Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: In today's episode of Critical Matters, we will discuss the medical management of postcardiotomy complications in the ICU.
Speaker: Specifically, we will discuss the management of postcardiotomy hemorrhage and postcardiotomy cardiac arrest.
Speaker: Our guest is Dr. Christopher Noll, a critical care attending at Cooper University HealthCare.
Speaker: Dr. Noll is an assistant professor of medicine at Cooper Medical School of Rowan University.
Speaker: He's also the Associate Program Director for the Critical Care Medicine Fellowship and the Clerkship Director for Critical Care Medicine, Clerkship for Medical Students.
Speaker: He's an excellent clinician and clinical educator who has a special interest in critical care echocardiography, extracorporeal support, simulation training, and medical education.
Speaker: We had the opportunity to talk with Chris about temporary pacemakers not too long ago, and I encourage our listeners to check out that episode if they have not heard it.
Speaker: Chris, welcome back to Critical Matters.
Speaker: Thanks for having me, Sergio.
Speaker: Really excited to be here to talk about this.
Speaker: I know this is a topic that...
Speaker: is close to your practice but also to your area of interest.
Speaker: You work with the fellows and getting them ready to take care for CT surgery patients, which obviously are an important part of many ICUs in terms of the patient population today and a growing number of our patients.
Speaker: A lot of times these patients sail through, but sometimes they're difficult.
Speaker: And I think understanding some of the issues related to the management of complications, such as the ones we're talking about today, I think is very important for all our clinicians at the bedside in the ICUs.
Speaker: So why don't we start with just telling us your perspective of why these two complications, post-op bleeding and post-op cardiac arrest, are important topics for bedside critical care clinicians to know.
Speaker: Absolutely.
Speaker: You know, so I think for anyone who's has the privilege of working with postcardiotomy, cardiac surgery patients, they can be, like you said, very straightforward and their care can be very protocolized.
Speaker: But when things go bad, it's important to have an approach and perspective on what we need to do.
Speaker: And
Speaker: like many things that we are there for us providing supportive care as a critical care provider can really make a difference in their post-surgical outcomes and particularly with post-operative bleeding and cardiac arrest we're often the ones there at the bedside the surgeon may be in the OR or maybe we're there at night and they're not around and so recognizing
Speaker: When we're dealing with a problem that needs to go back to the operating room or taking an appropriate intervention in the most severe cases, particularly a cardiac arrest, is really critical and can make a difference to try to save that patient.
Speaker: Excellent.
Speaker: And as we were discussing pre-recording, post-op bleeding is extremely common, right?
Speaker: Not everybody has to go back to the OR, but we'll talk about that.
Speaker: So it's something that intensivists should be very familiar with managing and how to communicate appropriately with our colleagues in the OR.
Speaker: Cardiac arrest is not as common, but quite dramatic, obviously, and interventions that are done in a time-sensitive manner can make the difference.
Speaker: So I think that these both are very important, and I think it's a nice combination to discuss together today.
Speaker: Let's start with post-cariotomy bleeding or hemorrhage, and maybe you could just give us a little bit of an overview of the causes of post-op bleeding to introduce the topic.
Speaker: Yeah, I think for those who are familiar with managing any type of surgical patient or those who care for any type of surgical patient, whenever there's bleeding, whether that be we see it through the drains that they have in place or otherwise,
Speaker: We always want to think about, is that due to a medical cause, general coagulopathy, or is it due to a surgical problem that needs operative fixation, such as tying off a vessel or fixing something that is going wrong?
Speaker: So when we think about that in terms of medical bleeding, really we're looking at why might they be coagulopathic, and for patients who've undergone cardiac surgery, there's a lot of reasons for that.
Speaker: You know, one is that they may have gotten blood product resuscitation in the OR related to expected operative bleeding.
Speaker: And so, you know, if that wasn't necessarily balanced resuscitation, they may lead to clotting factor depletion.
Speaker: Many of these patients will undergo cardiopulmonary bypass support during their operation.
Speaker: And just contacting with that bypass circuit can cause things such as fibrinolysis or platelet dysfunction.
Speaker: Those who are on cardiopulmonary bypass are heparinized, and while they do receive protamine postoperatively, that may have been not enough or too much.
Speaker: Other things that they come out with often is they may have acidosis, either respiratory or metabolic, that can contribute to the coagulopathy.
Speaker: They're hypothermic after a cardiopulmonary bypass.
Speaker: And really any other common reasons that we can think about for any other patients.
Speaker: And so those are the things that when I see a patient who's having, you know, I'm concerned about bleeding, I want to make sure that I'm addressing those while also keeping in mind if this could be a surgical issue.
Speaker: Because when we think about patients going back to the operating room, it's very easy for us to, as the intensivist, say, oh, yeah, they should just go back to the operating room.
Speaker: But in the surgeon's mind, they really want to address anything that's non-surgical up front because these patients who go back to the OR, if they don't need to go there, ultimately that's worse for the patient, more invasive, and they have worse outcomes.
Speaker: And I think another important aspect to mention, Chris, is that most of the patients have medical bleeds, right, that can be resolved.
Speaker: Of those who we think have a surgical bleed and go back to the OR, there's still a big number that they don't find anything, right?
Speaker: So like you said, I mean, having that systematic approach to make sure that we take the ones we need to go and can deal with the other ones in the ICU is very important.
Speaker: Yeah, absolutely.
Speaker: Absolutely.
Speaker: What are some of the risk factors for postcardiotomy bleeding?
Speaker: Yeah, so some of the things you want to think about is just in general, you know, how frail was the patient going into the OR?
