(BQ) Part 2 book Manual of perioperative care in adult cardiac surgery has contents: Fluid management, renal, metabolic, and endocrine problems, cardiovascular management, respiratory management, mediastinal bleeding,.... and other contents.
CHAPTER Mediastinal Bleeding Overview 347 Etiology of Mediastinal Bleeding 348 Prevention of Perioperative Blood Loss: Blood Conservation Measures 351 Assessment of Bleeding in the ICU 356 Management of Mediastinal Bleeding 363 Blood Transfusions: Red Cells 367 Blood Components, Colloids, and Blood Substitutes 369 Mediastinal Reexploration for Bleeding or Tamponade 371 Technique of Emergency Resternotomy 373 OVERVIEW 347 Mediastinal Bleeding I Overview A The use of cardiopulmonary bypass (CPB) during cardiac surgical procedures causes a significant disruption of the coagulation system that may contribute to a coagulopathy of varying degrees.1 In addition to hemodilution from a crystalloid prime, which reduces levels of clotting factors and platelets, contact of blood with the extracorporeal circuit activates platelets and the extrinsic and intrinsic coagulation systems, and triggers fibrinolysis In fact, systemic heparinization alone causes platelet dysfunction and induces fibrinolysis.2 In addition, cell-saving devices that are routinely used for red cell salvage eliminate platelets and coagulation factors from the blood B Off-pump coronary artery bypass surgery (OPCAB) avoids hemodilution and minimizes platelet activation, and is associated with reduced usage of blood products.3 The ability of the antifibrinolytic agents to reduce bleeding suggests that low-grade fibrinolysis is still present.4 Although a coagulopathy after OPCAB is very unusual, it may occur in patients who have sustained substantial blood loss with blood scavenged in and returned from the cell-saving device This will result in depletion of coagulation factors and platelets The occurrence of substantial bleeding after an OPCAB procedure generally indicates a surgical source C Either 28–32 Fr PVC or silicone malleable chest tubes or 24 Fr silastic fluted (Blake) drains are placed in the mediastinum and opened pleural cavities They are connected to a drainage system and placed to À20 cm of H2O suction They are gently milked or stripped to maintain patency after surgery Both are equally effective in evacuating blood, although the Blake drains may be more comfortable for the patient.5,6 Some surgeons not obligatorily place chest tubes into widely opened pleural spaces, especially after off-pump surgery However, any bleeding that occurs in the pleural space will tend to accumulate and not be drained by the mediastinal tubes This can produce a deceptive picture with insidious bleeding that can only be detected by chest x-ray Following minimally invasive surgery, the number and location of tubes may vary After MIDCABs, only one pleural chest tube is placed, so blood could potentially accumulate around the heart and not be drained through the pericardial opening Following ministernotomy incisions, one mediastinal tube is placed unless the pleural cavity is entered With right thoracotomy approaches to the aortic or mitral valve, one mediastinal and one pleural tube are placed Chest-tube positioning is difficult and Manual of Perioperative Care in Adult Cardiac Surgery, Fifth Edition © 2011 Robert M Bojar ISBN: 978-1-444-33143-1 Robert M Bojar 348 MEDIASTINAL BLEEDING not ideal after these procedures, so the potential for undetected blood accumulation around the heart or in the pleural spaces is enhanced Thus, extra vigilance for undrained blood in the unstable patient is imperative D Postoperative bleeding gradually tapers over the course of several hours in the majority of patients, but about 1–3% of patients will require reexploration in the operating room for persistent mediastinal bleeding Prompt assessment and aggressive treatment in the intensive care unit (ICU) may frequently arrest “medical bleeding”, but evidence of persistent or increasing amounts of bleeding should prompt early exploration (see section VIII, pages 373–374) E Bleeding invariably requires use of various blood products to maintain normovolemia and adequate hemodynamic parameters, correct anemia to ensure adequate tissue oxygen delivery, and correct a coagulopathy to help arrest the bleeding Transfused blood is not benign and can cause a variety of complications that may increase operative mortality.7– The safe lower limit for hematocrit (HCT) is not precisely defined, but in the bleeding patient in the early postoperative period, hemodynamic considerations and potential impairment of tissue oxygen delivery mandate transfusions to maintain a safe HCT, which is probably at least 25% Blood component therapy ideally should be selected based upon identification of specific coagulation abnormalities by point-of-care testing and treatment algorithms, although clinical judgment remains essential in making prompt therapeutic decisions F Mediastinal bleeding can be a highly morbid and lethal problem Although hypovolemia can be corrected by volume infusions, the bleeding patient tends to be hemodynamically unstable out of proportion to the degree of bleeding and fluid replacement Most importantly in the immediate postoperative period is the potential for blood to accumulate around the heart, causing cardiac tamponade The restriction to cardiac filling may produce severe hemodynamic compromise that can precipitously cause cardiac arrest Constant attention to the degree of bleeding and to trends in hemodynamic parameters should allow steps to be taken to avert this problem If profound hypotension or a cardiac arrest develop, emergency sternotomy in the ICU is indicated II Etiology of Mediastinal Bleeding (Table 9.1) Mediastinal bleeding is somewhat arbitrarily categorized as “surgical” or “medical” in nature Significant bleeding after uneventful surgery is usually “surgical”, especially when initial coagulation studies are fairly normal However, persistent bleeding depletes coagulation factors and platelets, causing a coagulopathy that is self-perpetuating Bleeding that is noted after complex operations with long durations of CPB is frequently associated with abnormal coagulation studies and is considered “medical” However, even after correction of coagulation abnormalities, discrete bleeding sites may be present that will not stop without reexploration Thus, the initial approach to bleeding is to try to identify any contributing factors that might account for the degree of bleeding and then take the appropriate steps to correct them.1 A A number of risk factors have been identified that increase perioperative bleeding and/ or the requirement for transfusions (Table 9.2).7 Aside from stopping antiplatelet or anticoagulant medications preoperatively, most of these factors cannot be modified However, they should alert the healthcare team to the increased risk of a coagulopathy, the necessity of utilizing blood conservation measures, and the importance of early aggressive treatment of bleeding to minimize or prevent hemodynamic compromise and organ system dysfunction ETIOLOGY OF MEDIASTINAL BLEEDING 349 Table 9.1 Etiology of Mediastinal Bleeding Surgical bleeding sites Heparin effect – residual or rebound Excessive protamine administration Platelet dysfunction Thrombocytopenia Clotting factor deficiency Fibrinolysis Table 9.2 Patients at Increased Risk for Mediastinal Bleeding Patient-related Variables Older patients Females or smaller body surface area Preoperative anemia Advanced cardiac disease (shock, poor LV function) Comorbidities (renal or hepatic dysfunction, diabetes, peripheral vascular disease) Known coagulopathies (von Willebrand’s disease, uremia) Preoperative Medications High-dose aspirin Clopidogrel/prasugrel Low-molecular-weight heparin within 18 hours Fondaparinux within 48 hours Incomplete reversal of INR off warfarin Emergency surgery after IIb/IIIa inhibitors or thrombolytic therapy Procedure-related Variables Complex operations (valve-CABG, thoracic aortic surgery, especially requiring deep hypothermic circulatory arrest) Urgent/emergent operations Reoperations Use of bilateral ITA grafting 350 MEDIASTINAL BLEEDING B Surgical bleeding is usually related to: Anastomotic sites (suture lines) Side branches of arterial or venous conduits Substernal soft tissues, sternal suture sites, bone marrow, periosteum Raw surfaces caused by previous surgery, pericarditis, or radiation therapy C Anticoagulant effect related to heparin or excessive protamine Preoperative use of low-molecular-weight heparin (enoxaparin) within 12–18 hours of surgery or of fondaparinux, a factor Xa inhibitor, within 48 hours of surgery are associated with increased perioperative bleeding since neither can be completely reversed with protamine.10– 12 Residual heparin effect may result from