Junior Doctor Induc on handbook for the

Department of Cardiothoracic Surgery

Reviews
Luke Williams August 2021
Ismail Vokshi August 2020
Jason Ali August 2019
ti
 Table of Contents
Introduc on .......................................................................................................................4
Structure of the department ..............................................................................................4
Surgeons ....................................................................................................................................4
Ward Doctors .............................................................................................................................4
Ward Bleeps ...............................................................................................................................5
Advanced nurse prac oners (ANP) ...........................................................................................5
ALERT team ................................................................................................................................5
Administra on ...................................................................................................................6
Educa onal supervisor ...............................................................................................................6
Rota............................................................................................................................................6
Educa onal mee ngs .................................................................................................................6
Medical student teaching ...........................................................................................................6
Informa on Technology ..............................................................................................................7
Lockers and phone numbers .......................................................................................................7
Du es of the Ward Doctor..................................................................................................7
Structure of the working day ......................................................................................................7
Speci c Ward Doctor Roles .........................................................................................................8
Speci c tasks: .............................................................................................................................8
Discharge summaries ....................................................................................................................................9
Preopera ve admissions ...............................................................................................................................9
Reviewing unwell pa ents ............................................................................................................................9
Upda ng consultants ....................................................................................................................................9
Referring pa ents to local hospitals ..............................................................................................................9
Pre-weekend planning ................................................................................................................................10
Pa ent deaths .............................................................................................................................................10
Outpa ent clinics ........................................................................................................................................10
On-call – bleep 509 ...................................................................................................................10
Admission process ............................................................................................................12
Process of reviewing preopera ve admissions ..........................................................................12
Common preopera ve issues ....................................................................................................13
A ending theatre ............................................................................................................14
Opera ve procedures ...............................................................................................................15
Applying for cardiothoracic surgical training ....................................................................15
Audit and research involvement .......................................................................................16
Postopera ve management .............................................................................................17
Postopera ve medica ons........................................................................................................17
Cardiac surgery pa ents..............................................................................................................................17
Pulmonary endarterectomy ........................................................................................................................17
tt
ti
ti
ti
fi
fi
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
 Postopera ve inves ga ons .....................................................................................................18
Common postopera ve clinical problems .........................................................................19
Low urine output ......................................................................................................................19
‘Fast’ atrial brilla on...............................................................................................................20
Weaning of dopamine in post-cardiac surgery pa ents .............................................................22
Cardiac arrest following cardiac surgery ..........................................................................22
Miscellaneous informa on ...............................................................................................24
Pacing boxes .............................................................................................................................24
Reques ng PICC lines, Echocardiograms and 24-hour tapes ......................................................25
ti
ti
fi
ti
ti
ti
ti
ti
ti
 Introduc on
Royal Papworth Hospital is a leading cardiothoracic centre specialising in all aspects of
cardiac and thoracic medical and surgical care. In April 2019 the hospital relocated to a
purpose built, state of the art building located in the Cambridge Biomedical Campus.

Royal Papworth Hospital features heavily in the history of cardiothoracic surgery and
transplanta on, and currently has the best outcomes for adult cardiac surgery, thoracic
surgery and cardiothoracic transplanta on in the UK.

During your me at Papworth you should aim to make the most of the resources available.
For those interested in surgery there are plenty of opportuni es to a end theatre and
develop surgical and other prac cal skills; there are also many opportuni es for those
interested in other aspects of medicine throughout the hospital.

By the me you leave Royal Papworth Hospital you should aim to be familiar with the
preopera ve assessment and the postopera ve management of cardiothoracic surgical
pa ents, including management of common postopera ve complica ons.

Structure of the department

Surgeons

The cardiothoracic surgical department has 17 consultant surgeons divided into 4 cardiac
surgical and 1 thoracic surgical teams:

RED (Thoracic) Team (#310) - Mr Coonar (ASC), Mr Aresu (GA), Mr A Peryt (AP)

The cardiac registrars are divided between the four cardiac teams, covering their speci c
consultants:

PURPLE Team – Mr Jenkins (DJ), Mr Taghavi (JT), Mr Dronavalli (VD)

BLUE Team – Mr Large (SRL), Mr Wells (FCW), Mr Tsui (ST), Miss Iyer (SI)

GREEN Team - Mr Moorjani (NM), Mr Ra q (UR), Mr Ng (CNG), Mr Kaul (PK)

ORANGE Team - Mr Nashef (SN), Mr Berman (MB), Mr De Silva (RDS)

Ward Doctors

On call SHO #509

Dr Rasoel Kushiwal #844 (North)

ti
ti
ti
ti
ti
ti
ti
ti
fi
ti
ti
ti
ti
tt
ti
fi
 Ward Bleeps

5 North East SHO/ANP #141

5 North West SHO/ANP #970
5 South East SHO/ANP #029
5 South West SHO/ANP #957
Thoracic Surgery SHO #310
In-House Urgent (IHU) ANP #984

Advanced nurse prac oners (ANP)

There are a team of ANPs whose roles overlap somewhat with the ward doctor team. The
ANPs are an essen al part of the surgical team and your me at Papworth will be enhanced
by forming good rela onships with them. Teamwork is essen al and working together with
the ANP team will provide you opportuni es for theatre me and other ac vi es.

