**6. Complicated postoperative**

### **Cardiovascular**

16 Special Topics in Cardiac Surgery

40% when compared with controls. This study has been criticized for lack of blind control, administration of high doses of glucose control and high incidence of hypoglycemia. The current recommendation is to try to keep blood glucose below 150 mg / dl, this was secondary to a study called normoglycemia in Intensive Care Evaluation Survival Using Glucose Algorithm-Regulation (NICE-SUGAR) used to test the hypothesis that intensive of blood sugar reduces mortality 90 days in this study showed higher mortality from severe hypoglycemia. Because polyuria in the early hours, the release of antidiuretic hormone and hyperaldosteronism that characterizes the patient operated on with CPB, it is common the presence of hypokalaemia which must be corrected for values greater than 4.0 mEq / L, just as occurs hypomagnesemia should be corrected usually there is usually no changes in

The dilutional hyponatremia type being increased total body sodium, the use of mannitol and / or furosemide during CPB produces a polyuria in the first two to three hours postoperatively INSTANT that can reach 1000 ml / hour, with a tendency to normalize within hours, the usual consequence is the need to infuse fluids resulting hypovolemia. 48.49

It is essential in the first 24 hours because it is not uncommon to find deficits in different degrees and which are generally grouped into cognitive dysfunction, which is the most common disorder and unnoticed, and that their identification will be necessary to carry out mini-mental and demonstrate an early deficit and time of their higher mental functions. All patients coming to the unit with residual sedation TiPQ so within the next 6 hours there is a 95% elimination of sedatives, since coming patients should be evaluated clinically to assess the integrity of the stem bark and well-get a first impression to rule out diagnoses and cerebral ischemic event or bleeding. In patients who quickly integrates a focus fasciocorporal study should be completed image and a more detailed review to have an

Moreover, patients with prolonged CPB tend to have greater involvement of cardiorespiratory function and hemodynamic instability preoperatively intraoperative surgery more complicated, hence the increased incidence of neurological disorders may be related to these factors rather than the CPB time, now happens with hypotension and cerebral hypoperfusion which is another postulated mechanism of neurological damage. The CBP is under hypothermia and anesthesia, both of which lower the cerebral metabolism and thus cerebral blood flow as there is less demand on the other hand, hemodilution decreases blood viscosity by decreasing its resistance to move, so lower blood pressure can keep the same cerebral blood flow. Thus, it alters the autoregulation curve of cerebral blood flow may keep it even with blood pressures of 50 to 60 mm Hg, studies measuring regional cerebral blood flow in patients during CPB have shown that blood pressure can reach 50 mm Hg without altered cerebral blood flow. Moreover, the flow can reach 19 cm 3 per 100 grams of tissue per minute without psychometric alterations detected between pre and post operative. Glasgow is interpreted evaluation at baseline and 6 hours by issuing a neurological assessment, monitoring with bispectral index (BIS) in patients who have to initiate a secondary sedation is necessary to identify a

Hematologic monitoring after surgery is associated with anemia hemodilution and blood loss, the minimum necessary use of blood products has shown improvement in morbidity

serum calcium or other ions that require correction.

early management and prevent secondary damage. 50.51

**Neurological monitoring** 

level of sedation adecuado.52, 53 , 54

**Hematologic monitoring** 

Hypotension and hypoperfusion injury may condition not directly related to the surgical procedure and include cardiac tamponade, a new myocardial ischemia, tension pneumothorax, hemothorax or significant bleeding related to arterial cannulation. Rarely produce acute thrombosis of a graft or coronary embolization. The electrocardiogram (ECG) may be of diagnostic aid because it is expected that the initial postoperative ECG changes does not show or reveal abnormalities preoperatively limited ST-T. If there are significant changes in ECG repeated, should be thought of an occlusive lesion of one of the grafts.

In the presence of suspected acute ischemia should indicate intravenous nitroglycerin, the risk of a perioperative myocardial infarction is present from the preoperative to the hospital and even after the diagnosis of acute myocardial infarction (AMI) presents difficulties in the perioperative You must have a combination of ECG, cardiac enzymes and echocardiography can occasionally make the diagnosis. Frequently observed nonspecific ECG changes a large percentage of patients have an increased enzyme and troponin I (TnI) generally exceeds the levels observed in AMI unrelated to cardiac surgery. The loss of graft thrombosis has been reported in up to 10% of grafts in the first week in the hours following the surgery, aspirin and possibly clopidogrel appears to reduce the prevalence of AMI diagnosis although postoperative postoperative AMI is difficult itself has a significant effect on morbidity and mortality in the long term.

### **Arrhythmias**

Low cardiac output syndrome

The low cardiac output syndrome (LCOS), is characterized by decreased performance of cardiac function where the cause may damage myocardial and cardiogenic shock condition corresponds to a failure in the balance between central cardiac pump and control components peripherals, including: a) the tone of the peripheral circulation and b) neurohumoral regulators of vascular tone, with the arrival insufficient oxygenated blood to peripheral tissues to meet metabolic needs, their presence is associated with high mortality at that requires immediate diagnosis and treatment. The multiple causes can produce or aggravate this syndrome can be grouped, for descriptive purposes, the following pathogenic mechanisms:

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 19

The hemodynamic evaluation allows continuous monitoring of cardiac function postoperatively, being indispensable implementation in this particular group of patients. This is done by direct measurement of cardiac output by thermodilution technique. Authors such as J. Kirklin consider being in the presence of low cardiac output when cardiac index less than 2.2 L/min/m2 in the early hours after surgery and less than 2.4 L/min/m2 in the first postoperative day, other authors consider the value 2.0 L/min/m2 index of heart as the limit for the diagnosis of low cardiac output syndrome, with values between 2 and 2.5 L/min/m2 cardiac index usually require therapeutic intervention, whatever its value must be accompanied by systemic vascular resistance values normal or elevated, for differentiation vasoplegic syndrome that presents with decreased systemic vascular resistance. The radionuclide ventriculography with Technetium 99 is an excellent diagnostic tool, with it you can obtain the ejection fraction as much of the left ventricle of the right ventricle, and allows cardiac tamponade diagnosed by the presence of pericardial blood or clots in relation to Echocardiography its main drawback is to obtain an acceptable acoustic window in this group of patients, however these problems have been solved with transesophageal echocardiography. LCOS mortality is very high, the study CONAREC III mortality of patients suffering from low cardiac output syndrome was 44.7%, compared to those patients who did not suffered and whose mortality was only 4.9% in the same study when considering all the excuses of death, this syndrome was the most frequent (28.9%) in patients undergoing coronary bypass surgery. Another study observed the ESMUCICA un12% mortality in CABG and valve surgery in 25-45%) and ESMUCICA II (26% mortality

The therapeutic management should follow a similar pattern of the pathogenesis stating:

The optimal preload for each patient is different and depends on the heart for each patient and how they estimated. When you need to optimize the preload is used intravascular volume expansion with either colloids, crystalloids or both, while, as if what is required is a decrease in preload is done with diuretics, vasodilators, with predominant effect in the venous bed as nitroglycerin, mechanical ventilation with PEEP or hemofiltration if the

Afterload also depends on heart disease for each patient and if you have any other special situation. The most commonly used drugs to reduce vascular resistance and therefore afterload are vasodilators with predominant effect on the arterioles, such as sodium nitroprusside. Another important therapeutic elements are warming persist in hypothermic patients, sedation and analgesia in patients who have pain or anxiety they generate strong isometric muscle contraction, and oxygen in varying concentrations in those with hypoxemia and pulmonary vasoconstriction bed with increased pulmonary vascular resistance and consequently the right ventricular afterload. To get the rhythm and heart rate can be used atrial pacing in case of a sub-optimal heart rate in sinus rhythm and normal atrioventricular conduction, ventricular pacing in cases of atrial fibrillation with low ventricular response, and sequential pacing, atrioventricular case of complete atrioventricular block. The presence of tachyarrhythmias can be managed with drug

therapy, over-stimulation or cardioversion shock as appropriate.

in valvular).

a. Optimize preload b. Optimizing afterload

d. Increase inotropy.

patient is oliguric renal failure.

c. Optimizing the pace and heart rate.


The diagnosis of low cardiac output syndrome after surgery can be established through the clinic or by hemodynamic monitoring. Hypotension is the warning sign and used more widely, however, patients with moderate decrease in cardiac index may retain acceptable levels of low systemic blood pressure which minute volume is high or normal. Oliguria is the most common signs of urinary volume monitoring is time and calculate the minute volume through the renal plasma flow and rhythm of diuresis, but lacks specificity. No doubt the hypothermia of the extremities and the temperature difference between central and extremity: these signs are not very useful in the immediate postoperative period because patients usually come to body temperature, cardiovascular recovery with low and sometimes remain so for several hour, despite attempts to overheat. In the first hours after surgery are patients with marked vasomotor instability (vasoconstriction - vasodilation) for which no specific capillary filling. On the other hand in the first hours after surgery can be found lactic acidosis, which in many cases does not reflect the present situation, but situations of decreased perfusion in the operating room occurred body, markedly decreasing the diagnostic and prognostic value with other medical and Finally, the decrease in mixed venous saturation, this parameter depends on cardiac output and oxygen consumption level of the tissue, so in the first 60 minutes is more specific cardiac output. Due to the low sensitivity and specificity of symptoms from the first sign of consensus definitions in cardiovascular recovery, recently published, is required to make the clinical diagnosis of low cardiac output syndrome, patients present simultaneously at least 2 of the following criteria:

Hypotension (systolic blood pressure below 90 mmHg). Oliguria (urine output less than 0.5 ml / kg / hr).

The hemodynamic evaluation allows continuous monitoring of cardiac function postoperatively, being indispensable implementation in this particular group of patients. This is done by direct measurement of cardiac output by thermodilution technique. Authors such as J. Kirklin consider being in the presence of low cardiac output when cardiac index less than 2.2 L/min/m2 in the early hours after surgery and less than 2.4 L/min/m2 in the first postoperative day, other authors consider the value 2.0 L/min/m2 index of heart as the limit for the diagnosis of low cardiac output syndrome, with values between 2 and 2.5 L/min/m2 cardiac index usually require therapeutic intervention, whatever its value must be accompanied by systemic vascular resistance values normal or elevated, for differentiation vasoplegic syndrome that presents with decreased systemic vascular resistance. The radionuclide ventriculography with Technetium 99 is an excellent diagnostic tool, with it you can obtain the ejection fraction as much of the left ventricle of the right ventricle, and allows cardiac tamponade diagnosed by the presence of pericardial blood or clots in relation to Echocardiography its main drawback is to obtain an acceptable acoustic window in this group of patients, however these problems have been solved with transesophageal echocardiography. LCOS mortality is very high, the study CONAREC III mortality of patients suffering from low cardiac output syndrome was 44.7%, compared to those patients who did not suffered and whose mortality was only 4.9% in the same study when considering all the excuses of death, this syndrome was the most frequent (28.9%) in patients undergoing coronary bypass surgery. Another study observed the ESMUCICA un12% mortality in CABG and valve surgery in 25-45%) and ESMUCICA II (26% mortality in valvular).

The therapeutic management should follow a similar pattern of the pathogenesis stating:

a. Optimize preload

18 Special Topics in Cardiac Surgery

1. Reduced preload. The major cause is the leakage of fluid into the interstitial space, excessive bleeding, polyuria, the use of high levels of positive end-expiratory warming

2. Increase in afterload. It can affect both the left and right ventricle. in the cause of increased afterload are systemic hypertension, pulmonary hypertension, the

3. Reduced contractility. The main causes of decreased contractility are perioperative AMI, drugs with negative inotropic effect, the phenomena exaggerated ischemiareperfusion during aortic clamping, and so on. In relation to the phenomenon of ischemia reperfusion is important to note contractile deterioration often not immediately apparent to the patient's admission to the ICU. In these cases, there is a period of normo-or hyper ventricular early after reperfusion. This period is short (hours) and is followed by a gradual depression of systolic function, leading in many cases to a false sense of security in the early postoperative hours, when this

4. Changes in heart rate and heart rate. Are due to extreme bradycardia, supraventricular

5. Metabolic and electrolyte. Acidosis, hypoxemia, hypo-or hypercapnia, hyperkalemia,

6. Inadequate surgical management. Sometimes not achieved the expected result from the technical point of view and this can generate a low output syndrome, such as poor condition can bridge aortocoronary junction in myocardial revascularization surgery, prolonged pump time with poor poor systemic perfusion and hypothermia induced, the presence of a residual stenosis in mitral commissurotomy, miss-match of prosthetic

The diagnosis of low cardiac output syndrome after surgery can be established through the clinic or by hemodynamic monitoring. Hypotension is the warning sign and used more widely, however, patients with moderate decrease in cardiac index may retain acceptable levels of low systemic blood pressure which minute volume is high or normal. Oliguria is the most common signs of urinary volume monitoring is time and calculate the minute volume through the renal plasma flow and rhythm of diuresis, but lacks specificity. No doubt the hypothermia of the extremities and the temperature difference between central and extremity: these signs are not very useful in the immediate postoperative period because patients usually come to body temperature, cardiovascular recovery with low and sometimes remain so for several hour, despite attempts to overheat. In the first hours after surgery are patients with marked vasomotor instability (vasoconstriction - vasodilation) for which no specific capillary filling. On the other hand in the first hours after surgery can be found lactic acidosis, which in many cases does not reflect the present situation, but situations of decreased perfusion in the operating room occurred body, markedly decreasing the diagnostic and prognostic value with other medical and Finally, the decrease in mixed venous saturation, this parameter depends on cardiac output and oxygen consumption level of the tissue, so in the first 60 minutes is more specific cardiac output. Due to the low sensitivity and specificity of symptoms from the first sign of consensus definitions in cardiovascular recovery, recently published, is required to make the clinical diagnosis of low cardiac output syndrome, patients present simultaneously at least 2 of the

or ventricular tachyarrhythmias and impaired high-risk condition.

hypocalcemia and may contribute to the development of this syndrome.

excessive vasodilator drug use, cardiac tamponade, and so on.

replacement of the mitral valve in mitral regurgitation, etc..

phenomenon is unknown.

following criteria:

valve replacement or plasty, and so on.

Hypotension (systolic blood pressure below 90 mmHg). Oliguria (urine output less than 0.5 ml / kg / hr).


The optimal preload for each patient is different and depends on the heart for each patient and how they estimated. When you need to optimize the preload is used intravascular volume expansion with either colloids, crystalloids or both, while, as if what is required is a decrease in preload is done with diuretics, vasodilators, with predominant effect in the venous bed as nitroglycerin, mechanical ventilation with PEEP or hemofiltration if the patient is oliguric renal failure.

Afterload also depends on heart disease for each patient and if you have any other special situation. The most commonly used drugs to reduce vascular resistance and therefore afterload are vasodilators with predominant effect on the arterioles, such as sodium nitroprusside. Another important therapeutic elements are warming persist in hypothermic patients, sedation and analgesia in patients who have pain or anxiety they generate strong isometric muscle contraction, and oxygen in varying concentrations in those with hypoxemia and pulmonary vasoconstriction bed with increased pulmonary vascular resistance and consequently the right ventricular afterload. To get the rhythm and heart rate can be used atrial pacing in case of a sub-optimal heart rate in sinus rhythm and normal atrioventricular conduction, ventricular pacing in cases of atrial fibrillation with low ventricular response, and sequential pacing, atrioventricular case of complete atrioventricular block. The presence of tachyarrhythmias can be managed with drug therapy, over-stimulation or cardioversion shock as appropriate.

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 21

lung area available for gas exchange and consequently arterial oxygenation. Different methods are used alveolar recruitment in the postoperative patient, it is important to know that before the maneuver is to have an adequate intravascular volume and residual sedation after surgery. Ventilatory strategies proposed to achieve alveolar recruitment in surgical patients are based on the use of pressure (PEEP or CPAP) ranging between 20 and 40 cm H2O for varying periods of time. The effects of positive end-expiratory should be monitored continuously, as some of the side effects include decreased venous return by increasing the average pressure of the airways, impaired lung perfusion overdistended areas (increase dead space), increased pulmonary vascular resistance and right heart dysfunction, barotrauma and impaired renal blood flow, which are frequent causes of hemodynamic compromise in critically ill patients with cardiovascular disease and those with intravascular volume deficit. Pleural effusion is frequently observed in the immediate postoperative period, but a considerable percentage persist for more than 30 days, the incidence is 41-87% in postoperative patients, although most are not significant pleural effusions, a study of 602 heart postoperative patients showed pleural effusion in 63%, more than 30 days but less than 5% need thoracentesis for resolution in those patients who had more than 5 days chest drains pleural related to infections associated with atelectasis and ipsilateral lung infection, said box by fever, productive cough and an alveolar infiltrate on chest radiograph. It is important to differentiate whether it is indeed a spill transudate or if there is a pulmonary complication due to an infection with a pleural early. To make this distinction using the criteria of Light, which are more sensitive at identifying exudates, they meet at least one of the following criteria: (transudates none)

3. In pleural fluid LDH greater than the 2 / 3 parts of the upper limit of normal for serum

The thoracic duct that enters the thorax through the right diaphragm and flows into the left subclavian vein, has collateral lymphatic sometimes can be injured during surgery and result in a chylothorax. This pleural fluid milky-white at times and some colored (yellow or red) in other, has high content of lymph (chylomicrons), with a triglyceride level above 100 mg / dl and cholesterol below 200 mg / dl , treatment includes not remove the chest tubes because the fistula may close spontaneously in the thoracic duct short time, starting with parenteral nutrition for 10 to 14 days to reduce the production of intestinal lymph and thereby reduce the flow through the thoracic duct. If despite these measures fail to control the chylothorax, pleurodesis can be performed. Injury or acute progressive respiratory insufficiency (ALI / ARDS) is a multifactorial process of respiratory damage from pulmonary or extrapulmonary origin and is defined by the

In patients with postoperative heart surgery the incidence is 5 to 20% depending on the type of surgery, severity, time in surgery, bleeding, age, EuroSCORE, comorbidities, and so on. In elderly patients shows the highest incidence due to low physiological reserve and are more likely to have postoperative complications, the impact of gender remains controversial, although female gender was not shown to be an independent predictor of LPA in a large study recent cohort, two small studies identified a strong association between

1. Relationship between pleural fluid protein and serum 0.5, 2. Relationship between pleural fluid LDH and serum 0.6,

Other proposed criteria for an exudative pleural effusion are:

5. Gradient-pleural serum albumin less than 1.2 g / dl.

LDH.

4. Cholesterol> 43 mg / dl,

European-American consensus.

Commonly used catecholamines such as dopamine, dobutamine, isoproterenol, epinephrine, norepinephrine and inotropic catecholamines not milrinone and levosimendan, being necessary in many cases the combination of more than one. Catecholamines, particularly dopamine are the drugs most often used and indiscriminately without taking into account many times the preload. The most important are the catecholamines and phosphodiesterase inhibitors, there are few data concerning the use of levosimendan. these agents have proven effective in improving myocardial contractility or heart rate or both catecholamines are more potent chronotropic and inotropic agents determine side effects such as increased myocardial oxygen consumption of the myocardium, tachycardia, arrhythmias, and increased in afterload can make your job difficult. Β-adrenergic receptors may also be downregulated in patients with previous heart failure. This has increased the interest in the use of inhibitors of phosphodiesterase III and more recently, the calcium sensitizer levosimendan. In a study by Labriola et al. Nijhawan et al.) Drug compared to placebo in patients with low cardiac output syndrome after surgery, in which documented an increase in cardiac output and ejection fraction and a decrease systemic vascular resistance in patients treated with levosimendan. Gillies et al. Conducted a systematic review of the literature on the use of inotropic agents in patients with cardiac surgery, in which certain recommendations were documented, each with a particular level of evidence.

#### **Respiratory**

Respiratory dysfunction in postoperative heart surgery patients is a common problem that results in a significant increase to 25% mortality and significant morbidity with impact on cost and hospital stay, atelectasis is a frequent occurrence in the immediate postoperative period The incidence of atelectasis in the postoperative period of 40 to cardiac 70%, the term is derived from Greek: Atel and ektasis mean incomplete expansion of a segment or lobe is characterized by volume loss and collapse of alveolar region manifested radiographically as an area opacified. The severity of atelectasis increases with more time to pump, more bridges and prolonged ischemia, the opening of the pleura, phrenic nerve injury, intraoperative and very low temperatures. Thoracotomy alters lung function by shallow breathing (restrictive functional pattern), and vital capacity may be reduced by up to 45 to 70%, the pain diminishes deep breath and a cough can lead to ineffective with the consequences in lung mechanics and bronchial hygiene. Another important factor is the presence of atelectasis, diaphragmatic paralysis caused possibly by phrenic nerve injury caused by surgery or by the use of topical agents or cold cardioplegia. Decubitus position maintained, leads to changes in regional distribution of ventilation and perfusion of the lung, lung inflation decreases along a vertical axis from ventral to dorsal supine and when spontaneous breathing begins immediately after surgery and in the supine position ventilation is distributed mainly dependent areas of the lung. In contrast, during mechanical ventilation, this pattern changes and the distribution of ventilation is primarily aimed at non-dependent areas in both positions, therefore, the subsidiaries tend to collapse. Studies have shown that prone position ventilation becomes more homogeneous. Mechanical restraint of ventilation is produced by several factors explain such as bronchial secretions accumulating in dependent areas, pleural effusion or dysfunction of chest drains in the first hours after surgery. Alveolar recruitment maneuver is a technique that uses a sustained increase in airway pressure with the aim of reducing atelectasis by recruiting collapsed alveolar units, increasing the lung area available for gas exchange and consequently arterial oxygenation. Different methods are used alveolar recruitment in the postoperative patient, it is important to know that before the maneuver is to have an adequate intravascular volume and residual sedation after surgery. Ventilatory strategies proposed to achieve alveolar recruitment in surgical patients are based on the use of pressure (PEEP or CPAP) ranging between 20 and 40 cm H2O for varying periods of time. The effects of positive end-expiratory should be monitored continuously, as some of the side effects include decreased venous return by increasing the average pressure of the airways, impaired lung perfusion overdistended areas (increase dead space), increased pulmonary vascular resistance and right heart dysfunction, barotrauma and impaired renal blood flow, which are frequent causes of hemodynamic compromise in critically ill patients with cardiovascular disease and those with intravascular volume deficit. Pleural effusion is frequently observed in the immediate postoperative period, but a considerable percentage persist for more than 30 days, the incidence is 41-87% in postoperative patients, although most are not significant pleural effusions, a study of 602 heart postoperative patients showed pleural effusion in 63%, more than 30 days but less than 5% need thoracentesis for resolution in those patients who had more than 5 days chest drains pleural related to infections associated with atelectasis and ipsilateral lung infection, said box by fever, productive cough and an alveolar infiltrate on chest radiograph. It is important to differentiate whether it is indeed a spill transudate or if there is a pulmonary complication due to an infection with a pleural early. To make this distinction using the criteria of Light, which are more sensitive at identifying exudates, they meet at least one of the following criteria: (transudates none)


Other proposed criteria for an exudative pleural effusion are:

4. Cholesterol> 43 mg / dl,

20 Special Topics in Cardiac Surgery

Commonly used catecholamines such as dopamine, dobutamine, isoproterenol, epinephrine, norepinephrine and inotropic catecholamines not milrinone and levosimendan, being necessary in many cases the combination of more than one. Catecholamines, particularly dopamine are the drugs most often used and indiscriminately without taking into account many times the preload. The most important are the catecholamines and phosphodiesterase inhibitors, there are few data concerning the use of levosimendan. these agents have proven effective in improving myocardial contractility or heart rate or both catecholamines are more potent chronotropic and inotropic agents determine side effects such as increased myocardial oxygen consumption of the myocardium, tachycardia, arrhythmias, and increased in afterload can make your job difficult. Β-adrenergic receptors may also be downregulated in patients with previous heart failure. This has increased the interest in the use of inhibitors of phosphodiesterase III and more recently, the calcium sensitizer levosimendan. In a study by Labriola et al. Nijhawan et al.) Drug compared to placebo in patients with low cardiac output syndrome after surgery, in which documented an increase in cardiac output and ejection fraction and a decrease systemic vascular resistance in patients treated with levosimendan. Gillies et al. Conducted a systematic review of the literature on the use of inotropic agents in patients with cardiac surgery, in which certain recommendations were documented, each with a particular level

Respiratory dysfunction in postoperative heart surgery patients is a common problem that results in a significant increase to 25% mortality and significant morbidity with impact on cost and hospital stay, atelectasis is a frequent occurrence in the immediate postoperative period The incidence of atelectasis in the postoperative period of 40 to cardiac 70%, the term is derived from Greek: Atel and ektasis mean incomplete expansion of a segment or lobe is characterized by volume loss and collapse of alveolar region manifested radiographically as an area opacified. The severity of atelectasis increases with more time to pump, more bridges and prolonged ischemia, the opening of the pleura, phrenic nerve injury, intraoperative and very low temperatures. Thoracotomy alters lung function by shallow breathing (restrictive functional pattern), and vital capacity may be reduced by up to 45 to 70%, the pain diminishes deep breath and a cough can lead to ineffective with the consequences in lung mechanics and bronchial hygiene. Another important factor is the presence of atelectasis, diaphragmatic paralysis caused possibly by phrenic nerve injury caused by surgery or by the use of topical agents or cold cardioplegia. Decubitus position maintained, leads to changes in regional distribution of ventilation and perfusion of the lung, lung inflation decreases along a vertical axis from ventral to dorsal supine and when spontaneous breathing begins immediately after surgery and in the supine position ventilation is distributed mainly dependent areas of the lung. In contrast, during mechanical ventilation, this pattern changes and the distribution of ventilation is primarily aimed at non-dependent areas in both positions, therefore, the subsidiaries tend to collapse. Studies have shown that prone position ventilation becomes more homogeneous. Mechanical restraint of ventilation is produced by several factors explain such as bronchial secretions accumulating in dependent areas, pleural effusion or dysfunction of chest drains in the first hours after surgery. Alveolar recruitment maneuver is a technique that uses a sustained increase in airway pressure with the aim of reducing atelectasis by recruiting collapsed alveolar units, increasing the

of evidence. **Respiratory** 

5. Gradient-pleural serum albumin less than 1.2 g / dl.

The thoracic duct that enters the thorax through the right diaphragm and flows into the left subclavian vein, has collateral lymphatic sometimes can be injured during surgery and result in a chylothorax. This pleural fluid milky-white at times and some colored (yellow or red) in other, has high content of lymph (chylomicrons), with a triglyceride level above 100 mg / dl and cholesterol below 200 mg / dl , treatment includes not remove the chest tubes because the fistula may close spontaneously in the thoracic duct short time, starting with parenteral nutrition for 10 to 14 days to reduce the production of intestinal lymph and thereby reduce the flow through the thoracic duct. If despite these measures fail to control the chylothorax, pleurodesis can be performed. Injury or acute progressive respiratory insufficiency (ALI / ARDS) is a multifactorial process of respiratory damage from pulmonary or extrapulmonary origin and is defined by the European-American consensus.

In patients with postoperative heart surgery the incidence is 5 to 20% depending on the type of surgery, severity, time in surgery, bleeding, age, EuroSCORE, comorbidities, and so on.

In elderly patients shows the highest incidence due to low physiological reserve and are more likely to have postoperative complications, the impact of gender remains controversial, although female gender was not shown to be an independent predictor of LPA in a large study recent cohort, two small studies identified a strong association between

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 23

During the first 6 hrs of PO should immediately obtained objective results of platelet count and coagulation, for early medical or surgical management, clinical criteria is in relation to

In the management of patients with heavy bleeding PO should commence administration of blood products such as red cell concentrates without doubt the goal is to maintain the optimum level in arterial blood content [CaO2 = CaO2 = Hb (g/100ml) x 1.34 (ml O2 / g) x% SaO2 + (PaO2 x 0.0031) = ml blood O2/100ml)]. They are prepared with 300 ml volume with low WBC (<5x106 cells) to reduce alloimmunization and avoid possible TRALI or lung damage. Cell salvage, the process by which collects a patient's own blood during surgery for later transfusion in the same patient is a reliable alternative to donor blood transfusion when needed. We found 23 studies investigating the effectiveness of cell salvage in cardiac surgery, conclude that apparently there is insufficient evidence to support the use of cell salvage in cardiac surgery but the methodology in the studies were flawed and may be

Alterations in the number or function of platelets may have effects ranging from a clinically insignificant prolongation of bleeding time to large defects of hemostasis, platelet transfusion is usually required when it decreases the count: <50,000, is individualized 50-100 the case and over 100,000 were transfused if the time of Ivy is more than 10 minutes with continued bleeding. Can be obtained by platelet concentrates (40-70ml) or platelet apheresis

The use of fresh frozen plasma in postoperative patients offers all the clotting factors and plasma proteins needed to improve the prothrombin time and clotting better ensure hemodilution coagulopathy, caution should be exercised in bleeding secondary to heparin, as a source ATIII natural and should not be used prophylactically. To replace clotting factors to be used a dose of 10 to 20 mL / kg, which could increase the concentration factor by 20%

The cryoprecipitate is a concentrate of plasma proteins of high molecular weight cold rush its volume is approximately 15 to 20 mL after removing the supernatant plasma containing concentrations of factor VIII: C (procoagulant activity), 80 to 120 U; factor VIII: vWF (von

Most of the work with hemostatic agents were designed to assess the therapeutic efficacy and to assess potential toxic effects, so that there are still definite data on the safety of hemostatic agents. Many studies on these agents have used perioperative blood loss and other parameters with endpoints of little clinical importance, whereas other studies did not have enough power to evaluate the clinical outcome of importance, such as mortality or

Pharmacological agents that decrease postoperative bleeding are desmopressin is a synthetic analogue of natural vasopressin, with the advantage of having less vasoconstriction, is recommended for use in the immediate postoperative hemostatic, unlike aprotinin has fewer side effects such as anaphylaxis, thrombosis and renal failure. Aprotinin has been used in recent times but because it is a bovine protein, there is an increased risk of anaphylaxis, especially if you already had previous exposure, and its cost is higher. When used at low doses acts as antidiuretic hormone and is 10-20 times the dose that increases hemostatic function and plasma levels of factor VIII, von Willebrand factor (vWF) and tissue plasminogen activator (tPA), releasing these factors endothelium and liver. Also observed increased platelet aggregation, the result is the shortening of bleeding time. Administered

Willebrand factor), 40 to 70%, fibrinogen, 100 to 250 mg, and Factor XIII, 20 to 30%.

the following table.

biased.

(200-300ml).

immediately after infusion. 58,59,60

need for reoperation.

female gender and the incidence of ALI after cardiac surgery. Vascular risk factors are independent predictors of LPA include diabetes, kidney failure, hypertension. These markers of systemic atherosclerotic disease are associated with an increased risk of major complications. Preexisting renal insufficiency is a strong predictor of ALI (OR, 2.3), which confirms the findings of several studies, increased atherosclerotic burden associated with renal failure. Chronic obstructive pulmonary disease (COPD) identified preoperative was also an independent risk factor, confirming that patients with COPD who are undergoing valve surgery or surgery RVM have two or three times the chance of LPA in severe COPD has been associated with excess postoperative mortality in patients with MVR. Pathophysiological observed that lung damage is mixed but the most important finding in the lungs during the early stages of ALI / ARDS is the presence of severe pulmonary edema secondary to increased permeability of capillary endothelium and alveolar epithelial barrier of . Simultaneously, increased pulmonary vascular resistance as a result of thromboembolic events and reflex vasoconstriction, these morphological characteristics are a complex reaction of the lung to different nosological agents and processes and not related to the nature of the causal process. During mechanical ventilation in the immediate postoperative behavior is rest to follow by pulmonary alveolar protection strategy as ALI / ARDS is a syndrome characterized by loss of functional residual capacity, increased lung and short circuits refractory hypoxemia FiO2. The standard or optimal tidal volume is difficult to determine, because in the inflamed lung or ALI / ARDS alveolar pressures each area has specific and requires its own level of PEEP to keep open during expiration. The alveolar pressures and volumes that can reach areas not dependent overdistended lung, are often insufficient to ensure the recruitment of regions dependent edema and atelectasis by maintaining recruitable lung areas open, there is distension of the healthy areas of the lung, it is explained that the regional compliance of the lung are different as well as mentioned Gattinoni.

#### **Postoperative bleeding**

One of the most frequent complications encountered in the management of patients, approximately 20% of patients present with significant bleeding and only 5% required reintervention. Predictive factors for bleeding include age, renal failure, cardiopulmonary bypass time, liver failure, hypothermia, secondary fibrinolysis, NSAIDs, etc; bleeding contributes to more days of ventilation hospital stay and mortality.

The definition of excessive bleeding in postoperative patients occurs in 5% -10% approximately and only 3% required reoperation, bleeding, and reoperation are 2 independent predictors of poor prognosis. In those patients with postoperative bleeding can be divided into two categories: surgical bleeding (bleeding venous layer anastomosis, sternum, anywhere stitches), non-surgical bleeding (caused by coagulopathy).

Risk factors for bleeding are preoperative such as pharmacologic agents (thrombolytic PTCA, antiplatelet drugs, anticoagulation) in the case of ASA should be discontinued 5-7 days before surgery and anticoagulation is recommended to have INR <1.5, five days prior to surgery, vitamin K malabsorption, liver disease due to decreased synthesis of clotting factors, SLE, amyloidosis, prior chemotherapy, and so on.

Intraoperative risk factors are: pump bypass, hypothermia, use of heparin during cardiopulmonary bypass generation of fibrinolytic activity and postoperative risk factors known are octogenarians, non-elective surgery, low BMI, CPB> 150 min, grafts ≥ 5, surgical reintervention.

female gender and the incidence of ALI after cardiac surgery. Vascular risk factors are independent predictors of LPA include diabetes, kidney failure, hypertension. These markers of systemic atherosclerotic disease are associated with an increased risk of major complications. Preexisting renal insufficiency is a strong predictor of ALI (OR, 2.3), which confirms the findings of several studies, increased atherosclerotic burden associated with renal failure. Chronic obstructive pulmonary disease (COPD) identified preoperative was also an independent risk factor, confirming that patients with COPD who are undergoing valve surgery or surgery RVM have two or three times the chance of LPA in severe COPD has been associated with excess postoperative mortality in patients with MVR. Pathophysiological observed that lung damage is mixed but the most important finding in the lungs during the early stages of ALI / ARDS is the presence of severe pulmonary edema secondary to increased permeability of capillary endothelium and alveolar epithelial barrier of . Simultaneously, increased pulmonary vascular resistance as a result of thromboembolic events and reflex vasoconstriction, these morphological characteristics are a complex reaction of the lung to different nosological agents and processes and not related to the nature of the causal process. During mechanical ventilation in the immediate postoperative behavior is rest to follow by pulmonary alveolar protection strategy as ALI / ARDS is a syndrome characterized by loss of functional residual capacity, increased lung and short circuits refractory hypoxemia FiO2. The standard or optimal tidal volume is difficult to determine, because in the inflamed lung or ALI / ARDS alveolar pressures each area has specific and requires its own level of PEEP to keep open during expiration. The alveolar pressures and volumes that can reach areas not dependent overdistended lung, are often insufficient to ensure the recruitment of regions dependent edema and atelectasis by maintaining recruitable lung areas open, there is distension of the healthy areas of the lung, it is explained that the regional compliance of the lung are different as well as mentioned

One of the most frequent complications encountered in the management of patients, approximately 20% of patients present with significant bleeding and only 5% required reintervention. Predictive factors for bleeding include age, renal failure, cardiopulmonary bypass time, liver failure, hypothermia, secondary fibrinolysis, NSAIDs, etc; bleeding

The definition of excessive bleeding in postoperative patients occurs in 5% -10% approximately and only 3% required reoperation, bleeding, and reoperation are 2 independent predictors of poor prognosis. In those patients with postoperative bleeding can be divided into two categories: surgical bleeding (bleeding venous layer anastomosis,

Risk factors for bleeding are preoperative such as pharmacologic agents (thrombolytic PTCA, antiplatelet drugs, anticoagulation) in the case of ASA should be discontinued 5-7 days before surgery and anticoagulation is recommended to have INR <1.5, five days prior to surgery, vitamin K malabsorption, liver disease due to decreased synthesis of clotting

Intraoperative risk factors are: pump bypass, hypothermia, use of heparin during cardiopulmonary bypass generation of fibrinolytic activity and postoperative risk factors known are octogenarians, non-elective surgery, low BMI, CPB> 150 min, grafts ≥ 5, surgical

contributes to more days of ventilation hospital stay and mortality.

factors, SLE, amyloidosis, prior chemotherapy, and so on.

sternum, anywhere stitches), non-surgical bleeding (caused by coagulopathy).

Gattinoni.

reintervention.

**Postoperative bleeding** 

During the first 6 hrs of PO should immediately obtained objective results of platelet count and coagulation, for early medical or surgical management, clinical criteria is in relation to the following table.

In the management of patients with heavy bleeding PO should commence administration of blood products such as red cell concentrates without doubt the goal is to maintain the optimum level in arterial blood content [CaO2 = CaO2 = Hb (g/100ml) x 1.34 (ml O2 / g) x% SaO2 + (PaO2 x 0.0031) = ml blood O2/100ml)]. They are prepared with 300 ml volume with low WBC (<5x106 cells) to reduce alloimmunization and avoid possible TRALI or lung damage. Cell salvage, the process by which collects a patient's own blood during surgery for later transfusion in the same patient is a reliable alternative to donor blood transfusion when needed. We found 23 studies investigating the effectiveness of cell salvage in cardiac surgery, conclude that apparently there is insufficient evidence to support the use of cell salvage in cardiac surgery but the methodology in the studies were flawed and may be biased.

Alterations in the number or function of platelets may have effects ranging from a clinically insignificant prolongation of bleeding time to large defects of hemostasis, platelet transfusion is usually required when it decreases the count: <50,000, is individualized 50-100 the case and over 100,000 were transfused if the time of Ivy is more than 10 minutes with continued bleeding. Can be obtained by platelet concentrates (40-70ml) or platelet apheresis (200-300ml).

The use of fresh frozen plasma in postoperative patients offers all the clotting factors and plasma proteins needed to improve the prothrombin time and clotting better ensure hemodilution coagulopathy, caution should be exercised in bleeding secondary to heparin, as a source ATIII natural and should not be used prophylactically. To replace clotting factors to be used a dose of 10 to 20 mL / kg, which could increase the concentration factor by 20% immediately after infusion. 58,59,60

The cryoprecipitate is a concentrate of plasma proteins of high molecular weight cold rush its volume is approximately 15 to 20 mL after removing the supernatant plasma containing concentrations of factor VIII: C (procoagulant activity), 80 to 120 U; factor VIII: vWF (von Willebrand factor), 40 to 70%, fibrinogen, 100 to 250 mg, and Factor XIII, 20 to 30%.

Most of the work with hemostatic agents were designed to assess the therapeutic efficacy and to assess potential toxic effects, so that there are still definite data on the safety of hemostatic agents. Many studies on these agents have used perioperative blood loss and other parameters with endpoints of little clinical importance, whereas other studies did not have enough power to evaluate the clinical outcome of importance, such as mortality or need for reoperation.

Pharmacological agents that decrease postoperative bleeding are desmopressin is a synthetic analogue of natural vasopressin, with the advantage of having less vasoconstriction, is recommended for use in the immediate postoperative hemostatic, unlike aprotinin has fewer side effects such as anaphylaxis, thrombosis and renal failure. Aprotinin has been used in recent times but because it is a bovine protein, there is an increased risk of anaphylaxis, especially if you already had previous exposure, and its cost is higher. When used at low doses acts as antidiuretic hormone and is 10-20 times the dose that increases hemostatic function and plasma levels of factor VIII, von Willebrand factor (vWF) and tissue plasminogen activator (tPA), releasing these factors endothelium and liver. Also observed increased platelet aggregation, the result is the shortening of bleeding time. Administered

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 25

generate thrombin in the end much more and convert fibrinogen to fibrin. The clot is stabilized by inhibition of fibrinolysis, secondary to activation of the inhibitor of thrombinactivatable fibrinolysis mediated by rFVIIa. The availability of rFVIIa has expanded treatment options for acute bleeding in hemophilia patients. This drug is not a panacea, but it has efficacy in patients with trauma and excessive bleeding resistant to other treatments. However, the encouraging results obtained so far must be confirmed by other studies, are also necessary cost-effectiveness studies, as it is an expensive drug. The authors recommend to take with caution the results of studies recognized even before considering the evidence as a guideline. We have tried to increase the power and efficacy of rFVIIa by molecular

Although virtually all patients have some degree of increase in cardiac enzymes after surgery. The perioperative myocardial infarction is one of the most serious complications after CABG (RVM), an incidence of 5-20%, and is associated with significant morbidity and mortality in the post-surgical high. The pathogenesis of IPO vasa in the various mechanisms by which the placement of coronary artery bypass bridges leading to myocardial necrosis: The most common is acute occlusion of the hemoducto, twist it, subtotal graft stenosis or spasm, saying recent articles The presence of collateral arterioles protects perioperative

The perioperative myocardial infarction (IPO) type 5 belongs to heart and is defined according to the latest consensus established in 2007 by the AHA / ACC as an increase of at least 5 times the baseline or reference biomarkers, along with the emergence of new q waves left bundle branch block on electrocardiogram, or coronary angiography showing acute occlusion of hemoductos and imaging evidence of recent loss of viable myocardial tissue. According to Thielmann, the increase in markers of myocardial damage, can be used to discriminate between perioperative stroke related to the placement of coronary artery bypass bridge, or another cause. So analyzing 3308 patients with MVR, I conclude that the 94 who underwent coronary angiography, 56 had stroke related to the placement of coronary artery bypass bridges, 38 was not related to the procedure. Levels of troponin I, rather than CK / CK-MB rose significantly in the first group with respect to the second, considering the troponin I as the best marker to discriminate between IM surgery associated with those who are not associate the procedure with a cutoff of 10.5 ng / ml, and those in which MI was directly associated with the placement of non-hemoductos with a cutoff of

In peri-operative myocardial infarction not associated with coronary bypass grafts, is due to mechanisms such as inadequate cardioplegic perfusion, incomplete revascularization, distal coronary microembolization caused by surgical manipulation, recent unstable angina, poor left ventricular function. This early detection of perioperative myocardial infarction plays an important role in treating either early coronary angiography and angioplasty, trying to preserve left ventricular function as a predictor of long-term survival. Obviously the presence of perioperative myocardial infarction is associated with a high rate of heart failure and long-term mediately, as evidenced by Steuer, analyzing patients with MVR 7.493 assessing the number of readmissions for heart failure. Found that 7.7% (576) were readmitted for heart failure. Of these, 20% (114) had perioperative myocardial infarction.

engineering acting on DNA, but no studies. 71,72,73,74,75

**Perioperative myocardial** 

stroke patients.

35.5 ng / ml.

76,77,78,79,80,81

IV (0.3ug/Kg), SC (0.3ug/Kg) but for obvious reasons dministration IV is recommended in postoperative patients. The best response is expected between 30-60min after parenteral administration.

Inside are antifibrinolytic drugs: aprotinin (a direct inhibitor of the fibrinolytic enzyme plasmin) is the only drug approved by published and the Food and Drug Administration (FDA) to minimize transfusion requirements in coronary bypass surgery, directly inhibits the fibrinolytic enzyme plasmin, plasma kallikrein, tissue trypsin and activated coagulation factor XII, the highest recommended dose is> 700mg.

 Are also used tranexamic acid and aminocaproic acid, but have not been approved by the FDA for this indication, their mechanisms of action are the first to inhibit the binding of plasmin to fibrin occupying the binding sites of lysine of the proenzyme plasminogen and the second is the same mechanism of action, but 10 times more potent. Doses are 10-30g and maintenance 1-3gr/hr and the second 3-10gr with 20-250mg/hr maintenance.

