Procedure: AAA (Thoracic)
Indication: Thoracic AAA, usually greater than 5.5 cm in diameter, or rapid aneurysm expansion
Description: Open Surgical Repair – Median sternotomy for ascending and arch aneurysm repairs, left thoracotomy for descending aneurysms, and left thoracotomy incisions for thoracoabdominal aneurysms. An open surgical repair of thoracic aneurysms resembles standard abdominal aortic aneurysm repair with proximal and distal vacular control, minimal aneurysm manipulation, and prosthetic graft repair. End-organ revascularization is achieved with distal anastomosis, native arterial reimplantation with or without endarterectomy, or bypass grafting with saphenous venous or prosthetic control. Endovascular repair of the thoracic aorta (TEVAR) – minimally invasive approach that involves placing a stent-graft in thoracic or thoracoabdominal aorta.
- bleeding (monitor CT if applicable, if >200/hr alert provider)
- renal failure
- respiratory failure
- peripheral vascular injury
- endoleaks from TEVAR requiring life-long CT scans
- avulsion of the arteries
- paralysis from spinal hyoperfusion - lumbar drain for CSF pressures with MAP >80
Meds: Pain managed with NSAIDS and opiates, antiemetic’s for n/v, restart home meds as PO tolerated
Principles: maintain vs per protocol, limit IVF intake to prevent fluid overload, sternal precautions if they apply, lay flat for TEVAR for 6 hours post-op, no bending more than 45 degrees for 24 hours or as ordered, distal pulses checks, MAP’s >80
Care Plan: aline care, sternal precautions as they apply, pulmonary toileting, skin care/turning, CXR, weight, labs, Assess for bleeding/infection, ICU monitoring, manage pain
Course of Care: POD#1 ambulate, d/c foley, restart home meds, advance diet as tolerated
Room Setup: Humidified O2, yankaur, oral suction, standard IV pump setup, possible PCA setup, possible epidural setup, aline setup, bairhugger, 3 suction setup, possible ventilator set-up, blood tubing
Indication: CAD, valvular disease
Description: CABG: Sternotomy, placed on cardiopulmonary bypass, and saphenous vein is used to bypass occluded vessels. Chest tubes and pacer wires are put in place. Valve: Sternotomy, placed on cardiopulmonary bypass, diseased valve is either repaired or replaced with a mechanical or bioprosthetic valve, and chest tubes/pacer wires are put in place.
- Bleeding: Observe chest tube output frequently; if >200ml/hr, Immediately alert surgeon. Have extra blood admin and product tubing at bedside. Have bear hugger on patient: cold blood doesn’t clot.
- Cardiac Tamponade: Narrowing pulse pressures and decreased CO/CI, decreased UOP. Triad: muffled heart sounds, hypotension, and JVD. Give fluids and inotropes until intervention.
- Decreased CO/CI: Analyze PA numbers/BP, pacer, intrinsic rhythm, CVP, UOP, chest tube output, fluids/albumin/blood, pressors, inotropes, etc… Make a determination to increase CO/CI.
- Pulmonary HTN: Flolan (protect from light)
- Systolic Anterior Motion of the mitral valve (SAM) after MVR: Avoid inotropes, aggressive diuresis, and tachycardia. Give Beta blockers, and maintain MAP 80-90.
- Hyperglycemia: Insulin drip algorithm for 48hrs per protocol
- RHF: echo is main diagnostic tool. Inotropes and reduced SVR. Inhaled pulmonary vasodilators
- MI: troponins usually slightly elevated after heart surgery. Requires TEE and possibly IABP until intervention.
- Afib: Amiodarone load during operation, then 24hr drip (1mg/min for 6hrs followed by 0.5mg/min for 18hrs). Rate control, cardioversion and anticoagulation.
- Sternal wound infection and dehiscence: sternal precautions, mupirocin, and chlorehex baths.
- Thoracic Aortic surgery (AAA only): lumbar drain to augment CSF pressures, also keep MAP >80, these are to prevent paralysis from spinal hypoperfusion.
Meds: Comes out of the OR sedated on propofol. Insulin drip for 48hrs. Amiodarone load during operation, then 24hr drip (1mg/min for 6hrs followed by 0.5mg/min for 18hrs). Inotropes and vasoactive possibly for 24-36hrs. IV AbX post-op. 4mg magnesium immediately post-op. Other electrolytes per BMP (Mg >2, K>4, Po4>4, Ion Ca >2.2). MIVF/driver typically 100ml/hr. Keep all pressors and inotropes on central line through OR manifold. 3 albumin 250ml vials if needed (standing order). Heparin SQ. Mechanical valves require life-long anticoagulation.
Principles: Maintain MAP 60-90 (too high can cause bleeding). Strict sternal precautions. Have 2 RNs at bedside for first couple hours. “Fast-track” is to extubate within 2-4hrs of arrival to SICU.
Care Plan: PA cath care (if applicable). A-line care. Sternal Precautions. Aggressive pulm hygiene (IS, OOB, C&DB). Frequent skin care, turning. VAP prevention after initial 24hrs. Pacer assessment/care. Daily CXR/weights/labs/EKG.
Course of Care: "Fast-track": extubate within 2-4hrs, wean propofol, wean pressers as tolerated. Perform 6hrs post-op CBC and BMP. POD#1 OOB to chair, consider home Rx and lasix. Evaluate need for A-line, CVC, PA cath, and chest tubes. Daily EKG, weight, labs, and CXR.
Room Setup: Extra blood tubing, albumin bottle and tubing primed, blood product tubing and filters. SCD, bear hugger and full body blanket, 4 suction set-up: yankaur/oral, NG/OG, 2X chest tubes w/ extensions. IV fluid manifold and 4 primed pumps/tubing. A-line set-up. Possible CVP or PA cath set-up. Vent set-up (RT). O2 supplies for post-extubation.