The ANPs have some speci c roles:

- The ‘in-house urgent’ pathway coordina on – coordina ng the MDT and transfer of
pa ents referred for urgent surgery from local district general hospitals.

- Admissions coordinator – coordina on of the surgical admissions – both pa ents

admi ed as ‘same-day’ admissions and those being admi ed for surgery the
following day.

ANPs are also available to help on the ward, both on the ward rounds and managing teams.
There should be 1-2 ANPs available each day to help with ward work. Fully quali ed ANPs
are able to prescribe, whilst others are working towards this status and may require your
help with certain tasks during their training.

ALERT team

Papworth has a team of highly experienced ALERT nurses who are very senior nurses who
are o en the rst port of call for ward nurses when there are deteriora ng pa ents. They
are able to manage postopera ve pa ents with problems and form an important link with
ITU when pa ents need readmission or assessment by the ITU team.

There are ALERT nurses 24 hours a day, and you must work very closely with them during
your on-call shi s at Papworth – especially at night me. They have all worked at Papworth
for many years and are very experienced. If they are worried about a pa ent, so Ward
doctoruld you be. Follow their advice, they know what they are talking about!
ti
tt
ft
ti
fi
ft
ti
ti
ti
ti
fi
ti
ti
ti
ti
ti
ti
ti
ti
ti
tt
ti
ti
ti
ti
ti
ti
ti
fi
 Administra on

Educa onal supervisor

Your educa onal supervisor is the RCS Tutor who is Mr Giuseppe Aresu. You Ward doctoruld
make appointments to see him through his secretary: Julie Vaughan
(julie.vaughan2@nhs.net) to complete your relevant por olio documenta on.

Rota

The rota can be found on the shared drive. The rota coordinator is StR: Dan Sitaranjan
(daniel.sitaranjan@nhs.net).

All leave requests: annual leave and study leave, should be sent to the rota coordinator.
Study leave requests should also be sent to your AES for approval. Normally at least 6 weeks
is required for leave approval. There may be excep ons. We will always endeavour to allow
leave for urgent issues. If you require leave during your day/weekend or night on-calls,
please try and swap these prior to asking for annual leave.

Educa onal mee ngs

There are a large number of educa onal opportuni es at Papworth. The educa on
department will email you relevant metables at regular intervals.

The regular surgical mee ngs include:

• Cardiothoracic departmental mee ng

o Every Wednesday morning at 0815 in the 5th Floor Seminar room and via
Webex

• Monthly Audit and Morbidity & Mortality

o Every month from 9-12am. Discussion of morbidity and mortality in the
previous month. Occasionally you will be asked to present cases. If you
would like to do this for your own development, discuss with the organising
registrar

• Regional cardiothoracic teaching

o Every month there is regional teaching for the surgical registrars which
usually is a morning event. You are very welcome to a end these and will
be informed of the dates. Some of these sessions are wetlabs where you
will have the opportunity to prac ce surgical skills.

Medical student teaching

ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
tt
tf
ti
ti
 There are lots of medical students coming through Papworth. There are plenty of
opportuni es for teaching medical students if you are interested. Get in touch with the
educa on team if you are interested in pursuing this. There are opportuni es for both
delivering seminars and bed-side teaching.

Informa on Technology

Papworth Hospital uses an electronic pa ent record: Lorenzo, that you will receive training
on and require a ‘smartcard’ that you will be issued with.

Please contact IT on your rst day to request the following:

1. Obtain access to rota and team list folders

• S:\shared\Medical Sta ng Informa on\
• N:\Shared\CARDIOTHORACIC LISTS
2. Obtain access to EMR
3. Obtain access external link bu on on Lorenzo
4. A telephone extension

Lockers and phone numbers

To obtain a locker, please email a request to: rajesh.patel2@nhs.net

To obtain a phone number that you will require to log onto phones email:
alister.cresswell@nhs.net

Du es of the Ward Doctor

Structure of the working day

070 Thoracic: Update and print pa ent list prior to ward round (this is key to a
0 smooth ward round). Cardiac: review new admissions to ensure they are
prepared for surgery and review any overnight events/prepare ward round notes
073 Ward round led by registrar
0 Ward doctor documents important results and management plans in notes

080 Theatre brie ng led by registrar/consultant

0
081 Complete ward round and do jobs like booking inves ga ons, TTOs, transfer
5 le ers
084 Theatre opportuni es, Ward jobs etc.
5
tt
ti
ti
ti
ti
fi
ti
ffi
fi
ti
tt
ti
ti
ti
ti
ti
 150 Evening board round with registrar
0
164 Handover to #509
5

