Treatment of patients after cardiac surgery. Training program Intensive Care Radboud University Nijmegen Medical Centre

Transcription

1 Treatment of patients after cardiac surgery Training program Intensive Care Radboud University Nijmegen Medical Centre

2 General remarks Cardiac surgery reserved for complex cases Sicker patients with multiple comorbidities Older patients who have failed previous procedures On the other hand.. Increasing use of minimally invasive techniques Increasing use of off pump surgery Increasing use of mechanical circulatory support devices

3 Important risk factors Preoperative EF < 30% Left main coronary artery disease Diabetes mellitus Renal insufficiency (creatinine > 150) Symptomatic parenchymal lung disease Advanced age

4 Cardiopulmonary bypass

5 Sequelae of CPB Systemic inflammatory response with systemic vasodilation and endothelial leak syndrome Multifactorial coagulopathy Vascular injury at cannulation sites Myocardial dysfunction and conduction abnormalities due to inadequate cardioplegia Organ damage through nonpulsatile hypotension

6 Postoperative PA catheter EF < 30% Severe pulmonary hypertension RV failure Insufficient understood hemodynamics

7 EF in first 24 hours Ejection fraction (%) Preoperative 2 hours 24 hours 7 days

8 Prolonged EF decrease Preoperative EF < 30% Duration and severity of hypothermia Perioperative ischemia Bypass time > 120 minutes

9 Postoperative compliance 75 After surgery Pressure Normal 0 Volume

10 Vasoplegia depending on CPB time

11 Hypotension after cardiac surgery Myocardial dysfunction Hypovolemia Vasodilation LV Failure RV Failure Tamponade CI Low (< 2.2 l/min/m 2 ) Normal/High (> 2.6 l/min/m 2 ) Low Low Low CVP Low Low Variable High (> 18 mmhg) High (> 18 mmhg) PAOP Low Low High (> 18 mmhg) Low Variable ECHO Underfilled LV and RV cavities Hyperdynamic LV Poor LV function - adequate filling Normal LV function with small thick LV Hypokinetic RV with underfilled LV Restrictive MV inflow pattern with clot/ effusion Aetiology Hypovolemia/ bleeding Pneumothorax Tamponade Excessive PEEP AutoPEEP RV failure / PHT Prolonged CPB Vasodilators/ sedatives Residual protamine reaction Prolonged CPB Inadequate revascularization Stunned myocardium Graft occlusion Vasospasm Pre-op RV dysfunction RV ischemia Severe PHT Excessive bleeding with coagulation correction Surgical bleeding

12 Treatment goals MAP mmhg and SAP mmhg depending on specific circumstances (higher with preexistent HT / renal insufficiency, lower with poor LV function, MV repair, vulnerable aortic suture line, active bleeding) No specific CVP/PCWP - use dynamic parameters Clinical signs of hypoperfusion, SvO2, lactate CI > l/min/m 2

13 Fluid therapy Unusual to need > 2-3 L of cristalloids after complate rewarming (otherwise bleeding, tamponade, tension pneumothorax, valvular dysfunction, cardiac ischemia, heart failure) Pressure overloaded myocardium (AS/HT): usually more fluid - after each aliquot of volume: CI, RR, WP Volume overloaded myocardium (MI/AI): CI, RR - Filling pressures relatively insensitive

14 Preload in pressure overloaded myocardium Higher filling pressures necessary for adequate preload

15 Preload in pressure overloaded myocardium AVR with underfilled left ventricle

16 Systolic anterior movement

17 Inotropic agents Low Index High Index Low BP Low heart rate epinephrine milrinone/dobutamine + norepinephrine Pace, epinephrine, isoproterenol Norepinephrine Vasopressin No therapy High BP Afterload reduction Afterload reduction High heart rate epinephrine milrinone/dobutamine + norepinephrine No therapy or beta blockade Milrinone with RV failure / severe PHT Always remember increased myocardial oxygen demand / arrhythmogenecity

18 Preventive Levosimendan in patients with low EF (< 35%) MC RCT (N=882) Levosimendan 0.1 μg/kg/min vs placebo (24 hrs) in addition to standard care 30 Placebo Levosimendan 20 24,5 24,5 % 10 11,4 13,1 0 Composite outcome (4) Composite outcome (2) Composite 4 = D30 / RRT D30 / MI D5 / Assist Device D5 No differences in adverse effects Composite 2 = D30 / Assist Device D5 Metha RH. N Eng J Med 2017;376:

19 Levosimendan in p.o. low cardiac output syndrome MC RCT (N=506) Levosimendan μg/kg/min vs placebo (48 hrs) in addition to standard care 15 Placebo Levosimendan 10 % D Mortality RRT ECMO/VAD No differences in duration of MV, ICU-LOS and Hospital LOS Landoni G. N Eng J Med 2017;376:

20 Postoperative hypertension Causes Chronic hypertension Anxiety and agitation Pain and discomfort Perioperative withdrawal of antihypertensive agents Vasopressors / volume Sedation and pain control NTG μg/kg/min Nicardipine 1-15 mg/h Metoprolol 1-10 mg/h Labetolol mg/min Keep BP low with MVR (decrease afterload)

21 Heart rate/rhythm Higher heart rate than expected often optimal Sinus rhythm most important with pressure overloaded ventricle Increased heart rate often very well tolerated Atrial fibrillation in 30-40% (usually > 24 hours)

22 Heart rate in pressure overloaded myocardium Cardiac output Heart rate below time needed for maximal EDV Heart rate above time needed for maximal EDV Synchronized A-V contraction extremely important

23 Heart rate in volume overloaded myocardium More tolerant of tachycardia and loss of A-V synchrony Increase in heart rate decreases EDV but may improve systolic emptying Sinus rhythm < 75 usually more deleterious than abnormal rhythm around

24 Post operative arrhythmias Graft dysfunction Ischemia Hypoxemia Electrolyte imbalance Acid base disorders Ventricular arrhythmias - suspect cardiac ischemia

25 Specific treatment Atrial Flutter - atrial pacing (20 ma - 30 to 60 seconds at % of atrial rate) Atrial fibrillation - 85% convert to sinus rhythm in the first 24 hours - rate control is a viable alternative

26 N = 523 No differences in: Admission duration 5.1 vs 5 D Death Serious adverse events Millinov AM. N Engl J Med 2016;374:

27 Prevention of AF 1 0,8 Odds Ratio 0,6 0,4 0,2 0 Beta blocker Sotalol Amiodarone Atrial pacing Circulation 2002;106:75-80

28 Pacemaker Atrial pacing preferred With A-V block - AV sequential pacing Ventricular pacing only as a rescue therapy (cardiac standstill or failure of atrial leads to capture)

29 TRACS trial N = 502 (single centre) Adult patients after cardiac surgery with CPB Hematocrit 0.24 versus 0.30 Composite end-point 30 day mortality and cardiogenic shock/ards/aki Hajjar LA. JAMA 2010;304:

30 TRACS trial P < Receiving transfucion (%) Primary end-point (%) Restrictive Liberal 0 Restrictive Liberal Hajjar LA. JAMA 2010;304:

31 Age of transfused blood RECESS multicenter RCT Standard-blood (median 7 D) Fresh-blood (median 28 D) 40 Leukoreduced 30 35, ,3 34, ,4 0 6,6 5,7 90 D mortality ARDS Nosocomial infection MODS No differences in ICU LOS and hospital LOS N = Cardiac surgery with age > 12 Steiner ME. N Eng J Med 2015;372:

32 Tamponade

33 Low pressure tamponade Classic tamponade Sagrista-Sauleda J. Circulation 2006;114:

34 Tamponade Often aspecific

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36 Intra-aortic balloon pump Helium filled balloon with tip just distal from origin of LSA Reduced myocardial oxygen demand, enhanced coronary blood flow and increased cardiac output Timing of inflation/deflation by EKG, arterial pressure waveform or physiologic timing algorithm Total complication rate 2.6% with major complications < 0.5% (limb, bowel and renal ischemia) Attributable mortality < 0.05% Contraindicated in severe aortic regurgitation and dissection

37 Indications IABP Cardiogenic shock??? VSR and papillary muscle rupture with MI Intractable ventricular arrhythmias Unstable angina refractory to medical therapy High risk PCI / CABG

38 Tamponade

39 Low pressure tamponade Classic tamponade Sagrista-Sauleda J. Circulation 2006;114:

40 IABP Unassisted systole Diastolic augmentation Assisted systole Balloon inflation Unassisted aortic end diastolic pressure Assisted aortic end diastolic pressure Inflation: dicrotic notch - Deflation: arterial pressure rise

41 Inadequate timing Unassisted systole Diastolic augmentation Assisted systole Unassisted systole Diastolic augmentation Assisted systole Dicrotic notch Assisted aortic end diastolic pressure Early inflation Increases LV afterload and myocardial oxygen consumption Late inflation Minimises diastolic augmentation

42 Inadequate timing Diastolic augmentation Assisted systole Unassisted aortic end diastolic pressure Assisted aortic end diastolic pressure Unassisted systole Diastolic augmentation Widened appearance Prolonged rate of rise of assisted systole Assisted aortic end diastolic pressure Early deflation May promote retrograde blood flow from carotid and coronary arteries Late deflation Increases LV afterload and myocardial oxygen consumption

43 Percutaneous LVAD s Impella 2.5 Axial pump placed across the aortic valve via one of femoral arteries Impella LP (3.7) Impella 5.0

