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Critical Care of the Cardiac Surgery Patient
52 Plays6 years ago
In this episode of Critical Matters, we explore the role of the intensivist in the postoperative care of the cardiac surgical patient. Our guest is Dr. John Greenwood, a practicing intensivist who splits his clinical time between the Cardiac and Vascular ICU and the ED-ICU at the Hospital of the University of Pennsylvania.
Additional Resources:
Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care: https://www.ncbi.nlm.nih.gov/pubmed/25962078
Postoperative Critical Care of the Adult Cardiac Surgical Patient: Part II: Procedure-Specific Considerations, Management of Complications, and Quality Improvement: https://www.ncbi.nlm.nih.gov/pubmed/26136101
Critical Care Perspectives in Emergency Medicine – a monthly CME podcast on resuscitation and critical care-related issues that can present to the ED https://www.criticalcareinem.com/
Critical Care Project – a multi-institutional website designed to be a multidisciplinary educational resource on topics in critical care. http://ccproject.com/
Books Mentioned in This Episode:
How to Win Friends & Influence People: https://www.amazon.com/How-Win-Friends-Influence-People/dp/0671027034/ref=sr_1_3?ie=UTF8&qid=1521825606&sr=8-3&keywords=dale+carnegie
The Last Lecture: https://www.amazon.com/Last-Lecture-Pausch-Randy-Hardcover/dp/B011MCWCDW/ref=sr_1_2?ie=UTF8&qid=1521826496&sr=8-2&keywords=the+last+lecture
In the first of two episodes, we discuss general postoperative care, common complications, and the intensivist-cardiac surgeon relationship.
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Transcript
Introduction and Overview
00:00:09
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:17
Speaker
And now, your host, Dr. Sergio Zanotti.
00:00:21
Speaker
In today's episode of Critical Matters, we will talk about the critical care of the cardiac surgical patient.
00:00:28
Speaker
Cardiac surgery represents one of the most common categories of surgery performed in the United States today.
00:00:33
Speaker
For many reasons, intensivist involvement in the postoperative care of these patients continues to increase.
00:00:39
Speaker
Close collaboration between the intensivist and the operating surgeon is essential for a comprehensive and successful postoperative care.
00:00:47
Speaker
It's a pleasure to have as a guest Dr. John Greenwood, who's Assistant Professor of Clinical Emergency Medicine,
00:00:54
Speaker
Assistant Professor of Anesthesiology and Critical Care Medicine at the Medical School of the University of Pennsylvania and also Medical Director of the Resuscitation and Critical Care Unit of the Hospital of the University of Pennsylvania in the Department of Emergency Medicine.
Role of Intensivists in Cardiac Care
00:01:08
Speaker
Dr. Greenwood divides his time between the critical care and emergency medicine.
00:01:13
Speaker
Half of his clinical time is spent working in Penn's Heart and Vascular ICU and the other half in a relatively new EDICU space at HUP.
00:01:22
Speaker
He is the editor-in-chief of the EMRA Presserdex and has a particular interest in the resuscitation of cardiovascular emergencies, mechanical circulatory support, and time-sensitive critical illness.
00:01:35
Speaker
Dr. Greenwood is also an active participant and member of the FOM community and currently serves as administrator and contributor to Critical Care Perspectives and Emergency Medicine, a monthly CME podcast on resuscitation and critical care related issues that can present to the ED and to the Critical Care Project, CCP, a multi-institutional website designed to be a multidisciplinary educational resource on topics in critical care.
00:02:02
Speaker
John, welcome to the podcast.
00:02:06
Speaker
Well, thank you, Sergio.
00:02:06
Speaker
It's a pleasure to be here and talk about a particular topic that I love and spend a lot of time doing, which is the post-cardiac surgery patient.
00:02:14
Speaker
So thank you for having me.
00:02:16
Speaker
So I think we can start, I mean, we talked about how common it is, and for many reasons, what used to be the purview of CT surgeons alone now includes in an increasingly frequency the collaboration or as members of the team of intensivists with different backgrounds in terms of training.
00:02:34
Speaker
What is unique about caring for these post-op patients in general, John?
00:02:40
Speaker
Well, I think that the fun thing about this is that managing these patients as an intensivist, you kind of have to know a little bit about the surgical details of a lot of these different procedures.
00:02:50
Speaker
And some of the procedures we're going to touch upon are the general ones.
00:02:55
Speaker
So the most common surgeon
00:02:58
Speaker
and our surgeries that are done today are still cabbages and single valve replacements.
00:03:03
Speaker
And I think the goal of today is probably not to go too much into the surgical details or the specific complications, but talk about some of the most common things that can arise in a post-operative course.
00:03:14
Speaker
And so the important thing to know as an intensivist is really how to recognize these things and what to look out for.
00:03:19
Speaker
What are some of the signs that might be subtle at first, but can rapidly unravel and put the patient in shock
00:03:27
Speaker
So these are very dynamic patients and so really things that really need to stay on top of early and make some rapid clinical decisions because the implications and outcomes if the decision is not made correctly can be really, really important.
00:03:44
Speaker
So I think those are probably some of the most important things to discuss today.
Transition from OR to ICU
00:03:51
Speaker
Excellent.
00:03:51
Speaker
And I think that as a framework, we will talk a little bit about the routine postoperative management and then jump into, like you said, some of the most common complications.
00:04:00
Speaker
that we need to recognize and be aware of, and finally close with some of the relationship issues between cardiac surgery and the intensivist.
00:04:09
Speaker
But I would like to start with the first part of the post-op management, which is really what I consider to be a high danger zone, which is the patient leaves the OR and arrives to the ICU.
00:04:23
Speaker
Can you talk about that specific transition of care and what can we do to make it as safe as possible?
00:04:33
Speaker
Absolutely.
00:04:33
Speaker
So I think we can all agree that handoffs are probably one of the highest risk areas, whether or not they're coming from the emergency department or from the operating room.
00:04:43
Speaker
This is a critical time to learn a lot about what potentially is going on with the patient.
00:04:48
Speaker
And I know at HUP, what we've done is we've developed a specific handoff tool that I'd be happy to make available to the listeners.
00:04:56
Speaker
But it goes over basically a lot of the different things that happen in the operating room as well as and
00:05:03
Speaker
in terms of from the surgical side as well, the anesthesia side.
00:05:07
Speaker
Some of these surgical pieces of information that are important will be things like what were the cardiopulmonary bypass time, what was the cross clamp time, what did they find that the optimal filling pressures and hemodynamics were at the end of the operating room operative case, what were any of the intra-op issues, complications, and what are the surgeons' hemodynamic goals based on what they perceived during the operative case.
00:05:32
Speaker
And I think we can all agree that the operating room can sometimes be a little bit of a mystery, a black box.
00:05:38
Speaker
And, you know, it's not uncommon that, you know, the surgeons may have encountered something and to them might not have been a big issue.
00:05:47
Speaker
But it's important to get these details upfront to kind of know what the lie of the land is.
00:05:51
Speaker
And certainly from the cardiac anesthetist, they're going to provide some other vital information.
00:05:57
Speaker
How was the airway?
00:05:58
Speaker
Was it a difficult airway?
00:05:59
Speaker
Was it an easy airway access?
00:06:01
Speaker
What type of access is the patient coming out with?
00:06:05
Speaker
What were their post-operative and pre-operative echo findings, particularly with the TEE, that might impact your decisions on how to manage this patient in the ICU?
00:06:16
Speaker
Certainly what vasoactives, what inotropes the patient's on, how much blood they required.
00:06:20
Speaker
And then lastly, how did they decide to ventilate the patient over the course of the case?
00:06:25
Speaker
Did they have any issues with ventilation or hypoxemia?
00:06:28
Speaker
And certainly many of these patients come out with epicardial pacemaker.
