Pub Date : 2020-11-01DOI: 10.1093/med/9780190082482.003.0028
C. Choi, A. Masoumi
This chapter describes the intra-aortic balloon pump (IABP), which is the single most widely used mechanical circulatory assist device available today. Counterpulsation refers to balloon inflation in diastole and deflation in early systole: this results in increased coronary blood flow, left ventricular afterload reduction, and increased end-organ perfusion. Other uses of balloon counterpulsation include refractory ventricular arrhythmias, inability to wean from cardiopulmonary bypass, bridge to intervention in severe/critical aortic stenosis, and refractory pulmonary edema from decompensated heart failure. However, the absolute contraindications for IABP placement are aortic dissection, clinically significant aortic aneurysm, severe peripheral artery disease, significant aortic regurgitation, uncontrolled bleeding, and/or sepsis. The chapter then explains the optimal positioning for IABP. It also looks at complications associated with IABPs. These include thrombocytopenia and vascular complications, such as limb ischemia, bleeding, dissection, and hematoma/pseudoaneurysm formation. The presence of blood in the balloon tubing suggests the possibility of balloon rupture and gas embolism, an extremely uncommon but catastrophic event.
{"title":"Intra-aortic Balloon Pump","authors":"C. Choi, A. Masoumi","doi":"10.1093/med/9780190082482.003.0028","DOIUrl":"https://doi.org/10.1093/med/9780190082482.003.0028","url":null,"abstract":"This chapter describes the intra-aortic balloon pump (IABP), which is the single most widely used mechanical circulatory assist device available today. Counterpulsation refers to balloon inflation in diastole and deflation in early systole: this results in increased coronary blood flow, left ventricular afterload reduction, and increased end-organ perfusion. Other uses of balloon counterpulsation include refractory ventricular arrhythmias, inability to wean from cardiopulmonary bypass, bridge to intervention in severe/critical aortic stenosis, and refractory pulmonary edema from decompensated heart failure. However, the absolute contraindications for IABP placement are aortic dissection, clinically significant aortic aneurysm, severe peripheral artery disease, significant aortic regurgitation, uncontrolled bleeding, and/or sepsis. The chapter then explains the optimal positioning for IABP. It also looks at complications associated with IABPs. These include thrombocytopenia and vascular complications, such as limb ischemia, bleeding, dissection, and hematoma/pseudoaneurysm formation. The presence of blood in the balloon tubing suggests the possibility of balloon rupture and gas embolism, an extremely uncommon but catastrophic event.","PeriodicalId":207135,"journal":{"name":"Cardiothoracic Critical Care","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131017725","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-11-01DOI: 10.1093/med/9780190082482.003.0031
A. Doolan, G. Curley
This chapter reviews the management of a stable and tension pneumothorax after cardiac surgery and discusses persistent air leaks. It examines the features of pneumothorax on chest ultrasonography and compares the diagnostic accuracy of ultrasound to chest radiography and chest computed tomography (CT). It discusses the technique for needle decompression and chest drain insertion and troubleshoots problems with both. It describes the characteristics of persistent air leaks and summarizes the grading system. It compares the features of alveolar-pleural fistulas to bronchopleural fistulas and discusses various diagnostic techniques including chest CT, sequential balloon occlusion, and bronchoscopy. It outlines various treatment options including ventilation strategies, Heimlich valves, chemical pleurodesis, endobronchial/intrabronchial valves, occlusion coils, self-expanding airway stents, and surgery.
