From the Guidelines
Post sternotomy ICU care should prioritize admission to a specialized intensive care unit or intermediate care unit with medical and paramedical personnel specializing in critical cardiovascular surgery care to reduce morbidity, mortality, and length of stay. The care plan should focus on stabilizing the patient after cardiac surgery and preventing complications. Immediate priorities include:
- Maintaining hemodynamic stability with careful fluid management and vasopressor support as needed (norepinephrine 0.01-0.3 mcg/kg/min or vasopressin 0.01-0.04 units/min for hypotension) 1
- Pain control using multimodal analgesia with IV opioids (morphine 2-4mg or hydromorphone 0.5-1mg every 2-4 hours) transitioning to oral medications, supplemented with acetaminophen 1g every 6 hours
- Respiratory management involves mechanical ventilation initially with weaning parameters of FiO2 ≤40%, PEEP ≤5 cmH2O, and adequate spontaneous breathing efforts before extubation, followed by incentive spirometry every hour while awake
- Cardiac monitoring includes continuous ECG, invasive blood pressure monitoring, and assessment of cardiac output
- Chest tubes require hourly drainage monitoring with removal when output is <100 mL/24 hours
- Wound care involves sterile dressing changes and sternal precautions to prevent dehiscence
- Laboratory monitoring includes complete blood count, electrolytes, and coagulation studies every 6-12 hours initially
- Early mobilization should begin within 24 hours post-extubation, progressing from sitting to walking
- Glycemic control targeting blood glucose 140-180 mg/dL using insulin protocols helps reduce infection risk, as recommended by the 2011 ACCF/AHA guideline for coronary artery bypass graft surgery 1
- Prophylactic antibiotics (typically cefazolin 1-2g IV every 8 hours for 24-48 hours) and DVT prophylaxis with subcutaneous heparin or enoxaparin are standard. The use of specialized intermediate care units may be suggested for the better use of intensive care unit resources and faster rehabilitation of patients in an ERACS programme 1.
From the Research
Post-Sternotomy ICU Care
- The use of bilateral ultrasound-guided transversus thoracic muscle plane block (TTPB) has been shown to be effective in reducing post-sternotomy pain and improving patient outcomes, including shorter ICU stay lengths and lower postoperative analgesic doses 2.
- Chronic poststernotomy pain is a common complication after cardiac surgery, and its treatment is often inadequate, relying on opioids and other medications with significant adverse effects 3.
- Rigid plate fixation for closure of emergent sternotomies in trauma patients has been shown to be feasible and may reduce complications related to sternal closure, although further studies are needed to confirm these findings 4.
- Early implementation of upper body activity and exercise in patients recovering from median sternotomy may promote optimal and timely patient recovery, while minimizing the risk of complications 5.
- The use of cefazolin as antibiotic prophylaxis in cardiac surgery has been shown to be effective, and continuous infusion may provide pharmacokinetic and pharmacodynamic advantages over intermittent administration 6.
Pain Management
- TTPB has been shown to reduce pain scores and postoperative analgesic doses in patients undergoing heart surgery, including sternotomy 2.
- Chronic poststernotomy pain can have a significant impact on quality of life, and its treatment is often inadequate 3.
Sternal Closure
- Rigid plate fixation for closure of emergent sternotomies in trauma patients may reduce complications related to sternal closure, although further studies are needed to confirm these findings 4.
Physical Activity
- Early implementation of upper body activity and exercise in patients recovering from median sternotomy may promote optimal and timely patient recovery, while minimizing the risk of complications 5.
Antibiotic Prophylaxis
- The use of cefazolin as antibiotic prophylaxis in cardiac surgery has been shown to be effective, and continuous infusion may provide pharmacokinetic and pharmacodynamic advantages over intermittent administration 6.