00:06:31
Speaker
So what are their current pacemaker settings and thresholds in terms of obtaining capture?
00:06:38
Speaker
Those are all really, really important pieces of information.
00:06:41
Speaker
And what I hear, John, which is I think what we have seen in my own practice, what really helps is two factors in this handover, which is number one, team approach.
00:06:52
Speaker
So you need the OR team and the ICU team all present.
00:06:56
Speaker
And number two, a standardized approach where you cover these items
Hemodynamic Management
00:07:00
Speaker
every single time on every single patient.
00:07:03
Speaker
Yeah, that's right.
00:07:04
Speaker
And this is something that we place a high importance on in
00:07:07
Speaker
Every patient that's delivered to the ICU from the operating room, we have basically a team huddle at the bedside.
00:07:14
Speaker
It's not something that's done five minutes after the patient arrives, kind of at a conference room table, or that if there's an advanced practitioner managing or taking handover, this is done collectively as a group.
00:07:28
Speaker
Excellent.
00:07:29
Speaker
For the nurses to be involved, for the surgeons to be involved
00:07:34
Speaker
and everyone to feel, or basically communication to be optimized so that everyone kind of knows what to expect and what to look out for.
00:07:41
Speaker
Excellent.
00:07:41
Speaker
And I think another unique aspect of these cardiac surgery patients is that they might have a lot of hemodynamic instability in the first 24 hours, especially upfront after surgery, and then most of them end up being very stable and move forward and transition through a very protocolized pathway.
00:08:04
Speaker
Let's talk a little bit about the acute hemodynamic management, which I think is a great part of what we need to do in the ICU.
00:08:10
Speaker
Why don't we start with blood pressure issues that might be seen in these surgeries and your thoughts on that, John?
00:08:19
Speaker
No, sounds great.
00:08:20
Speaker
So, in my—and I don't think this is an opinion that's held by myself, but just by myself, but certainly nurses that are comfortable and experienced in managing post-cardiac surgery patients
00:08:34
Speaker
are truly worth their weight in gold.
00:08:36
Speaker
These patients are, in fact, some of the most dynamic patients that are going to present to your ICU.
00:08:41
Speaker
And certainly our approach is to provide a goal-directed approach that enables
00:08:47
Speaker
the bedside nurse to make clinical decisions rapidly at the bedside, whether that's titration of drips, vasopressors, synotropes, that's not required for the physician necessarily to be at the bedside making these titrations because these are often done on a minute-to-minute basis right out of the OR.
00:09:04
Speaker
So a strong clinical cardiac experience ICU nurse is invaluable.
00:09:11
Speaker
But when we're talking about specific resuscitation endpoints, I think, as we all do, probably divide them up into certain categories, and particularly blood pressure is one of them.
00:09:21
Speaker
And a MAP target, generally somewhere along the lines of 65 to 80 is usually reasonable.
00:09:27
Speaker
And this may be variable based on what the surgeon encounters in the operating room, whether or not that, or what surgery the patient had.
00:09:35
Speaker
But in general, somewhere between 65 and 80 is a reasonable target.
00:09:39
Speaker
Now, some of these things that might change that could be severe left ventricular hypertrophy or basically SAM or systolic anterior movement of the mitral valve found on echo.
00:09:51
Speaker
Some of these patients may have a really stiff left ventricle and require higher filling pressures and higher afterload.
00:09:57
Speaker
So again, going back to the importance of a handoff at the age of 20 is going to be important.
00:10:05
Speaker
other things that might change your target might be if the patient has some post-operative bleeding problems.
00:10:09
Speaker
So if the patient has some hemorrhaging, some oozing at the end, lower mean arterial pressure not to cause any excessive bleeding.
00:10:20
Speaker
So in order to achieve those things, we'll certainly focus on using a specific vasopressor and that may be something like a norepinephrine or even phenylephrine if
00:10:31
Speaker
if your unit feels comfortable with that.
00:10:33
Speaker
I think many people are leaning on the side of norepinephrine as first-line vasopressor.
00:10:37
Speaker
Now, outside of blood pressure in general, we want to focus on obviously cardiac index and not just the index or the macro circulatory variable, but obviously downstream numbers like SVO2 that focus on more or less oxygen extraction and perfusion.
00:10:52
Speaker
So in general, from a cardiac index standpoint, we usually target somewhere around 2 to 2.2 liters per minute per meter squared.
00:11:00
Speaker
And we still at HUP use a lot of pulmonary artery catheters.
00:11:03
Speaker
I know there are some surgeons that have moved on to doing cardiac surgery without pulmonary artery catheters, but we still rely on them heavily.
00:11:12
Speaker
But that's partly due to our patient population tends to be a little more higher risk, as they refer to a pretty higher level academic center.
00:11:23
Speaker
Other variables, so obviously right-sided filling pressures are CDP.
00:11:27
Speaker
We still do monitor, and there's lots of reasons for this, which we'll go into in just a little bit, but this target can be variable, and we don't usually use it for the idea or the concept of volume responsiveness, but nonetheless, keeping an eye on the right ventricle as well as filling pressures to make sure we're kind of optimized from a cardiac output perspective.
00:11:50
Speaker
PA pressures are something we're going to be monitoring heavily, especially with the PAC in place.
00:11:54
Speaker
And like I mentioned before, getting a good sense of not just what these maculatory variables are, but really what's happening to the patient, what's their lactate doing, are they clearing lactate, which can be kind of tricky, especially if they underwent cardiopulmonary bypass, is this number can oftentimes elevate in the initial phases of resuscitation despite
00:12:16
Speaker
gaining ground, if you will.
00:12:18
Speaker
Urinary output is helpful.
00:12:20
Speaker
And then obviously,
Medication Strategies for Post-Surgery
00:12:22
Speaker
first thing I do whenever I walk in the patient's room is feel their hands and feet.
00:12:26
Speaker
Are they cold?
00:12:26
Speaker
What's their capillary refill?
00:12:28
Speaker
Do they have clinical signs of perfusion?
00:12:33
Speaker
And I think that another aspect, obviously, that's very important in
00:12:37
Speaker
managing the hemodynamic aspect of these patients is fluid.
00:12:40
Speaker
And there are some particular, maybe, factors that are relevant.
00:12:45
Speaker
Patients who undergo cardiopulmonary bypass have many reasons to have third spacing, fluid depletion.
00:12:52
Speaker
And a lot of times when patients come up and have a low blood pressure, that might be the first intervention.
00:12:57
Speaker
Can you comment a little bit on the use of fluids in these patients, John?
00:13:02
Speaker
Absolutely.
00:13:03
Speaker
I think for the most part, after coming out of the operating room, there may be some degree of vasoplegia, vasodilation, or even a large amount of volume that was ultra-filtrated coming off a cardiopulmonary bypass.
00:13:14
Speaker
So in general, I think it's reasonable to start with a fluid challenge if the patient from their hemodynamics appear to be either volume-responsive and hypotensive or largely underfilled with a low
00:13:29
Speaker
I'll give latitude to the nurses to provide a 20 to 30 cc kilo fluid bowl.
00:13:34
Speaker
It's not all at once, but in 250 to 500 cc increments to see if that improves our cardiac output, if it should be low, and subsequently your blood pressure.
00:13:43
Speaker
In general, we used balanced crystalloids.
00:13:45
Speaker
So we may start with a normal saline bag coming up, but then quickly transition to something like lactated ringers.
00:13:53
Speaker
Just to kind of keep in mind that metabolic acidosis is something
00:13:58
Speaker
that we're going to be using to determine the efficacy of our resuscitation.
00:14:02
Speaker
So try to minimize anything that causes further acidosis like normal saline would be probably beneficial.
