What are the postoperative Cardiovascular Intensive Care Unit (CVICU) orders for a patient after left ventricular rupture repair following median sternotomy?

From the Guidelines

Postoperative CVICU orders for a patient after left ventricular rupture and repair should prioritize close hemodynamic monitoring, maintaining optimal cardiac function, and preventing complications. The patient's history of median sternotomy and repair indicates a high-risk procedure, and as such, requires intense monitoring and care. According to the guidelines outlined in the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease 1, patients who have undergone open repair of aortic aneurysms or dissection will require more intensive care. Key aspects of postoperative care include:

• Close monitoring of hemodynamic parameters, such as arterial line and central venous pressure monitoring, to maintain MAP >65 mmHg with vasopressors as needed
• Inotropic support with dobutamine or milrinone for cardiac support
• Mechanical ventilation with lung-protective strategies, targeting SpO2 >92%
• Strict fluid management, with careful monitoring of intake/output and daily weights
• Electrolyte replacement to maintain normal ranges, particularly potassium and magnesium
• Pain control and sedation with fentanyl infusion and propofol or dexmedetomidine
• Anticoagulation with heparin infusion should be considered 24-48 hours post-repair if hemostasis is achieved
• Cardiac medications, including beta-blockers, ACE inhibitors, and statin therapy, should be initiated once the patient is stable
• Hourly assessment of chest tube drainage, with surgical re-exploration if drainage exceeds 200 mL/hr for 2-3 consecutive hours
• Cardiac echocardiography should be performed within 24 hours to assess repair integrity and ventricular function, as mentioned in the guidelines for postoperative care of patients with thoracic aortic disease 1.

From the Research

Postoperative CVICU Orders

The patient has undergone a median sternotomy and repair for a left ventricular rupture. The following are some considerations for postoperative CVICU orders:

• Monitoring:
  • Continuous electrocardiogram (ECG) monitoring to assess for arrhythmias and ischemia
  • Arterial line for continuous blood pressure monitoring
  • Central venous line for monitoring of central venous pressure and administration of vasoactive medications
• Hemodynamic support:
  • Vasoactive medications such as milrinone or dobutamine may be considered to support cardiac function, as seen in a study where intratracheal milrinone administration improved right ventricular failure in 61.9% of patients 2
• Pain management:
  • Adequate pain control is essential to reduce stress and promote recovery, as minimally invasive surgical approaches have been shown to decrease pain and reduce recovery time 3
• Respiratory support:
  • Mechanical ventilation may be required to support respiratory function, with a goal of early extubation to reduce ventilator-associated complications
• Fluid management:
  • Careful fluid management is crucial to avoid volume overload and promote optimal cardiac function, as elevated postoperative fluid balance was found to be a predictor of persistent right ventricular failure 2
• Laboratory monitoring:
  • Regular laboratory tests, including complete blood counts, electrolyte panels, and cardiac biomarkers, to monitor for potential complications
• Antibiotic prophylaxis:
  • Broad-spectrum antibiotics may be considered to reduce the risk of mediastinitis and other infections, as seen in a case report of a patient who developed mediastinitis after median sternotomy 4

Considerations for Specific Complications

• Right ventricular failure:
  • May require inotropic support and careful fluid management, as seen in a study where lateral thoracotomy was associated with less early right ventricular failure compared to median sternotomy 5
• Bleeding:
  • May require re-exploration and transfusion of blood products, as seen in a study where reoperations for bleeding were required in 2-4% of patients 3
• Arrhythmias:
  • May require anti-arrhythmic medications and cardioversion, as seen in a study where patch glue repair without extracorporeal circulation was used to treat left ventricular free wall rupture 6