inadequate neutralization with protamine at the conclusion of CPB Administering fully heparinized “pump” blood towards the end of the protamine infusion will reintroduce unneutralized heparin into the blood Blood washed in cell-saving devices is usually given after protamine administration, but has been shown to contain insignificant amounts of heparin.13 Heparin rebound may occur when heparin reappears from tissue stores after protamine administration This is more common in patients receiving large amounts of heparin, especially obese patients Excessive protamine may cause a coagulopathy D Quantitative platelet defects Preoperative thrombocytopenia may result from use of heparin, drug reactions (especially antibiotics and IIb/IIIa inhibitors), infection, hypersplenism in patients with liver disease, and other chronic conditions (idiopathic thrombocytopenic purpura [ITP]) If a patient developing thrombocytopenia has recently been given heparin, it is essential to rule out heparin-induced thrombocytopenia (HIT) Hemodilution on CPB and consumption in the extracorporeal circuit reduce the platelet count by about 30–50%, and thrombocytopenia will be progressive as the duration of CPB lengthens Protamine administration transiently reduces the platelet count by about 30% E Qualitative platelet defects are a major concern with the liberal use of antiplatelet agents in patients with acute coronary syndromes Preoperative platelet dysfunction may result from antiplatelet medications (aspirin, clopidogrel, prasugrel), glycoprotein IIb/IIIa inhibitors (tirofiban, eptifibatide, abciximab), herbal medications and vitamins (fish oils, ginkgo products, vitamin E), or uremia Exposure of platelets to the CPB circuit with a-granule release and alteration of platelet membrane receptors impairs platelet function The degree of platelet dysfunction correlates with the duration of CPB and the degree of hypothermia after bypass Inadequate heparinization is a potent trigger for thrombin release, which activates platelets F Depletion of coagulation factors Preoperative hepatic dysfunction, residual warfarin effect, vitamin K-dependent clotting factor deficiencies, von Willebrand’s disease, and thrombolytic therapy reduce the level of clotting factors PREVENTION OF PERIOPERATIVE BLOOD LOSS 351 Hemodilution on CPB reduces most factors by 50%, including fibrinogen This is most pronounced in patients with a small blood volume Loss of clotting factors results from use of intraoperative cell-saving devices G Fibrinolysis results in clotting factor degradation and platelet dysfunction Preoperative use of thrombolytic agents causes fibrinolysis Use of CPB causes plasminogen activation Heparinization itself induces a fibrinolytic state III Prevention of Perioperative Blood Loss: Blood Conservation Measures (Table 9.3)7 A Preoperative assessment of the patient’s coagulation system should entail measurement of a prothrombin time (INR), partial thromboplastin time (PTT), and platelet count Any abnormality should be investigated and corrected, if possible, prior to surgery Although additional screening with bleeding times is not indicated for patients on aspirin, platelet function testing to assess platelet responsiveness to clopidogrel is helpful in determining when the bleeding risk is low enough to proceed with nonurgent surgery B Heparin-induced thrombocytopenia (HIT) may develop in patients receiving intravenous heparin for several days before surgery Thus, it is very important to recheck the platelet count on a daily basis in these patients If the patient develops thrombocytopenia, with documented heparin antibodies by ELISA testing and a positive functional assay (serotonin release assay or heparin-induced platelet aggregation test), an alternative means of anticoagulation will be necessary during surgery (see pages 202–204).14 C Cessation of medications with antiplatelet or anticoagulant effects is essential to allow their effects to dissipate to minimize blood loss A more detailed discussion of these medications is presented in Chapter (pages 133–139) Specific recommendations are as follows:7,15,16 Warfarin should be stopped days before surgery to allow for resynthesis of vitamin K-dependent clotting factors and normalization of the INR If interim anticoagulation is required for patients at high thromboembolic risk, heparin is substituted, either as unfractionated heparin or as low-molecular-weight heparin If the patient requires urgent surgery, vitamin K should be given to normalize the INR A slow IV infusion of mg over 30 minutes is effective in promptly correcting the INR, but it is preferable to give mg of oral Vitamin K if surgery can be delayed a day or two to avoid the risk of anaphylaxis If emergency surgery is indicated, fresh frozen plasma (FFP) may be necessary Unfractionated heparin (UFH) is used for patients with acute coronary syndromes, during catheterization, for critical coronary disease, or during use of an intra-aortic balloon pump (IABP) It is reversible with protamine and can be continued up to the time of surgery without increasing morbidity during line placement or increasing the risk of perioperative bleeding Low-molecular-weight heparin (LMWH) is given in a dose of mg/kg SC q12h for acute coronary syndromes or as a bridge to surgery once warfarin has been stopped The last dose should be given 18–24 hours prior to surgery to minimize the perioperative bleeding risk, since only 60–80% of LMWH is reversible with 352 MEDIASTINAL BLEEDING Table 9.3 Methods of Minimizing Operative Blood Loss and Transfusion Requirements Stop all anticoagulant and antiplatelet medications preoperatively (except low-dose ASA for CABG patients) Consider erythropoietin with iron for anemic patients prior to elective surgery Identify preoperative hematologic abnormalities (HIT, antiphospholipid syndrome) Transfuse patients requiring urgent surgery to a HCT >28% preoperatively Use antifibrinolytic therapy (e-aminocaproic acid or tranexamic acid) Consider off-pump coronary bypass grafting, if feasible Perfusion considerations a Autologous blood withdrawal prior to CPB if HCT >30% b Use heparin-coated circuit, if available c Use miniaturized CPB circuit, if available d Use heparin-protamine titration test to optimize anticoagulation and heparin reversal e Consider retrograde autologous priming of the bypass circuit f Avoid use of cardiotomy suction g Salvage pump blood via either hemofiltration or cell saver Employ meticulous surgical technique with careful inspection of anastomotic sites and all artery and vein side branches before coming off bypass Complete neutralization of heparin with protamine to return ACT to baseline 10 Administer appropriate blood component therapy based upon suspicion of the hemostatic defect (especially platelet dysfunction) or use point-of-care testing to direct blood component therapy 11 Use recombinant factor VIIa for intractable coagulopathic bleeding 12 Exercise patience protamine.10–12 Fondaparinux must be stopped at least 48 hours prior to surgery because it has a half-life of nearly 20 hours Aspirin (ASA) should be continued up to the time of surgery in patients with acute coronary syndromes or critical anatomy.7,15,16 A dose of 81 mg has not been associated with an increased risk of bleeding.17 Aspirin can probably be stopped days prior to elective CABG or valve surgery to minimize the risk of bleeding However, one can consider continuing aspirin in all CABG patients since some studies indicate that the risk of infarction and mortality may be lower when aspirin is continued up to the time of surgery.18,19 Antifibrinolytic drugs are useful in reducing bleeding associated with preoperative use of aspirin.20 Clopidogrel has antiplatelet effects that last for the life span of the platelet, and it should therefore be stopped 5–7 days prior to elective surgery.7,15,16 However, it is commonly given as a 300–600 mg load in patients with an acute coronary syndrome in anticipation of a stenting procedure, which will achieve significant platelet inhibition within a few hours If surgery is required on an urgent basis, significant bleeding may be encountered Exogenously administered platelets may be ineffective if given within hours of a loading dose or hours of a PREVENTION OF PERIOPERATIVE BLOOD LOSS 353 maintenance dose because the active metabolite may still be present in the bloodstream In patients with drug-eluting stents placed within the previous year, the risk of stent thrombosis is increased if clopidogrel is stopped In these patients, the options are to: a Continue the clopidogrel and accept the potential for more bleeding b Stop the clopidogrel for days to restore some platelet function while maintaining a lesser degree of platelet inhibition c Stop the clopidogrel and use a short-acting glycoprotein IIb/IIIa inhibitor as a bridge