
- Landry DW, Oliver JA. The pathogenesis of vasodilatory shock. N Engl J Med 2001; 345:588.
- Ortega Mateo A, Amaya Aleixandre de Artiñano . Nitric oxide reactivity and mechanisms involved in its biological effects. Pharmacol Res 2000; 42:421.
- Levin RL, Degrange MA, Bruno GF, et al. Methylene blue reduces mortality and morbidity in vasoplegic patients after cardiac surgery. Ann Thorac Surg 2004; 77:496.
- Woodman RC, Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood 1990; 76:1680.
- Ballotta A, Saleh HZ, El Baghdady HW, et al. Comparison of early platelet activation in patients undergoing on-pump versus off-pump coronary artery bypass surgery. J Thorac Cardiovasc Surg 2007; 134:132.
- Levi M, Cromheecke ME, de Jonge E, et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999; 354:1940.
- Munoz JJ, Birkmeyer NJ, Birkmeyer JD, et al. Is epsilon-aminocaproic acid as effective as aprotinin in reducing bleeding with cardiac surgery?: a meta-analysis. Circulation 1999; 99:81.
- Bednar F, Osmancik P, Vanek T, et al. Platelet activity and aspirin efficacy after off-pump compared with on-pump coronary artery bypass surgery: results from the prospective randomized trial PRAGUE 11-Coronary Artery Bypass and REactivity of Thrombocytes (CABARET). J Thorac Cardiovasc Surg 2008; 136:1054.
- Zimmermann N, Kurt M, Wenk A, et al. Is cardiopulmonary bypass a reason for aspirin resistance after coronary artery bypass grafting? Eur J Cardiothorac Surg 2005; 27:606.
- Zimmermann N, Gams E, Hohlfeld T. Aspirin in coronary artery bypass surgery: new aspects of and alternatives for an old antithrombotic agent. Eur J Cardiothorac Surg 2008; 34:93.
- Peng MJ, Vargas FS, Cukier A, et al. Postoperative pleural changes after coronary revascularization. Comparison between saphenous vein and internal mammary artery grafting. Chest 1992; 101:327.
- Allou N, Bronchard R, Guglielminotti J, et al. Risk factors for postoperative pneumonia after cardiac surgery and development of a preoperative risk score*. Crit Care Med 2014; 42:1150.
- Ibañez J, Riera M, Amezaga R, et al. Long-Term Mortality After Pneumonia in Cardiac Surgery Patients: A Propensity-Matched Analysis. J Intensive Care Med 2016; 31:34.
- Ailawadi G, Chang HL, O'Gara PT, et al. Pneumonia after cardiac surgery: Experience of the National Institutes of Health/Canadian Institutes of Health Research Cardiothoracic Surgical Trials Network. J Thorac Cardiovasc Surg 2017; 153:1384.
- Gupta H, Gupta PK, Schuller D, et al. Development and validation of a risk calculator for predicting postoperative pneumonia. Mayo Clin Proc 2013; 88:1241.
- Sladden, RN, Berkowitz, DE. Cardiopulmonary bypass and the lung. In: Cardiopulmonary Bypass, Gravlee, GP, Davis, RF, Utley, IR (Eds), Williams and Wilkins, Baltimore 1993. p.468.
- Ramsey, J. The Respiratory, renal, and hepatic systems: Effects of cardiac surgery and cardiopulmonary bypass. In: Cardiopulmonary Bypass, Mora, CT (Eds), Springer, New York 1995. p.147.
- Engoren M, Buderer NF, Zacharias A. Long-term survival and health status after prolonged mechanical ventilation after cardiac surgery. Crit Care Med 2000; 28:2742.
- Messent M, Sullivan K, Keogh BF, et al. Adult respiratory distress syndrome following cardiopulmonary bypass: incidence and prediction. Anaesthesia 1992; 47:267.
- Trachte AL, Lobato EB, Urdaneta F, et al. Oral sildenafil reduces pulmonary hypertension after cardiac surgery. Ann Thorac Surg 2005; 79:194.
- Lee JE, Hillier SC, Knoderer CA. Use of sildenafil to facilitate weaning from inhaled nitric oxide in children with pulmonary hypertension following surgery for congenital heart disease. J Intensive Care Med 2008; 23:329.
- Tuman KJ, McCarthy RJ, Najafi H, Ivankovich AD. Differential effects of advanced age on neurologic and cardiac risks of coronary artery operations. J Thorac Cardiovasc Surg 1992; 104:1510.
- Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 1996; 335:1857.
- Breuer AC, Furlan AJ, Hanson MR, et al. Central nervous system complications of coronary artery bypass graft surgery: prospective analysis of 421 patients. Stroke 1983; 14:682.
- Corwin HL, Sprague SM, DeLaria GA, Norusis MJ. Acute renal failure associated with cardiac operations. A case-control study. J Thorac Cardiovasc Surg 1989; 98:1107.
- Chertow GM, Lazarus JM, Christiansen CL, et al. Preoperative renal risk stratification. Circulation 1997; 95:878.
- Thakar CV, Worley S, Arrigain S, et al. Improved survival in acute kidney injury after cardiac surgery. Am J Kidney Dis 2007; 50:703.
- Conger JD. Interventions in clinical acute renal failure: what are the data? Am J Kidney Dis 1995; 26:565.
- Mazzeffi M, Zivot J, Buchman T, Halkos M. In-hospital mortality after cardiac surgery: patient characteristics, timing, and association with postoperative length of intensive care unit and hospital stay. Ann Thorac Surg 2014; 97:1220.
- Kim DH, Kim CA, Placide S, et al. Preoperative Frailty Assessment and Outcomes at 6 Months or Later in Older Adults Undergoing Cardiac Surgical Procedures: A Systematic Review. Ann Intern Med 2016; 165:650.
- 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