The ward lists are managed by the nurses, but there is a sec on for doctors notes, which you
Ward doctor should obtain access to edit. It is essen al that the following pieces of
informa on are documented on the lists for each cardiac pa ent:

- Preopera ve crea nine – so that degree of AKI can be assessed to guide

reintroduc on of medica ons

- Le ventricular func on – to guide postopera ve drug management

- Preopera ve weight – to guide postopera ve diure c management comparing

current weight with the preopera ve weight

Speci c Ward Doctor Roles

5 NORTH – You will do the ward round with Rasoel (#844), who is an experienced medic,
who looks a er post-opera ve cardiac pa ents. You will be responsible for documen ng the
ward round and ensuring all of the jobs are completed in a mely manner. If you have
concerns about a pa ent you should escalate to Rasoel in the rst instance.

5 SOUTH Cardiac – You will do the cardiac ward round with the ward registrar and are
responsible for ensuring all of the jobs for these pa ents are completed in a mely manner.
Any issues should be escalated to the ward registrar in the rst instance. You should obtain
their bleep/mobile number at the beginning of the day. In the event that you cannot get
hold of them you can escalate to Rasoel on #844 or the on call registrar on #744.

Thoracic #310 – You will need to update the thoracic list at 7am and then go on the ward
round with the thoracic registrar from 7:15-8. You will then document the ward round a er
brie ng and ensure the jobs are all done. You may be required to see “drain review”
pa ents. These are pa ents who have been discharged with a drain post-opera vely and
return to see if their drain can come out. You assess the drain for air leak and if there is none
clamp the drain and send them for an X-ray. If the lung stays up the drain can be removed
and the pa ent sent home a er a repeat CXR. The thoracic registrar will be in theatre all day,
but will come to check on the pa ents between cases and will expect you to update them on
their progress. If you feel the need to escalate about a thoracic pa ent but cannot get hold
of the registrar you should not hesitate to call the pa ent’s consultant for advice via switch.

Speci c tasks:
ft
ti
fi
fi
fi
ti
ti
ti
ti
ti
ft
ti
ti
ti
ti
ti
ti
ft
ti
ti
ti
ti
ti
ti
ti
ti
ti
fi
ti
ti
ti
fi
ti
ti
ti
ti
ft
 Discharge summaries

Discharge summaries are an important form of communica on between Papworth and the
pa ents GP who will be managing the pa ent going forward so it is important that there is
accurate and detailed informa on on the pa ents stay documented. Please be conscien ous
when comple ng this documenta on as discharge summaries are a common source of
complaints from GPs and local hospitals.

Speci c details on medica on changes should be documented and plans for diure cs and
cardiac medica ons should be documented -> ask the SpR seeing the pa ent to clarify this
during the ward round. Please include the results of any relevant inves ga ons and if you
ask a GP to do something, for example blood tests, please specify exactly what tests, when
and why and what the GP should do with the results. Please also ensure that pa ents are
discharged with adequate analgesia and this should include at least paracetamol and
codeine phosphate.

Preopera ve admissions

Preopera ve admission review is a task shared with the ANPs. The ANP admission
coordinator will distribute admissions each morning depending on the number of ANPs and
ward doctors working.

There are speci c things that need to be completed to perform the admission process – see
later sec on on admissions. Please ensure that all tasks are completed and anything
outstanding is handed over to the on-call ward doctor (509). If you iden fy any issues you
must escalate to the registrar scheduled to be in that theatre (see the opera on list) and if
unable to contact that person, escalate to the consultant.

Reviewing unwell pa ents

Review of deteriora ng pa ents is an important role. You may be contacted by ward nurses,
or the ALERT nurses. You should review the pa ents comprehensively, being aware of the
common complica ons of cardiothoracic surgery. Escala on is important and this should be
to the on-call surgical registrar, and/or the consultant.

Upda ng consultants

Do not hesitate to contact the pa ent’s consultants. All are very apprecia ve of ge ng in
touch to update them on their pa ents and this can be helpful for developing rapport to
facilitate you ge ng opportuni es in theatre. If the team registrars are in theatre and a
decision is required it is best to contact the pa ent’s consultant directly as this will be the
most e ec ve way of solving problems. If the consultant is not available, ask another
consultant from that team or the on-call consultant.

Referring pa ents to local hospitals

ti
fi
ti
ff
ti
ti
ti
ti
ti
ti
ti
fi
tti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
tti
ti
 Pa ents thought to require a period of rehabilita on prior to being able to go home safely
are referred back to their referring hospital to enable pa ent ow through Papworth. If
asked to refer the pa ent, you should call the relevant team in their referring hospital
(usually cardiologist). This should be correctly documented in Lorenzo and be aware that a
referral le er will be required. It is o en the best me to prepare this as you will have
reviewed the pa ents history when referring the pa ent.