Speaker: Things such as age, female sex can predispose, as associated, preoperative anemia, preexisting coagulopathy, any other major comorbidities they may have, lower BMI.
Speaker: And then if someone has chronic renal failure, the coagulopathy is associated with that.
Speaker: And then in intra-op, you want to think about, you know, how long was the procedure?
Speaker: How complicated was it?
Speaker: How much blood product resuscitation did they get?
Speaker: Did they have a longer cardiopulmonary bypass run?
Speaker: So thinking on the order of, you know, more than three hours is quite a very long run and puts a patient at risk for more complications.
Speaker: In terms of, and I think it's important to recognize those, and as you have an effective handoff with anesthesia and CT surgery, recognize, like you said, the patient and operative factors that might predispose somebody for more bleeding, but it's also important to recognize that there are sometimes patients who might not have any of these risk factors who do end up having a surgical bleed and a bleed, and that is always something that can be a surprise for everybody.
Speaker: But when the patient comes to the ICU, what are the things that you monitor?
Speaker: How do you approach the initial care of those patients, trying to figure out if they're bleeding at all?
Speaker: Absolutely.
Speaker: You know, most cardiac surgery patients, when they come out, they're going to have a number of drains, mediastinal as well as pleural.
Speaker: So in most cases, the initial suspicion for bleeding will be quite obvious.
Speaker: You'll see bloody output coming out of these drains.
Speaker: And just having output from the drains is not necessarily a bad thing.
Speaker: That's why they're there to help to evacuate those spaces as coagulathes are corrected.
Speaker: But you really want to keep an eye on what's the color of the blood that's coming out.
Speaker: Is it very bright red thin?
Speaker: Or is it having clots and seeming like it's starting to resolve?
Speaker: You also want to pay attention to particularly to the tempo of bleeding.
Speaker: And if you look in the literature, read guidelines on what rates of bleeding to consider when you might want to think about a surgical bleed versus a medical bleed, you'll see varying recommendations and ranges.
Speaker: One example, some, quote, 400, greater than 400 cc's.
Speaker: In one hour, greater than 300 cc per hour over two to three hours, or greater than 200 cc per hour over four hours.
Speaker: But it comes down, I think, more to what's that tempo and how is it escalating or de-escalating?
Speaker: You know, if you have a patient who's
Speaker: bled 150 cc's from their chest tubes within 10 minutes of coming out of the OR, that's something that should raise your eyebrows and be very concerned and be at the bedside watching what's coming out.
Speaker: And is that resolving very quickly?
Speaker: Or is that something that's continuing?
Speaker: And that can, you know, you want to pay attention and be very on top of that patient.
Speaker: And I think an important reminder for our listeners is to always add context to numbers.
Speaker: So a patient who you expected no bleeding at all might have a 200 an hour bleed, and that might be very concerning.
Speaker: versus a patient who maybe was on pavolopathic, on Plavix, and had a very wet post during surgery, and you've been giving blood products, maybe the surgeon is willing to tolerate a little bit longer because he thinks that eventually that will be corrected.
Speaker: So I think that also making sure that you evaluate a given number in the context of the patient you're treating is always very important.
Speaker: Yeah, absolutely.
Speaker: And as I'm sure we'll probably touch on later, but it's a lot of this comes down to discussion with your surgeon, with the cardiac anesthesiologist can give you a lot of insight onto what they expect and what you're watching for in the post-operative setting.
Speaker: Perfect.
Speaker: I wanted to ask you, go ahead.
Speaker: Some of the things I wanted to mention is, you know, in all these patients, we're getting immediate postoperative labs.
Speaker: So that may give us a clue in terms of our traditional markers of coagulopathy, INR, PTT, et cetera, as we would for any patient who are concerned about bleeding.
Speaker: But some places also, wherever you work, they may also protocolize the use of things such as Rotem or Teg.
Speaker: And that can be particularly helpful if that's available at your center for understanding where, if this is a medical coagulopathy that's leading to their bleeding, how you might best address that and resuscitate them.
Speaker: And is the use of Rotem and Teg increasing, you think, Chris?
Speaker: I don't have a lot of experience with that in our ICU.
Speaker: Yeah, I think it's variable.
Speaker: I think that there's increasing interest.
Speaker: You know, if you look at the literature around, you know, Rotem or Teg, a lot of the studies are kind of before and after in cardiac surgery patients.
Speaker: And the ones that I'm familiar with have shown reduced bleeding or reduced need for transfusion or reduced total overall bleeding, reduced need for transfusion when it's used in a protocolized fashion.
Speaker: So I think there's a number of centers who use it and whether that's used kind of upfront, we see it in the OR, here's what our rotem is, we check it in the ICU, or whether it's ad hoc, this patient is bleeding, therefore we're going to check it, you know, really comes down to the center.
Speaker: And I think it's worth discussions if that technology is available to you to think with your surgeons and anesthesiologists on how that's best to use.
Speaker: Excellent.
Speaker: And obviously, we talked about getting the basic labs.
Speaker: Any imaging that you usually use for these patients?
Speaker: I know that these patients usually get an x-ray immediately post-op, but what are things that you're looking for?
Speaker: Yeah, so x-ray is...
Speaker: standard, that's going to be very helpful.
Speaker: The most powerful thing, I think, from an x-ray for a patient that's bleeding is, do I see, am I concerned for maybe a pleural effusion that might suggest a retained hemothorax?
Speaker: So while I'm seeing blood coming out of the drains, maybe it's not adequately evacuating that space, and that would be more concerning for me than if I did not see a pleural effusion.