{"title":"Postoperative Pneumothorax","authors":"A. Doolan, G. Curley","doi":"10.1093/med/9780190082482.003.0031","DOIUrl":"https://doi.org/10.1093/med/9780190082482.003.0031","url":null,"abstract":"This chapter reviews the management of a stable and tension pneumothorax after cardiac surgery and discusses persistent air leaks. It examines the features of pneumothorax on chest ultrasonography and compares the diagnostic accuracy of ultrasound to chest radiography and chest computed tomography (CT). It discusses the technique for needle decompression and chest drain insertion and troubleshoots problems with both. It describes the characteristics of persistent air leaks and summarizes the grading system. It compares the features of alveolar-pleural fistulas to bronchopleural fistulas and discusses various diagnostic techniques including chest CT, sequential balloon occlusion, and bronchoscopy. It outlines various treatment options including ventilation strategies, Heimlich valves, chemical pleurodesis, endobronchial/intrabronchial valves, occlusion coils, self-expanding airway stents, and surgery.","PeriodicalId":207135,"journal":{"name":"Cardiothoracic Critical Care","volume":"46 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124192661","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-11-01DOI: 10.1093/med/9780190082482.003.0001
M. Hulse, S. Lowson
This chapter discusses the importance of cardiac surgical risk scoring models in classifying risk in adult patients. These scores first came into construct in the 1980s when the rate of mortality following coronary bypass graft surgery began to increase. Since this time, numerous scoring systems have been developed to define patient risk factors. The first widely used risk model was the initial Parsonnet score developed in 1989, which predicted cardiac surgical mortality based on preoperative risk factors thought to be clinically significant. Today, the most commonly used risk assessment tools for cardiac surgical patients are the European System for Cardiac Operative Risk Evaluation II and the Society of Thoracic Surgeons risk score. However, neither of these 2 major scoring systems assesses frailty. Frailty is consistently associated with a greater risk of morbidity and mortality in patients undergoing transcatheter aortic valve replacement procedures. The risk associated with frailty following open cardiac surgical procedures is less clear.
{"title":"Risk Assessment Scores in Cardiac Surgery","authors":"M. Hulse, S. Lowson","doi":"10.1093/med/9780190082482.003.0001","DOIUrl":"https://doi.org/10.1093/med/9780190082482.003.0001","url":null,"abstract":"This chapter discusses the importance of cardiac surgical risk scoring models in classifying risk in adult patients. These scores first came into construct in the 1980s when the rate of mortality following coronary bypass graft surgery began to increase. Since this time, numerous scoring systems have been developed to define patient risk factors. The first widely used risk model was the initial Parsonnet score developed in 1989, which predicted cardiac surgical mortality based on preoperative risk factors thought to be clinically significant. Today, the most commonly used risk assessment tools for cardiac surgical patients are the European System for Cardiac Operative Risk Evaluation II and the Society of Thoracic Surgeons risk score. However, neither of these 2 major scoring systems assesses frailty. Frailty is consistently associated with a greater risk of morbidity and mortality in patients undergoing transcatheter aortic valve replacement procedures. The risk associated with frailty following open cardiac surgical procedures is less clear.","PeriodicalId":207135,"journal":{"name":"Cardiothoracic Critical Care","volume":"22 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115043513","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-11-01DOI: 10.1093/med/9780190082482.003.0012
L. Shen
This chapter focuses on postoperative atrial fibrillation (POAF), which is very common after cardiothoracic surgery. Prevention of POAF involves continuation of preoperative beta-blockers, initiation of postoperative beta-blockers, and consideration of initiation of preoperative amiodarone in high-risk groups. In all patients, initial management of POAF includes correcting hypoxia and electrolyte abnormalities and consideration of weaning stimulating agents such as inotrope infusions. Medical management of hemodynamically stable patients includes the use of rate control agents such as beta-blockers, calcium-channel blockers, and digoxin or rhythm control agents such as amiodarone. When the patient is hemodynamically unstable, emergent synchronized cardioversion should be performed. Meanwhile, in refractory cases of rapid POAF, an aggressive rate control strategy may be pursued using one or more medications, but this approach must be weighed against the risk of requiring temporary or permanent pacing. Atrial flutter also occurs after cardiothoracic surgery, though at lower rates than POAF. It may be managed similarly to POAF, but it is typically more amenable to electrical cardioversion.
