Complications after cardiac

surgery
Padet Tanangterapong, MD
Complications after cardiac surgery
• CARDIAC DYSFUNCTION
• VASOPLEGIC SYNDROME
• POSTOPERATIVE BLEEDING
• PULMONARY COMPLICATION
• NEUROLOGIC COMPLICATIONS
• INFECTION
• RENAL DYSFUNCTION
CARDIAC DYSFUNCTION AFTER
CARDIAC SURGERY
• Low cardiac output syndrome
• Cardiac tamponade
• Right heart dysfunction
• Cardiac arrest
• Arrhythmias
• Graft occlusion
• Pericardiotomy syndrome
Low cardiac output syndrome
• decrease in cardiac output that is due to transient myocardial
dysfunction
• Cardiac index < 2 liter/min/m2
• Preload optimization
• Contractility and rhythm
• Inotropic support, mechanical support
• Pacemaker
• Afterload
• Proper SVR
Cardiac tamponade
• Pulsus paradoxus
• Urine output
• Excessive chest tube drainage
• Elevation of the CVP, PAWP
• Mediastinal widening from chest film
• Low cardiac output and hypotension
• Management
• Volume loading, reduction of airway pressure, inotropic support
• Reoperation
Right heart dysfunction
• Most common secondary to left sided failure
• May occur as isolated condition
• Clinical manifestation
• Low cardiac output due to poor LV filling
• Elevated CVP, poor RV contraction
• PAP may be elevated or may not be elevated in severly impaired RV.
• Management
• Optimization RV preload
• HR and rhythm
• Inotropic support and pulmonary vasodilator
• RV assisted device
Arrhythmias
• Bradycardia
• Atrial fibrillation
• Ventricular arrhythmias
Bradycardia
• Sinus bradycardia
• AV block
• Management
• Inotropic drug
• Pacing
• Epicardial pacing
• Tranvenous pacing
• Cause
• Tissue edema
• Surgical related conduction pathway injury
• Drug e.g. beta blocker, amiodarone
Atrial fibrillation
• The incidence has varied from 28% to 54% of patients undergoing cardiac operations.
• Therapeutic objective
• heart rate control
• Hemodynamic compromise >> cardioversion
• Hemodynamic stable >> control ventricular rate
• CCB e.g. verapamil, diltiazem
• Beta blocker e.g. esmolol
• Digoxin
• Amiodarone
• conversion to sinus rhythm
• Pharmacologic cardioversion e.g. amiodarone
• Electrical cardioversion
• prevention of embolic complications >> anticoagulants
• Correct precipitating factor e.g. electrolyte imbalance, pain, fever, pericardial effusion
Ventricular arrhythmias
• VF or VT management as cardiac arrest guideline
Cardiac arrest
Graft occlusion
• Early graft failure >> technical error
• Clinical manifestation
• ventricular arrhythmias
• hemodynamic compromise with evidence of ischemia
• may be clinically silent
• Perioperative myocardial infarction is defined by
• ECG changes
• serum biomarker measurements
• the development of new regional LV dysfunction
• Perioperative myocardial infarction does not result solely from graft or coronary occlusion.
• may result from compromised myocardial protection.
• Treatment is mainly supportive, with intravenous nitroglycerin and afterload reduction.
• Inotropic agents or IABP may be required during a period of myocardial recovery.
• Management of graft failure
• Graft revision
• Percutaneous interventions
Pericardiotomy syndrome
• Inflammatory response after any operation that violates the pericardium
• occurring in 10% to 30% of patients
• a self-limited condition beginning in the second or third week after surgery
• fever and pleuritic, precordial, or substernal chest pain
• Chest radiographs commonly show pleural and pericardial effusions.
• It is treated with nonsteroidal anti-inflammatory agents, although corticosteroids
may be necessary in severe cases.