Speaker: all of it, what I'm, all of what the bleeding is occurring is actually coming out of the chest strains.
Speaker: That would be more reassuring to me.
Speaker: The other imaging we can think about is, is echo.
Speaker: However, these patients have had sternotomy or other incision, and they are often very difficult to get our classic trans thoracic views on to really get an assessment of, you know, where is,
Speaker: Do we see collecting blood, whether that be, or do we see collecting blood essentially around the cardiac structures in the kind of where we would typically think of as the pericardial space?
Speaker: And another question I had, Chris, is we talked about chest tube output, right?
Speaker: Something that we were monitoring and obviously the tempo and the consistency or the aspect are both important indicators of potential issues.
Speaker: But what about the situation where somebody is having a profuse output and all of a sudden it stops?
Speaker: Yeah, that's certainly a concerning thing.
Speaker: And while you might think, well, that's good, they've stopped bleeding, the major concern there would be that your chest drains are no longer evacuating those potential spaces and that the patient actually has not stopped bleeding but is now collecting blood.
Speaker: in the pleural space around the paracardial space.
Speaker: And the major concern there would be that you cause compression and can lead to tamponade and cardiac arrest.
Speaker: That's, I guess, I mean, where you want to make sure that the chest tubes are patent and people talk about milking the chest tube, making sure that it's straining, correct?
Speaker: Yeah.
Speaker: Absolutely.
Speaker: And one of the first things that our critical care nurses will do as the patient comes out is making sure that we're stripping those chest tubes.
Speaker: And if you have a patient that's bleeding, we're not only paying attention to the tempo, but we want to make sure that those chest chains maintain patency.
Speaker: So we want more blood to come out.
Speaker: We want to strip those tubes in order to keep that coming out while we address any potential coagulopathy and resuscitate the patient.
Speaker: So we talked about what to monitor, how to evaluate what's going on when they first arrive.
Speaker: Can you talk about your therapeutic approach?
Speaker: What's the strategy that you take with these patients?
Speaker: Yeah, so...
Speaker: As we mentioned, we're really trying to address any potentially reversible causes before we commit to this as a surgical bleed.
Speaker: And one of the things that we can think about is if it's due to maybe diffuse kind of oozing coagulopathies, can we decrease any potential spaces?
Speaker: Can we apply essentially pressure on those bleeding sites?
Speaker: So two ways we can think about doing that is, you know, because this is interthoracic, we can try to increase our interthoracic pressure either through application of increased PEEP or increased tidal volume or both.
Speaker: And I think, you know, worth discussing with your surgeons kind of what they prefer or, you know, if they have a preference on one or both of those.
Speaker: So if I have a patient who's bleeding very quickly, if I see that the chest tube output is significant, I'm going to increase my PEEP and it may go up on my tidal volume to try to decrease that potential space and tamponade any sort of oozing coagulopathy type bleeding.
Speaker: So step number one, I mean, just, I mean, obviously some maneuvers you can do to just decrease the available space for blood to accumulate and put some pressure, right?
Speaker: Which is the first thing that we would do in any bleeding that we see is put pressure on, right?
Speaker: So I think that's a good analogy.
Speaker: What are some of the common things that you might overlook that are common in these patients and unrelated to the cardiac issue itself that we need to correct out of the OR?
Speaker: Yeah, I think so.
Speaker: Almost all of them come out cold, so making sure you get them on a bear hug or other external warming device if that's the case.
Speaker: You know, looking at your traditional labs, correcting any platelet deficiencies, say INR, fibrinogen, and then looking at your ionized calcium level.
Speaker: I think it's, and then also your acid-base status, so acidosis can contribute to the coagulopathy as well.
Speaker: I think one of the things is always keep in mind with these patients is that your traditional coagulation markers may not fully reflect the coagulopathy that may be going on.
Speaker: Perhaps they have platelet dysfunction.
Speaker: And so, you know, being...
Speaker: I think more aggressive about giving factors such as cryo, giving factors such as FFP and platelets in the patient who's significantly bleeding, despite of what your lab values see.
Speaker: Because as we know, with someone who's significantly bleeding, those numbers may lag, but also even if they are accurate to that specific time point, they may not fully reflect a coagulopathy that's present.
Speaker: And do you have any guidelines that you use?
Speaker: Obviously, this is going to be mostly, I mean, consensus, expert opinion, I presume, and not studied in randomized trials, but are there targets that you're trying to keep with these regulation and CBC parameters?
Speaker: Yeah, so generally I think, again, I want to stress the importance of discussing with your surgeons kind of what they prefer and also communicating with them in these settings because they may have an idea of something that we're going into the OR with or coming out of the OR with or just in general with their
Speaker: surgical practice.
Speaker: But certainly you want to keep your platelets above 50,000, possibly higher.
Speaker: INR, you know, let's try to keep it less than 1.5 and your fibrinogen above 150.
Speaker: But again, I think that
Speaker: Don't hang your hat on those values.
Speaker: Think about the overall picture and be suspicious for a coagulopathy that you can't recognize through just looking at those numbers or that they don't represent our time point now, which reflects ongoing blood loss and ongoing depletion of coagulation factors.
Speaker: Perfect.
Speaker: Any comments on correcting acidosis, Chris?
Speaker: Yeah, so, you know, I'm not aware of great literature to, you know, support that that's a huge difference maker, but the surgeons that I work with, they are, you know, in favor of using some bicarbonate to help to correct metabolic.
Speaker: acidosis coming out of surgery.