Pre-weekend planning

Weekends can be busy and there are a few things you can do to help your colleagues make
life easier:

- Prepare TTOs and discharge summaries for pa ents you an cipate will be discharged
- Ensure referral le ers are wri en for pa ents you have referred to their local
hospitals as wri ng transfer le ers for pa ents is not best done by the on-call doctor
- Ensure protocol blood tests and CXRs are requested

Pa ent deaths

You are not required to complete any paperwork rela ng to pa ent deaths. This should be
done by the team registrar.

Outpa ent clinics

You are not required to a end any outpa ent clinics. However, you are very welcome to
a end. It can be very useful for your professional development to see new pa ents, present
them to the consultant and then dictate le ers. It is an important skill that will be useful in
whatever area of medicine you end up. Again, another opportunity to work closely with
consultants. It is also a good opportunity to complete workplace based assessments
essen al for your comple on of each placement. Clinics run daily in the morning and
a ernoon in the outpa ents department.

On-call – bleep 509

Handover from the night ward doctor occurs at 0700 in the 3rd oor ALERT o ce (5 North).
Your du es include a ending all arrest calls (allocated role is scribe/ mekeeping), reviewing
unwell pa ents and to clerk any pa ents who arrive out-of-hours or as unscheduled/
emergency admissions.

At night, there is a cross-cover rota for cardiothoracic surgery, cardiology, transplant and
respiratory. Handover is at 1900 in the 3rd oor ALERT o ce (5 North). There will be another
ward doctor who will carry 502 and generally covers pa ents on the 4th and 3rd oors
(cardiology and respiratory), whilst you will cover pa ents on the 5th oor (Surgery and
Transplant). There is a respiratory and transplant registrar on call who should be the rst
point of call for their pa ents. Only if they are not available (Transplant SPR may be out on
tt
ft
ti
ti
ti
ti
ti
ti
tt
ti
ti
tt
ti
tt
ti
ti
tt
ti
tt
tt
ti
ft
ti
ti
ti
fl
tt
ti
ti
ti
ti
ti
ti
ti
ffi
ti
ti
fl
ti
fl
ti
fl
ffi
ti
fl
fi
 retrieval for example) should you take responsibility for their care and as these tend to be
highly complex pa ents, any decisions should be discussed with a senior.

There is a hospital at night mee ng at 2200 in the ALERT O ce, which you should a end
and document a “safety huddle” note for the surgical pa ents discussed. This is a ended by
ALERT, ICU and the surgical, anaesthe c, cardiology and respiratory registrars and is an
excellent opportunity to raise any concerns about unwell pa ents.

Referrals from GPs and other hospitals should be directed to the on-call registrar.

It is essen al that everyone works together as a team. The on call ward doctor can be very
busy, so every e ort should be made to help your colleagues when they are carrying 509 by
comple ng your own rm’s administra ve tasks. Inves ga on requests, referrals, TTOs and
transfer le ers must be done before you go to theatre.

IN THE EVENT OF ANY URGENT / EMERGENCY SITUATION THERE IS ALWAYS A

SURGICAL REGISTRAR OUT OF THEATRE CARRYING BLEEP 744 AND AN ITU
REGISTRAR ON BLEEP 500.
ti
ti
tt
ff
ti
fi
ti
ti
ti
ti
ti
ti
ffi
ti
tt
tt
 Admission process

Process of reviewing preopera ve admissions

The responsibility for comple ng clerking on both elec ve and non-elec ve surgical pa ents
falls to the ward doctor and ANP’s. We currently have one ANP who is the admissions co-
ordinator who allocates all daily admissions to the ward doctors and ANPs.

The admission co-ordinator holds bleep 029

Most surgical pa ents will have been seen in preadmission and so come for surgery with
most of their admission clerking already completed.

Some of these pa ents will be admi ed as a ‘Same Day Admission’ (SDA) whereby all that is
required is to authorise the VTE and Mandatory blood forms, check that bloods and x match
are in date, ensure INR checked if appropriate and transfer medica ons onto the ‘inpa ent’
chart on Lorenzo.

Any pa ent that has not been seen in pre admission, which includes the PTE pa ents will
require full clerking.

All pa ents should have a yellow CAF (Current ac vity folder) which should have:

- Signed Surgical Consent form

- Signed Tissue Consent Form
- Name labels

The forms that are required to be completed as part of the clerking process are:

• Papworth Surgical Integrated Care Pathway – found in admissions tab. Right click, go
to forms (2nd line down), and go to Surgical ICP. You need to complete page 1, 2 and
3. (If the form has already been commenced in preadmission you may need to add to
it on admission so you need to ‘complete’ not con nue)
• VTE form. Found either in the Surgical ICP form or as a standalone document. (Found
in admissions tab. Right click; go to forms (9th line down).
• Mandatory blood form. Found either as part of the Surgical ICP or as a standalone
document. (Found in admissions tab. Right click; go to forms (1st line down).
• Tissue Consent Form – pa ent may decline permission but we should s ll strike
through the form and leave in the CAF folder.
• Recon rm surgical consent.