to surgery Prasugrel is a strong antiplatelet agent that may supplant use of clopidogrel in patients with acute coronary syndromes undergoing a percutaneous coronary intervention (PCI).21 It is associated with more periprocedural bleeding and may pose significant bleeding problems in patients requiring emergency surgery Surgery should be delayed days after the last dose is taken Tirofiban (Aggrastat) and eptifibatide (Integrilin) are short-acting IIb/IIIa inhibitors which allow for recovery of 80% of platelet function within –6 hours of being discontinued They should be stopped about hours prior to surgery.7 Some studies have shown that continuing these medications up to the time of surgery may preserve platelet function on pump, leading to increased platelet number and function after bypass with no adverse effects on bleeding.22 Abciximab (ReoPro) is a long-acting IIb/IIIa inhibitor used for high-risk PCI that has a half-life of 12 hours If surgery needs to be performed on an emergency basis, platelets are effective in producing hemostasis since there is very little circulating unbound drug Ideally, surgery should be delayed at least 12 hours and preferably 24 hours Although platelet function remains abnormal for up to 48 hours, there is little hemostatic compromise at receptor blockade levels less than 50% Direct thrombin inhibitors are primarily used in patients with HIT, but bivalirudin has been used as an alternative to UFH in patients undergoing PCI It has a short half-life of 25 minutes and should not pose a significant issue if emergency surgery is required Its use as an alternative to heparin during surgery in patients with HIT has been associated with comparable outcomes, although bleeding tends to be more problematic.23 10 Thrombolytic therapy is an alternative to primary PCI in patients presenting with ST-elevation myocardial infarctions (STEMIs) Although currently used agents have short half-lives measured in minutes, the systemic hemostatic defects persist much longer These effects include depletion of fibrinogen, reduction in factors II, V, and VIII, impairment of platelet aggregation, and the appearance of fibrin split products If surgery is required for persistent ischemia after failed thrombolytic therapy, it should be delayed at least 12–24 hours If it is required emergently, fresh frozen plasma and cryoprecipitate will probably be necessary to correct the anticipated coagulopathy D Antifibrinolytic therapy should be used to reduce intraoperative blood loss in all on- and off-pump surgical cases (see doses on page 199).24–27 e-aminocaproic acid (Amicar) is an antifibrinolytic agent that preserves platelet function by inhibiting the conversion of plasminogen to plasmin It is effective in 354 MEDIASTINAL BLEEDING reducing blood loss and the amount of transfusions, although it has not been shown to reduce the rate of reexploration for bleeding.7 Because of its low cost, it is usually the drug of choice for most cardiac surgical procedures Tranexamic acid (Cyclokapron) has similar properties and benefits to e-aminocaproic acid It has been shown to reduce perioperative blood loss in both on- and off-pump surgery.4 Aprotinin is a serine protease inhibitor that was the most effective drug available to reduce blood loss, transfusion requirements, and reexploration for bleeding It preserves adhesive platelet receptors during the early period of CPB, exhibits antifibrinolytic properties by inhibiting plasmin, and also inhibits kallikrein, blocking the contact phase of coagulation and inhibiting the intrinsic coagulation cascade Because of concerns that it increased the risks of mortality, renal dysfunction, myocardial infarction, and stroke (most of which have not been confirmed in numerous studies), aprotinin was no longer available in the USA as of late 2007.28 E Heparin and protamine dosing Ideal anticoagulation for CPB should minimize activation of the coagulation cascade, be fully reversible, and minimize perioperative bleeding The most commonly used drug is heparin, which binds to antithrombin III to inhibit thrombin and factor Xa Empiric dosing of heparin (3–4 mg/kg) to achieve an activated clotting time (ACT) >480 seconds is routine, although patients with antithrombin III deficiency may be heparin-resistant and require fresh frozen plasma or Thrombate to achieve a satisfactory ACT.29 Inadequate heparin dosing increases thrombin generation which in turn activates platelets and can trigger clotting within the CPB circuit Lower doses of heparin may be used in biocompatible circuits (see section F.3, below) Systems that provide heparin–protamine titration tests measure circulating heparin concentrations and determine dose–response curves to achieve the desired ACT These systems provide the optimal level of heparin and allow for calculation of the precise amount of protamine sulfate needed to reverse heparin effect The end result is generally a reduction in perioperative bleeding Some studies with the Medtronic Hepcon system have found that it is necessary to use higher doses of heparin, yet this is associated with less thrombin and platelet activation, preservation of higher levels of clotting factors, and a reduction in fibrinolysis, and subsequently less bleeding.7,30 In contrast, another study using dose–response curves with the Hemochron RxDx system (International Technidyne) found that lower doses of heparin are sufficient and associated with less blood loss.31 One of heparin’s advantages is that its anticoagulant effect can be reversed with protamine In contrast, other effective anticoagulants that can be used for CPB, such as the direct thrombin inhibitors (bivalirudin or argatroban used in HIT patients), are not reversible Protamine is usually given in a 1:1 ratio or a 0.5:1 ratio to the dose of heparin Using point-of-care hemostasis systems with dose–response curves, lower doses of protamine are usually used to adequately reverse heparin, which may result in less bleeding Excessive protamine (varying from 1.5:1 up to 2.6:1 in three studies) serves as an anticoagulant that directly impairs platelet function and elevates the ACT.32–34 PREVENTION OF PERIOPERATIVE BLOOD LOSS 355 F Perfusion considerations that may be considered to optimize blood conservation include the following (see also Chapter 5): Autologous blood withdrawal before instituting bypass (acute normovolemic hemodilution) protects platelets from the damaging effects of CPB This has been demonstrated to preserve red cell mass and reduce transfusion requirements However, its efficacy in reducing perioperative bleeding is controversial.7,35 It can be considered when the calculated on-pump hematocrit after withdrawal remains satisfactory (greater than 20–22%) This can be calculated using the following equation: amount withdrawn ¼ EBV À 0:22 EBV ỵ PV ỵ CVị HCT where: EBV ¼ estimated blood volume (70 Â kg) PV ¼ priming volume CV ¼ estimated cardioplegia volume HCT ¼ prewithdrawal hematocrit Platelet-rich plasmapheresis entails the withdrawal of platelet-rich plasma using a plasma separator at the beginning of the operation with its readministration after protamine infusion This improves hemostasis and reduces blood loss Although it might be beneficial in reoperations, it is expensive, time-consuming, and probably of little benefit when prophylactic antifibrinolytic medications are used, and probably is of no greater benefit than fresh whole blood withdrawn before CPB.7,36 The use of biocompatible circuits (usually heparin-bonded) may reduce activation of platelets and the coagulation cascade with a subsequent reduction in blood loss These systems may allow for use of lower doses of heparin in uncomplicated cases (ACT of 350 seconds) However, one study suggested that reduction of heparin dosing reduced platelet loss, but did not suppress the platelet release reaction, and thus was not beneficial to platelet function.37 The potential remains that inadequate heparinization may increase thrombin generation, causing more platelet activation on CPB that may in fact increase perioperative bleeding Furthermore, use of low-dose heparin combined with antifibrinolytic medications might theoretically raise the risk for thrombotic events.7 Thus, biocompatible circuits may improve hemostasis, but the lower limit of heparinization has not been well defined Additional considerations, such as avoiding cardiotomy suction, are important in realizing clinical advantages with these circuits Avoidance of cardiotomy suction may reduce perioperative bleeding Blood aspirated from the pericardial space has been in contact with tissue factor and contains high levels of factor VIIa, procoagulant particles, fat particles, and activated complement proteins, and exhibits fibrinolytic activity.7,38 Blood aspirated with cardiotomy suckers drains into a reservoir and mixes directly