Speaker: One thing that is fairly common that we will do is if you see the patient has a respiratory acidosis or can compensate respiratory-wise, then you want to think about your minute ventilation on the ventilator increasing their respiratory rate to compensate until that is further corrected.
Speaker: And is there a role for recombinant factor 7?
Speaker: Is that something that people have used in this situation?
Speaker: Yeah, great question.
Speaker: So thinking about your patient who is bleeding and you're resuscitating them with various blood products, trying to address the coagulopathy, as we mentioned, if they're still bleeding and it's to the point where you're thinking, hey, this is not working, I may be thinking about going back to the OR, then I think it's worth the discussion with your surgeon about their preference for recombinant factor VII.
Speaker: So this is something that is published in the literature for use most validated in post-cardiac surgery to help to correct severe coagulopathies.
Speaker: It's really something that I would think about if you can't correct it with all of your usual measures, increasing the PEEP, tidal volume, resuscitation, correcting your acid-base status, correcting your hypothermia.
Speaker: It does tend to work in cases where, at least anecdotally for me, where cases are severe bleeding, which are not secondary to a surgical problem.
Speaker: And that's shown in some studies.
Speaker: They're not...
Speaker: beautiful randomized trials, but there is some improvement in bleeding with its use in cardiac surgery patients.
Speaker: But I think this is really important.
Speaker: You got to talk with your surgeon about this because it does carry a non-
Speaker: it's not an insignificant risk for thrombosis associated with its use.
Speaker: So we're talking on the order of 5%, and that can include stroke, MI, DVT, or intercardiac thrombus, or potentially your grafts from a CABG being occluded.
Speaker: And I think it will very much depend on the surgeon, whether that's something they want to consider or whether they would prefer just to take the patient back to the operating room.
Speaker: So I guess, I mean, it's a tool to have, but not to deploy lightly, right?
Speaker: I mean, obviously in conversation with your surgeon and my sense is that a lot of situations, the patient probably will go back to the OR before they do that.
Speaker: But it is important to have that in the back of our mind as an option.
Speaker: Right.
Speaker: So when does the patient go back to the OR?
Speaker: Obviously, that's, I think, like you mentioned at the beginning, Chris, it's easy for us as clinicians at the bedside, non-surgical clinicians, to always say, oh, they should just go back to the OR.
Speaker: But there's a lot that comes with that.
Speaker: And it's not always something that is successful.
Speaker: And when you take somebody back and you don't find anything, you wonder, well, maybe we wait a little bit longer.
Speaker: We would have saved, I mean, this patient a lot of grief, right?
Speaker: And reopening and all that that entails.
Speaker: So obviously, this is a surgical decision.
Speaker: But can you tell us a little bit more about how you see that?
Speaker: Yeah, I think I see it with one is do I feel like I'm addressing all the things that we talked about?
Speaker: Have I, you know, and that includes empiric blood product resuscitation.
Speaker: I've given platelets.
Speaker: I've given FFP.
Speaker: I've given fiberinogen.
Speaker: In the patient who I'm still able to support their hemodynamics, that's a patient I'm on the phone with my surgeon multiple times about whether we should go back to the operating room.
Speaker: The other scenario is someone who's just profoundly hematomically unstable and we're not able to keep up with the resuscitation.
Speaker: That may be someone we pulled the trigger earlier on going back to the OR rather than still trying to resuscitate at the bedside.
Speaker: I think I mentioned some numbers that are published or talked about in various textbooks and articles.
Speaker: They can give a guide, but it's really no replacement for what you're seeing at the bedside.
Speaker: What's the tempo over the last 10 minutes?
Speaker: What's the tempo over this 10 minutes for your chest tube output?
Speaker: How's the patient doing from a hematomagic standpoint?
Speaker: And I think one of the responsibilities that we have is communication with the surgeon, but also they're sometimes relying on us to make the case that, hey, we've done everything else that we can think of or all the things that we discussed doing.
Speaker: And it's still not working.
Speaker: And it's the middle of the night.
Speaker: And I need you to come in and take the patient to the OR because I think we're running out of options.
Speaker: And we're going to end up in a much more dangerous and emergent situation, you know, potentially leading to things like cardiac arrest.
Speaker: And since you mentioned cardiac arrest, and before we go on to that topic, when is a bedside ICU emergent thoracotomy indicated?
Speaker: Yeah, so this is really with the surgeon and the patient's stability to get out of the ICU to the operating room.
Speaker: I think any surgeon will tell you that they prefer to operate in the OR where they have all their tools, the nice sterile environment, familiar equipment, etc.
Speaker: But if that patient is not stable enough and
Speaker: there's high suspicion for a surgical cause of bleeding, then an ICU emergency re-exploration would be indicated.
Speaker: And then also, it sounds like we'll talk about pretty shortly about whether if they do have a cardiac arrest, that would be another time when that would be considered.
Speaker: Is there anything else you want to add on the management of post-op bleeding?
Speaker: We will definitely talk about communication interaction with itchy surgery as a whole topic a little bit later.
Speaker: But anything else you want to add on this particular topic before we move on to cardiac arrest?
Speaker: No, I don't think so right now.
Speaker: I think we've covered some, you know, we've covered it.
Speaker: And I think, again, the take-home message for me here, Chris, is this is a common problem.
Speaker: Most patients don't have to go back to the OR, but I think it's important for us to have a systematic approach of correcting the things that we can correct.
Speaker: making sure that we're addressing the general things, the quagulopathy, that we're in close contact with our surgical team and communicating and portraying to them exactly what's going on at the bedside so that the best decision can be made for the patient.