Note: some pa ents have been clerked using old clerking forms which are a separate
Cardiac surgical history form and surgical physical examina on form

Inves ga ons that should be checked are:

• Bloods: FBC, U and E’s, LFT’s, Glucose, INR (if appropriate) Clo ng
ti
ti
fi
ti
ti
ti
ti
ti
ti
ti
ti
tt
ti
ti
ti
ti
tti
ti
ti
ti
ti
ti
ti
 • X match (must be less than one month old or needs repea ng)
• CXR (must be less than 6 weeks. Must be Chest and lateral view for cardiac surgery
pa ents)
• Echocardiogram (must be less than one year)
• Angiogram
• MRSA result (must be within three months unless the pa ent has had a hospital
admission in that me and therefore needs to be repeated)
• PTE pa ents should have a walk test booked on admission – PTE team organise this

Prescrip ons:
• PTE pa ents will have stat dose of prednisolone 1mg/kg for night pre op

Common preopera ve issues

Stopping medica ons pre-op:

• Aspirin 5-7 days – unless in-house urgent or thoracic surgery when it is usually
con nued
• Clopidogrel 7 days
• Warfarin 4-5 days
o If high risk then may need bridge with therapeu c LMWH un l 1 day pre-
op
o Includes PTE pa ents and those with mechanical valves in situ
o Protocol is on intranet
• DOACS 2 days
• Me ormin 2 days
• ACEi or AR2B night before
• Con nue beta blockers pre-op

Current infec ons for valve pa ents:

• Ensure valve pa ents have seen a den st in the last 6 months

• If leucocytes and/or nitrites posi ve on urinalysis then send urgent MSU to
Addenbrookes and follow-up the microscopy
• Inform registrar or consultant – if pa ent is asymptoma c usually, they will
proceed
• However, this is at the discre on of the consultant

Deranged clo ng:

• If the APTT is >38 then please discuss with Dr Besser (consultant haematologist)
• If unavailable, then contact the on-call haematology registrar at Addenbrookes
• These pa ents will require further inves ga ons that take several hours so the
sooner this is acted on the fewer delays there are in theatres
ti
tf
ti
ti
ti
ti
ti
ti
ti
tti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
 Abnormal pre-opera ve inves ga ons:

• New murmur requires echocardiogram

• Caro d bruits
• Absent peripheral pulses
• Varicose veins or previous varicose vein surgery
• Nodules on CXR or CT scans – check the reports for any alerts
• Please inform relevant registrar or consultant, out of hours please inform 744

Diabetes: protocol on intranet

A ending theatre
Papworth is very pro-training and has the reputa on of being the best centre for
cardiothoracic training and surgery in the UK. There should be plenty of opportunity to
a end theatre. Furthermore, you are very welcome to a end theatre on your days o if you
are interested.

Important guidance for a ending theatre:

- Ensure you handover your bleep – nd a colleague who can cover your team whilst
you are in theatre. Teamwork is essen al. If you work together you can spend a lot of
me in theatre, but you must be willing to reciprocate and hold your colleagues
bleep in exchange.

- See the pa ents before going to theatre - you will be expected to have seen the
pa ent prior to a ending theatre. You should expect to be asked ques ons on the
pa ents history.

- Speak to the consultant before a ending – It is advisable that you speak to the
consultant the night before a ending theatre. If you are hoping to perform a
procedure this should be discussed before the day of the opera on. It is a good
opportunity to discuss the pa ent history and your examina on ndings etc. and can
use this as an opportunity for a WBA.

- A end the theatre brie ng – this is at 8:00 every morning and will be where the
cases for the day are presented. You may be asked by the consultant to present the
cases.

If you intend going to theatre, you can liaise with the admission coordinator ANP and
request that the pa ents you will be in theatre with are allocated to you so that you review
them on admission.
ti
tt
tt
tt
ti
ti
ti
ti
tt
ti
ti
fi
tt
tt
ti
ti
tt
ti
fi
ti
ti
tt
ti
ti
fi
ti
ff
 Opera ve procedures

There are many opportuni es to develop your surgical skills. The following parts of
procedures can be performed by ward doctors depending on your experience. It is best to
s ck to a few consultants so you develop rapport and they can see what you can do and with
me they will let you do more and more.

- Saphenous vein harves ng – supervised by the surgical care prac oners

- Radial artery harves ng
- Sternotomy
- Cannula on of the aorta and IVC for cardiopulmonary bypass
- Closing of sternotomy
- Proximal coronary anastomoses
- Distal coronary anastomoses

There are a lot of wetlab courses designed to help you gain competence at these procedures
and lots of videos online that you should watch in prepara on for undertaking these
procedures yourself.

