Admission to the ICU and Monitoring Technique

 Intraoperative monitoring with

Early Postoperative Care

 Intraoperative monitoring with Swan-Ganz catheter measurements and transesophageal echocardiography
(TEE) are routinely used to direct hemodynamic management and fluid administration
 The pathophysiology noted after off-pump surgery is slightly
different in that patients are not subjected to the insults of CPB and cardioplegia, two factors
that contribute to a systemic inflammatory response and transient myocardial depression.

Basic Features of the Early Postoperative Period

 Adequate pharmacologicsedation and pain control is essential at this time and during the weaning process
from the ventilator
 Early extubation is usually defined as withdrawal of mechanical ventilation within 8 hours of surgery
 Right ventricular function may be improved when positive-pressure ventilation is not required
 Important to provide adequate analgesia to these patients without producing respiratory depression,
generally using nonsteroidal anti-inflammatory drugs or low doses of narcotics
CARDIOPULMONARY BYPASS
 Virtually all valve surgery and most coronary bypass surgery is performed using CPB
 Basically, the blood drains by gravity or with vacuum assist from the right atrium into a reservoir, is
oxygenated, cooled or warmed, and then returned to the patient through an arterial cannula usually placed
in the ascending aorta
 Arterial blood gases are measured to ensure that the oxygenator is providing adequate oxygenation and that
CO2 extraction is sufficient
 Venous oxygen saturation is measured to determine if the systemic flow rate is adequate (>65–70%)
 Systemic hypothermia is utilized to varying degrees during on-pump surgery as a means of organ protection
during a period of nonphysiologic, nonpulsatile flow at lower mean pressures
 The serum level of antibiotics falls approximately 30–50% at the time of initiation of CPB and an additional
dose of a cephalosporin should be considered at that time. Alternatively, a second dose can be given 3–4
hours after the initial dose
 The optimal mean blood pressure during CPB to maintain adequate organ system perfusion is controversial.
It has been shown that cerebral blood flow is more dependent on blood pressure than on flow rate
 The brain is able to maintain cerebral blood flow by autoregulation until the pressure falls below 40 mm Hg,
but this response is inadequate in diabetic and hypertensive patients, in whom a higher pressure must be
maintained
 Hypotension may be related to hemodilution, use of preoperative vasodilators (ACE inhibitors, ARBs,
calcium channel blockers, and amiodarone), vasodilation during rewarming, and autonomic dysfunction. It
may also result from inadequate systemic flow rates, impairment of venous drainage, aortic regurgitation,
the administration of cardioplegia, and during return of large amounts of cardiotomy-suctioned blood into the
circulation
 Hypertension may be related to vasoconstriction with hypothermia, inadequate levels of anesthesia and
analgesia, elevation in endogenous catecholamine levels, and alterations in acid-base balance and blood
gas exchange
 Although a higher mean blood pressure (around 80 mm Hg) might reduce some of the neurocognitive
changes seen after bypass, the standard management is to maintain a mean blood pressure around 65 mm
Hg using vasodilators (narcotics or inhalational anesthetics) or vasopressors (phenylephrine,
norepinephrine, or vasopressin) as long as flow rates are adequate. A venous oxygen saturation exceeding
65% generally indicates that the systemic flow rate is satisfactory, although there may be differences in
regional flow (i.e., less to the kidneys and splanchnic circulation). The venous saturation tends to be higher
during systemic hypothermia due to lower oxygen extraction, and may decrease significantly during
rewarming, necessitating an increase in flow rates.
 Blood glucose tends to be elevated due to the hormonal stress response to surgery and CPB with insulin
resistance. The infusion of insulin to maintain blood glucose <180–200 mg/dL during surgery has not been
shown to reduce inotropic requirements or the occurrence of arrhythmias, but may reduce the incidence of
neurocognitive dysfunction and other adverse outcomes, including death
CABG
 Hindari peningkatan O2 demand (karena takikardia, hipertensi), terutama saat pre-bypass dan selama
induksi
 Hindari ischemia dan hipertensi (karena hipotensi) karena penggunaan vasodilating agent dengan cairan
dan α-agonist
 Iskemia dapat dideteksi dengan TEE, tandanya :
o regional wall motion abnormalities
o peningkatan PAP
o ECG – perubahan ST segmen
 Iskemia, terapi :
o Nitroglycerine
o β-blocker (esmolol)
o Narcotic
o Jika tidak membaik, segera CPB
 Fast track - low-dose fentanyl or sufentanil, inhalational anesthetics, and propofol or dexmedetomidine
 Ultra Fast track - short-acting narcotic remifentanil along with a volatile inhalational anesthetic with rapid
onset and offset of effect, such as sevoflurane or desflurane
 OP-CAB (off pump)
o Jantung masih berdetak
o Penggunaan Swan-Ganz dan in-line mixed vein oxygen saturation monitoring
o Bed posisi trendelenburg dan miring kanan – agar cardiac filling membaik, judicious fluid
administration, antiarrhythmic therapy (lidocaine/magnesium), a-agents (phenylephrine) and
inotropes (epinephrine/milrinone), and, on occasion, insertion of an intra-aortic balloon pump
(IABP) may be used
PANGGILAN
1. Panggilan 1 (menanyakan berapa pump, pakai bio sensor / edward, mostcare, NIRS, dll)
2. Panggilan 2 (mengantar bed ICU ke OK PPJT)
3. Panggilan 3 (pasien proses pindah dari OK ke bed, tim ICU PPJT bersiap menjemput pasien)
4. Panggilan 4 (menjemput pasien ke OK)