Complications after cardiac surgery
• CARDIAC DYSFUNCTION
• VASOPLEGIC SYNDROME
• POSTOPERATIVE BLEEDING
• PULMONARY COMPLICATION
• NEUROLOGIC COMPLICATIONS
• INFECTION
• RENAL DYSFUNCTION
Vasoplegic syndrome
• Inflammatory reponse after CPB >> vasodilatory shock
• Diagnosis
• An arterial pressure of less than 50  mm Hg
• A cardiac index of greater than 2.5 liter/min/m2
• A right atrial pressure of less than 5  mm Hg
• A left atrial pressure of less than 10  mm Hg
• Low systemic vascular resistance (<800 dyne • sec/cm5)
• Management
• Vasopressor eg. norepinephrine, phenylephrine, or vasopressin
• Methylene blue
Complications after cardiac surgery
• CARDIAC DYSFUNCTION
• VASOPLEGIC SYNDROME
• POSTOPERATIVE BLEEDING
• PULMONARY COMPLICATION
• NEUROLOGIC COMPLICATIONS
• INFECTION
• RENAL DYSFUNCTION
Postoperative bleeding
• Coagulopathy
• Heparin effect
• Thrombocytopenia
• Thrombasthenia >> the platelet count is normal, but clot formation is
inadequate.
• CPB effect or antiplatelet drug
• Specific factor deficiency
• PT,PTT
• specific genetic disorder, liver disease, prior Coumadin therapy, hemodilution, or disseminated
intravascular coagulation (DIC).
• FFP, Cryoprecipitate
Postoperative bleeding
• The observed rate of bleeding must be correlated with its character
• Large amounts of clot that repeatedly obstruct the tubes >> a surgical source of bleeding.
• Nonclotting, freely draining blood or the presence of loosely organized clot >> a state of
coagulopathy
• Bleeding at a rate of more than 200 mL/hr
• requires immediate action to search for and correct the underlying cause
• Delays in laboratory testing frequently preclude accurate and timely diagnosis.
• The single most practical treatment is to administer platelet concentrate.
Postoperative bleeding
• The major side effects of postoperative bleeding are volume loss and retention of clotted
blood in the mediastinum.
• continuous, adequate volume replacement
• maintenance of free drainage
• application of suction
• stripping and milking of chest tubes >> can be potentially damaging to entrapped tissues
• if necessary, Fogarty catheter thrombectomy of the mediastinal tubes.
• prevention of hypothermia
Postoperative bleeding
• Volume resuscitation
• Crystalloid or colloid solution
• Blood component
• Pharmacologic agent
• Desmopressin
• ε-Aminocaproic acid (EACA) and tranexamic acid (TXA)
• Recombinant Activated Factor VII
Complications after cardiac surgery
• CARDIAC DYSFUNCTION
• VASOPLEGIC SYNDROME
• POSTOPERATIVE BLEEDING
• PULMONARY COMPLICATION
• NEUROLOGIC COMPLICATIONS
• INFECTION
• RENAL DYSFUNCTION
Pulmonary complication
• 12% of patients develop mild lung injury after CPB, 1.3% develop frank acute respiratory distress
syndrome (ARDS).
• This problem is more common in older, obese adults and patients with low cardiac output or
pulmonary hypertension, and after long CPB.
• In most cases of CPB-related lung injury, full recovery occurs
• but severe lung injury has a mortality of greater than 50%
Complications after cardiac surgery
• CARDIAC DYSFUNCTION
• VASOPLEGIC SYNDROME
• POSTOPERATIVE BLEEDING
• PULMONARY COMPLICATION
• NEUROLOGIC COMPLICATIONS
• INFECTION
• RENAL DYSFUNCTION
Neurological complication
• a major cause of death and disability after cardiac surgery.
• A spectrum of disorders
• Stroke
• Easiest to detect, mostly from emboli
• Increase hospital stay and mortality
• Early detection and investigation >> neurological intervention
• cognitive dysfunction
• defined as a change in memory, concentration, psychomotor speed, or dexterity
• However, the relationship of CPB to neurocognitive dysfunction after cardiac surgery has been called into
question.
• failed to show a clear benefit of off-pump compared with on-pump surgery in terms of the incidence of neurocognitive
dysfunction.
• the same rate of neurocognitive decline as those patients undergoing on-pump CABG and control.
• the use of neurocognitive testing as a measure is debatable.