00:14:11
Speaker
But after that, if we are still requiring volume to improve our cardiac output and our MAP, we'll
00:14:21
Speaker
likely look to other things to use, and oftentimes, if there's a concern of bleeding, we'll quickly transition to a balanced transfusion strategy of red blood cells, FFP, and platelets once we get to kind of that one-to-one-to-one ratio if needed.
00:14:37
Speaker
And certainly, thinking about other things that might benefit the patient if they're coagulopathic or if they need fibrinogen to form a clot, early cryoprecipitate is often
00:14:49
Speaker
given to these patients if they're actively hemorrhaging.
00:14:52
Speaker
We really don't use a lot of albumin in terms of colloid.
00:14:55
Speaker
If we're really going to focus on use of colloid rather than crystalloid, we really focus on balanced blood product transfusion.
00:15:02
Speaker
Unless we really start getting into large volume requirements, then we might lean on something like an albumin infusion, but I can tell you this is usually exception to the rule.
00:15:12
Speaker
So another aspect that I think is unique to these patients, which we don't see in medical patients or other categories of critically ill patients, is that often, and I think this might be variable from program to program, but surgeons will use a combination of a vasopressor and a vasodilator.
00:15:30
Speaker
Can you comment on that combination, which seems a little bit odd a priori, but probably has some reasons behind it?
00:15:37
Speaker
No, yeah.
00:15:37
Speaker
So when we talk about goal-resuscitated post-cardiac surgery care, we really
00:15:42
Speaker
I try to make it simple, or at least as simple as possible for the nurses to kind of decide which vasoactive to titrate.
00:15:50
Speaker
So really, when we're coming up with a comprehensive plan for this patient in their postoperative course, we focus on which drug are we using to achieve which goal.
00:16:00
Speaker
So do we have a low blood pressure?
00:16:04
Speaker
And if we're trying to improve our MAP, we really want to focus on using a vasopressor.
00:16:07
Speaker
And like I said before, we have a few options here, and institutionally, this might be variable,
00:16:12
Speaker
The most important thing probably is that there's a standard kind of pathway for each achievable goal.
00:16:18
Speaker
So if your goal is to improve your MAP, do you want your nurse to titrate your norepi, or are they using something like vasopressin or neosinephrin or phenylephrine to achieve this MAP goal?
00:16:29
Speaker
And there has been some research recently that's been published in terms of trying to decide if one's better than the other.
00:16:36
Speaker
And particularly in post-cardiac surgery vasoplegic patients, there is a question of should we be using a catecholamine like norepinephrine or something like vasopressin, which targets a little bit of a different receptor, but obviously in some belief that it spares pulmonary artery pressure from sort of vasopressor effect.
00:16:59
Speaker
particular study was the VANCS trial that was just published last year, where they looked at comparing norepinephrine to vasopressin for post-cardiac surgery vasoplegia, and they examined particular composite outcomes of mortality and severe complications at 30 days, and the general complications that they looked at in this composite group were stroke, prolonged mechanical ventilation, acute kidney injury, and what they found was that the vasopressin group did
00:17:28
Speaker
seem to have a reduced primary outcome and lower incidence of atrial fibrillation, which I guess there's some biologic plausibility here because if you're not attacking sort of your beta adreneric receptors as much, might reduce your catecholamine surge and AFib rates.
00:17:42
Speaker
But obviously, there are some criticisms here to this study because it was a single center study and it certainly wasn't definitive
00:17:50
Speaker
but does add to the evidence base for some clinical decision-making.
00:17:54
Speaker
So whether to use a catecholamine or vasopressin as your primary vasopressor certainly is something worth discussing with your intensivist group.
00:18:03
Speaker
Now, if you're looking to the second variable, which often we use, which is cardiac index, certainly you're going to want to use something like an inotrope.
00:18:10
Speaker
And our standard practice at HUP is we often
00:18:14
Speaker
can use epinephrine as our primary inotrope.
00:18:16
Speaker
So if our cardiac index is low, starting to go up on your epinephrine dose.
00:18:20
Speaker
And certainly at lower doses, it's believed that epinephrine is actually an inodilator more than an inopressor.
00:18:25
Speaker
So having someone on two to four mics a minute of epinephrine, or if you're using weight-based dose, that might be a little bit different, is a reasonable approach to improve your cardiac index.
00:18:37
Speaker
Now, some of these patients might have concomitant pulmonary hypertension, and if that's the case and they're not hypotensive, the use of PD inhibitor or something like milrinone might be a reasonable choice.
00:18:48
Speaker
But obviously, both of these medications have their side effects and will limit the clinical care or decisions that you might be making.
00:18:56
Speaker
The vasodilatory effect of milrinone can often be profound, and so a patient who's hypotensive really might not tolerate all that much milrinone at all.
00:19:05
Speaker
But certainly, if you encounter a patient with some RV dysfunction coming out of the operating room with the elevated pulmonary pressure, milrinone might be the ideal medication for them to improve their cardiac output.
00:19:17
Speaker
Now, certainly epinephrine is a reasonable choice and, again, doesn't have as much hypotensive effect.
00:19:24
Speaker
It's usually a go-to right out of the OR, at least at our institution.
00:19:30
Speaker
John, what about the other side of the spectrum, hypertension?
00:19:34
Speaker
A lot of patients come up with hypertension.
00:19:35
Speaker
There also might be some concerns regarding very high pressures and their effect on LV afterload or even suture lines in valvular
Ventilatory and Bleeding Management
00:19:43
Speaker
surgery.
00:19:43
Speaker
Can you comment on that?
00:19:45
Speaker
Yeah, so we are really aggressive about maintaining a strict range for blood pressure coming out.
00:19:52
Speaker
And I think we have a few options.
00:19:55
Speaker
Now, certainly, it may just be they need a afterload reducer, and so something like hydralazine for a single dose might be reasonable, and to kind of see how the patient responds.
00:20:07
Speaker
Other things, common things being common, focus on addressing things like postoperative pain and agitation.
00:20:13
Speaker
So these patients coming out of the OR certainly might be uncomfortable,
00:20:17
Speaker
So before you get into the afterload reducers, make sure that the patient has adequate pain control using morphine or fentanyl.
00:20:27
Speaker
These are easy things to fix that might bring down your pressure altogether.
00:20:31
Speaker
Now, if you've addressed these things and the patient's not in pain, they're comfortable on the ventilator, then you can start looking to these other afterload reducers.
00:20:42
Speaker
of hydralazine, patients still hypertensive, certainly starting a vasoactive like nicartipine might be reasonable.
00:20:51
Speaker
There are some side effects of nicartipine that are worth looking out for.
00:20:55
Speaker
Obviously, it's vasodilator, so you can encounter some hypoxemia as it might reduce your patient's pulmonary vasoconstriction to kind of fix, and you might get some shunting.
00:21:10
Speaker
So keeping an eye on that might be important, but nicardipine is a reasonable approach to addressing postoperative hypertension, at least right off the bat.
00:21:20
Speaker
Excellent.
00:21:21
Speaker
And I think that there's a, we can move on to maybe the mechanical ventilation aspect.
00:21:25
Speaker
And there's a very small group of patients with very specific surgeries that usually might be extubated in the OR, but the vast majority of patients come to the ICU, intubate it, and this is an important part of a quality measure.
00:21:37
Speaker
Can you comment a little bit on the immediate post-op ventilator management?
00:21:44
Speaker
No, absolutely.
00:21:44
Speaker
So I think that one of the things
00:21:48
Speaker
that we pay very close attention to, obviously, is lung protective ventilation.
00:21:52
Speaker
And it is reasonable to do this in post-cardiac surgery patients.
00:21:55
Speaker
I mean, I'm not getting as strict as, you know, the ARDS patient, the six cc's per kilo dipping down to five, that sort of thing.