with the pump blood that is reinfused in the CPB circuit Most groups use cardiotomy suction routinely and not find that it has a significant effect on bleeding Miniaturized CPB circuits require low priming volumes (500–800 mL) that limit the degree of hemodilution, thus maintaining a higher HCT on pump Studies 806 INDEX Prednisone for bronchospasm, 428 for postpericardiotomy syndrome, 663 Pregnancy anticoagulation during, 707 mitral valve procedures during, 31 Preload and aortic stenosis, 21, 188, 325 and HOCM, 42, 189 and low cardiac output syndrome, 447–449, 448t, 453–454, 454f and mitral regurgitation, 33, 35, 190 and mitral stenosis, 30–31, 189 and pericardial effusions, 65, 193 and vasoconstriction, 313 and vasodilation, 314–315 basic concepts of, 439–440 excessive, 448–449 manipulation of, 453–454, 588–589 Premature atrial complexes (PACs), 536–537 ECG of, 537f from hypokalemia, 618 treatment of, 523, 530t, 537, 540 Premature ventricular contractions (PVCs), 549–551 and digoxin toxicity, 563 ECG of, 550f treatment of, 523, 550–551, 530t Preoperative blood donation, 149–150 blood setup guidelines, 152, 154t checklist, 154 history, 133–145 laboratory tests, 147–148, 153t, 730a medications, 150–152, 176 order sheet, 153t, 730a physical examination, 132t, 145–146 preparation, 131–155 Pressure-controlled ventilation, 420 Pressure-limited ventilation, 419–420 Pressure-support ventilation, 394, 420, 424–425 Prevacid (lansoprazole), 700, 748a Prilosec (omeprazole), 700, 748a Primacor (see milrinone) Procainamide dosage of, 555 drug profile of, 555 electrophysiologic classification of, 554 Procardia (see nifedipine) Prochlorperazine (Compazine), 650t, 735a, 744a, 749a Procrit (erythropoietin), 61, 149, 352t, 666 Profilnine SD, 673, 673f, 741a Profound hypothermia (see circulatory arrest) Prolonged ventilation, 159, 162, 385, 396–398, 397t, 405–406 Pronestyl (see procainamide) Propafenone dosage of, 541, 557 drug profile of, 557–558 electrophysiologic classification of, 554 for atrial fibrillation, 530t, 541, 542t, 543f, 546 Prophylactic antibiotics, 151–152, 153t, 154, 674–675, 677 (see also cefazolin, vancomycin) Prophylaxis for VTE, 137, 284t, 403t, 405, 649t, 653, 655–656, 731a, 735a Propofol and vasodilation, 313 dosage of, 196t, 286t, 304t, 733a, 745a for anesthesia, 187, 189, 194, 195t, 196t, 387 for cardioversion, 193 for hypertension, 363, 496 for postoperative sedation, 286t, 304t, 308–310, 364, 388t, 389–390, 395, 399, 410, 411f hemodynamics of, 195t Prostacyclins during mitral valve surgery, 189 for CPB with HIT, 204 for RV failure/pulmonary hypertension, 318, 328, 454t, 456 Prostaglandin E1 (PGE1), 456–457 Prostate disease, 144 Prosthetic heart valves (see mechanical or tissue valves) Prosthetic valve endocarditis, 21, 39–40, 708 Protamine, 208, 210–212 adverse reactions to, 207, 210–211, 243, 246, 446, 453 and insulin, 143, 210 and low-molecular-weight heparin, 137 and NPH insulin, 154, 210 excessive bleeding from, 349t, 350, 354, 363t, 364–366, 365f for reversal of heparin, 210, 215, 246, 352t, 363t, 365f, 366 dosage of, 210, 354 heparin-protamine titration test, 139, 200, 210, 241, 246, 352t, 354 with calcium chloride, 618 Protein C deficiency, 139, 668 Protein intake, 706 Protein S deficiency, 139 INDEX 807 Prothrombin complex concentrate (Profilnine), 673, 673f, 741a Prothrombin time (PT) and hepatic dysfunction, 704 postoperative, 212, 357t, 358, 364, 365t, 732a, 734a preoperative, 132t, 147, 730a Proton pump inhibitors, 144, 296, 415t, 417, 610, 676, 700–701, 704 Protonix (see pantoprazole) Proventil (albuterol), 284t, 404, 411, 428, 616t, 617, 650t, 654, 731a, 736a Prozac (fluoxetine), 751a Pseudomonas aeruginosa, 417, 493 Pseudo-obstruction, of colon, 698 Psychiatric disorders, 691 Psychotherapy, 689 PT (see prothrombin time) PTCA (percutaneous transluminal coronary angioplasty) (see percutaneous coronary intervention) PTT (see partial thromboplastin time) Pullback gradient, 19, 95, 97f Pulmocare, 416 Pulmonary artery catheters (see Swan-Ganz catheters) Pulmonary artery diastolic pressure (see preload) Pulmonary artery perforation, 180, 292–293 Pulmonary autograft (Ross procedure), 21–22, 24f, 185 Pulmonary capillary wedge pressure (PCWP) (see also preload) and calculation of PVR, 441t and left ventricular aneurysms, 335 and low cardiac output, 447 at catheterization, 95, 96t–97t basic concepts of, 439–440 during surgery, 177, 179f to identify ischemia, 187, 197 to measure mitral valve area, 29–30 to measure PVR, 441t to measure transpulmonary gradient, 440 measurement of, with use of PEEP, 410 Pulmonary complications, 425–428, 653–656 Pulmonary edema and acute aortic regurgitation, 26 and acute mitral regurgitation, 33–35 and acute respiratory insufficiency, 406–407, 654 and ARDS, 413–414 and chronic respiratory insufficiency, 413–414 and ventricular septal rupture, 16 as indication for CABG, during pericardiectomy, 194 from CPB, 386 from protamine reaction, 211 noncardiogenic, 386, 406, 413–414 Pulmonary embolism and acute respiratory distress, 407 and cardiac arrest, 507, 508t and RV failure, 453 embolectomy for, 656 from endocarditis, 37 postoperative, 651–652, 655–656 Pulmonary embolization for PA rupture, 180 Pulmonary function extubation criteria and, 402t optimization of, 140–141, 398–399 postoperative changes in, 386–387 testing, preoperative, 139–140, 753a Pulmonary hypertension (see also pulmonary vascular resistance, right ventricular failure) after mitral valve surgery, 318, 327–329, 452–457, 454t and mitral valve disease, 29–31 and right ventricular failure, 453–457 and tricuspid valve disease, 191 and weaning from ventilator, 401 catastrophic, from protamine, 211, 453 management of, 454t, 454–457, 482, 499 Pulmonary infarction, from Swan-Ganz catheter, 292 Pulmonary toxicity from amiodarone, 141, 559 Pulmonary vascular resistance (see also pulmonary hypertension) and acidosis, 454, 620 and acute respiratory failure, 409 and blood transfusions, 318, 387, 440 and mitral valve disease, 31, 189 and PEEP, 409 and protamine reactions, 210–211 and RV failure, 318 and tricuspid valve disease, 31, 37, 191 formula for, 441t medications to reduce, 189, 318, 328, 454–457, 454t, 482 Pulmonary vasodilators for RV failure/pulmonary hypertension, 189, 318, 328, 454–457, 454t, 482 use with RVADs, 482–483 Pulmonary vein isolation, 55, 190, 330 Pulsatile pumps, 488, 489f–490f, 490, 492, 492f PulseCO, 213 Pulse oximetry, 140, 281, 287, 289–290, 388t, 389, 392, 403t, 404 808 INDEX Pulseless electrical activity (see cardiac arrest) Pulsus paradoxus, 652, 661 PVD (see peripheral vascular disease) PVR (see pulmonary vascular resistance) Pyogenic pericarditis, 63, 66 Q waves, 90, 513–515 Quetiapine (Seroquel), 689, 751a Quinidine, 554 QT prolongation from 5-HT3 antagonists, 696 from amiodarone, 546, 559 from dofetilide, 547, 560 from dronedarone, 559 from ibutilide, 546, 561 from procainamide, 556 from sotalol, 540, 560 hypocalcemia and, 618 potassium chloride for, 554 torsades de pointes and, 551 Quinapril (Accupril), 749a R2 external defibrillator pads, 197, 198t Rabeprazole (Aciphex), 700 Racemic epinephrine, 428 Radial artery grafting and alpha agents, 465 for CABG, 10–11, 322 infections after, 682 medications to prevent spasm with, 11, 322, 500–502 Radial nerve palsy, 692 Radiation pericarditis, 63, 65 Radiofrequency ablation of atrial fibrillation, 51, 55, 190, 330 of ventricular tachycardia, 57 Radiography (see chest x-ray) Radionuclide angiography, 92, 94 Ramipril (Alace), 506, 749a Ramsey scale, 410, 411t Ranitidine (Zantac) (see also H2 blockers) and platelet reactions, 369 and protamine reactions, 211 dosage of, 743a, 747a for GI bleeding, 700 Rapid atrial pacing for atrial flutter, 520, 523, 524f, 530t, 542t, 543 for supraventricular tachycardia, 520, 547 technique of, 523, 524f Rapid shallow breathing index, 400t, 423 Rapid ventricular pacing, for ventricular tachycardia, 520, 525, 553 Recombinant activated protein C (Xigris), 676 Recombinant erythropoietin, 149, 352t, 666 Recombinant factor VIIa, 212, 352t, 363t, 366, 673, 673f, 741a Recombinant hirudin (see lepirudin) Recombinant platelet factor 4, 212 Rectus flap, for sternal wound infection, 680 Recurrent laryngeal nerve injury, 694 Recurrent myocardial ischemia, postoperative, 659–660 Red cells (see transfusions) Red-neck syndrome, 154 Redon catheters, 680 Reentrant arrhythmias, 520 Reexploration for bleeding, guidelines for, 371–373 Refludan (see lepirudin) Regional cerebral oxygen saturation (see cerebral oximetry) Reglan (see metoclopramide) REMATCH trial, 492 Remifentanil dosage of, 196t, 304t for early extubation, 187, 195, 308–309, 387 hemodynamics of, 195t via PCA pump, 310, 390, 405 Removal of lines and tubes, 296–297, 647 Renal atheroembolism, 595t Renal blood flow, 584 and dopamine, 590 and fenoldopam, 599 Renal dysfunction/failure (acute kidney