• Delirium
Delirium
• state characterized by confusion and disorientation in the presence of an altered state of consciousness.
• common condition 3% to 72%
• classified as hyperactive, hypoactive, or mixed
• Prevention
• frequent orientation and noise reduction
• early mobilization out of bed
• having a familiar face at the bedside
• treatment
• nonpharmacologic measures, and symptomatic drug therapy.
• The patient’s medication list should be critically reviewed, and any drugs with anticholinergic side effects should be tapered.
• Benzodiazepines are GABA agonists and may therefore decrease consciousness and REM sleep—tapering these agents
may alleviate delirium.
• Haloperidol remains the recommended agent for severe agitation.
• The α2-adrenergic agonists clonidine and dexmedetomidine may also be useful in those patients with sympathetic overactivity.
• Suspected signs of delirium should not be ignored and instead promptly investigated and treated.
Complications after cardiac surgery
• CARDIAC DYSFUNCTION
• VASOPLEGIC SYNDROME
• POSTOPERATIVE BLEEDING
• PULMONARY COMPLICATION
• NEUROLOGIC COMPLICATIONS
• INFECTION
• RENAL DYSFUNCTION
Infection
• Fever
• Fevers not related to infectious causes are most commonly low grade (<38.9° C, rectal)
• most resolve before the 15th postoperative day.
• A temperature higher than 38.9° C at any time in the postoperative course is more likely to be related to a specific infection.
• The presence or absence of leukocytosis has not been helpful in this differentiation.
• When infection is suspected, aggressive evaluation is indicated.
• Aerobic and anaerobic cultures of blood, urine, sputum, and abnormal fluid collections are mandatory and should precede
broad-spectrum antibiotic coverage.
• Indwelling catheters should be considered potential infectious sites.
• Soft tissue infection
• saphenous vein harvest
• represent a significant source of morbidity after coronary revascularization
• occur in 3% of patients and is more common in the thigh harvest site
• prevented by careful selection of harvest sites and the use of meticulous surgical technique
Sternal wound complication
• Sternal dehiscence
• median sternotomy wound breakdown in the absence of clinical or microbiologic evidence of infection.

• Sternal infection
• clinical or microbiologic evidence of infected presternal tissue and sternal osteomyelitis, with or without mediastinal
sepsis and with or without unstable sternum.
• Superficial sternal wound infection
• confined to the subcutaneous tissue; and deep wound infection (mediastinitis)
• Deep sternal wound infection
• associated with sternal osteomyelitis with or without infected retrosternal space.
• the presence of an organism isolated from culture of mediastinal tissue or fluid
• evidence of mediastinitis seen during operation
• one of the following conditions: chest pain, sternal instability or fever (>38° C) in combination with either purulent discharge
from the mediastinum or an organism isolated from blood culture or culture of mediastinal drainage.
Sternal wound complication
• Risk factor • Prevention
• Obesity • Smoking cessation and weight loss
• diabetes mellitus • Prophylactic antibiotics prior to surgery are
• COPD recommended
• heart failure
• Blood glucose levels should be controlled,
• renal failure
because maintenance at or below 110
• smoking
mg/dL
• poor dental hygiene
• older age • Surgical management
• male gender • Open drainage, dressing +/- VAC dressing
• Primary closure and irrigation
• Soft tissue flap eg pectoral flap, omental flap,
Complications after cardiac surgery
• CARDIAC DYSFUNCTION
• VASOPLEGIC SYNDROME
• POSTOPERATIVE BLEEDING
• PULMONARY COMPLICATION
• NEUROLOGIC COMPLICATIONS
• INFECTION
• RENAL DYSFUNCTION
Renal dysfunction
• associated with increased hospital and ICU stay and mortality
• Nonpulsatile flow, obstructive atheromatous microemboli and the diffuse inflammatory change
may contribute to renal dysfunction.
• the incidence of ARF varies across studies, with a range of 1 to 30%
• Prevention
• Optimization of Renal Perfusion
• Optimize cardiac output
• Avoidance of Nephrotoxins
• Medications such as NSAID and other nephrotoxic agents should be discontinued.