Speaker: And there is a subset of patients that will go back to the OR.
Speaker: And I think that trying to figure out the timing of that in a time-sensitive way is what's really, really important for our patients.
Speaker: So you did mention that, obviously, bleeding that is not controlled can lead to a cardiac arrest.
Speaker: So let's talk a little bit about postcardiotomy cardiac arrest.
Speaker: And maybe we can start with the etiology of cardiac arrest postcardiac surgery.
Speaker: Sure.
Speaker: So obviously a scary thing.
Speaker: We don't want this to happen to our patients, but it is not that uncommon.
Speaker: Somewhere in the order of less than 1% to 8%, depending on which literature study you look at, we'll talk about post-cardiotomy, cardiac arrest.
Speaker: The most common etiology of that is going to be ventricular arrhythmias, V-FIV, V-TAC, followed closely by tamponade and bleeding.
Speaker: In addition to all the other typical causes of cardiac arrest that we can think about in a critically ill patient, but the big ones that really pertain to the surgical patient is going to be ventricular arrhythmias, blood loss,
Speaker: leading to profound hypovolemic shock and tamponade from the situations we talked about where that blood is not adequately evacuated from the space and then can collect and cause that.
Speaker: Obviously, these patients are usually out of the OR and in the ICU.
Speaker: They're usually intubated.
Speaker: They usually have an sternotomy and have pacing wires very frequently.
Speaker: So the management...
Speaker: of the cardiac arrest has some nuances right that are particular and I think are important for us to review I know that the Society of Thoracic Surgeons many years ago had a expert consensus post-cardic and surgery management of these cardiac arrests could you just walk us through that protocol and how you think about it mentioning what is the same what is different that we need to be paying attention to
Speaker: Yeah, absolutely.
Speaker: And I encourage the listeners to refer to the 2017 article published by STS because I think it's very informative and talks through this in much more detail.
Speaker: But really what this group was trying to do was to highlight what are the common reasons that these patients arrest and also balance.
Speaker: And so to address those very rapidly, which our standard ACLS algorithm may not focus on.
Speaker: to one, address those, but two, to balance addressing the problem with the risks of doing things like CPR or administering high-dose epinephrine empirically in these patients.
Speaker: And so with that, there's a few differences with resuscitating these patients in the event of a cardiac arrest from our standard cardiac arrest patient.
Speaker: So one is if they, and a lot of it has to do with the, or it all has to do with the rhythm.
Speaker: So what they recommend is if your patient has a V-fib arrest, the difference between AHA and the STS guidelines is that they advocate to delay CPR for up to a minute.
Speaker: and deliver three sequential shocks without intervening CPR.
Speaker: So how does that look?
Speaker: Patient goes into ventricular fibrillation, immediately deliver defibrillation,
Speaker: If they're not converted to sinus and, again, perfusing, immediately deliver another defibrillation.
Speaker: And then, again, if they still remain in BFIP, immediately another defibrillation prior to proceeding with BLS or closed chest compressions or usual resuscitation and then administration of amiodarone, which they advocate to give through a central line, which most of these patients will have.
Speaker: So that's one.
Speaker: We'll talk about how this progresses once you've started BLS.
Speaker: But the other is if you have a patient in asystole, what they advocate for is
Speaker: not an insignificant portion of these patients will have pacing dependence coming out of the OR.
Speaker: And so if they have epicardial wires, they again recommend that we can delay CPR for up to a minute while trying to pace these patients with their epicardial wires or transcutaneously if those are not available prior to initiating our usual closed chest compressions.
Speaker: And then finally, if the patient is in PEA, they do advocate for immediate administration closed chest compressions, but they also recommend that if the patient is paced and you're seeing this PEA as a paced rhythm on the monitor to briefly turn off the pacemaker to make sure that they're not in V-fib underlying that.
Speaker: So in those categories, V-fib, acetylsy, and PEA, again, trying to address common things right up front with slight delay in initiation of closed chest compressions if possible, but again, initiating those within a minute, don't delaying those beyond a minute if maybe you're gathering equipment or it's just not happening, go ahead and start that.
Speaker: And all these things are to try to address common reasons that the patient can go into a cardiac arrest while also preparing what's important to prepare for a re-sternotomy.
Speaker: And the reason that we're thinking about a re-sternotomy and why they recommend proceeding with that if these are not addressing the issues is the common reasons for cardiac arrest in the post-article patient.
Speaker: So thinking about bleeding, thinking about tamponade.
Speaker: So the...
Speaker: So to summarize that, again, we're starting with our patient who goes into cardiac arrest.
Speaker: We are having slight nuanced approach to various rhythms.
Speaker: while at the same time in parallel we're getting prepared to perform a restrenotomy to open up that chest in order to address those potential complications.
Speaker: So if I'm the code leader and I'm called into the room and a patient who has a post-cardiac surgery who's just had a rest, I'm immediately asking for equipment
Speaker: The recommendation from STS is that that happens within five minutes of the arrest for patients within 10 days of their surgery.
Speaker: Beyond 10 days, we're thinking that they may have had adhesions, and that's a discussion that would be completely up to the surgeon, but generally not recommended beyond 10 days.
Speaker: So I'm the code leader.
Speaker: I'm asking for that equipment.
Speaker: As I'm quickly addressing the rhythm,
Speaker: administering three sequential shocks for V-fib prior to chest compressions if that is immediately available.
Speaker: I'm looking at the patient acetyl and attempting to pace them.