Applying for cardiothoracic surgical training

If you are interested in cardiothoracic surgery as a career, Papworth is a great place for you
to prepare for your applica ons. There are two entry points: ST1 ‘run-through’ and ST3. We
have a long history of successfully suppor ng applicants.

If you are interested in cardiothoracic surgery as a career you need to become very familiar
with the na onal recruitment website: h p://www.wessexdeanery.nhs.uk/recruitment/
na onal_ct_surgery_st1__st3.aspx

This website contains all the informa on you need. Most importantly, the applica on scoring
matrix which highlights exactly what you need to achieve in order to score points on your
applica on form.

Don’t hesitate to approach the registrars who will be very willing to help you through this
process. There are trainees at Papworth who have entered at both ST1 and ST3 level.
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
tt
ti
ti
ti
ti
ti
 Audit and research involvement
There are plenty of opportuni es for involvement in audit and research projects. You should
aim to get involved with projects early in your placement to give you the best chance of
comple ng them. Approach registrars and consultants who may have ideas for projects.
There is also a lot of clinical ac vity in Papworth and many opportuni es for case reports.

There are several mee ngs each year to which you can aim to submit abstracts:

- Royal Society of Medicine Cardiothoracic sec on – has 2 mee ngs each year where
submissions including case reports are welcomed for oral presenta on and posters.
There are prizes available

- The Society of Cardiothoracic Surgery (SCTS) annual mee ng – abstract deadline

November 5th each year, mee ng in Feb/Mar

- European Associa on of Cardiothoracic Surgery (EACTS) annual mee ng – abstract

deadline in April, mee ng in October

- European Society of Thoracic Surgery (ESTS) annual mee ng – abstract deadline in

early January, mee ng in May/June
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
 Postopera ve management

Postopera ve medica ons

Cardiac surgery pa ents

Pa ents will be discharged from ITU to the ward with a drug chart already completed on
Lorenzo. However, this can some mes be inaccurate, and you should be familiar with the
usual postopera ve prescrip ons:

Analgesia: Paracetamol 1g po/IV QDS

Codeine 30-60mg PO QDS
Oramorph 1.25-10mg PO 2 hourly PRN

Laxa ves: Senna TT ON

Laxido T-TT BD

Diure cs: Furosemide 20mg IV/PO BD

Amiloride 5mg PO OD

An -eme cs: Cyclizine 50mg PO/IV PRN TDS

Ondansetron 4mg PO/IV PRN TDS

An -platelets: Aspirin 75mg OD PO for all CABG

Clopidogrel 75mg OD PO if recent ACS

PPI: Omeprazole 20 PO OD
Lansoprazole 15-30mg if on clopidogrel

An coagulants: Usually restarted on ward rather than ITU

Universal guideline for post-op an coagula on available on intranet NOACs are restarted on
discharge

Beta-blockers and ACE-I are o en started/re-started post-op depending on BP, renal func on
and LV func on. The registrar will review these on the morning ward rounds. They are
restarted at a small dose and trated based on the clinical picture – not restarted at the
preopera ve dose.

Pulmonary endarterectomy

• Pulmonary hypertension agents (bosentan, sildena l, iloprost) are stopped/

con nued at the consultants’ discre on depending on the opera ve result and
residual PA pressure
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ft
ti
ti
ti
ti
ti
fi
ti
ti
 • An coagula on is important and pa ents must achieve an INR of >2.0 as
soon as possible - if the INR is <2.0 on day 3, therapeu c enoxaparin should be
started (1.5mg/kd in two divided doses)
• Oxygen is usually weaned a er the opera on but many pa ents have home
oxygen so this is not a requirement for safe discharge
• Discharge planning can be more complicated as PTE pa ents are referred from all
over the UK/Europe/Middle East
• TTOs should usually include diure cs for discharge (please review with the
registrar) and three days of S/C therapeu c enoxaparin to cover any period of sub-
therapeu c INR early a er leaving Papworth

Any concerns about PTE pa ents can be discussed with PTE nurse specialist, bleep
785 or directly with Mr Jenkins/Mr Tsui/Mr Taghavi/Mr Ng.

Postopera ve inves ga ons

Aim to adhere to the following protocol. Addi onal tests should only be requested if
clinically indicated as there is a signi cant cost associated with unnecessary inves ga ons.

Pre Op FBC, UE, LFT, lipids, coagula on, glucose, x-match

Post Op (days) 1 2 3 4 5 6 7 8 9
FBC FBC FBC FBC FBC FBC
UE UE UE UE UE UE
CXR LFT LFT CXR
CXR

When a chest drain is in situ, CXR are rou nely performed as above. However, a CXR should
be performed a er chest/medias nal drain removal.