00:22:02
Speaker
But a reasonable lung protective approach of six to eight cc's per kilo per ideal body weight is a good initial approach for most of these patients.
00:22:11
Speaker
Again, like you mentioned, these usually are short-term mechanical ventilation runs.
00:22:15
Speaker
So oftentimes,
00:22:19
Speaker
you'll be getting these patients excavated relatively quickly, but at least to start getting with lung protective ventilation is a good approach.
00:22:26
Speaker
Now, certainly there are some targets as well as we talked about kind of goal-directed care.
00:22:31
Speaker
So some PaO2 targets, though usually greater than 70 is reasonable.
00:22:37
Speaker
There may be some times when you might push an oxygenation target a little bit higher.
00:22:40
Speaker
So if the patient has right ventricular dysfunction, it's reasonable to have a little bit of a higher target, somewhere between 85 to 100.
00:22:48
Speaker
just because we do know that hypoxemia or relative hypoxemia can lead to pulmonary vasoconstriction and increased RV afterload.
00:22:57
Speaker
And the right ventricle is a little bit more sensitive as it does have a little bit of a decreased amount of coronary blood flow.
00:23:04
Speaker
So certainly we want to make sure that it has adequate oxygenation, but certainly not allowing for excessive periods of hyperoxia.
00:23:12
Speaker
That is something that we do pay close attention to.
00:23:15
Speaker
In terms of ventilation targets or PACO2 target, probably reasonable to be to have a normal target, somewhere between 30 to 40 or 25 to 45, not allowing too much hypercapnia or permissive hypercapnia in these patients, but we can usually achieve that pretty easily.
00:23:34
Speaker
Now, you did bring up something that's actually a really important quality metric, which is something called fast-track extubation, I think is the common term.
00:23:44
Speaker
And in general, this is a quality metric that looks at how fast you're able to extubate your post-operative cardiac surgery patients, particularly ones that underwent a CABG or a single valve replacement.
00:23:56
Speaker
And so the target of six hours is really important.
00:24:00
Speaker
And this is used as a quality metric by the STS as well as a few other, not only six hours, but really 24-hour extubation rates is really, really important.
00:24:14
Speaker
institutions rating in terms of things like STS stars, which are publicly reportable.
00:24:23
Speaker
So I think that achieving this is really, again, getting back to this multidisciplinary in the OR.
00:24:30
Speaker
And a lot of times, the anesthetists are using very short-acting, whether or not it's fentanyl, remifentanyl, narcotics in the OR so that basically the effects of these drugs basically go away pretty
00:24:44
Speaker
things like rewarming in the operating room rather than delivering the patient cold to the ICU.
00:24:48
Speaker
These are things that can shave off substantial amounts of time in terms of getting the patient ready for extubation.
00:24:57
Speaker
So I think that minimizing sedation early and accepting that you can extubate patients on a good amount of vasopressor is reasonable, partly because we often can get a sense of what the trajectory of the patient's going to be.
00:25:14
Speaker
It just needs a little bit of time.
00:25:15
Speaker
It's not like the medical patient that comes up who has a primary lung problem or is in septic shock.
00:25:20
Speaker
These patients should recover relatively quickly.
00:25:22
Speaker
So getting your providers comfortable with extubating patients on vasopressin will do really well.
00:25:30
Speaker
But certainly there's times when the complications might prohibit this and should be the exception rather than the rule.
00:25:36
Speaker
But...
00:25:38
Speaker
Certainly, some of these things that might cause a problem coming out or might limit your ability to get these patients extubated in a timely fashion.
00:25:46
Speaker
And I think that since we touched on an important quality metric, like you mentioned, the fast-track extubation, another very important quality measure that I think intensivists need to be very aware of is glycemic control in the immediate post-op period.
00:25:59
Speaker
Do you want to comment a little bit on that, John?
00:26:00
Speaker
Mm-hmm.
00:26:03
Speaker
Yeah, absolutely.
00:26:04
Speaker
So glycemic control is something that we do pay very close attention to, particularly making sure that the blood glucose gets down less than 150.
00:26:13
Speaker
We do provide a relatively tight glucose control, so it's not uncommon for us to start insulin infusions on our patients pretty quickly.
00:26:22
Speaker
And there's a lot of reasons why patients tend to be hyperglycemic in the acute postoperative phase.
00:26:27
Speaker
Obviously epinephrine, it's a common inotrope that we use, causes some relative insulin
00:26:33
Speaker
sensitivity issues.
00:26:35
Speaker
So patients, we don't allow them to stay hyperglycemic for very long.
00:26:40
Speaker
So starting on insulin fusion early, getting the glucose under control within the first hour, one to two hours is imperative.
00:26:49
Speaker
So our nurses are very well trained in insulin titration.
00:26:53
Speaker
This isn't usually an intermittent dose kind of thing.
00:26:56
Speaker
We usually start them off on an insulin drip quickly.
00:27:01
Speaker
Excellent.
00:27:01
Speaker
I think that in the next portion of the podcast, I would like to dive into some of the complications that can occur post-cardiac surgery.
00:27:10
Speaker
And I know that there's a lot that we can talk about, but I would like to kind of frame this as common complications that occur on a regular basis in a cardiac ICU.
00:27:19
Speaker
Post-operative would include some degree of bleeding and arrhythmias, and then maybe the more
00:27:25
Speaker
feared or severe complications that would be refractory shock, including cardiac tamponade and cardiac arrest.
00:27:32
Speaker
So why don't we start with bleeding, which I think is something that we're always monitoring and that is very common.
00:27:41
Speaker
Absolutely.
00:27:41
Speaker
So bleeding is something that
00:27:45
Speaker
we're going to really rely on our nurses to keep us updated on, and particularly chest tube bleeding is one of the most common sites that we'll be able to actually see if the patient is actually having some bleeding.
00:27:56
Speaker
If they come out of the OR, usually they'll have some mediastinal drains as well as a left-sided pleural drain if it was a cabbage, sometimes a lot of bilateral pleural drains, depending on whether or not the right side of the chest is best.
00:28:07
Speaker
So some that are important to me.
00:28:10
Speaker
So
00:28:10
Speaker
If the patient's coming out within the first three hours and has a bleeding rate of somewhere between 200 or 400 mLs an hour, that's a concerning sign for me and certainly might be a concern that the patient needs to go back to the OR for exploration.
00:28:25
Speaker
Now, certainly as an intensivist, a medical intensivist, I'm trying to fix the fixables.
00:28:30
Speaker
And it is warm.
00:28:32
Speaker
Have the malapathy that's present?
00:28:35
Speaker
Is there PTT down to normal?
00:28:37
Speaker
Thinking about things like what's their platelet count?
00:28:39
Speaker
What's their fibrinogen?
00:28:40
Speaker
So getting their platelets above 100,000, making sure that they don't have any clear platelet dysfunction.
00:28:46
Speaker
Were they on any preoperative Plavix that might be causing some delayed issues?
00:28:51
Speaker
What's this fixed in the operating room?
00:28:54
Speaker
Getting the fibrinogen, making sure that the fibrinogen levels over 80 or 100.
00:28:59
Speaker
Those are some things that I can actually fix relatively quickly because I can tell you it's not uncommon, especially as we get
00:29:06
Speaker
evening and we operate regularly past midnight and these patients will come out around one o'clock.
00:29:12
Speaker
You know, it's two, three o'clock where I'm like, you know, hey, the chest tube output's been about 400 an hour for the past two hours.
00:29:18
Speaker
You know, I'm concerned that it might have an intercostal bleed or something like that.
00:29:21
Speaker
And they're like, you know, fix the coagulopathy, right?
00:29:23
Speaker
That's that's if you're fix the fix the coagulopathy.
