**Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery**

Villalobos J. A. Silva, Aguirre J. Sanchez, Martinez J. Sanchez, Franco J. Granillo and Garcia T. Zenón *Universidad Nacional Autónoma de México (UNAM), Tamaulipas México* 

### **1. Introduction**

The cardiac surgery continues having a fundamental roll in the therapeutic arsenal of many heart deseases in spite of the spectacular advances that determined drugs or different forms of interventionist cardiology have experimented during the past few years. The present impact of the heart surgery is due to the constant increase of the cardiovascular risk factors, related to the increase in the life expectancy in last the three decades, the clinical approach of the ischemic cardiopathy towards the repair has taken to the creation and development of techniques and methods at the moment used in the miocardic revascularization surgery; the roll of the coronary surgery initiated by Sabiston in 1962 and popularized by Favaloro in 1967 has had an exponential development with the purpose of to exclude the ill part from the artery by placing a bypass to improve the perfusion of the ischemic area. Nevertheless the other side of the balance is the pharmacological treatment whose objective is to look for the balance between the supply and demands in the ischemic scope at the expense of a smaller consumption of oxygen (VO2), diminution of the inflammatory local metabolism, control of trombotics phenomena, etc. Now on the basis of the knowledge and acquired experience we establish a margin of durability of 90% to 10years in grafts of internal mammary (AMI) and 50-60% of venous grafts (HV), depending on the vascularized area and the type of vein, in relation to the arterial grafts the average life is of 90% to 5 years with sufficient information of early stenosis problems. Most of the post-operated patients recover in a fast and complete form, which depends on the quality of the performed surgery and an opportune and suitable handling as all the symptoms of the organism recover of the effects of: anesthesia, cardiopulmonary derivation (CEC) and surgical stress. Nevertheless some patients who present combinations of indicators of preoperative risk like: age outpost, antecedents of miocardic revascularization, recent and acute miocardic heart attack (IAM), ejection fraction (EF) low or diabetes, have a much greater surgical risk to the one of the habitual patient. At the moment there are certain characteristics that have determined a fast recovery as they are the early extubation, to avoid major sedation, the disconnection of the support devices and the suspension of drugs as rapidly as possible. A fast treatment before a: Low cardiac cost, alteration of the pulmonary function, hemorrhages, coagulopathy and fever is essential to be able to obtain a fast recovery of the patients; at the moment the surgical indications of the miocardiac revascularization (RVM) have been based in relation to the number and degree of affectation of the coronary arteries, decreased ventricular

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 3

Predictors of post-CABG mortality

Height Weight

CHF

DM CVD PVD COPD

Is the most important aspect of perioperative mortality, the important factors are: severe valvular disease, reoperation, left ventricular function, infarct to the myocardium previous,

The pulmonary disease chronicle is a risk factor to prolong the mechanical ventilation, to have a more difficult weaning, and associated to the pulmonary arterial hypertension, its

The explanation of the diminution in mortality has been the present methods of myocardic protection with retrograde cardioplegia, hypothermia since the ischemia diminishes triphosphate of adenosine (ATP), altered sanguineous flow, calcium overload, reduction of intracellular calcium sensitivity, sarcoplasmatic dysfunction and the presence of free oxygen radicals. The morbidity and mortality fall significantly in spite of being increased the risk factors, the tendency of the secondary complications of comorbid sufferings have increased

The preoperative cardiovascular evaluation provides recommendations for stratification with risk and handling of proposals by the American College of Physicians: Medical history, clinical exploration, ECG, X-ray of thorax, laboratories, tests ECG to the exercise, ambulatory monitoring (Holter), ventriculography to radio nuclear, heart ultrasound,

In resistance to indices of multi-factor risk, the functional classification New York Heart Association (NYHA) and the American Society of Anesthesiology (HANDLE) are used of routine by the anesthesiologist. Nevertheless, these classifications do not designate a predicting result after the surgery reason why its predictive ability in operating room is

cardiac insufficiency, emergency surgery and upheavals of the rate.

coronary angiography, thallium scintiscanning. 4.5.6.7.8.9 (**CHART 2**)

Healthy patient, with a process located without systemic affection.

PCI during current admission Date of most recent MI History of angina Ventricular arrhythmia

Mitral regurgitation

Creatinine level

Age Sex

LVEF

Chart 1.

*Mortality* 

until in 30-40%.

limited. **ASA** 

>70% stenosis

*Cardiovascular state* 

*Respiratory function* 

extubation requires major care.

Urgency of operation Prior heart surgery

Percent stenosis of LM coronary artery Number of major coronary arteries with

function and more and more by the increase of percutaneous interventions there are patients with greater risk and worse diagnosis which has modified the results in the last years, as well as a reduction in the number of surgeries per year. Mortality in Europe and the United States is lower than 2,5% with a survival that oscillates respectively between 97-80% of 1 to15 years. Its reduction increased as of the eighth year, is in relation to the average life of the grafts, its occlusion, progression of the disease and development of its comorbidities. 1,2,3.