injury), 590–615, 664 and alpha agents, 451, 464, 595t and antifibrinolytics, 199, 308, 354, 597 and circulatory assist devices, 494 and CPB, 584–585 and delayed tamponade, 661 and hetastarch, 587 and hyperkalemia, 615 and low hematocrit, 244, 585 and metabolic acidosis, 594, 620 and OPCAB, 12, 585, 596t, 597 and operative risk, 591–594 and sternal wound infections, 677 and stroke, 683 and thoracic aortic surgery, 334 assessment of, 605–606, 605t biomarkers for, 584, 602 chronic, 594 classification of, 594, 595t definition of, 590–591, 601, 755a dialysis for (see renal replacement therapy) INDEX 809 digoxin toxicity and, 562–563 drug modification in, 743a–752a etiology of, 594, 595t, 603–604 management of, 606–615 medications to prevent, 108, 192, 204t, 207, 304t, 334, 399, 505, 596t, 598–600 mortality of, 591t, 592, 594 nutrition during, 607t, 610–611 occult, 591–592 oliguric, 600–602, 601t patterns of, 604–605, 604f postoperative, 600–615 preoperative, 590–594 prevention of, 159, 206, 590–600 renal replacement therapy for, 611–615, 611t risk factors for, 593–594 risk models for, 592, 592f–594f use of acetylcysteine and, 596, 596t use of diuretics for, 607t, 608–609 use of dopamine and, 461, 609–610 use of fenoldopam for, 607t, 609 use of nesiritide for, 467, 607t, 609 VADs and, 494 Renal failure (see renal dysfunction/failure) Renal management, routine, 586–590 Renal replacement therapy (RRT), 601–602, 611–615, 611t continuous arteriovenous hemodialysis, 615 continuous venovenous hemodialysis, 611t, 613–615 for hyperkalemia, 611–612, 611t, 617 hemodialysis, 611t, 612–613 indications for, 611–612 in sepsis, 676 preoperative, 597, 612 Renal ultrasound, 606 Renin-aldosterone, 584 Renin inhibitors, 604 Reoperation for bleeding, guidelines for, 371–373 ReoPro (abciximab), 134t, 138, 151, 350, 353 Reperfusion injury (see ischemia/reperfusion injury) Respirators (see ventilators) Respiratory acidosis (see hypercarbia) Respiratory alkalosis, 393–394 (see also hypocarbia) Respiratory complications, postoperative, 425–428, 653–656 Respiratory failure/insufficiency acute, 405–412 (see also acute respiratory failure) and circulatory assist devices, 494 and nutrition, 415t, 416, 706 and operative risk, 139–140, 157, 162t chronic, 413–418 (see also chronic respiratory failure) risk model for, 397f Respiratory management, postoperative, 385–428, 653–656 Respiratory mechanics, and extubation criteria, 402t Respiratory quotient, 416 Rest-redistribution imaging, 94 Resternotomy, emergent, 373–375, 506, 507f, 509 Restoril (temazepam), 752a Restriction, 64 Restrictive lung disease, and mechanical ventilation, 388 Resynchronization therapy, 62 Reticulocyte count, and hemolysis, 708 Retinol-binding protein, 597 Retrograde autologous priming (RAP), 242, 304t, 352t, 356, 398 Retrograde cardioplegia, 240f, 268–273, 270f, 304t Retrograde cerebral (SVC) perfusion, 52, 192, 250, 252, 333 Retroperitoneal bleeding, 147, 697–698 Reversible neurologic deficits, 685 Rheumatic fever, and mitral stenosis, 29 Richmond agitation scale, 410, 412t RIFLE criteria, 601–602, 601t Right heart bypass, 12, 252 (see also right ventricular assist devices) Right heart catheterization, 95, 96t in pericarditis, 63, 663 Right heart failure (see right ventricular failure) Right upper quadrant ultrasound, 699 Right ventricular assist devices, 481–482 cannulation for, 480f, 482 complications of, 493–494 indications for, 454t, 457, 479t, 482 management of, 482 results of, 482 Right ventricular dysfunction (see right ventricular failure) Right ventricular failure after mitral valve surgery, 327–328 and hepatic dysfunction, 703 and low cardiac output syndrome, 317–318, 446, 452–457, 454t and tricuspid regurgitation, 36–37, 703 from blood transfusions, 318, 387, 453 IABP for, 454, 454t, 472 810 INDEX Ringer’s lactate, 230, 314, 586, 588, 623 Risk assessment, 155–163 Risk models for infection, 675f for mortality, 157, 158t, 159f, 160t–161t for renal failure, 592f–594f for respiratory failure, 397f Risperidone (Risperdal), 689, 751a Robotic surgery, 13, 188 anesthetic considerations in, 215–216 postoperative care after, 331–332 Rocuronium, 195t–196t, 197, 745a R-on-T phenomenon, 288 Root shot, 96, 99f Rosiglitazone (Avandia), 749a Ross procedure (pulmonary autograft), 21–22, 24f, 185 Rosuvastatin (Crestor), 750a ROTEM (thromboelastometry), 359 Routine fluid management, postoperative, 586–590 rt-PA (see thrombolytic therapy) Rupture of coronary sinus, 232, 249, 271 left ventricle, 13 pulmonary artery, 180, 292–293 RVAD (see right ventricular assist devices) Salt-poor albumin, 588 Sandostatin (Octreotide), 427 Saphenous vein grafting antiplatelet therapy after, 322, 669 for CABG, 10 in diabetics, 143 neuropathy after, 694 preoperative evaluation for, 144, 146 Saphenous vein stripping, 144, 146 Sarns Delphin pump, 486 Schatzki’s ring, 181 Sciatic nerve palsy, 692–293 SCUF (slow continuous ultrafiltration), 611t, 613–615 Second degree heart block, 524, 528, 533–534, 533f Sedation algorithm for, 411f during mechanical ventilation, 309–310, 389–390, 411f, 422 during weaning from ventilator, 410, 415t, 416, 422 for acute respiratory failure, 410, 411f for hypertension, 496 medications for, in the ICU, 286t, 411f, 745a Seizures from lidocaine, 557, 689 postoperative, 689 Select 3D cannula, 236f, 237t Selective antegrade cerebral perfusion (see antegrade cerebral perfusion) Selective brachiocephalic perfusion (see antegrade cerebral perfusion) Selective decontamination of the gut, 417 Sepsis and acute abdomen, 697 and cardiovascular instability, 446 and circulatory assist devices, 695 and critical illness polyneuropathy, 691 and early extubation, 397t, 398 and endocarditis, 27, 37, 39 and hyperglycemia, 624 and mesenteric ischemia, 701 and metabolic acidosis, 620 and paralytic ileus, 697 and postoperative delirium, 688 and postoperative fevers, 652 and postoperative shortness of breath, 652 and renal failure, 545t, 676 and respiratory insufficiency, 414 and sinus tachycardia, 535 and sternal wound infections, 676, 678 and thrombocytopenia, 666 management of, 676 Septal alcohol ablation, 42 Septal myectomy, 8, 42f, 43 Sequential compression devices, 405, 653, 655–656 Seroquel (quetiapine), 689, 751a Serotonin release assay, 147, 201, 667 Sertraline (Zoloft), 751a Serum albumin and cirrhosis, 141 and serum osmolarity, 583–584 and total calcium levels, 618 SESTAMIBI, 49, 94 Sevoflurane, 187, 195–196, 244, 309 Shivering and metabolic rate, 305 medications to control, 304t, 306, 364, 395, 496 Shock liver, 703 Shortness of breath, differential diagnosis of, 651–652 Sick sinus syndrome, 90, 531, 657 Sildenafil, 454, 457, 482 INDEX 811 SIMV (see synchronized intermittent mandatory ventilation) Simvastatin (Zocor) and amiodarone, 559, 709 and dronedarone, 559 dosage of, 287t, 559, 649t, 709, 735a, 750a Sinus bradycardia, 529, 531 and digoxin toxicity, 563 ECG of, 531f pacing for, 523, 531 treatment of, 523, 530t, 531 Sinus rhythm, ECG of, 519f Sinus tachycardia, 535–537 adverse effects of, 450–451 ECG of, 536f etiology of, 515, 535 treatment of, 530t, 536 Sinus tracts, 679–680 Sinusitis, 652 Skin preparation, preoperative, 153t, 155, 730a Sliding plasties, 36f, 329 Slow continuous ultrafiltration (SCUF), 611t, 613–615 Slow junctional rhythm, atrial pacing for, 523 Small bowel obstruction, 697 Smoking and coronary artery disease, and extubation criteria, 398 and surgical risk, 140, 653–654, 683 preoperative evaluation of, 140 Smooth muscle myosin heavy chains, 44 Sniff test, for diaphragmatic motion, 416, 654 Society of Thoracic Surgeons database, 131, 133t, 157, 677, 682 definition of myocardial infarction, 321–322, 514–515, 755a guidelines for antibiotics, 152, 154, 674 for antiplatelet therapy, 322, 669 risk models for infection, 675f prolonged ventilation, 397f renal failure, 594f specifications, 753a–755a Socks, antiembolism (see T.E.D stockings) Sodium bicarbonate dosage of, 622 during CPB, 245 during dialysis, 613–614 for cardiac arrest, 508t, 512 for cyanide toxicity from nitroprusside, 498 for hyperkalemia, 616t, 617 for metabolic acidosis, 245, 621–622, 704 for renoprotection during catheterization, 108, 595 for renoprotection during surgery, 207, 399, 596t, 599 Sodium channel blockers, 547, 554, 559 Sodium-hydrogen exchange inhibitors, 268t, 271, 513 Sodium nitrite, for thiocyanate toxicity, 498 Sodium nitroprusside (see nitroprusside) Sodium polystyrene sulfonate (Kayexalate), 616t, 617 Sodium thiosulfate, for cyanide toxicity, 498 Soft-Flow cannula, 233, 236f, 237t, 249 Solumedrol (see methylprednisolone) Somanetics (see cerebral oximetry) Somatosensory evoked potentials, 334, 692 Somatostatin, for GI bleeding, 700–701 Sonata (zalepon), 752a Sonoclot analysis, 359, 361f Sorbitol with kayexalate for hyperkalemia, 616t, 617 with lactulose, for hyperammonemia, 704 Sotalol dosage of, 540, 542t, 