00:29:26
Speaker
And if you can go back, can you say, listen, my patient's 98 degrees, their platelets are normal, INR is fixed, their PTTs, you know, have
00:29:35
Speaker
number, 30, and a second fixed, but they're still bleeding, you paint a case that maybe this patient should actually go back to the OR rather than sit and get an extensive amount of transfusions in your ICU.
00:29:51
Speaker
Even other simple things like keeping a close eye on your blood pressure, keeping your systolic down 90 to 100 in these aggressively bleeding patients.
00:29:59
Speaker
These are some things that you can really stay on top of and basically make a case
00:30:04
Speaker
that it's not your fault.
00:30:07
Speaker
And I think this is very important and I would like to reemphasize because obviously when we see bleeding, we're very likely to think, oh, this patient needs to go to the OR.
00:30:16
Speaker
But like you said, what we can control is make sure the patient's warm,
00:30:20
Speaker
Make sure that we corrected the quagulopathies in the platelets.
00:30:24
Speaker
Make sure the blood pressure is controlled.
00:30:26
Speaker
And make sure that we have that information.
00:30:28
Speaker
And the other piece I think that is very important as a reference is if you're bleeding or you're draining more than 200 cc per hour, that should be something that you should be paying attention to.
00:30:39
Speaker
Go ahead.
00:30:42
Speaker
No, absolutely.
00:30:43
Speaker
And then I think the flip side of that is something that many of us are in tune to as medical intensives in terms of hemoglobin triggers for just red blood cell transfusions.
00:30:53
Speaker
You know, transfusions in cardiac surgery, cardiac surgeons oftentimes will treat transfusions no big deal.
00:30:59
Speaker
But I think the medical side of me thinks, well, each of these is a little transplant, comes with all potential complications.
00:31:06
Speaker
I want to try to minimize the amount of blood I'm giving my patient.
00:31:10
Speaker
I'm usually, I'm pretty much guided at this point by a recent trial that came out of using a transfusion trigger of about 7.5 to 8 grams per deciliter in general cardiac surgery patients.
00:31:24
Speaker
This trial looked at basically a composite outcome that was death from any cause and post-operative MI stroke and new onset renal failure.
00:31:34
Speaker
And between a conservative or liberal strategy of 7.5 versus 9.5 grams per deciliter
00:31:39
Speaker
there really wasn't all that much difference in outcome.
00:31:41
Speaker
So I think it's reasonable to kind of hold off for a transfusion trigger of eight in most patients.
00:31:48
Speaker
And I think- Certainly that might be a little bit different if the patient has, go ahead.
00:31:53
Speaker
No, no, no.
00:31:53
Speaker
Go ahead, finish, sorry.
00:31:57
Speaker
I was going to say, I think sometimes you may decide to up the transfusion to maybe if the patient's having ongoing or active ischemia for some reason.
00:32:07
Speaker
But in general, I stick to that eight grams per deciliter pretty well.
00:32:11
Speaker
And I think that what I was going to comment is that in this field, as in many other areas of critical care, we have moved to more restrictive transfusion parameters.
00:32:21
Speaker
And even our CT surgeons are usually more comfortable with a little bit lower hemoglobin before they transfuse, especially in patients who are hemodynamically stable.
00:32:29
Speaker
Now, if somebody's bleeding or they're unstable, it might be a different story like you mentioned.
00:32:35
Speaker
And I mean, other things to kind of keep in your back pocket, I think, is intensive.
00:32:39
Speaker
We're becoming more facile with the use of ultrasound.
00:32:42
Speaker
So if there is a chest tube that's bleeding and then abruptly stops, or if the hemoglobin's dropped in, they haven't got a whole lot of crystalloid, taking the ultrasound over to the bedside is often at least a useful tool for me.
00:32:57
Speaker
I'll take a look at the
00:32:59
Speaker
at the pleural cavities to see if there's any obvious effusions.
00:33:03
Speaker
Maybe that chest tube's actually clogged or there's a loculated effusion somehow or in some way.
00:33:09
Speaker
And some people might think that you actually can't get any good cardiac use with a bedside TTE, but you actually can.
00:33:17
Speaker
Don't be afraid to move the dressing over a tiny bit and try to get a look at see if there's a pericardial effusion.
00:33:22
Speaker
And if your patient's not doing all that well, you'll often be surprised at what you'll find.
00:33:28
Speaker
And so even if
00:33:29
Speaker
It's just giving an initial trial, doing some simple views.
00:33:35
Speaker
Ultrasound is an invaluable tool in the post-cardiac surgery patient.
00:33:40
Speaker
And I think that the last part of bleeding that I would just want you to comment briefly, John, which is out of our domain, but the surgical management, right?
00:33:48
Speaker
At one point, a surgeon, and a lot of times based on what happened in the OR, it might happen earlier, will decide to take the patient who continues to bleed back to the OR.
00:33:57
Speaker
Any comments on what usually happens there?
00:34:02
Speaker
Yeah, so certainly it's preferable.
00:34:05
Speaker
And I think that there are times when,
00:34:10
Speaker
it's in the middle of the night and the patient's not doing well and there might be a concern for bleeding where a surgeon may decide to do something in the ICU at the bedside.
00:34:19
Speaker
But this has largely become more of an exception rather than the rule.
00:34:23
Speaker
I think that doing bedside procedures can often put a significant strain on the nursing staff as well as the clinical staff.
00:34:32
Speaker
It can really tie up a lot of research, I'm sure,
00:34:38
Speaker
kind of on the other side of the ICU.
00:34:39
Speaker
And inevitably, you know, the bleeding patient that you have in your unit is on the exact opposite side as the other sickest patient in your unit.
00:34:46
Speaker
And so you're left kind of running back and forth and trying to check on two things.
00:34:50
Speaker
So we do try to encourage our surgeons and our surgical trainees to
00:34:55
Speaker
take things back to the operating room to look closely to where the site of bleeding is.
00:35:01
Speaker
And this may in fact delay your exhumation times and a few other things, but as with anything in critical care, moving slow is moving fast.
00:35:10
Speaker
So doing it right the first time is probably more important than trying to take a shortcut.
00:35:15
Speaker
Our surgeons have been great.
00:35:17
Speaker
They're really supportive about, hey, if the patient's bleeding, you're really concerned about them.
00:35:21
Speaker
This is a clinical diagnosis.
00:35:23
Speaker
We'll take them back to the operating room once everything's fixed.
00:35:25
Speaker
So it's better for the patient from a sterility standpoint.
00:35:29
Speaker
Obviously, it's always a concern in any of the pleural or mediastinal cavities.
00:35:33
Speaker
So we still regularly, if there's a concern, they'll go back to the OR.
Managing Atrial Fibrillation and Shock
00:35:39
Speaker
The other common complication that I think that we could just touch on briefly because it happens so often is the incidence of atrial fibrillation and other supraventricular arrhythmias.
00:35:50
Speaker
Any comments you want to make on that, John?
00:35:52
Speaker
Yeah, absolutely.
00:35:53
Speaker
So AFib is common.
00:35:54
Speaker
We see it in nearly every patient.
00:35:57
Speaker
And there's lots of reasons for this.
00:35:59
Speaker
They just basically had their myocardium cut into the tissues, basically irritable.
00:36:05
Speaker
And I think the clinical question is whether you use a beta blocker versus another drug like amiodarone for rhythm control versus rate control.
00:36:13
Speaker
And I think from the literature standpoint, there really doesn't seem to be all that much of a difference for most patients.
00:36:20
Speaker
The last study published on our trial was in 2016.
00:36:24
Speaker
Gyllenhaf basically was a randomized control trial, rhythm versus rate controls.
00:36:28
Speaker
And what they looked at
00:36:30
Speaker
as their primary endpoint was number of days in the hospital, complication rate, and persistent AFib.
00:36:35
Speaker
And what they found at 60 days, there was basically no difference between using beta blocker versus amiodarone.