44 Meta-analysis plvad s Cheng JM. Eur Heart J 2009;30:

45 Engström AE. Ned Ttijdschr Geneeskd 2010;154:

46 VA-ECMO VA-ECMO (return FA - default strategy for reversible CS) VA-ECMO (central - failure to wean from CPB) VA-ECMO (return AA - in case of lower-limb vascular disease and high flow not required) VA-ECMO + Impella (for better LV decompression)

47 LV drainage canula in case of closed AV

48 Peripheral VA-ECMO

49 Increasing ECMO flow increases LV afterload and Ea - consequently LVEDP, LAP and PCWP

50 Literature research Comparison of pva-ecmo and cva-ecmo 44% reexploration for p- and 100% for cva-ecmo (indication bleeding) 16% ischemic leg complications (pva-ecmo) Saeed D. Artif Organs 2014

51 VA-ECMO - general changes Loss of arterial flow pulsatility Preload reduction with PBF Coronary artery perfused with desaturated blood coming from bronchial circulation, sinus venosus and Thebesian veins Increase in LV afterload leading to a distended LV Certain degree should always be promoted to prevent IC clot formation: 20-30% of total CO pulse pressure mmhg Low dose inotropes Pump flow Otherwise venting essential IABP

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53 Most important complications of peripheral VA-ECMO Limb ischemia Supra-coronary and coronary hypoperfusion Left ventricular dilatation with pulmonary edema

54 The most important problem Incidence limb ischemia (meta-analysis N = 1800) 10% Vessel obstruction (large canula size), nonpulsatile flow, low systolic BP, vessel injury, coagulopathy Pulselessness, poikilothermia, pallor, pain, paresthesia and paralysis

55 Recent literature Femoral artery cannulation (N = 101) Eighteen (17.8%) had vascular complications Mean duration of cannulation 7.2 days Sixteen (89%) needed surgical intervention with femoral endarterectomy/patch angioplasty (8) and below knee amputation (1) Aziz F. Ann Vasc Surg 2014;28:

56 Distal limb ischemia Placement of a 5 or 7 F distal perfusion catheter Connected with a 6 inch extension tube and 3-way stopcock connected to the side-port of the arterial cannula Patch closure of arteriotomy after removal

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58 (Supra) coronary hypoperfusion Monitoring of R radial artery PaO2 + SpO2 NIRS vva-ecmo Treatment Increasing ECMO flow/optimizing MV settings Central canulation vva-ecmo

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60 Left ventricular dilatation 327 Soleimani B and Pae WE Residual venous return or from collaterals from bronchial and PA artery Severe LV dysfunction with high afterload due to ECMO often with MV regurgitation Failure of AV to open or AV insufficiency Reported in 12-68% of vafigure 1. Transoesophageal echocardiogram showing a ECMO patients four-chamber view of a heart supported by a HeartMate II left ventricular assist device (LVAD). The image demonstrates complete decompression of the left ventricle (LV) and the left atrium (LA). 328 Perfusion 27(4) Figure 2. Chest radiograph showing pulmonary oedema in patient supported with extracorporeal membrane oxygenator (ECMO). The inflow cannula is positioned appropriately in the right atrium. The tip of the intra-aortic balloon pump (IABP) is at the aortic knuckle.

61 Left ventricular dilatation Treatment Optimal position of venous canula + adequate pump flow Optimize cardiac function and treat fluid overload Unloading the LV with IABP or Impella Arial septostomy with connection to venous circuit or direct trans- aortic LV vent (idem) PA catheter connected to venous circuit Last resort: direct left atrial canulation through sternotomy (idem)

62 LV or proximal aorta thrombosis Adequate anticoagulation Inotropic agents with failure of AV opening Transseptal left atrial decompression Subxiphoid left ventricular drainage

63 Position of drainage canula may also be abnormal

64 N = 33 Weaning trial minutes ECMO flow 66% or minutes ECMO flow 33% or L Successful if MAP > 60 mmhg Predictors of successful decanulation VTI 10 cm LVEF > 20-25% Mitral annulus PSV 6 cm/s Aissaoui N. Intensive Care Med 2011;37:

65 INTERMACS classification INTERMACS Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Level 7 Criteria Critical cardiogenic shock ( crash and burn ) Progressive decline on inotropic support Stable but on inotropic support Resting symptoms on home oral therapy Exertion intolerant Exertion limited Advanced NYHA Class III Interagency Registry for Mechanical Circulatory Support

66 Emergency HTx N = In-hospital mortality (%) 37, ,5 Primary graft failure (%) / /4 INTERMACS Class INTERMACS Class INTERMACS 1 also associated with higher need for RRT Barge-Caballero E. Circ Heart Fail 2013;6: