**4. Cardiac risk evaluation of anesthetic (CARE)**

The scale used most recently is called Cardiac Anesthesia Risk Evaluation Score (CARE), prospective studies in cardiac surgery demonstrated a significant number of prognostic information was obtained from only a few clinical variables or clinical trial, were validated and compared with 3.548 patients with Parsonet, Tuman, and Tu, the CARE is a simple risk classification predicts morbidity and mortality on a scale which means ordinary CARE1 low risk, high risk means CARE5 and Care 2-4 as intermediate risk, based on clinical trial recognized three variables: 21.22

### **Scale of anesthetic Cardiac Risk Assessment (CARE).**


### **Cardiopulmonary bypass (CBP)**

6 Special Topics in Cardiac Surgery

**Risk factors Punctuation** 

Female sex 1 Morbid obesity 3 Hypertension (p. s.> 140 mmHg) 3

Good> 50% 0 Moderate 30-49% 2 Poor <30% 4

70-74 7 75-79 12 >80 20

Primary 5 Secundary 10 Preoperative BIAC 2 Left Ventricular Aneurysm 5 Emergency surgery and angioplasty 10 Dialysis 10 Catastrophic States 10-50 Mitral valve surgery 5 PAP > 60mmHg 8 Aórtic 5 Gradient > 120 mmHg 7 Revascularization + Valve Surgery 2

Due to differences in adult cardiac surgery in the countries of Europe the EuroSCORE is responsible for assessing the quality of surgical care, the analysis is performed for each individual to individual and predicting mortality among the countries of the study is were: Germany, England, Spain, Finland, France and Italy. The EuroSCORE model was satisfactory in all countries with a p <0.05, despite epidemiological differences between European countries the discriminative power of EuroSCORE was good in Spain and in other

The scale used most recently is called Cardiac Anesthesia Risk Evaluation Score (CARE), prospective studies in cardiac surgery demonstrated a significant number of prognostic information was obtained from only a few clinical variables or clinical trial, were validated

EJECTION FRACTION

age years

**Reoperation** 

Chart 3.

countries excellent. 14, 15,16,17, 18,19,20.

**4. Cardiac risk evaluation of anesthetic (CARE)** 

On-pump bypass also known as cardiopulmonary bypass is a method used in coronary bypass surgery, this device has been used in cardiac surgery since 1960, due to the high incidence of perioperative mortality due to low spending, it is increasingly used in the last decade, increasing its survival up to 60%. Cardiac surgery and cardiopulmonary bypass activate the inflammatory response, characterized by cardiovascular and pulmonary disorders, this inflammatory response that occurs during cardiac surgery is presented by three processes:


The extent and duration of the inflammatory response depend on many factors including the composition of the solution pump, the presence of pulsatile perfusion, pharmacological agents used to reduce the response, the use of mechanical filtration, the type of extracorporeal circuit and temperature during cardiopulmonary bypass. During CPB flow decreased splenic occurs, which induces the crossing of endotoxins by the lumen, activating the inflammatory response, endotoxins are potent initiators of the inflammatory cascade, which in turn causes production of cytokines and complement activation.

A frequent complication of systemic inflammatory response is the evolution to multiple organ failure (MOF) including respiratory failure, shock and renal failure, development of FOM is the most important determinant for the postoperative increases those patients who have risk factors such as prolonged mechanical ventilation (intubation ≥ 48 hours), increased volumes of lower urinary nitrogenous and persistence of vasopressors, resulting in an increase in mortality to 41%. The inflammatory response and also condition FOM phenomena of hemolysis, thrombocytopenia and leukopenia, in the first 24 hours of the end of cardiopulmonary bypass can be seen that the total count of leukocytes undergoes an increase with significant changes in the differential count, the leukocytosis persisted in 72 hours, in the differential count reports a significant increase in neutrophils and monocytes and decreased lymphocyte counts during the first days. Postoperative fever in the second and third day in patients undergoing cardiac surgery is accompanied by an increase in neutrophils, two times the initial value during cardiopulmonary bypass activation of neutrophils is manifested by leukocyte sequestration in the pulmonary circulation at the

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 9

Christeson, showed that the use of preoperative IABP reduced hospital costs and length of stay in revascularized and reoperation, Dietl, also reported a stay of 10 days vs. 12 days in those with BIAC those who did not have it at a cost average hospital stay of \$ 4000 per paciente. Although minor complications associated with IABP placement has been estimated at 6.5% and higher (vascular surgery and requiring transfusion) of 2.1% is greater than the benefit conferred on all preoperative placement to reduce mortality significantly vs to who are placed in the postoperative period (mortality 8.8% vs 28.2%, p <0.0001) in conclusion, the use of BIAC has increased over the past 10 years, significantly as evidenced by the record made in 29, 961 patients England and Canada, where the increase in aortic

There should be a systematic evaluation of the patient immediately on arrival to postoperative intensive care unit (TiPQ), communication with the surgical team and anesthesia should provide an overview of the intervention performed and the response of the cardiovascular system and perioperative hemodynamic treatment and handling of medication. Although initially it may focus attention on an aspect of patient status (eg, existing arrhythmia on arrival), it is essential to develop a systematic approach to evaluation. The patient is fully independent and dysfunction of the elements of support systems can be fatal quickly. Surgical dressings must be kept intact during the first 24 hours in order to control the infection. If handling is necessary for diagnostic purposes must follow a strict technique. Upon transfer, the patient should continue with the pharmacological management started in the operating room and continued monitoring that includes at least fan movement, Electrocardiography digital, non-invasive blood pressure (PBIN) and pulse oximetry (SO2). Upon arrival to the ICU should be corroborated electrocardiographic tracing displayed on the monitor and make an immediate transfer line 12-lead ECG or chest circle when necessary. Capnography (PECO2) and central venous pressure (CVP) are measures that must be reactivated immediately, it also calibrates the transducer invasive blood pressure monitor confirms his bed and his blood pressure is checked immediately after the pacemaker (MCP ) epicardial and functionality, if the patient arrives with pulmonary catheter also must be calibrated immediately and make a hemodynamic profile to assess their cardiovascular status at the time and determine current therapeutic recommendations behaviors common pulmonary catheter placement are EF <40%, patients with combined valve implantation (aortic-mitral) or severe acute heart failure diagnostic doubt its hemodynamic profile. It is important to immediately verify the patency of chest tubes and immediately upon arrival quantify pleural drainage at 15, 45 minutes and hourly for the first 24 hours, and assess their macroscopic features and clot formation. The ventilatory parameters must be set in the next 5 minutes upon arrival and assess the degree of de-recruitment and the need for alveolar opening Pa02/Fi02 if their relation ship is less than 200 mm Hg and if their hemodynamic status is not compromised, the monitoring hypothermia and its management is immediate. During the first 15 minutes should be evaluated central venous saturation (SvO 2), arterial blood gases, acid-base status, serum electrolytes (ABG) and serum examinations required, such as hemoglobin, platelets, hematocrit, serum

*Low cardiac output syndrome, perioperative As a bridge to cardiac transplantation* 

*Perioperative arrhythmias are difficult to control* 

counterpulsation in cardiac surgery in the last 6 years is 47%. 29.30.

**Initial assessment and aost-aurgical therapy (TiPQ)** 

*Acute mitral insufficiency* 

time of reperfusion of the vascular bed can lead to endothelial and parenchymal injury, in immunocompromised patients and prolonged intubation favors the development of infections. Neutrophils represent the most significant source of oxygen free radicals, which is associated with myocardial dysfunction and pulmonar.23, 24,25,26,27.

The CBP decreased flow causes splenic bacterial translocation which conditions, these cross the intestinal lumen and activate the inflammatory response have different degrees of hemodynamic compromise, noting in addition sequential elevations of endotoxin followed by elevations in levels of cytokines and these correlate the degree of myocardial dysfunction. Endotoxins are potent initiators of the inflammatory cascade causing cytokine production, production and complement activation, their presence is associated with the development of lactic acidosis, decreased peripheral vascular resistance and left ventricular dysfunction. The cardiovascular effects of cytokines are mediated by nitric oxide which involves interaction between leukocytes and endothelium and the mechanisms that cause these effects are the presence of circulating endotoxin, lipopolysaccharide (LPS) of gramnegative bacterial cell wall that interact with host cells to promote the release of mediators, lipopolysaccharide increases because the immune response by binding to protein carriers of LPS forms a complex that is a thousand times more potent to induce the release of tumor necrosis factor (TNF) and the union lipopolysaccharide occurs between the CD14 receptor of macrophages is that the activation of kinases and TNF. The inflammatory response can be maintained by several factors including the production of cytokines such as TNF-alpha (α), interleukin 1 (IL-1), IL-1 (beta), interleukin 2 (IL-2), interleukin 6 ( IL-6), interleukin 8 (IL-8), interleukin 10 (IL-10), interferon and colony stimulating factors, which may be related to postoperative complications. The release of cytokines produce clinical manifestations in patients with cardiopulmonary bypass, such as fever, altered level of consciousness that occurs microembolisms due to encephalopathy. The crystalloid solutions used to prime the pump bypass hemodilution while causing turbulence and osmotic pressure during cardiopulmonary bypass cause lesions in the cell membrane of erythrocytes and hemolysis eventually causing mainly postoperative bleeding and coagulopathy platelet dysfunction. It is possible that renal failure during cardiopulmonary bypass is due to changes in renal perfusion during periods of hypotension or, for low blood flow, vasoconstriction and microembolism, likewise, hemoglobinuria may also cause significant renal dysfunction as a result of hemolysis during CPB, cardiopulmonary bypass can also cause susceptibility to infections, Sabick et al found that deep sternal infection occurs in 2% in patients undergoing extracorporeal pump versus 0.2% in off-pump patients (p <0.04).28

#### **Intra aortic balloon counterpulsation (BIAC)**

The intra-aortic balloon counterpulsation is the method used in the treatment of severe cardiac dysfunction and potentially reversible in the perioperative and postoperative cardiac surgery is indicated in the shock associated with myocardial infarction or other complications intractable cardiac ischemia, with or without infarction, ventricular failure post CPB, and so on.

There are two main effects of this device, the first is to increase coronary blood flow improved myocardial oxygen availability by increasing diastolic perfusion pressure and the second is the blood moves during balloon inflation reduces ventricular work by reducing afterload with rapid deflation in systole and thus decreasing myocardial oxygen demand, this increases the heart rate up to 20%, thus the signs associated with BIAC surgical procedure are:

*Low cardiac output syndrome, perioperative As a bridge to cardiac transplantation Acute mitral insufficiency Perioperative arrhythmias are difficult to control* 

8 Special Topics in Cardiac Surgery

time of reperfusion of the vascular bed can lead to endothelial and parenchymal injury, in immunocompromised patients and prolonged intubation favors the development of infections. Neutrophils represent the most significant source of oxygen free radicals, which

The CBP decreased flow causes splenic bacterial translocation which conditions, these cross the intestinal lumen and activate the inflammatory response have different degrees of hemodynamic compromise, noting in addition sequential elevations of endotoxin followed by elevations in levels of cytokines and these correlate the degree of myocardial dysfunction. Endotoxins are potent initiators of the inflammatory cascade causing cytokine production, production and complement activation, their presence is associated with the development of lactic acidosis, decreased peripheral vascular resistance and left ventricular dysfunction. The cardiovascular effects of cytokines are mediated by nitric oxide which involves interaction between leukocytes and endothelium and the mechanisms that cause these effects are the presence of circulating endotoxin, lipopolysaccharide (LPS) of gramnegative bacterial cell wall that interact with host cells to promote the release of mediators, lipopolysaccharide increases because the immune response by binding to protein carriers of LPS forms a complex that is a thousand times more potent to induce the release of tumor necrosis factor (TNF) and the union lipopolysaccharide occurs between the CD14 receptor of macrophages is that the activation of kinases and TNF. The inflammatory response can be maintained by several factors including the production of cytokines such as TNF-alpha (α), interleukin 1 (IL-1), IL-1 (beta), interleukin 2 (IL-2), interleukin 6 ( IL-6), interleukin 8 (IL-8), interleukin 10 (IL-10), interferon and colony stimulating factors, which may be related to postoperative complications. The release of cytokines produce clinical manifestations in patients with cardiopulmonary bypass, such as fever, altered level of consciousness that occurs microembolisms due to encephalopathy. The crystalloid solutions used to prime the pump bypass hemodilution while causing turbulence and osmotic pressure during cardiopulmonary bypass cause lesions in the cell membrane of erythrocytes and hemolysis eventually causing mainly postoperative bleeding and coagulopathy platelet dysfunction. It is possible that renal failure during cardiopulmonary bypass is due to changes in renal perfusion during periods of hypotension or, for low blood flow, vasoconstriction and microembolism, likewise, hemoglobinuria may also cause significant renal dysfunction as a result of hemolysis during CPB, cardiopulmonary bypass can also cause susceptibility to infections, Sabick et al found that deep sternal infection occurs in 2% in patients undergoing

is associated with myocardial dysfunction and pulmonar.23, 24,25,26,27.

extracorporeal pump versus 0.2% in off-pump patients (p <0.04).28

The intra-aortic balloon counterpulsation is the method used in the treatment of severe cardiac dysfunction and potentially reversible in the perioperative and postoperative cardiac surgery is indicated in the shock associated with myocardial infarction or other complications intractable cardiac ischemia, with or without infarction, ventricular failure

There are two main effects of this device, the first is to increase coronary blood flow improved myocardial oxygen availability by increasing diastolic perfusion pressure and the second is the blood moves during balloon inflation reduces ventricular work by reducing afterload with rapid deflation in systole and thus decreasing myocardial oxygen demand, this increases the heart rate up to 20%, thus the signs associated with BIAC surgical

**Intra aortic balloon counterpulsation (BIAC)** 

post CPB, and so on.

procedure are:

Christeson, showed that the use of preoperative IABP reduced hospital costs and length of stay in revascularized and reoperation, Dietl, also reported a stay of 10 days vs. 12 days in those with BIAC those who did not have it at a cost average hospital stay of \$ 4000 per paciente. Although minor complications associated with IABP placement has been estimated at 6.5% and higher (vascular surgery and requiring transfusion) of 2.1% is greater than the benefit conferred on all preoperative placement to reduce mortality significantly vs to who are placed in the postoperative period (mortality 8.8% vs 28.2%, p <0.0001) in conclusion, the use of BIAC has increased over the past 10 years, significantly as evidenced by the record made in 29, 961 patients England and Canada, where the increase in aortic counterpulsation in cardiac surgery in the last 6 years is 47%. 29.30.

#### **Initial assessment and aost-aurgical therapy (TiPQ)**

There should be a systematic evaluation of the patient immediately on arrival to postoperative intensive care unit (TiPQ), communication with the surgical team and anesthesia should provide an overview of the intervention performed and the response of the cardiovascular system and perioperative hemodynamic treatment and handling of medication. Although initially it may focus attention on an aspect of patient status (eg, existing arrhythmia on arrival), it is essential to develop a systematic approach to evaluation. The patient is fully independent and dysfunction of the elements of support systems can be fatal quickly. Surgical dressings must be kept intact during the first 24 hours in order to control the infection. If handling is necessary for diagnostic purposes must follow a strict technique. Upon transfer, the patient should continue with the pharmacological management started in the operating room and continued monitoring that includes at least fan movement, Electrocardiography digital, non-invasive blood pressure (PBIN) and pulse oximetry (SO2). Upon arrival to the ICU should be corroborated electrocardiographic tracing displayed on the monitor and make an immediate transfer line 12-lead ECG or chest circle when necessary. Capnography (PECO2) and central venous pressure (CVP) are measures that must be reactivated immediately, it also calibrates the transducer invasive blood pressure monitor confirms his bed and his blood pressure is checked immediately after the pacemaker (MCP ) epicardial and functionality, if the patient arrives with pulmonary catheter also must be calibrated immediately and make a hemodynamic profile to assess their cardiovascular status at the time and determine current therapeutic recommendations behaviors common pulmonary catheter placement are EF <40%, patients with combined valve implantation (aortic-mitral) or severe acute heart failure diagnostic doubt its hemodynamic profile. It is important to immediately verify the patency of chest tubes and immediately upon arrival quantify pleural drainage at 15, 45 minutes and hourly for the first 24 hours, and assess their macroscopic features and clot formation. The ventilatory parameters must be set in the next 5 minutes upon arrival and assess the degree of de-recruitment and the need for alveolar opening Pa02/Fi02 if their relation ship is less than 200 mm Hg and if their hemodynamic status is not compromised, the monitoring hypothermia and its management is immediate. During the first 15 minutes should be evaluated central venous saturation (SvO 2), arterial blood gases, acid-base status, serum electrolytes (ABG) and serum examinations required, such as hemoglobin, platelets, hematocrit, serum