00:36:41
Speaker
Now, that's kind of a long-term scope of kind of interventions that you're going to use for your patient.
00:36:49
Speaker
In general, early on though, you're kind of limited by some of the other medications that the patient's on.
00:36:53
Speaker
So at least in the first 24 hours postoperatively, it's not uncommon for a patient to be on catecholamine, epinephrine, norepinephrine, something like that.
00:37:01
Speaker
So it doesn't make a whole lot of sense to use a beta blocker in those patients.
00:37:04
Speaker
So I do tend to use amiodarone liberally in boluses of 150.
00:37:09
Speaker
And I may give two, three, even four doses of amiodarone as a bolus to try and get this patient
00:37:18
Speaker
rhythm controlled, but oftentimes it's the rate control effect of AMIO that kicks in first.
00:37:24
Speaker
So many people might
00:37:27
Speaker
not know that amio actually has a pretty significant beta blocker effect, and that usually kicks in after a few doses.
00:37:33
Speaker
And if I'm not achieving rate control, rhythm control, I may start them on an amio infusion just while I'm trying to wean off my catecholamines.
00:37:41
Speaker
Now, certainly if the patient's unstable after they go into AFib, electrical cardioversion is something that you may have to do.
00:37:50
Speaker
Certain patients are more sensitive to being in sinus rhythm if they have
00:37:55
Speaker
underlying a dilated atria and they need that atrial kick.
00:37:59
Speaker
But AMEO early on is something that I tend to do.
00:38:03
Speaker
But after they're off their vasoactives, instituting something like a beta blocker for rate control is kind of a next step sort of thing.
00:38:12
Speaker
Excellent.
00:38:12
Speaker
So let's talk about refractory shock.
00:38:14
Speaker
So patients who we have treated aggressively with hemodynamic support, their parameters keep getting worse.
00:38:23
Speaker
We have excluded or don't think that they are bleeding.
00:38:26
Speaker
What are the things that we should be worried about and how should we approach these patients?
00:38:32
Speaker
Yeah, so I think in my mind, there's like the big three of post-cardiac surgery refractory shock.
00:38:38
Speaker
And the big three here are going to be tamponade, and this is usually secondary to bleeding, but sometimes the result of something else I'll talk about, which is called loss of domain.
00:38:49
Speaker
Right ventricular failure is another thing to keep a close eye on or eye out for.
00:38:54
Speaker
And then post-cardiopulmonary bypass vasoplegia is another common cause of post-cardiotomy shock.
00:39:02
Speaker
So I think to start out, let's just touch on tamponade first.
00:39:05
Speaker
And I think that there's a few signs that we all are really keeping a close eye out for, which, like I mentioned before, something using other hemodynamic signs.
00:39:16
Speaker
So oftentimes an abrupt rise in your CVP or a meeting of your CVP to PA diastolic pressure is a concerning sign that there's something compressing in
00:39:31
Speaker
in the pericardium that's not allowing your heart to fill.
00:39:33
Speaker
And if you're seeing your CDP creep up slowly towards your PAD, that should be a sign that, hey, you know, my cardiac index is low, my SVO2 is low.
00:39:44
Speaker
You know, I think we need to either take a look with an echo
00:39:47
Speaker
or call the surgeon over because I'm concerned this low cardiac index state that's not responding to my epinephrine that's been escalating over the past two hours might be tamponade.
00:39:56
Speaker
And oftentimes, this may even just be a clinical diagnosis, and I think oftentimes is.
00:40:00
Speaker
But tamponade is something you have to keep an eye out for.
00:40:04
Speaker
And the other thing, the other kind of subtle clue that oftentimes you'll get pushed with is the nurse will be like, you know, I gave them fluid bowls.
00:40:12
Speaker
They continue to be fluid responsive, but their index is low.
00:40:16
Speaker
Well, oftentimes it's just because, you know, you're increasing their filling pressure, they're able to provide a cardiac output, but the pericardial pressures are kind of becoming overcome by your fluid challenge.
00:40:27
Speaker
So that's another kind of hint that, hey, something's not going right.
00:40:31
Speaker
Do I need to be worried about tamponade?
00:40:34
Speaker
The tricky part about tamponade as well is unlike our, you know, oncology patients, renal patients that often will have
00:40:41
Speaker
kind of this diffuse pericardial effusion.
00:40:45
Speaker
Post-cardiac surgery, this could be due to a simple clot somewhere that you may not even see on echo.
00:40:50
Speaker
So a focal clot can cause tamponade as well.
00:40:55
Speaker
And again, this is sort of why I say tamponade still is a clinical diagnosis because you're often left using your hemodynamic numbers to make this diagnosis.
00:41:07
Speaker
Now, let's just say you go up
00:41:10
Speaker
to the patient, you do your echo, you don't see any obvious clot or pericardial effusion.
00:41:16
Speaker
Another thing that you have to be worried about is this concept of loss of domain.
00:41:19
Speaker
And what loss of domain is, is eventually cardiac tamponade, but can be basically due to a high intrathoracic pressure that can happen from a multitude of reasons.
00:41:29
Speaker
So going back to the handoff, you know, a long cross clamp time, long OR time, maybe some excessive fluid administration can cause edema of the chest wall.
00:41:40
Speaker
And that patient may need a little bit of higher filling pressure, but as they close and they put their metastinal wires in, might cause a relative tamponade due to a high, basically chest pressure or thoracic pressure that is another cause of tamponade.
00:41:59
Speaker
So loss of domain is something that when you reopen the chest, and this sometimes does happen at the bedside, you'll see the hemodynamics all go back to normal as soon as those wires are cut.
00:42:10
Speaker
So loss of domain is something that if things aren't adding up, you don't see an obvious tamponade, but clearly is looking like tamponade.
00:42:16
Speaker
Loss of domain is something to keep a close eye on.
00:42:22
Speaker
So I think a good lesson here… Moving into the kind of the… Go ahead.
00:42:25
Speaker
Go ahead.
00:42:25
Speaker
A good lesson for our intensivists would be that the transthoracic especially, being a normal exam does not necessarily rule out tamponade, and that we should really be thinking about it in terms of hemodynamic parameters and have a high index of suspicion.
00:42:41
Speaker
Go ahead.
00:42:42
Speaker
Sorry.
00:42:45
Speaker
No, absolutely.
00:42:46
Speaker
So another clinical scenario where you'll see a rising CDP and a reduced cardiac output, and this is where it gets a little bit tricky, is in postoperative ventricular failure.
00:42:56
Speaker
I think that many of us who work in heart vascular ICUs primarily are certainly sensitive to this, but this is something that can be a little bit more sneaky.
00:43:05
Speaker
So taking a look with your ultrasound often will give you a sense of, hey, is my ventricular a little bit more dilated than it was once before?
00:43:15
Speaker
If you go up on your epinephrine and you start to get a response, that might be something to key you in that the right ventricle is failing.
00:43:24
Speaker
And RV failure is something that, again, you're starting to think about what other hemodynamic parameters can I manipulate to unload the right ventricle.
00:43:32
Speaker
So minimizing excessive IV fluid and blood product administration can be valuable in this case.
00:43:39
Speaker
Starting the patient even on something like an inhaled pulmonary vasodilator, we often use a lot of inhaled flowlan at our institution if the patient goes into the operating room with a high PA pressure.
00:43:51
Speaker
This oftentimes will allow you to support the right ventricle through their post-operative course.
00:43:57
Speaker
I know dilators, particularly milrinone, again, we talked about before, but can be helpful in reducing your PA pressures while also providing some inotropic support to the RV.
00:44:06
Speaker
So these are all kind of tools in your toolbox that you can use if you're concerned that the patient is having RV failure.
00:44:12
Speaker
Another subtle sign that you might see if the patient is an early V-wave even in your CVP line.
00:44:18
Speaker
So as the first kind of change that
00:44:21
Speaker
patients will undergo if their RV is starting to fail is RV dilation.
00:44:26
Speaker
And so as that RV starts to dilate, the tricuspid annulus will start to dilate as well, and you'll see a new wave on your CBP line.
00:44:35
Speaker
That can be a sign of right ventricular dysfunction and failure early on.
00:44:41
Speaker
Excellent.
00:44:42
Speaker
Any comments, John, on the vasoplegic syndrome or the vasoplegic patient?
00:44:46
Speaker
So, um,
00:44:51
Speaker
Vasoplegia is pretty common, and I think the incidence goes up the longer the bypass time.
00:44:57
Speaker
And oftentimes, this is kind of the patient's blood response in contact with the artificial circuit.
00:45:05
Speaker
And unfortunately, we don't have a whole lot of predictors for who's going to respond.
00:45:09
Speaker
But I think at the bedside, some of the things that we're looking at are obviously a low filling pressure, a low CVP might suggest vasodilation.
00:45:18
Speaker
a high cardiac output.
00:45:20
Speaker
So if your cardiac index is greater than 2, 2, or your output's greater than 4, you're seeing almost like a septic-type picture, might key you in that, you know, this patient's vasoplegic.
00:45:33
Speaker
And in that case, I'm really leaning on my vasopressors first, you know, norepinephrine to try and provide some additional systemic vascular resistance is helpful.
00:45:43
Speaker
You know, start escalating up on your catecholamines,
00:45:48
Speaker
I'm thinking about maybe some other things to do in patients with refractory vasoplegia.
00:45:52
Speaker
So every now and then, we'll have these patients who are escalating on their vasopressor, and you may provide something like early methylene blue is an option as kind of a salvage therapy.
00:46:02
Speaker
There's not a whole lot of evidence for this.
00:46:04
Speaker
I think one of the more exciting new drugs that have come in, angiotensin 2, it'll be interesting to see if that has an impact on post-cardiac surgery vasoplegia.
00:46:15
Speaker
It was studied in just general vasoplegic patients, but certainly another receptor that you could potentially saturate.
00:46:23
Speaker
But again, vasoplegia is common, and usually you get patients through with just a little bit of extended norepinephrine dose.
00:46:29
Speaker
Limiting the amount of crystalloid you're giving is going to be important, but is common, but usually fixable after about 24 hours of aggressive care.
00:46:39
Speaker
And of course, for all these refractory shock patients, post-cardiac surgery, there is a host of mechanical interventions or devices that we can implement that I think will be maybe a topic for another podcast.
Intensivist-Surgeon Collaboration
00:46:55
Speaker
No, absolutely.
00:46:55
Speaker
But I think it's a very important point that you bring up, Sergio, is that if the patient's not doing well, allowing them to remain in shock for even just a few hours can be disastrous.
00:47:07
Speaker
So
00:47:08
Speaker
being in close contact with your cardiac surgeon, letting them know the interventions you've done, as well as your clinical concern.
00:47:15
Speaker
It's not on postcardiomy shock is something that is at least temporized by early ECMO support that your surgeon should be obviously well-adapted to be able to come in and provide.
00:47:30
Speaker
Other mechanical support options like a balloon pump are reasonable as a bridge to maybe more definitive therapy.
00:47:36
Speaker
We are seeing a lot more Impella use.
00:47:38
Speaker
However, I'm still a little bit skeptical about the use of Impella as a primary support device for postcardiomy.
00:47:48
Speaker
I think it is a little bit more challenging to place.
00:47:50
Speaker
Oftentimes it has to be placed, at least at our institution.
00:47:53
Speaker
It's not done at the bedside.
00:47:55
Speaker
And the amount of support provided is, you know, I think that we think that it provides, you know, at least the Impella 5s up to 5 liters of support.
00:48:04
Speaker
But
00:48:05
Speaker
our institutional outcomes have been a little bit less robust in terms of what we would hope.
00:48:09
Speaker
So a definitive intervention like postcardiomide shock delivered fixed with ECMO is what we go to first.
00:48:18
Speaker
Excellent.
00:48:19
Speaker
I think that as we move to the close of the podcast, a very important aspect, which I think at the end of the day, John, is the critical aspect in everything we do, which is the human part in terms of relationships is worth discussing.
00:48:32
Speaker
And I do believe that for many intensivists,
00:48:35
Speaker
the relationships, especially in the early phases with the CT surgeon, might be difficult for many, many reasons.
00:48:41
Speaker
But I would definitely want to hear from you your insights and your thoughts on why this relationship is so difficult and how we as intensivists can make it stronger and better.
00:48:54
Speaker
So, yeah, this is maybe even the most important part of the podcast, I think.
00:49:00
Speaker
As a fellow, I did my
00:49:04
Speaker
critical care training at University of Maryland, and we had a very high acuity cardiac surgery service.
00:49:09
Speaker
And the medical director there, Dan Herr, he's worked in cardiac surgery, I think, for about 20 or 30 years now, but he's a medical intensivist.
00:49:17
Speaker
And he really, really pushed the relationship aspect because communication is obviously important here.
00:49:26
Speaker
But one of the things he pushed really too is, hey, try to take a step back.
00:49:32
Speaker
and think about the implications of complications in terms of how it impacts this cardiac surgeon.
00:49:37
Speaker
You know, oftentimes you come up with that there may be a conflict in terms of which way or what interventions might benefit the patient.
00:49:47
Speaker
And his kind of approach was, listen, as a medical intensivist, my job is to make sure the ship moves forward.
00:49:52
Speaker
And if the intervention is not going to kill the patient, then maybe it's okay to be a little bit
00:49:59
Speaker
flexible.
00:50:00
Speaker
We don't treat this like working in a closed medical ICU.
00:50:02
Speaker
This is a truly collaborative environment, but it's also important to keep in touch with the surgeons early, so let them know what's going on and what's actually happening with their patient.
00:50:14
Speaker
The worst thing that could happen is you call six hours in and be like, hey, I've done this, this, and this, and they're still in shock.
00:50:20
Speaker
They often really want to know what's going on early on, and it's not a failure to call your surgeon.
00:50:26
Speaker
It's often
00:50:28
Speaker
you know, just a progression.
00:50:29
Speaker
And so if I'm escalating vasopressors and the patient's not really behaving the way I suspect, it's usually just a, hey, FYI, this is happening.
00:50:40
Speaker
And this is what I'm going to do about it, but I'll let you know in an hour, even if it's just by a simple call or text message, how things go.
00:50:46
Speaker
It kind of prepares them mentally to kind of expect what might happen and that might require them to, you know, these kind of,
00:50:57
Speaker
relationship-type decisions, if you give the surgeons a heads-up early on, it's much appreciated, not looked at as a bother.
00:51:07
Speaker
So I think that it can be challenging, and certainly these surgeons are often tied to their outcomes much more differently than you or I would be as a general intensivist.
00:51:20
Speaker
So one of the public reporting things, as we mentioned, kind of with the quality rating, are their outcomes.
00:51:25
Speaker
And a death after CABG can be devastating to these surgeons in terms of their public reporting metrics.
00:51:34
Speaker
So they're very sensitive about complications, whether it's stroke, death, obviously, as this may impact their business.
00:51:44
Speaker
So putting yourself in their shoes is going to be important.
00:51:48
Speaker
it's not necessarily reflected on your care per se as an intensivist, but obviously some of the other things that they're thinking about and worrying about should this patient not come out of the operating room as they hoped.
00:51:59
Speaker
Yeah, and I think from my perspective, just a couple of pearls are three things that I really have worked on over the years and I think that really can help develop a strong relationship with your CT surgery team, especially with the surgeons is first remember that like any human being,
00:52:15
Speaker
If you engage them in the things that they enjoy and find out what their interests are outside of the hospital and have those conversations on a regular basis in the ICU, it's a lot easier to have a conversation when things are not going very well with the patient.
00:52:31
Speaker
So develop some rapport with them and just understand what are things that are important for them outside of maybe the ICU and the OR.
00:52:39
Speaker
Number two, I think, is that surgeons love to tell us what they did in the OR.
00:52:43
Speaker
So especially when they're doing new cases or complicated cases, ask them about the surgery, learn about what they're doing, learn from their perspective.
00:52:52
Speaker
And I think it's a great way of establishing also a conversation and a relationship.
00:52:57
Speaker
And finally, I think what you mentioned, John, we need to be empathetic about how these outcomes really impact the way they're viewed by their colleagues, by the system, and by patients in a way that we as intensivists don't experience that with any of the things that we do.
00:53:14
Speaker
Sergio Sanotti has X percent of deaths or X percent of pneumothoraces with his central lines or clapses.
00:53:22
Speaker
All these things can be found in the public domain.
00:53:25
Speaker
And I think that really they own those outcomes.
00:53:27
Speaker
And that's why, like you
Personal Insights and Life Lessons
00:53:29
Speaker
mentioned earlier, they want to be informed early of what's going on so there's no surprises.
00:53:39
Speaker
So the last portion of the podcast, John, with your permission, we would like to ask you some general questions not related to CT surgery, just to tap into your wisdom in life in general.
00:53:51
Speaker
Yeah, so happy to do this, Sergio.
00:53:54
Speaker
And I think this is, you passed along some interesting questions.
00:54:00
Speaker
Which one would you want to tackle first?
00:54:01
Speaker
So let's go with the first one, which is what book or books have influenced you the most or what book have you gifted most often to others?
00:54:10
Speaker
Okay, so interestingly enough, I think that when I was a chief resident, I did my primary training through emergency medicine.
00:54:20
Speaker
My original program director was a professor at Amal Matu.
00:54:25
Speaker
And during our chief year, I did a kind of like a faculty development kind of twist on my chief year.
00:54:33
Speaker
And it was required reading that we read a book by Dale Carnegie.
00:54:37
Speaker
And this is an old,
00:54:40
Speaker
old book.
00:54:41
Speaker
I think it was published back in the 1930s, but the title was How to Win Friends and Influence People.
00:54:45
Speaker
And maybe this was a little bit of foreshadowing that I was going to find interest in cardiac surgery because a lot of these lessons translate into the surgical ICU and how to kind of work with the cardiac surgeons, but just in general with people.
00:55:00
Speaker
And this book has by far had a major impact on my life, not just in clinical medicine, but in general with friends, family, and meeting new people at work.
00:55:16
Speaker
And I think that some of the examples of the lessons that are taught in this book are simple things that are kind of like no duh, common sense sort of thing.
00:55:25
Speaker
So Dale Carnegie talks about
00:55:29
Speaker
You know become genuinely interested in other people kind of do things on the ICU on the unit like smile remember the person's name be a good listener Get to know other people's interests and kind of their perspective It's a it's a wonderful read and really brings just some common sense things back to the front of your brain that I think can make you much happier in the ICU now I
00:55:58
Speaker
The other one is the question, I guess, which one do I gift most often?
00:56:01
Speaker
And it's a book called The Last Lecture by Randy Pausch.
00:56:05
Speaker
The book is basically a short autobiography about a professor at Carnegie Melvin University.
00:56:13
Speaker
And he was a professor where he was an engineer in virtual reality, and he was diagnosed with pancreatic cancer.
00:56:23
Speaker
And
00:56:24
Speaker
What he was tasked to do at Carnegie Mellon, they have this lecture series called The Last Lecture where they ask professors to talk about their life and what they've learned.
00:56:32
Speaker
And it's a short book.
00:56:33
Speaker
It's a quick read.
00:56:34
Speaker
You can probably read it in about a day or two.
00:56:37
Speaker
But it goes through his reflections about things that have made him, kind of his goals, his successes, his failures.
00:56:43
Speaker
That's a real eye-opening look at some really important things in life.
00:56:48
Speaker
So Randy Pausch, Last Lecture, I highly recommend it.
00:56:52
Speaker
Well, both excellent recommendations.
00:56:54
Speaker
And I think that the Dale Carney book in particular is extremely applicable to the ICU and the world of CT surgery as well, because like you mentioned, it's an old book, but it really speaks to a lot of truth and human relationships and how we can take control of making any relationship, especially at work, better.
00:57:13
Speaker
Excellent recommendations.
00:57:14
Speaker
And we'll add these to the show notes if people have interest in picking them up.
00:57:18
Speaker
And the second question is,
00:57:20
Speaker
What do you believe to be true in medicine or life that most other people don't believe to be true?
00:57:30
Speaker
So I think as intensivists, a lot of the work that we do tends to be complex.
00:57:35
Speaker
But I think one of the truths I try to stick to is that simplicity is imperative in what we do in work and life.
00:57:45
Speaker
I certainly think there's a lot of art and medicine, but in large, a lot of the problems that we face are truly kind of like little engineering problems.
00:57:52
Speaker
And my background isn't in engineering or science.
00:57:56
Speaker
I actually did my undergraduate education in economics.
00:58:02
Speaker
But as I've gone through medicine, I've taken a more technical look at kind of what we do.
00:58:08
Speaker
And the complex problems are not just with the patients, with their physiology and everything else, but the other complex problems
00:58:15
Speaker
relationships are with patients and patients' families and kind of the decisions that they're making.
00:58:19
Speaker
And so I really try to make things as simple as possible rather than complex.
00:58:26
Speaker
And particularly in clinical decision-making, if you can make things simple for the providers that are providing care, it truly makes their job easier.
00:58:34
Speaker
And our job is to create that user interface for, you know, the families, for care providers.
00:58:41
Speaker
And so if you can make things simple and not
00:58:44
Speaker
go on these drawn out complicated kind of treatment algorithms, I think you'll have a lot more success than the complex route.
00:58:55
Speaker
And I think that's great advice.
00:58:56
Speaker
And I would agree with you that especially physicians tend to make things more complicated than they need to be.
00:59:02
Speaker
And I think you're in good company because Albert Einstein said that everything should be as simple as possible, but not simpler.
00:59:11
Speaker
Excellent.
00:59:13
Speaker
The last question, John, it relates to what would you want every intensivist who's listening to this podcast to know?
00:59:23
Speaker
I don't know.
00:59:24
Speaker
I mean, I think that kind of tying on to this theory or this idea of simplicity, I guess Steve Jobs is probably one of the faces or was one of the faces of simplicity.
00:59:37
Speaker
And there's a little quote that I like from him that basically simple can be harder than complex.
00:59:41
Speaker
You have to work hard to get your thinking clean to make it simple.
00:59:45
Speaker
But it's worth it in the end because once you get there, you can move mountains.
00:59:49
Speaker
So I think a lot of times what we do is feeling like we're trying to move mountains, but putting in the work to get things simple, whether it's in the hospital or in life, pays off dividends.
01:00:02
Speaker
So I guess that's the quote we can leave today with.
01:00:06
Speaker
Excellent.
01:00:07
Speaker
And John, I want to thank you for your time and for your expertise.
01:00:11
Speaker
We definitely would look forward to having you again on Critical Matters to dive into more specific nuances of different types of surgeries and mechanically support devices.
01:00:20
Speaker
But again, it was a real pleasure talking to you today.
01:00:24
Speaker
Absolutely.
01:00:24
Speaker
Thanks for having me, Sergio.
01:00:28
Speaker
Thanks again for listening to Critical Matters.
01:00:30
Speaker
Make sure to subscribe to this podcast on iTunes or Google Play.