INR should be monitored closely while loading, par cularly if pa ents have pacing wires in
situ, or if they are on interac ng drugs eg. amiodarone, cipro oxacin. This is because pacing
wires can only be removed if the INR is <3. The interac on with these drugs can be
enormous.
ti
ti
ti
ti
ft
ti
ft
ti
ti
ft
ti
ti
ti
ti
ti
fi
ti
ti
ti
ti
ti
ti
ti
ti
ti
fl
ti
ti
ti
 Common postopera ve clinical problems

Low urine output

De ni on
• <1ml/kg rst 8 hours post-op for cardiac surgery pa ents
• <0.5mg/kg a er 8 hours post-op
• Pa ents rou nely have hourly uid balance and daily weights to aid diagnosis

Assessment
• ABCDE
• Iden fy and treat respiratory failure, sepsis, op mise haemodynamics and cardiac
output based on pa ent’s LV func on

Inves ga on

• If the pa ents volaemic status is unclear consider asking Alert team to measure
CVP using the pa ents central line
• Arterial blood gas to assess potassium and lactate par cularly
• Always consider cardiac tamponade and this can be excluded with echocardiogram
• Inform seniors early especially if poor ini al response to treatment or worried
about tamponade/bleeding

Treatment
• Monitor and maintain K+ between 4.5-5.0
• If overloaded start with furosemide 40mg IV bolus and consider infusion
• In this case trate diure cs un l polyuric and trate down to maintain urine
output
• If hypovolaemic consider uid resuscita on based on LV func on
• If moderate-poor LV or PTE pa ent consider small 100-200ml bolus of gelofusin
ini ally

Indica ons for CVVH

• Refractory hyperkalaemia or metabolic acidosis
• Refractory pulmonary oedema
• Uraemia
ti
ti
fi
ti
ti
ti
ti
ti
ti
fi
ti
ti
ft
ti
ti
ti
fl
ti
ti
ti
fl
ti
ti
ti
ti
ti
ti
ti
ti
 ‘Fast’ atrial brilla on

Approximately 30-40% of pa ents develop atrial brilla on as a complica on a er cardiac

surgery. The peak incidence is during the 2nd and 3rd postopera ve day. The presenta on
may range from palpita ons to cardiogenic shock.

When called to see a pa ent in AF, note the following:

• 12 lead ECG
• Heart rate
• Blood pressure
• Oxygen satura on
• Urine output
• Potassium on VBG
• Volaemic status
• Pre-opera ve rhythm

The aims of treatment are:

• Check pacing box set to VVI 80 (if not familiar with pacing then discuss with 744)
• Ensure that the serum potassium is above 4.5 mmol/l and correct as necessary
• Increase enoxaparin dose to 1.5mg/kg S/C in 2 divided doses
• For thoracic and SN pa ents control the rate (<120bpm) with digoxin
• For all other cardiac consultants aim to chemically cardiovert with amiodarone
• If a pa ent remains symptoma c then discuss with SpR/consultant as to whether
DC cardioversion is appropriate

Digoxin loading regime

• Loading dose 1.5mg given IV/PO in 3 (500mcg/500mcg/500mcg) doses over 24

hours
• Maintenance dose 125mcg PO OD (reduce if deranged renal func on)

Amiodarone loading regime

• IV Loading (only via central venous access)

o 300mg IV in 250mI Glucose 5% over 1 hour
o Then 900mg IV in 500ml Glucose 5% over 23 hours
o Then followed by standard oral loading regime
• Fast Oral Loading
o 400mg PO TDS over 24hrs
o Then followed by standard oral loading regime
• Standard Oral Loading
o 200mg po tds for 7/7
o Then 200mg po bd for 7/7
ti
ti
fi
ti
ti
ti
ti
ti
ti
ti
fi
ti
ti
ti
ti
ft
ti
 o Then 200mg po od as maintenance

Your registrar or consultant may decide a pa ent needs DC cardioversion. You should book
the procedure as described below. The procedure is performed by the on-call ward doctor
under a brief general anaesthe c administered by the anaesthe c team in the theatre
treatment room and so you should handover to the on-call ward doctor that you are
booking it so they are expec ng the call.

Booking a DCCV:

• You will need

o Consent
o Latest K+ result
o An coagula on status to determine if TOE is required
o Nil by mouth for 6 hours, clear uids for 2 hours prior to procedure
• Inform theatre coordinator (bleep 900)
• Inform on call consultant anaesthe st (bleep number on rota watch)
• Add pa ents details to emergency theatre list on board in main theatre corridor

Consent:

• Intended bene ts
o Symptoma c relief
o Reduce stroke risk
o Reduce medica ons
• Important and common risks and complica ons
o Failure to revert to sinus rhythm (20%)
o Bradycardia and other arrhythmias
o Pulmonary oedema
o Emboliza on/stroke (<1% if an coagulated)
o Musculoskeletal pain
o Minor skin injury
ti
ti
ti
ti
ti
fi
ti
ti
ti
ti
fl
ti
ti
ti
ti
 Weaning of dopamine in post-cardiac surgery pa ents

The following protocol shall apply to all ward based post-opera ve cardiothoracic pa ents
who have either a Moderate or Good LV status and excludes pa ents with known AKI or
CKD.