Speaker: And for the patient who looks like they're in PEA but they have a paced rhythm on the monitor, I'm briefly turning off that pacer in order to just make sure that they're not in V-fib underneath.
Speaker: And then I'm proceeding with my usual resuscitation with chest compressions while preparing for a re-sternotomy in discussion with the cardiac surgeon over the phone.
Speaker: Chris, go ahead.
Speaker: I was going to ask you a little bit, two specific questions about, like you said, the usual CPR.
Speaker: So I wanted to hear a little bit about airway and ventilation, if you could give some tips to the team.
Speaker: Oh, yeah.
Speaker: And then also, if you had any recommendations for the actual chest compressions.
Speaker: Absolutely.
Speaker: So when we think about, certainly these patients in cardiac arrest could have other reasons for that, all the usual things we want to think about.
Speaker: One of the recommendations that the STS guidelines have is that, similar to what we do for patients who are in cardiac arrest for other reasons, is removing them from the mechanical ventilator and
Speaker: applying zero PEEP and the rationale for that is that one potential cause of arrest may be attention pneumothorax and they want to obviously mitigate that but also if the patient is severely hypovolemic from bleeding, they want to try, their recommendation is to use zero PEEP in order to improve your venous return in any way you can so that maybe you can regain a ROSC and regain a perfusing pressure.
Speaker: Also, you know, certainly we do this for, you know, all of our other aquatic arrests, but administering 100% oxygen as we would normally do.
Speaker: What about epinephrine?
Speaker: Great question.
Speaker: So the guidelines, really what they say is they do not recommend routine administration of epinephrine unless guided by, quote, a senior clinician.
Speaker: And this recommendation that they make based on the argument that if this is a rapidly reversible condition, they want to avoid the risk of severe hypertension that can occur after receiving epinephrine, thinking about that leading to potential catastrophic bleeding.
Speaker: And that also is...
Speaker: one of the reasons why they make the recommendation that if you can address these other causes such as defibrillation, pacing the patient, to delay chest compressions for up to a minute.
Speaker: because in patients with postcardiotomy and a sternotomy, there are a number of case reports and described injuries that can occur with closed chest compressions, as you might imagine from that sternum, which has just recently been opened, and the heart, which has just been operated on.
Speaker: So just, again, these are balancing the need for perfusion,
Speaker: addressing common reversible causes and the potential risks of doing our usual ACLS algorithm with closed chest compressions and epinephrine leading to surgical complications and bleeding.
Speaker: Is there any particular care or recommendations for the actual chest compressions?
Speaker: Yeah, so same rate as we would normally do.
Speaker: So, you know, they advocate for 100 to 120.
Speaker: They also advocate for watching.
Speaker: Many of these patients will have an arterial line in place.
Speaker: So watching your systolic blood pressure, and they recommend that we target above a systolic blood pressure of 60 in their guidelines.
Speaker: I would say that as a practice for the people who are actually doing CPR, while this isn't really addressed in the guidelines, is one thing that we often do at our institution is use something such as maybe a board in order to protect potentially the person who's doing the chest compressions.
Speaker: So put that board over the stern.
Speaker: them and then they compress on the board in order to you know avoid if they're perhaps they end up with a fractured wire from their sternotomy we don't want that provider to become injured have a you know stick injury related to that can you comment on a how to manage the intra-aric balloon pump in case a patient has one of those which is not uncommon in some of these patients
Speaker: Yeah, so the guidelines advocate to change these to pressure trigger mode.
Speaker: So why is that?
Speaker: So a lot of our balloon pumps may trigger off the EKG in order to time the inflation and deflation of the balloon.
Speaker: If you have a patient who's in cardiac arrest, as you've probably seen when we do cardiac arrest, if you look at the monitor while CPR is ongoing, it can show, it may look like the patient's in ventricular tachycardia.
Speaker: They may have other artifacts on their EKG, which could cause the bloom pump to...
Speaker: inflate and deflate inappropriately and not actually provide any perfusing displacement of blood within the aorta.
Speaker: So if you do it based on pressure, that allows it to synchronize with the chest compressions that are happening and potentially improve perfusion to the heart and other organs.
Speaker: And like you mentioned earlier, Chris, obviously the goal is to get return of spontaneous circulation, stabilize the patient, which a lot of times, I mean, the outcomes for these patients is obviously, especially when it's immediately post-op, is good because commonly there are things that we can reverse post-surgery.
Speaker: But if you're not getting ROSC, the next step within five minutes is re-sternotomy.
Speaker: Can you talk a little bit about emergency re-sternotomy?
Speaker: Yeah.
Speaker: So again, this is the recommendation is to try to address things such as severe bleeding.
Speaker: So trying to get hemorrhage control or tamponade by just opening that chest, you may be able to relieve that pressure and relieve the tamponade and get ROSC.
Speaker: So, you know, they're, they advocate, and you should think about it for resuscitating these patients in cardiac arrest is getting all the equipment, getting the personnel ready right away from the start, being prepared to do that within five minutes.
Speaker: How does that look is,
Speaker: Essentially, you're doing your resuscitation.
Speaker: If we're not getting ROSC, then we will be prepping the chest
Speaker: and then opening through the midline sternotomy.
Speaker: And the guidelines acknowledge that, you know, it's not always that the surgeon is immediately available at bedside 24-7.
Speaker: And so they advocate for any trained personnel to do this.
Speaker: And this could be an advanced practice provider, another physician.
Speaker: They even advocate for, you know, cardiac and even
Speaker: you know, bedside nurses who've been appropriately trained to do this.
Speaker: And they recommend that protocols be set up within your hospital in discussion with your surgeons about what that looks like.
Speaker: I think from, you know, our, at my institution, that practice would be a discussion with the surgeon on the phone, whether that would be something that we would proceed with.
Speaker: I know there are other institutions that that's already in place, that that is what is going to happen and doesn't necessarily need, you know, the discussion with the surgeon over the phone, that that's the right thing to do in the setting of the arrest.
Speaker: Any tips?
Speaker: Obviously, this is something, like you said, that people need to be trained for, but it's not exclusive domain of surgeons.
Speaker: So CT surgery intensivist or people who have training can get to do this.
Speaker: But any tips or any suggestions?
Speaker: I think that the take-home message that I take as somebody who's not trained to do these is
Speaker: is that if a patient under my care arrests, I start getting ready immediately, getting things ready for the person who can do it, but also obviously immediate communication with the surgical team.
Speaker: Yeah, absolutely.
Speaker: I think those are the key things.
Speaker: And once it's identified who would be performing that and that's indicated, essentially the procedure involves, well, so the procedure involves essentially opening up the incision along the sternum and then cutting the sternal wires and removing them with a needle driver.
Speaker: And that alone should allow the chest to open up to some degree.
Speaker: But the next steps would involve putting in a sternal retractor, opening up that space, using sterile suction to suck at any hematoma or manually evacuating any hematoma that you may see, and then performing, getting control of any surgical bleeding you see, as well as performing internal cardiac massage.
Speaker: And so...
Speaker: how this is achieved, it really doesn't require that many steps.
Speaker: And the guidelines advocate for a very simple kit to have ready for this, not a full sternotomy tray with many surgical instruments, which can be overwhelming in the setting of an emergency or certainly someone who's not a surgeon who's asked to perform this.
Speaker: And so they recommend really just having a scalpel, wire cutters,
Speaker: needle driver, sternal retractor, and a suction device within that kit.
Speaker: And that's really all you need to perform a re-sternotomy and potentially get rust just from relieving tamponade or evacuating hematoma.
Speaker: Any aid for echocardiography, bedside ultrasound, or TEE in these situations, or usually just because of the time frame you're focusing on other things?
Speaker: Yeah, I think it comes down to the resources you have available.
Speaker: I think all the patients who are bleeding and there's concern for potentially retained blood products, I think it's always worth trying a trans-thoracic bedside echo.
Speaker: There's no harm in doing that, but often you're not going to get great pictures and not get great images.
Speaker: And the other thing that you can, the pitfall is that you can also have localized tamponade where only one cardiac
Speaker: hematoma that you really can't see on transthoracic images.
Speaker: So I think while something to do and try, don't rely fully on that and have a high index of suspicion for tamponade because you can get fooled and not actually see those focal collections.
Speaker: Now, TE is much more powerful in that sense because you're not limited by your poor trans-thoracic windows in the post-cardiotomy setting.
Speaker: And you can get more detail on perhaps where that hematoma or if there's a focal collection may be.
Speaker: So I think in settings where you have that resource immediately available, I think it's worth deploying it early on, not necessarily after the patient arrests
Speaker: to try to get an idea of what we're dealing with.
Speaker: Are we seeing all the blood product from this bleeding patient being evacuated, or is there retained hemothorons that we need to be particularly concerned about and getting on the phone sooner with our surgeon that this actually needs to go back to the operating room?
Speaker: Excellent.
Speaker: So as we close, Chris, obviously this is all a very collaborative enterprise.
Speaker: And I think it's a growing trend that intensivists are helping care for post-op cardiac patients.
Speaker: We talked in other episodes of the podcast about the increasing growth of mechanical circuitry support, a different population, but definitely we're seeing, I think, a growth of cardiac patients in our ICUs.
Speaker: So like anything where there's multiple stakeholders and parties involved, I think communication is the key to providing the best care possible.
Speaker: So I wanted to close with maybe some comments on your side in terms of how to optimize communication and collaboration with CT surgery.
Speaker: Maybe start with some of the common pitfalls that we should avoid.
Speaker: Absolutely.
Speaker: I think some common pitfalls would be, one, to just go kind of do something on your own without, you know, discussing with them or discussing.
Speaker: you know, having them involved in that decision, because these really, if you think about these, the surgeons, they're taking these patients into their office, bringing them in often for, for planned, you know, semi-elective surgeries.
Speaker: And so they, they really invest an incredible amount in,
Speaker: I think it's even difficult for us to imagine kind of being in their shoes in these settings.
Speaker: So they should really be involved with discussion about what's going on.
Speaker: So I think, you know, certainly do that.
Speaker: It's a huge pitfall to not do that.
Speaker: And I think it can only, you know, lead to trouble.
Speaker: You know, in that regard, the...
Speaker: I think what's helpful is to establish relationships with them.
Speaker: And then as they kind of understand what your capabilities are, your knowledge base, then you can have a framework within to practice and also have them know what's going on.
Speaker: What are some of the pearls that you have learned over the years in terms of optimizing the collaboration interaction with CT surgery, which ultimately is most important for our patients, but I think it's also a great way to have a better practice, right?
Speaker: The better we work with those around us, the more satisfying our job is.
Speaker: You mentioned some of the things, but anything else you want to add as a pearl?
Speaker: Yeah, I think setting expectations or understanding what expectations are is helpful.
Speaker: I think it gives us more freedom to act and take care of the patients and also can free us up from having to make phone calls in situations where we kind of know the next step and also letting the surgeon maybe get some sleep.
Speaker: So at our institution, one of the things we have is an escalation protocol.
