Cardiac Surgery

Proposed protocol for perioperative surgical home model of care of patients presenting for cardiac surgery

Coronary artery bypass and single valvular repair/ replacement surgery. (McUnu patients only)

INDICATIONS

1. Coronary artery disease

2. Single valvular aortic repair or replacement

3. Pulmonary valvular replacement

4. Tricuspid annular repair, replacement

5. Atrial myxoma resection

6. Simple ASD, VSD repair (excluding the presence of Eisenmenger syndrome or severe pulmonary hypertension)

Approach:

Coronary artery bypass

Valvular replacement/repair

ASD, VSD repair

Preoperative optimization:

1. Counseling per surgery and PAU for anesthetic plan

2. Smoking cessation

3. ETOH abstinence

4. Immunonutrtion (IMPACT) 5-7 days prior to surgery

5. Nutrition counseling

6. Physical exercise counseling-exercise plan (surgery clinic)

7. Daily incentive spirometry (provided by PAU)

8. Pedometer (provided by PAU)

9. Preop labs including TEG

Morning of surgery:

1. PO water up to 2 hours the morning of surgery

2. Boost breeze 2-4 hours before the surgery except for diabetics. If diabetics consider low glucose breeze.

3. PO analgesic cocktail- acetaminophen 1gm, gabapentin 600 mg, oxycontin 10 mg, scopolamine patch

Intraoperative care:

1. Forced air warming to maintain normothermia

2. SCD

3. BIS monitoring (maintain between 40-60), cerebral oximetry monitoring

4. Orogastric suction

5. No N2O

6. Maintain glucose levels under 180mg/dl

7. Magnesium 1 gram q 2hour, first dose on induction (Do not give on cross clamp release or coming off bypass)

8. Dexamethasone 4 mg on induction and 4 mg at initiation of CPB

9. Antimicrobial prophylaxis within 60 minutes prior to surgery

10. Protective ventilation strategy (TV <8ml/kg PBW), decrease FiO2 as tolerated (based on ABGs)

11. Use PAC/CVP/flotrac/Urine output to direct fluid resuscitation.

12. Maintain urine output at near zero balance -0.5mg/kg/hour

13. Ondansetron 4mg IV at emergence

14. Bilateral subpectoral/ subcutaneous plane catheters (APM or surgeon)

15. Fast track extubation criteria (in or extubation to up to 4 hours post op)

16. Limit the doses of midazolam and fentanyl, consider using shorter acting opioids such as sufentanil or remifentanil

Postoperative care:

1. Elective BiPAP/ High flow NC, especially in patients with COPD, morbid obesity (BMI>40)

2. Redose acetaminophen if over 6 hours have passed from the last dose. Continue 1gm q 6hr for 48 hours

3. Goal to maintain adequate CI pressors free

4. Use PAC/CVP/flotrac/Urine output to direct fluid resuscitation.

5. Continue to maintain urine output of 0.5 mg/kg/min

6. Monitor and maintain adequate ventilation arterial blood gases every 30 minutes for the first 2 hours then hourly for 4 hours

7. Maintain adequate pain relief avoiding long acting opioids, IV PCA hydromorphone

8. Early mobilization (in chair first post op morning onwards) and incentive spirometry

9. Head of bed 30 degrees

10. Early feeding (lactulose 10 gm twice daily until bowel movement)