Dopamine is to be rou nely weaned o all pa ents (as speci ed above) as follows:

• Urine output is deemed the best indicator of end organ perfusion not blood
pressure.

• If UO is >0.5ml/kg/hour + pa ent warm and well perfused +

• Systolic BP >90mmHg

• Then dopamine should be weaned at a rate of 1ml/hour or 2mls/every 2 hours

(either regime is acceptable). Weaning should take e ect regardless of it being day or
night- me.

• If the pa ent is polyuric, a faster weaning approach of 2mls/hour is deemed

acceptable (please check with the duty FY2 #509 or ALERT team #432 before doing
so).

In pa ents with a systolic BP <90mmHg hold further dopamine weaning and request a
review by the WARD DOCTOR (509) or ALERT team (432). They will prescribe a 250ml
gelofusin uid challenge +/- IV Hartmann’s maintenance uid to follow if required.

Once SBP>90mmHg (+ UO>0.5ml/kg/hour) resume dopamine weaning as outlined above.

*For pa ent’s that have a Poor LV status the responsible consultant cardiothoracic surgeon
will determine a clear plan for weaning dopamine (as this is not straigh orward and may
require a slower or staggered weaning approach) – this protocol excludes pa ents with a
known poor LV status*.

Cardiac arrest following cardiac surgery

A cardiac arrest following cardiac surgery is di erent. There is a high likelihood that there is a
reversible issue that can be resolved. As such is it common for pa ents in cardiac arrest to
be immediately transferred to ITU or theatre and have their chests opened. You will be
expected to help the registrar and so should be familiar with the procedure. There is a
guideline to managing cardiac arrest in post cardiac surgical pa ents. This is Cardiac surgery
Advanced Life Support (CALS). Papworth runs many CALS courses each year and you should
ti
ti
ti
ti
fl
ti
ti
ff
ti
ff
ti
ff
fl
fi
ti
ti
ti
ti
tf
ti
ti
 aim to a end one of these, there are usually subsidised spaces for junior doctors. See the
following website for more informa on: h ps://www.csu-als.com/
tt
ti
tt
 Miscellaneous informa on

Pacing boxes

All pa ents following cardiac surgery have placement of temporary epicardial pacing wires
and will have pacing boxes. It is worth having a look at these and understanding the se ngs.

The pacing box can be used in a variety of ways to modulate the heart rate and therefore
cardiac output. The most common se ngs you will use are DDD and VVI for an -bradycardic
pacing.

I II III
Chamber(s) Chamber(s) Response to
paced sensed sensing
Ventricular demand pacing, no
V V I
synchronisa on with atrial beat (eg. AF)
D D D AV sequen al pacing
A, atrium; V, ventricle; D, both chambers; I, inhibits; O, does not apply

Pacing threshold:

• This is the amplitude required to produce consistent cardiac capture or

depolarisa on
• This will increase over me due to brosis of the epicardium under the leads
• Set this threshold on the pacing at double of the minimum threshold to be safe

Sensi vity threshold:

• This is the amplitude at which the pacing box is sensing ac vity in the heart
chamber
• Increasing the sensi vity threshold will REDUCE the sensi vity to any na ve
ac vity
ti
ti
ti
ti
ti
ti
ti
ti
ti
fi
tti
ti
ti
ti
ti
tti
 Reques ng PICC lines, Echocardiograms and 24-hour tapes

To request a 24 hour tape, please use the following form:

Echocardiograms are requested on a programme called ICE, and you should bleep 850 to
speak to the technician to arrange the me of any urgent echocardiograms.

PICC lines are inserted by Stephanie Currie, who can be contacted via switch or usually
found in ICU. They can also be done by Addenbrookes when you should use the form below
and email it to: add-tr.vaascularaccess@nhs.net and follow-up calling them on: 01223
596020
ti
ti
 PICC inser on reques ng form

Pa ent Forename

Pa ent Surname

NHS number
DOB

Pa ent Address

Name and address of GP

GP telephone

GP email

Relevant diagnosis and treatment

Type of line required PICC
Number of lumens 2
Date and me of inser on As soon as possible

Date and results of last FBC & clo ng screen/ Will send full set of bloods with pa ent
INR

Date of MRSA screen – Not isolated

Results of MRSA screen (if available)
Is the pa ent on an coagulants Tinzaparin s/c injec on
If yes, please specify
Inpa ent
Is the pa ent inpa ent/outpa ent
Does the pa ent have an infec on? No

Indica on for line access – Chemotherapy/ IV access for taking blood for giving IV abx
nutri on/ hydra on/ abx/ other (please
specify)

Expected dura on of treatment >6weeks

(0-3 month, 3-6 weeks, >6weeks)

Referring clinician Dr (Bleep 509)

Contact number 01223 638515 (5 South West ward)

Admi ng consultant Mr
ti
ti
ti
ti
ti
tti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
ti
tti
ti