Speaker: So if certain triggers are met,
Speaker: the surgeon will want a phone call.
Speaker: So let's say we're transfusing for a particular amount of blood product or we're escalating our vasopressor support significantly.
Speaker: That's a phone call that they want to have versus some lesser concerns.
Speaker: They trust our judgment and tact on that.
Speaker: So I advocate for setting those expectations early on.
Speaker: Yeah, and I think that's very helpful.
Speaker: And again, them getting to know you and understand what's going on.
Speaker: I mean, it's about building a relationship, right?
Speaker: And learning together, but also I think being very clear on when escalation is needed, what are the things that we should be managing, and it's an ongoing process.
Speaker: But
Speaker: I do believe that this is not going away from critical care.
Speaker: It's going to keep growing.
Speaker: And it's important for our listeners, wherever they are, if they're taking care of CT surgery patients, to build really a culture of growth at their institution where they collaborated with surgery.
Speaker: And I think that one of the things I would add, Chris, is that empathy on both sides is very helpful, right?
Speaker: Trying to understand, like you said, empathy.
Speaker: The surgeon meets the patient in their office.
Speaker: They say everything's going to be okay.
Speaker: They're measured by all these parameters that are publicly reported that we don't have.
Speaker: And I think recognizing a little bit of that as well is important.
Speaker: And again, the surgeon can also see our position that we're there when they're not there in the OR and making sure that they're also available and giving us the best support to obtain the best outcomes, which at the end I think is something that everybody can agree on.
Speaker: Yeah, absolutely.
Speaker: I think a lot of our patients in the ICU, particularly surgical patients, I think of them as we're helping provide a service for those surgeons, and I think we should always keep that in mind.
Speaker: Excellent.
Speaker: Well, this was a, I think, a fascinating discussion of problems that I'm sure a lot of our listeners have encountered.
Speaker: And we definitely will add some of the references you mentioned in the show notes.
Speaker: You've been on the podcast before, Chris, you know how we roll.
Speaker: So we're going to talk about a couple of things that are unrelated to the clinical topic.
Speaker: Is that okay?
Speaker: Yeah, absolutely.
Speaker: So the last time you were on, we talked about books.
Speaker: So we're not going to talk about books today, but I'm curious to hear a little bit about your preferences or what has impacted you from a musical perspective.
Speaker: So the question is, what music or album, I'm a little bit of an old school, I like vinyl, and would you want to have with you if you were stuck on an island or we were back in the isolated for a new pandemic?
Speaker: Well, I think I'd pick being stuck on an island than a new pandemic, but, um, for sure.
Speaker: If I had, if I had to choose a, an album, I think, um, you know, one, one that comes to mind is the outsiders by Eric church.
Speaker: Um, some great songs on there.
Speaker: Talladega, like a wrecking ball.
Speaker: Um,
Speaker: So I enjoy that album and his work.
Speaker: The other might be the title album from Collective Soul.
Speaker: So Collective Soul by Collective Soul is another great album that I would like to have with me.
Speaker: And I have to admit that these are not on my radar and I'll have to pick them up and listen to them.
Speaker: So we were talking about this before we started recording.
Speaker: I think it just tells us that Chris is expecting I'm a grandfather, right?
Speaker: That's usually the difference in age.
Speaker: But definitely thanks for these.
Speaker: I mean, I will look into those.
Speaker: Second question is, could you share with us something you have changed your mind about over the last couple of years?
Speaker: You know, that's a tough one.
Speaker: I think, I mean, there's many things I'm sure the same amount about.
Speaker: Well, this may be
Speaker: an odd, odd answer, but, um, you know, I've, I've come around to using roller suitcases at the, at the airport.
Speaker: So I, um, was resistant and always wanted to, uh, to carry my duffel, but now I've come around to, uh, to using the roller suitcase and find them very convenient and helpful to get around.
Speaker: Wheels are powerful.
Speaker: They do move the world.
Speaker: So I think that that's something to, to, that you definitely have changed.
Speaker: And I think we've all gone through that transition at one point.
Speaker: Yeah.
Speaker: The last question, Chris, to close is, what would you want every intensivist listening to us to know?
Speaker: Could be a quote, a fact, or just a departing thought.
Speaker: Yeah, I think I have actually two things.
Speaker: One, I think I've realized in my practice it's never really about one piece of data.
Speaker: So I think it's easy whether you –
Speaker: read a paper or listen to a podcast or, you know, hear a learning point from someone about, you know, if I see this, then this is going on, you know, whether that be a value on your Swann-Gans catheter, a finding you have in your ultrasound.
Speaker: I think the
Speaker: my recommendation is, you know, don't always hang your hat on those things.
Speaker: It's about the whole picture and, uh, keep it in mind as a piece of data, but don't get, don't get fixated or stuck or on a soapbox about it because you'll, you'll be proven wrong or, um, you know, go down the wrong path with that.
Speaker: And then the same token is, I think it's really important.
Speaker: We listen to, you know, what the patient's telling us or what the family's telling us.
Speaker: Cause while it may be, uh,
Speaker: you know, not necessarily related to their condition.
Speaker: A lot of times their concerns or suggestions are very pertinent and they'll pick up on things that you don't necessarily see as someone who doesn't know them very well.
Speaker: Awesome.
Speaker: I think this is a perfect place to stop.
Speaker: Chris, always a pleasure to have you on the podcast.
Speaker: Look forward to having you back soon.
Speaker: Thanks for sharing your expertise and being so generous with your time with our audience.
Speaker: Thank you so much for having me.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sounds transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