560, 748a drug profile of, 560 electrophysiologic classification of, 554 for prevention of atrial fibrillation, 540, 542t for treatment of atrial fibrillation, 542t, 546 Spasm, coronary artery (see coronary vasospasm) SPECT scanning, 91, 94–95, 691 Spinal cord ischemia and aortic dissections, 44, 48, 192, 332, 692 and thoracic aortic surgery, 51, 53, 192, 334 Spironolactone (Aldactone), 61, 624, 751a Splanchnic hypoperfusion and CPB, 243, 248, 695 and GI complications, 694, 695, 699, 701 and norepinephrine, 451, 470 and phenylephrine, 470 and vasopressin, 452, 470, 589 Splinting, 403 Spontaneous breathing trials, 401, 423 Square-root sign, in constrictive pericarditis, 63, 64f, 663 Stanford classification of aortic dissections, 43, 44f Staphylococcus aureus, 678, 708 and circulatory assist devices, 493 endocarditis from, 39 methicillin-resistant, 144, 155, 417, 674 812 INDEX Staphylococcus aureus (Continued ) mupirocin for, 153t, 155, 163, 287t, 649t, 675, 677, 730a, 733a, 735a nosocomial, 674 Staphylococcus epidermidis, 39, 677, 708 Starling’s law, and fluids, 583–584 Starr-Edwards valve, and anticoagulation, 671 Statins and amiodarone, 559, 709 and aortic stenosis, 18 and atrial fibrillation, 151, 541 and delirium, 151, 686 and elevated LFTs, 141, 703 and hepatic dysfunction, 141, 703 preoperative use of, 3, 4, 10, 151, 541 upon hospital discharge, 709 Stem cell transplantation, 63 STEMI, 3–4, 7, 16, 107, 138, 353, 513 Stent thrombosis, 5, 10, 352 Stentless valves, 21, 23f, 28 Stents (see percutaneous coronary intervention) Stents, endovascular (see endovascular stents) Sternal debridement, 680 Sternal talons, 374 Sternal wound infections, 677–681 and circulatory assist devices, 493 and hyperglycemia, 143, 625 and postoperative chest pain, 651 and tracheostomy, 418 evaluation of, 679 mortality associated with, 162t, 677, 681 presentation of, 678–679 prevention of, 163, 677–678 risk factors for, 677 treatment of, 679–681 Sternocutaneous fistula, 679 Sternotomy emergency, 373–375 infection of (see sternal wound infection) pulmonary function after, 386–387 Steroids (see also dexamethasone, methylprednisolone) and elevations in BUN, 605 and protamine reactions, 211 and systemic inflammatory response, 229, 309 during circulatory arrest, 52, 192, 251 following stroke, 687 for air embolism, 250 for bronchospasm/COPD, 141, 411, 416 for delayed paraplegia, 334 for fast-track protocols, 304t, 399 for laryngeal edema, 422 for pericardial effusions, 663 for pituitary apoplexy, 628 for platelet transfusions, 369 for postpericardiotomy syndrome, 663 for prevention of AF, 541 for sepsis, 676 perioperative use of, 10, 151, 198 STICH trial, 16, 62 Stool softeners, 650t, 696, 736a Stored blood, 368 Streptococcus viridans, 39, 708 Stress imaging (see also dobutamine) postoperative, 651, 659 preoperative, 91, 92f Stress tests, 91–92, 93f, 94–95 Stress ulcer prophylaxis, 415t, 417, 676, 695, 699–700, 704 Stridor, 422, 428 Stroke (see also neurologic complications), 682–694 and aortic dissection, 44 and chronic respiratory failure, 414 and circulatory assist devices, 494 and CPB, 244 and hematocrit on CPB, 685 and OPCAB, 682, 685–686 and operative risk assessment, 160t, 162 evaluation of, 686 mechanisms causing, 244, 684–685 preoperative, 143 presentation of, 685 prevention of, 685–686 prognosis after, 687 risk factors for, 682–684 treatment of, 687 Stroke volume, formula for, 441t Stroke volume index, 441t, 450 STS (see Society of Thoracic Surgeons) ST-segment elevation infarction (STEMI), 3–4, 7, 16, 107, 138, 353, 513 Stunned myocardium, 319, 446, 512–513 Subcutaneous emphysema, 295, 410, 426 Substance abuse and delirium, 687 and endocarditis, 36, 39–41 preoperative risk with, 158t Subxiphoid pericardial window, 65, 66f, 194, 508t, 661 Subxiphoid pericardiostomy, 65, 66f Succinylcholine, 194 INDEX 813 dosage of, 196t hemodynamic effects of, 195t Sucralfate (Carafate), 144, 286t, 296, 415t, 417, 676, 700, 733a, 747a Suction embolectomy, for pulmonary embolism, 656 Sudan III staining, for triglycerides, 427 Sudden death and aortic stenosis, 20 and HOCM, 41 and left ventricular aneurysms, 13 implantable cardioverter-defibrillator for, 58 Sufentanil, 309 dosage of, 196t for anesthesia, 187, 195, 304t, 387 hemodynamics of, 195t Superior vena cava (SVC) cannulation of, 238, 239t retrograde perfusion of, 52, 192, 250, 252, 333 Supracoronary grafting, 22, 51 Suprapubic tubes, 144 Supraventricular tachycardia, paroxysmal, 547–548 ECG of, 548f from hypokalemia, 618 overdrive pacing of, 523, 530t, 547 Surgical anterior ventricular endocardial restoration (SAVER), 15–16, 15f, 62–63 Surgical ventricular restoration, 15–16, 15f, 62–63 Sustained ventricular tachycardia, 551–554 (see also cardiac arrest) SVC (see superior vena cava) SVG (see saphenous vein grafts) Swallowing tests, 696 Swan-Ganz catheter, 176–180, 291–293 and continuous cardiac outputs, 176, 179, 179f, 213, 291 and diastolic dysfunction, 317 and left bundle branch block, 149, 180, 292 and low cardiac output syndrome, 316 and mixed venous oxygen saturation, 179, 290–291 and right heart catheterization, 95 and thrombocytopenia, 282 and tricuspid regurgitation, 177, 291, 293, 327, 443, 453 as cause of arrhythmias, 292, 529, 549 complications of, 292–293 during OPCAB, 213 during surgery for aortic dissections, 191 during surgery for left ventricular aneurysms, 188 during surgery of pericardium, 193 during tricuspid valve surgery, 190 during thoracic aortic surgery, 192 for detection of cardiac tamponade, 357, 372 for detection of myocardial ischemia, 187, 197 for diagnosis of ventricular septal rupture, 16 pacing catheters, 179, 215–216, 324, 522, 527–528 postoperative uses in ICU of, 208, 208t, 291–293, 408, 439–440, 607 pressure measurements during use of PEEP, 410 pulmonary artery rupture from, 180, 292–293 removal of, 296, 647 technique of insertion of, 178, 178f–179f volumetric catheters, 180 Sweep rate, 232, 244 Sympathoadrenal axis, 584 Synchronized IMV (see synchronized intermittent mandatory ventilation) Synchronized intermittent mandatory ventilation, 387, 401, 419, 422–424 Syncope and aortic dissection, 44 and aortic stenosis, 18–19 SYNTAX score, 5, Synthes titanium fixation plates, 374, 681 Synthroid (levothyroxine), 627 Systemic embolism (see air, fat, or gas embolism) Systemic hypertension (see hypertension, systemic) Systemic inflammatory response syndrome, 229, 244, 309, 312, 314–315, 385, 393, 398, 413, 584, 690 Systemic vascular resistance (see also alpha agents, and afterload, ACE inhibitors and ARBs, and vasodilators) and CPB, 242–243 and hypothermia, 305 and perioperative MI, 515 and protamine reactions, 210–211 basic concepts of, 440 effect of anesthetic drugs on, 195t formula for, 441t manipulation of, 449–450 Systolic anterior motion (SAM) and HOCM, 41–42 and mitral valve surgery, 114t, 186, 329 Systolic ejection period (SEP), 19 SaO2 (see arterial blood gases) 814 INDEX T3 (see triiodothyronine) Tachy-brady syndrome, 90, 528, 531, 657 Tachycardia (see specific tachycardia) Tamponade (see cardiac tamponade) Tandem Heart, 485–486, 486f TAVI (see transcatheter aortic valve implantation) Technetium sestamibi (Cardiolyte), 91 T.E.D stockings, 284t, 403t, 405, 648t, 655–656, 731a, 734a Tegretol (cabamazepine), 692, 752a Tekturna (aliskiren), 604 Temazepam (Restoril), 752a Temperature afterdrop, 192, 205, 306 gradient during bypass, 246, 252 management systems, 188, 214, 306, 323, 334 Temperature probe Foley catheter, 296 Temporary transvenous pacing wires, 40, 91, 191, 526–527 Tenormin (atenolol), 428, 538, 558, 748a Tension pneumothorax and acute respiratory failure, 407, 426 and cardiac arrest, 507, 508t and low cardiac output syndrome, 446, 453 and sinus tachycardia, 535 Tepid cardioplegia, 269–272 Terlipressin, 246 Terminal warm blood cardioplegia, 270, 273, 304t Tetrastarch (Voluven), 357, 587–588 Tetrofosmin (Myoview), 91, 93f TEVAR (see thoracic endovascular aortic repair) Tezosentan, 457 Thallium, scanning, 49, 91–92, 94 THAM (tromethamine) for treatment of metabolic acidosis, 622, 704 in cardioplegia, 267, 268t Theodur (theophylline), 752a Theophylline (Theodur), 752a Thermodilution cardiac output, 177–180 and tricuspid regurgitation, 177, 291, 293, 327, 443, 453 Thermogard, 214, 323 Thiamine, 141, 689 Thiazides, 607t, 608–609, 623, 745a, 751a Thiocyanate toxicity, from nitroprusside, 470, 498 Thiopental (see also barbiturates) during circulatory arrest, 192 for induction, 194, 195t, 196t Third degree (complete) heart block, 524, 528, 530t, 534–535, 534f Third nerve palsy, 628 Thoracentesis for pleural effusion, 416, 427 technique of, 758a Thoracic aortic aneurysms, 48–53 anesthetic considerations for, 192–193 arch aneurysms, 49, 52, 53f, 192, 333–334 ascending, 48–49, 49f–50f, 51–52, 333–334 Crawford classification of, 51f descending, 49, 52–53, 192–193, 334 imaging of, 