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 11

sinus rhythm below 75 beats per minute tends to be more deleterious to an abnormal rhythm frequencies above 90 per minute, with low heart rates, prolonging the diastolic filling time committed ventricular ejection fraction because the ventricle is more dilated. Ultimately in ventricles with volume overload tachycardia and loss of atrioventricular synchrony can be better tolerated than sinus bradycardia. Determining the degree of reduction in contractility admission to TiPQ is problematic, the main contributors to the decrease in postoperative contractility including ejection fraction before surgery less than 35%, CPB time, especially if the duration exceeds 120 minutes. In patients undergoing valve procedures, it is advisable to perform intraoperative transesophageal echocardiography at the end of CPB as this is useful to assess valve function and ventricular dynamics. If the preoperative ejection fraction is greater than 35% and the operative course was satisfactory, decrease myocardial compliance in the first 4-6 hours in the unit and then quickly returns TiPQ values similar to or better than the preoperative values. Patients with an ejection fraction before surgery less than 35%, presence of perioperative ischemia or complicated operative course may require a longer time to recover or make permanent dysfunction, myocardial depression may persist for an extended period of time. These factors may affect the withdrawal of ventilatory support and necessitate the use of oxygen in prolonged, the tachypnea may be a reflection of compromised perfusion rather than primary respiratory

Maintaining normal blood pressure is critical in the early hours of postoperative necessarily invasive measurement must be continued for at least 24 hours for analysis beat to beat but if it is non-invasive measurement must be measured regularly every 5 minutes but the objectivity of plethysmographic measurements are reliable non-invasive automatic in the absence of intense vasoconstriction and a very high frequency. Class I recommendation, level of evidence C. The optimal MAP in the first 6 postoperative hours especially in revascularized patients should be 65 to 80mmHg, maintaining adequate tissue perfusion to all organs and prevent bleeding at the sites of anastomosis of the bypass. The goal of hemodynamic monitoring of critically ill patients is to assess the adequate perfusion and tissue oxygenation, using intermittent or continuous measurement of oxygen saturation both considered acceptable, although the measurement of lactate may be useful lacks precision as a measure of status tissue metabolism in patients with mechanical ventilation is recommended central venous pressure of 12-14 mm Hg to offset the increase in intrathoracic pressure especially those with PEEP> 5mmHg. A similar consideration is the elevation of intra-abdominal pressure (IAP is approximately normal. 5-7 mmHg in critically ill patients) as it is inversely proportional to tissue perfusion pressure (PPP) and dependent on the mean

The good use in the immediate postoperative period of Swan-Ganz implies a broad knowledge of hemodynamics by the doctor for a proper training and constant use of the device, much of the value of this catheter for monitoring the hemodynamic status is based on their ability adequate to measure pulmonary capillary pressure which we take as a measure of left ventricular preload. The subsequent interpretation of a good wedge pressure curve are not simple things, implies among other things, the tip of the catheter has been placed in a part of the lung that the condition of zone 3, the ball was not over-inflated or default, the catheter is floating in the right place and has not migrated back, there is no strong auto-PEEP and various other things. However there are many more and more data, which indicate that the use of postoperative pulmonary catheter in heart depends on many

failure.

arterial pressure (MAP) ie: PPA = MAP - IAP.

electrolytes, coagulation, time Ivy, myocardial enzymes, prealbumin, liver function tests (LFT), nitrogenous, Cystatin C, urine sediment and start of urine collection for urinary urea nitrogen (NUU), subsequent tests are given in the next 6 hours or before be necesario.31, 32,33,34,35