PVR naik (mengakibatkan Qp menurun (Qp<Qs) - (R to L dominant)) :

 Vasoconstricting drugs
 Hypoxemia
 Acidemia
 Hypercapnia (high partial pressure of arterial carbon dioxide [PaCO2])
 Atelectasis
 Ventilasi tekanan positif yang berlebihan

POST OPERASI OH (OPEN HEART)

1. Pasien tiba di ICU di cek lab lengkap (DL, RFT, LFT, Alb, SE, Ca, Mg, FH, GDA). Lain-lain sesuai request.
2. Cek BGA via ISTAT dilaporkan oleh tim AKV ke konsultan membius
3. Lapor BGA dan lab post op ke konsultan yang membius dan konsultan mingguan saat pasien baru datang.
Sisanya, hanya lapor ke konsultan yang membius.
4. Setiap perubahan kondisi penting dilaporkan ke konsultan ICU
5. Beberapa konsultan yang membius, minta tetap dilapori pasien-pasien post op yang masih observasian
atau bermasalah, walaupun sudah 24 jam post op atau sudah divisite oleh konsultan icu.
6. Isi ecalyptus di lakukan oleh tim pagi
7. Target balance cairan post OH
o Defisit 10 - 30 ml/kg/hari
o Jika tidak tercapai dapat diberikan lasix extra  evaluasi apakah perlu maintenance atau
penurunan dosis
Notes :
 Beberapa kondisi slight hiperkalemia disengaja, jgn dikoreksi bila tidak ada advis. Kalau bingung, mending
dilaporkan aja sambil usul koreksi supaya mereka aware.
 Koreksi hipovolum kebanyakan dengan Plasbumin 5% atau koloid lain. Kalau bisa diresepin aja post OH
biar keluarga ga bolak balik.
 Kadang juga beberapa minta loading Kristaloid (paling sering Asering sih kalo aku)
 Biar ga konsul bolak balik, mungkin bisa diliat tren nya aja untuk hemodinamik dan suhu rectal. Kalau
terkesan bermasalah, lapor sambil minta advis
 Misal : " mohon ijin dok, untuk suhu trennya cenderung naik dibandingkan saat turun dari OK. jika di atas
37,5 apa boleh kami extra pct 1 gr" (misalnya.. )
 Jika TD namun euvolume  dapat diberikan NE atau Adrenalin pada pediatri
 ST elevasi di semua lead  curiga Perikarditis post-op
 Weaning inotropik dan vasoaktif
o Adre / NE dlu setelah itu Dobu / Dopa terakhir Milrinon
o Sebelum aff Milrinon masuk Captopril dlu sebagai Vasodilator.

BP TURUN
 Hypovolemia
 Sudden termination of a drug infusion
 Acute blood loss (drain)
 Myocardial ischemia
 Severe myocardial dysfunction
 Arrhythmias
 Ventilatory problems
 Kinking or transient occlusion of the line, producing a dampened tracing

MENILAI KECUKUPAN CAIRAN

 MAP
 CVP target > 6-8
  PLR kenaikan > 20%
 IVC

KOREKSI NaBic
 1 mEq/KgBB dalam 3 jam
 100 mEq dalam 4 jam (dewasa)
(Tergantung kondisi)

PVR turun :
 Vasodilating drugs
 Alkalemia
 Hypocapnia (low PaCO2)
 Strenuous exercise

SVR naik :
 Hypothermia
 Hypovolemia
 Cardiogenic shock
 Stress response
 Syndromes of low cardiac output

SVR turun :
 Anaphylactic and neurogenic shock
 Anemia
 Cirrhosis
 Vasodilation

DRAIN POST OPERASI

 5cc/kg/jam  REOPEN
 3cc/kg/jam dalam 3 jam berturut - turut  REOPEN
(tiap jam evaluasi : dapat diberikan extra Transamin 1 gram dan Vit K 2 ampul)