From the Guidelines
Patients after cardiac surgery are at high risk for complications, and management strategies should prioritize early detection and prevention of bleeding, infection, arrhythmias, pain, respiratory complications, and venous thromboembolism to minimize morbidity, mortality, and improve quality of life. The primary risks include:
- Bleeding: regular monitoring of drain outputs, hemoglobin levels, and coagulation parameters is essential, with potential interventions including blood product transfusions or surgical re-exploration if necessary 1
- Infection: prevention involves strict wound care, prophylactic antibiotics (typically cefazolin 1-2g IV every 8 hours for 24-48 hours), and monitoring for signs of infection
- Arrhythmias: management often includes beta-blockers (metoprolol 25-100mg twice daily) or amiodarone (200mg three times daily for one week, then twice daily for one week, then daily) for atrial fibrillation, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1
- Pain: control typically involves multimodal analgesia with acetaminophen (1g every 6 hours), NSAIDs if not contraindicated, and opioids as needed, transitioning to oral medications before discharge
- Respiratory complications: prevention involves early mobilization, incentive spirometry (10 breaths every hour while awake), chest physiotherapy, and supplemental oxygen as needed
- Venous thromboembolism: prophylaxis includes early ambulation, compression stockings, and pharmacological prophylaxis with enoxaparin (40mg daily) or heparin (5000 units three times daily) until fully mobile, as recommended by the 2014 ESC/ESA guidelines on non-cardiac surgery 1
The use of anticoagulation therapy, such as aspirin, should be continued after stent implantation, and the initiation of beta-blocker therapy before noncardiac surgery should be based on individual patient risk assessment 1. Additionally, the management of postoperative atrial fibrillation should include rate control and anticoagulation, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.
The 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery emphasizes the importance of individualized patient assessment and management, and highlights the need for further research on the optimal use of perioperative beta-blockers and anticoagulation therapy 1. Overall, a comprehensive approach to post-cardiac surgery care, including careful monitoring, prophylactic measures, and evidence-based management of complications, is essential to minimize morbidity, mortality, and improve quality of life.
From the Research
Post-Cardiac Surgery Risks
The risks associated with cardiac surgery are numerous and can be categorized into several areas, including:
- Cardiovascular complications, such as atrial fibrillation and stroke 2
- Respiratory complications, such as those related to mechanical ventilation 3
- Renal complications, including kidney injury 3
- Central nervous system complications, including cognitive impairment and stroke 3
- Bleeding complications, including severe post-operative bleeding 4
- Infections, including sternal wound infections 5
Management Strategies
To mitigate these risks, several management strategies can be employed, including:
- Targeted fluid and inotrope administration to maintain a cardiac index above 3 l/min/m throughout the perioperative period 3
- Use of volatile anaesthesia and mechanical ventilation with low tidal volumes, low driving pressure, and moderate-low positive end-expiratory pressure 3
- Preoperative steroids to reduce postoperative atrial fibrillation 3
- Antimicrobial prophylaxis, such as cefazolin, to prevent sternal wound infections 5
- Use of direct oral anticoagulants (DOACs) for anticoagulation in patients with post-operative cardiac surgery atrial fibrillation, which has been shown to be safe and effective compared to warfarin 2, 6
- Standardized management for perioperative discontinuation of DOAC therapy to minimize hemorrhagic complications 6