116, 118–123, 117f–123f indications for surgery in, 48–49 left heart bypass for, 53, 192, 252, 253f Marfan syndrome and, 27–28, 48–49 pathophysiology of, 48 postoperative care for, 333–334 preoperative considerations in, 49, 51 size and risks of complications, 48–49, 49f–50f surgical procedures for, 25f, 51–53, 53f thoracoabdominal, 49, 52–53, 192–193, 334 Thoracic duct ligation, for chylothorax, 427 Thoracic endovascular aortic repair, 48, 53, 334 Thoracic epidural analgesia (see epidural analgesia) Thoracoabdominal aneurysms (see thoracic aortic aneurysms) Thoracostomy tubes (see chest tubes) Thoratec HeartMate II, 63, 483, 488, 490, 490f Thoratec HeartMate XVE, 481, 492, 493f, 494 Thoratec pneumatic VAD, 483, 488, 490, 492 Three-dimensional echocardiography (see echocardiography) Thrombate III (antithrombin III concentrate), 139, 201, 247, 354, 370 Thrombin, and CPB, 199–200, 229–230, 232, 241, 350, 354–355 Thrombin time, 200, 241 Thrombocytopenia (see also platelet counts) and inamrinone, 463, 470 and mediastinal bleeding, 349t, 350, 358–359, 365, 365f, 369–370 causes of, 666 from CPB, 350 from IABP, 476, 666 heparin-induced (see heparin-induced thrombocytopenia) idiopathic thrombocytopenic purpura (ITP), 158t, 350 postoperative, 350, 365, 365f, 369, 666–669 preoperative, 349t, 350 thrombotic thrombocytopenic purpura (TTP), 666 INDEX 815 use of platelets for, 212, 363t, 364–366, 365f, 369–370, 666 Thromboelastogram, 212, 357t, 359, 360f, 364 Thromboelastometry, 359 Thromboembolism (see also anticoagulation, venous thromboembolism) and left ventricular aneurysms, 13 and mitral stenosis, 30 from circulatory assist devices (VADs), 494 from prosthetic heart valves, 706–707 prophylaxis for VTE, 137, 284t, 403t, 405, 649t, 653, 655–656, 731a, 735a Thrombolytic therapy, and emergency heart surgery, 138, 151, 349t, 350, 353 Thrombosis, of heart valves, 96, 101f, 707 Thrombotic thrombocytopenic purpura, 666 Thromboxane, 133, 135, 211 Thyroid hormone (see triodothyronine, thyroxine) Thyroid-stimulating hormone (TSH), 132t, 148 Thyroxine, for hypothyroidism, 627 Tibial nerve palsy, 692–693 Ticagrelor, 134t, 136, 150 Time-tension index, 473 Tirofiban (Aggrastat) and perioperative bleeding, 350 for acute coronary syndrome, for CPB with HIT, 204 preoperative cessation of, 134t, 138, 176, 353 Tissue oxygenation, basic concepts of, 442–443 Tissue valves and endocarditis, 40 anticoagulation for, 326, 330–331, 669–670, 670t durability of, 708 use of, 21–22, 23f, 37 Titanium sternal plates (Synthes), 374 Tobacco use (see smoking) Toradol (see ketorolac) Torsades de pointes, 512, 551–552, 554 ECG of, 553f from disopyramide, 557 from droperidol, 552, 696 from haloperidol, 552 from ibutilide, 546 from metoclopramide, 552 from procainamide, 556 from sotalol, 540, 560 treatment of, 554 Total artificial heart, 492 Total parenteral nutrition (see parenteral nutrition) Totally endoscopic coronary artery bypass (TECAB), 13 T-piece weaning, 401, 422–423 Tracheostomy after thoracic aortic surgery, 334 and sternal wound infection, 418 indications for, 415t, 416–418 technique of percutaneous, 761a–763a Tracrium (atracurium), 195t–196t, 197, 745a TRALI (transfusion-related acute lung injury), 367, 387, 392, 399, 407, 414 Trandate (see labetalol) Tranexamic acid, 199, 304t, 308, 352t, 354, 596t, 597 Transcatheter aortic valve implantation (TAVI), 25–26, 26f, 29 Transcatheter ablation of AF, 54 Transcatheter pulmonary embolization, 293 Transcutaneous pacing, 511, 527 Transcutaneous phrenic nerve stimulation, 655 Transdiaphragmatic pressures, 655 Transesophageal atrial pacing, 214, 528 Transesophageal echocardiography (see echocardiography) Transfer order sheets, 648t–650t, 734a–736a Transferrin, 706 Transfusion reactions, 367–369 Transfusion-related lung acute lung injury (TRALI), 367, 387, 392, 399, 407, 414 Transfusions and 2,3 DPG, 367, 391–392, 412, 442 autologous, 149–150 autotransfusion, 295–296, 356, 368–369 blood, 365–369, 448t, 452 (see also transfusion trigger) blood substitutes, 371 calcium chloride for, 366 complications from, 367, 387, 674, 677, 684, 695, 699, 702–703 cryoprecipitate (see cryoprecipitate) for anemia, 147, 150 fresh frozen plasma (see fresh frozen plasma) nosocomial infections and, 674 of shed mediastinal blood, 368–369 platelet (see platelet transfusions) preoperative, 8, 147 preoperative blood setup guidelines, 152, 154t pulmonary dysfunction and, 387, 413 religious concerns about, 149 sternal wound infection and, 677 816 INDEX Transfusions (Continued ) triggers intraoperative, 244, 678 postoperative, 150, 311–312, 348, 365, 367, 399, 408t, 412, 442, 448t, 452, 665, 678 preoperative, 352t, 398 Transient ischemic attacks, 143, 685, 753a, 755a Transmyocardial revascularization (TMR), 13 Transplantation for end-stage heart failure, 63 stem cell, 63 Transpulmonary gradient, 440 Transseptal approach to mitral valve, 329, 532 Transthoracic echocardiography (see echocardiography) Transvenous pacing wires, 40, 91, 191, 526–527 Transverse arch aneurysms (see thoracic aortic aneurysms) Transverse titanium plates, 374, 681 Triazolam (Halcion), 752a Tricuspid annuloplasty, 37, 38f Tricuspid commissurotomy, 37 Tricuspid regurgitation and chronic passive congestion, 37, 148, 191, 703 and Swan-Ganz catheters, 177, 291, 293, 327, 443, 453 anesthetic considerations in, 190–191 echocardiographic evaluation of, 36 functional with mitral valve disease, 29, 31, 35 pathophysiology of, 36 preoperative considerations in, 37 surgical procedures for, 31, 37, 38f, 40–41 use of mixed venous O2 saturations with, 443 Tricuspid stenosis anesthetic considerations in, 190–191 indications for surgery in, 37 pathophysiology of, 36 Tricuspid valve replacement, 37 Tricuspid valvulectomy, 40–41 Tricuspid valve disease, 36–38 anesthesia for, 190–191 chest radiograph in, 88f echocardiography in, 36 indications for surgery, 37 repair or replacement for, 37, 38f, 40 pacemaker after repair of, 38 Trifurcation graft, 52, 53f, 251, 333 Triggered activity, 551, 556 Triglycerides, and chylothorax, 427 Triiodothyronine and calcium channel blockers, 466 dosage of, 466 for hypothyroidism, 627 for low cardiac output syndrome, 466, 627 for prevention of atrial fibrillation, 466, 541 hemodynamic effects of, 466 indications for, 466 Trillium coating, 230 Tromethamine (THAM) for metabolic acidosis, 622 in cardioplegia solutions, 267, 268t Troponin I or T postoperative, 320, 322, 514–515 preoperative, TSH (see thyroid-stimulating hormone) Tube feedings, 611, 702, 705–706 Tube thoracostomy (see also chest tubes), technique for, 759a–760a Tuberculous pericarditis, 63, 66 Tubular casts, 605, 605t Turtle shell incision, 664 Tylenol (see acetaminophen) Tylenol #3, 650t, 735a Type A dissections (see aortic dissections) Type B dissections (see aortic dissections) U waves, and hypokalemia, 618 Ulcer disease, prophylactic medications for, 144, 700 Ulnar nerve palsy, 692 Ultrafast extubation, 303 Ultrafiltration continuous arteriovenous hemofiltration (CAVH), 615 continuous venovenous hemofiltration (CVVH), 611t, 613–615, 614f intraoperative (MUF), 233 slow continuous (SCUF), 611t, 613–615 Ultrasound of abdomen, 697, 699, 705 of bladder, 605 of diaphragm, 655 UniVent tubes, 180, 192, 215–216, 293 Unstable angina (see acute coronary syndromes) Upper gastrointestinal bleeding, 699–701 Upper GI endoscopy, 700 Uremia (see also renal insufficiency) and coagulopathy/platelet dysfunction, 349t, 350, 364 and encephalopathy, 611 and pericarditis, 64, 611 dialysis for (see renal replacement therapy) INDEX 817 Urinalysis in renal dysfunction, 605t preoperative, 132t, 148, 730a Urinary (Foley) catheter, 144, 296–297, 606, 607t, 610 Urinary tract infection nosocomial, 652, 674 preoperative, 144, 148 Urine osmolality, 605–606, 605t, 628 Urine output (see also oliguria) and RIFLE criteria, 601–602, 601t Urine sodium, 605t, 606 Urologic symptoms, 144 V/Q mismatch (see ventilation/perfusion mismatch) V/Q scanning (see ventilation/perfusion scanning) Vacuum-assisted closure (VAC dressing), 680–681 Vacuum-assisted drainage, 231, 250 VADS (see ventricular assist devices) Vagal stimulation, for paroxysmal supraventricular tachycardia, 547 Valium (diazepam), 689 Valsartan (Diovan), 750a Valve-associated issues, 706–708 Valve thrombosis, 101f, 703, 707 Vancocin (see vancomycin) Vancomycin dosage of, 153t, 154, 286t, 649t, 730a, 733a, 735a, 744a for Clostridium Difficile colitis, 701–702 for endocarditis prophylaxis, 683t for ventilator-associated pneumonia, 417 paste, 678 prophylactic use of, 151–152, 153t, 154, 197, 674 red-neck syndrome from, 154 Varenicline (Chantix), 140, 398, 752a Varicose veins, 132t, 146 Vascaths, 612 Vascular resistance systemic (see systemic vascular resistance) pulmonary (see pulmonary vascular resistance) Vasectomy, and protamine reactions, 210 Vasoconstriction, management of, 312–313 (see