{"title":"Postoperative Atrial Fibrillation","authors":"L. Shen","doi":"10.1093/med/9780190082482.003.0012","DOIUrl":"https://doi.org/10.1093/med/9780190082482.003.0012","url":null,"abstract":"This chapter focuses on postoperative atrial fibrillation (POAF), which is very common after cardiothoracic surgery. Prevention of POAF involves continuation of preoperative beta-blockers, initiation of postoperative beta-blockers, and consideration of initiation of preoperative amiodarone in high-risk groups. In all patients, initial management of POAF includes correcting hypoxia and electrolyte abnormalities and consideration of weaning stimulating agents such as inotrope infusions. Medical management of hemodynamically stable patients includes the use of rate control agents such as beta-blockers, calcium-channel blockers, and digoxin or rhythm control agents such as amiodarone. When the patient is hemodynamically unstable, emergent synchronized cardioversion should be performed. Meanwhile, in refractory cases of rapid POAF, an aggressive rate control strategy may be pursued using one or more medications, but this approach must be weighed against the risk of requiring temporary or permanent pacing. Atrial flutter also occurs after cardiothoracic surgery, though at lower rates than POAF. It may be managed similarly to POAF, but it is typically more amenable to electrical cardioversion.","PeriodicalId":207135,"journal":{"name":"Cardiothoracic Critical Care","volume":"39 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129824072","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-11-01DOI: 10.1093/med/9780190082482.003.0029
C. Read, Emer Curran
The incidence of cardiac tamponade following cardiothoracic surgery can reach 6% and can be a life-threatening emergency. The diagnosis of cardiac tamponade in the postoperative setting can be challenging for several reasons, which include the variety of etiologies of shock after cardiac surgery, that the historical clinical signs are seldom seen, and because investigative aids, such as echocardiography, have their limitations. A high index of suspicion of cardiac tamponade is therefore always warranted when assessing a deteriorating patient following cardiac surgery along with an up-to-date knowledge of cardiac arrest after cardiac surgery management. Surgical decompression of the mediastinum by emergency resternotomy is required for 20%–50% of cardiac arrests after cardiac surgery and may need to take place in the critical care environment, so awareness of and training in this procedure are imperative.
{"title":"Cardiac Tamponade","authors":"C. Read, Emer Curran","doi":"10.1093/med/9780190082482.003.0029","DOIUrl":"https://doi.org/10.1093/med/9780190082482.003.0029","url":null,"abstract":"The incidence of cardiac tamponade following cardiothoracic surgery can reach 6% and can be a life-threatening emergency. The diagnosis of cardiac tamponade in the postoperative setting can be challenging for several reasons, which include the variety of etiologies of shock after cardiac surgery, that the historical clinical signs are seldom seen, and because investigative aids, such as echocardiography, have their limitations. A high index of suspicion of cardiac tamponade is therefore always warranted when assessing a deteriorating patient following cardiac surgery along with an up-to-date knowledge of cardiac arrest after cardiac surgery management. Surgical decompression of the mediastinum by emergency resternotomy is required for 20%–50% of cardiac arrests after cardiac surgery and may need to take place in the critical care environment, so awareness of and training in this procedure are imperative.","PeriodicalId":207135,"journal":{"name":"Cardiothoracic Critical Care","volume":"92 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128974887","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In this chapter we describe the case of a patient presenting with signs and symptoms of infective endocarditis following a recent mitral valve replacement. We describe the epidemiology of infective endocarditis and discuss its features including echocardiographic features. We discuss diagnosis, treatment (both medical and surgical), complications and prognosis with a focus and emphasis on the ICU patient. The clinical presentation of IE in the ICU setting may be atypical and classic features may be masked by critical care interventions and concomitant pathology. Echocardiography can be particularly challenging in the ICU setting. There should be a low threshold for TEE in critically ill patients with Staphylococcus aureus catheter-related bloodstream infection because of its high propensity to cause IE.
{"title":"Endocarditis","authors":"Ruth Boylan, I. Conrick-Martin","doi":"10.32388/uon4at","DOIUrl":"https://doi.org/10.32388/uon4at","url":null,"abstract":"In this chapter we describe the case of a patient presenting with signs and symptoms of infective endocarditis following a recent mitral valve replacement. We describe the epidemiology of infective endocarditis and discuss its features including echocardiographic features. We discuss diagnosis, treatment (both medical and surgical), complications and prognosis with a focus and emphasis on the ICU patient. The clinical presentation of IE in the ICU setting may be atypical and classic features may be masked by critical care interventions and concomitant pathology. Echocardiography can be particularly challenging in the ICU setting. There should be a low threshold for TEE in critically ill patients with Staphylococcus aureus catheter-related bloodstream infection because of its high propensity to cause IE.","PeriodicalId":207135,"journal":{"name":"Cardiothoracic Critical Care","volume":"16 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2016-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127376337","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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