also vasodilators) and low cardiac output syndrome, 450 from hypothermia, 305 Vasoactive medications (see inotropic drugs) Vasodilation, management of, 313–315 (see also alpha-agents, norepinephrine, phenylephrine, vasopressin) Vasodilators, 496–506 basic concepts of, 496 dosages of, 497t for aortic regurgitation, 27, 188 for low cardiac output syndrome, 312–313, 450 for mitral regurgitation, 34–35, 190 for radial artery grafts, 11, 322, 501–502 for RV failure/pulmonary hypertension, 189, 318, 328, 454–457, 454t for systemic hypertension, 319, 496–506, 658 selection of, 505–506 weaning of, 471–472 Vasodilatory shock (see vasoplegia) Vasoplegia (vasodilatory shock), 209, 246, 248, 314–315, 451, 494, 589 Vasopressin and circulatory assist devices, 482, 494 and coronary spasm, 452 and renal function, 452 and splanchnic vasoconstriction, 452, 470, 589 dosage of, 286t, 315, 452, 510t, 732a during CPB, 205, 243, 584, 589 for cardiac arrest, 507f, 510–511, 510t for GI bleeding, 701 for refractory hypotension (vasoplegia), 191, 205, 209, 246, 248, 286t, 315, 448t, 451–452, 589, 732a Vasopressors (see inotropic medications) Vasospasm (see coronary vasospasm) Vasotec (enalapril), 749a VATS, for pericardial window, 65 Vaughan-Williams classification, 554 Vecuronium (Norcuron), 197 dosage during surgery, 196t, 745a for postoperarive shivering, 395 hemodynamics of, 195t Vegetations, 108, 110, 110f Vein strippings, 132t, 144 Venlafaxine (Effexor), 751a Venodyne boots, 403t, 405, 655–656 Venous cannulation, 237t, 238, 239f–240f, 240 Venous drainage, pump-assisted, 231, 250 Venous oxygen saturation (see also mixed venous oxygen saturation) during CPB, 205, 241t during OPCAB, 214, 242–243 Venous thromboembolism (VTE), 655–656 prophylaxis for, 137, 284t, 403t, 405, 649t, 653, 655–656, 731a, 735a treatment of, 656 818 INDEX Ventavis (see Iloprost) Ventilation, mechanical complications of, 394, 401, 408, 417, 420, 427–428, 677, 695–696, 699 dependence on, 413–418 extubation criteria, 402t initial settings for, 388, 388t methods of ventilatory support, 418–421 predictors of prolonged, 159, 162, 396–398, 397t, 405–406 weaning from, 400–403, 400t–402t, 421–425 Ventilator-associated pneumonia, 415t, 417, 676 Ventilation/perfusion scanning, for pulmonary embolism, 656 Ventilation/perfusion mismatch, 501 (see also hypoxic vasoconstriction) after cardiac surgery, 386, 389 and nicardipine, 561 and nitroprusside, 498 Ventilator settings, routine postoperative, 388, 388t Ventilators pressure-limited, 419–420 volume-limited, 418–419 Ventilatory support (see also ventilation, mechanical) methods of, 418–421 tracheostomy for, 417–418 Ventolin (albuterol), 284t, 404, 411, 428, 616t, 650t, 653, 731a, 736a Ventricular arrhythmias, 549–554, 657 (see also ventricular tachycardia and fibrillation) after CABG, 207, 320, 516 and cardiac arrest, 506–512, 507f and CHF, 62 and circulatory assist devices, 494 and coronary spasm, 516 and HOCM, 41 and hypomagnesemia, 619 and left ventricular aneurysms, 13 and low cardiac output syndrome, 446 and pacing wires/pacemakers, 525 and perioperative MI, 514, 516 pathophysiology of, 549–554 postoperative, 549–554 preoperative, 90 treatment of, 552–554 Ventricular assist devices (see circulatory assist devices) Ventricular ectopy (see premature ventricular contractions) Ventricular fibrillation, 551–554 (see also cardiac arrest) and cardiac arrest, 83, 506–510, 507f and hyperkalemia, 616 and hypokalemia, 618 and hypothermia, 508t and metabolic acidosis, 620 and pacemakers, 552 ECG of, 553f induction of, during ICD implantation, 60, 193 postoperative, 530t, 551, 553–554 Ventricular overdrive pacing, for ventricular tachycardia, 520, 525, 553 Ventricular pacing, 525–526 ECG of, 525f for sinus bradycardia, 531 for slow ventricular response to atrial fibrillation, 525, 530t for torsades, 554 indications for, 525 nomenclature for, 522t rapid, for ventricular tachycardia, 520, 525, 553 Ventricular septal defect (see ventricular septal rupture) Ventricular septal rupture, 16–17 and assessment of operative risk, 156, 158t, 161t anesthetic considerations in, 188 echocardiographic evaluation of, 16 indications for surgery with, 16 IABP for, 16, 188, 472 pathophysiology of, 16 preoperative considerations in, 16 recurrent, postoperative, 114t, 632 surgical procedures for, 8, 17, 17f Ventricular tachycardia, 56–60, 551–554 (see also cardiac arrest) after CABG, 320 and cardiac arrest, 506, 507f, 509–510 and digoxin toxicity, 563 and HOCM, 41 and LV aneurysms, 13 ECGs of, 552f from antiarrhythmic drugs, 559–561 from hypokalemia, 618 ICD for, 58–59, 335, 553–554 indications for surgery for, 58–59 inducible, 57–58, 553 monomorphic, 551–553 nonsustained, 320, 551, 552f, 553 INDEX 819 pacemakers and, 525, 527 pathophysiology of, 56–57 polymorphic, 551–554 postoperative, 551–554 preoperative, 90 pulseless (see cardiac arrest) surgical procedures for, 59–60 sustained, 530t, 551–554, 552f treatment of, 58–59, 552–554 Ventriculogram, 98f–99f Verapamil, 502 and digoxin levels, 561–562 dofetilide with, 560 dosage of, 497t, 502, 561, 748a for coronary/radial spasm, 322, 517 for HOCM, 41 for hypertension, 502, 506 for paroxysmal supraventricular tachycardia, 530t hemodynamic effects of, 500t Vernakalant, 547 Versed (see midazolam) VF (see ventricular fibrillation) Viability studies, 94–95 Vicodin (hydrocodone), 405, 546a, 733a, 735a, 747a Video-assisted thoracoscopic procedures (VATS), 65 Vigileo FloTrac, 177, 180, 190, 213, 291, 293, 294f, 327, 408, 441, 453 Visual deficits, postoperative, 9, 244, 685 Vital capacity, during weaning from mechanical ventilation, 402t Vitamin C, 541 Vitamin E, 139, 350 Vitamin K for overanticoagulation, 672–673, 673f, 741a preoperative use of, 137–138, 151, 351 use with warfarin, 673, 707 Vocal cord paralysis, 694 Volume-limited ventilators, 418–419 Volumetric Swan-Ganz catheters, 180, 189, 327 Voluven (tetrastarch), 357, 587–588 Von Willebrand’s disease/factor, 138, 349t, 350, 587, 701 use of cryoprecipitate for, 370–371 use of DDAVP for, 366 VOO pacing, 525 VSD (see ventricular septal rupture) VT (see ventricular tachycardia) VTE (see venous thromboembolism) VVI pacing, 522, 525 (see also ventricular pacing) and triggering of ventricular tachycardia, 525, 527 definition of, 521t–522t Waffle procedure, for constrictive pericarditis, 66, 664 Warfarin after aortic valve surgery, 326–327, 669, 670t, 671 after Maze procedure, 330 after mitral valve surgery, 330–331, 670, 670t, 671 and amiodarone, 559 and argatroban, 668 and delayed tamponade, 660 and gastrointestinal bleeding, 699 and hepatic dysfunction, 704 and HIT, 668 and mediastinal bleeding, 350 and Vitamin K, 673, 707 during pregnancy, 707 drug interactions with, 742a for atrial fibrillation, 542t, 543f, 545 for mechanical valves, 326–327, 331, 670t, 671 for mitral rings, 330, 670–671, 670t for patent foramen ovale, 68 for pulmonary embolism, 656 for tissue valves, 326, 330–331, 669–670, 670t postoperative use of, 287t, 647, 649t, 733a, 735a preoperative discontinuation of, 31, 134t, 137–138, 144, 151, 176, 349t, 350–351 protocol for initiation of, 672t, 740a upon hospital discharge, 709 Warm cardioplegia, 269–273 Warm induction cardioplegia, 270, 272 Warming, techniques of, 188, 214, 284t, 323, 334, 305–307, 307f, 731a Weaning of intraaortic balloon, 471, 476–477 of VADs, 481–483 of vasoactive drugs, 470–472 of ventilator, 400–403, 400t–402t, 421–425 Wellbutrin (bupropion), 140, 398, 751a Wenckebach, 533, 533f White blood cell count, 132t, 147, 652 White blood cell scanning, 679 Withdrawal, alcohol, 687–689 Work of breathing, 418–419, 424 820 INDEX Wound aspiration, 679 Wound care, postoperative, 674 Xanax (alprazolam), 751a Xigris (drotrecogin), 626 Xopenex (levalbuterol), 428, 650t, 653, 736a Xylocaine (see lidocaine) Zaleplon (Sonata), 752a Zantac (see ranitidine) Zaroxolyn (metolazone), 608, 751a Zebeta (bisoprolol), 61, 540, 748a Zemuron (rocuronium), 195t–196t, 197, 745a Zestril (lisinopril), 506, 749a (see also ACE inhibitors) Zetia (ezetimibe), 750a Zinc deficiency, 696 Zinc sulfate, 704 Zocor (simvastatin), 287t, 559, 649t, 709, 735a, 750a Zofran (see ondansetron) Zoloft (sertraline), 751a Zolpidem (Ambien), 752a Zyban (bupropion), 140, 398, 751a Zyprexa (olanzapine), 688, 751a ... heparin or excessive protamine Preoperative use of low-molecular-weight heparin (enoxaparin) within 12 18 hours of surgery or of fondaparinux, a factor Xa inhibitor, within 48 hours of surgery. .. surgery without increasing morbidity during line placement or increasing the risk of perioperative bleeding Low-molecular-weight heparin (LMWH) is given in a dose of mg/kg SC q12h for acute coronary... continuing aspirin in all CABG patients since some studies indicate that the risk of infarction and mortality may be lower when aspirin is continued up to the time of surgery. 18,19 Antifibrinolytic