There are reviews of meta-analysis on the effectiveness of antifibrinolytic agents compared with placebo, aprotinin or tranexamic acid, but not aminocaproic acid, reduced the need for blood transfusion by 30% and saved about 1 unit of blood per operation. There was no difference in efficacy between regimens with high or low doses of aprotinin, while varying doses of tranexamic acid and aminocaproic's not possible to assess the relationship between dose and efficacy. As for the most relevant clinical events, the relative risk of reoperation for excessive bleeding was significantly reduced in patients receiving aprotinin, compared with those receiving placebo, although the mortality rate remained unchanged. Both tranexamic acid and aminocaproic acid significantly decreased these events. Therefore, the results of the work checked and reviews indicate that antifibrinolytic drugs are effective hemostatic agents in cardiac surgery. Reductions in transfusion requirements and reoperation for bleeding seem to be confirmed by the narrow confidence intervals of likelihood ratios, indicators of relative risks. There were no sufficient data on the effectiveness that allow definitive conclusions regarding the use of antifibrinolytic agents in other situations. 61,62,63,64,65,66,67

While other review reports that aminocaproic acid and tranexamic acid are safe, it is noteworthy that the works included were smaller than the jobs studied aprotinin. Therefore, the authors say, the safety data are not reliable, especially with regard to thrombosis. Currently, the Blood Conservation using Antifibrinolytics: a randomized work in a population submitted to cardiac surgery (Randomized Trial in a Cardiac Surgery Population) or BART, which is still enrolling patients, is designed to enroll 2970 patients with indications for cardiac surgery high risk, to determine whether aprotinin is superior to tranexamic acid or aminocaproic acid to reduce the risk of massive postoperative bleeding. Secondary endpoints were overall mortality and adverse effects such as cardiovascular disease and kidney failure. For all available data, the authors argue that the evidence that aprotinin reduces perioperative bleeding and immediate postoperative transfusion requirement is sound. However, note that despite the large number of clinical trials that have addressed the drug, its effectiveness in reducing the need for reoperation has just emerged from reviews and lack of evidence about its effect on mortality. 68,69,70

Recombinant activated factor VII (rFVIIa) acts locally at the site of tissue injury and alterations of the vascular wall by binding to exposed tissue factor, generating small amounts of thrombin sufficient to activate platelets. The activated platelet surface can then form a template on which rFVIIa half the direct or indirect activation of coagulation to generate thrombin in the end much more and convert fibrinogen to fibrin. The clot is stabilized by inhibition of fibrinolysis, secondary to activation of the inhibitor of thrombinactivatable fibrinolysis mediated by rFVIIa. The availability of rFVIIa has expanded treatment options for acute bleeding in hemophilia patients. This drug is not a panacea, but it has efficacy in patients with trauma and excessive bleeding resistant to other treatments. However, the encouraging results obtained so far must be confirmed by other studies, are also necessary cost-effectiveness studies, as it is an expensive drug. The authors recommend to take with caution the results of studies recognized even before considering the evidence as a guideline. We have tried to increase the power and efficacy of rFVIIa by molecular engineering acting on DNA, but no studies. 71,72,73,74,75

#### **Perioperative myocardial**

24 Special Topics in Cardiac Surgery

IV (0.3ug/Kg), SC (0.3ug/Kg) but for obvious reasons dministration IV is recommended in postoperative patients. The best response is expected between 30-60min after parenteral

Inside are antifibrinolytic drugs: aprotinin (a direct inhibitor of the fibrinolytic enzyme plasmin) is the only drug approved by published and the Food and Drug Administration (FDA) to minimize transfusion requirements in coronary bypass surgery, directly inhibits the fibrinolytic enzyme plasmin, plasma kallikrein, tissue trypsin and activated coagulation

 Are also used tranexamic acid and aminocaproic acid, but have not been approved by the FDA for this indication, their mechanisms of action are the first to inhibit the binding of plasmin to fibrin occupying the binding sites of lysine of the proenzyme plasminogen and the second is the same mechanism of action, but 10 times more potent. Doses are 10-30g and

There are reviews of meta-analysis on the effectiveness of antifibrinolytic agents compared with placebo, aprotinin or tranexamic acid, but not aminocaproic acid, reduced the need for blood transfusion by 30% and saved about 1 unit of blood per operation. There was no difference in efficacy between regimens with high or low doses of aprotinin, while varying doses of tranexamic acid and aminocaproic's not possible to assess the relationship between dose and efficacy. As for the most relevant clinical events, the relative risk of reoperation for excessive bleeding was significantly reduced in patients receiving aprotinin, compared with those receiving placebo, although the mortality rate remained unchanged. Both tranexamic acid and aminocaproic acid significantly decreased these events. Therefore, the results of the work checked and reviews indicate that antifibrinolytic drugs are effective hemostatic agents in cardiac surgery. Reductions in transfusion requirements and reoperation for bleeding seem to be confirmed by the narrow confidence intervals of likelihood ratios, indicators of relative risks. There were no sufficient data on the effectiveness that allow definitive conclusions regarding the use of antifibrinolytic agents in other situations.

While other review reports that aminocaproic acid and tranexamic acid are safe, it is noteworthy that the works included were smaller than the jobs studied aprotinin. Therefore, the authors say, the safety data are not reliable, especially with regard to thrombosis. Currently, the Blood Conservation using Antifibrinolytics: a randomized work in a population submitted to cardiac surgery (Randomized Trial in a Cardiac Surgery Population) or BART, which is still enrolling patients, is designed to enroll 2970 patients with indications for cardiac surgery high risk, to determine whether aprotinin is superior to tranexamic acid or aminocaproic acid to reduce the risk of massive postoperative bleeding. Secondary endpoints were overall mortality and adverse effects such as cardiovascular disease and kidney failure. For all available data, the authors argue that the evidence that aprotinin reduces perioperative bleeding and immediate postoperative transfusion requirement is sound. However, note that despite the large number of clinical trials that have addressed the drug, its effectiveness in reducing the need for reoperation has just

emerged from reviews and lack of evidence about its effect on mortality. 68,69,70

Recombinant activated factor VII (rFVIIa) acts locally at the site of tissue injury and alterations of the vascular wall by binding to exposed tissue factor, generating small amounts of thrombin sufficient to activate platelets. The activated platelet surface can then form a template on which rFVIIa half the direct or indirect activation of coagulation to

maintenance 1-3gr/hr and the second 3-10gr with 20-250mg/hr maintenance.

administration.

61,62,63,64,65,66,67

factor XII, the highest recommended dose is> 700mg.

Although virtually all patients have some degree of increase in cardiac enzymes after surgery. The perioperative myocardial infarction is one of the most serious complications after CABG (RVM), an incidence of 5-20%, and is associated with significant morbidity and mortality in the post-surgical high. The pathogenesis of IPO vasa in the various mechanisms by which the placement of coronary artery bypass bridges leading to myocardial necrosis: The most common is acute occlusion of the hemoducto, twist it, subtotal graft stenosis or spasm, saying recent articles The presence of collateral arterioles protects perioperative stroke patients.

The perioperative myocardial infarction (IPO) type 5 belongs to heart and is defined according to the latest consensus established in 2007 by the AHA / ACC as an increase of at least 5 times the baseline or reference biomarkers, along with the emergence of new q waves left bundle branch block on electrocardiogram, or coronary angiography showing acute occlusion of hemoductos and imaging evidence of recent loss of viable myocardial tissue.

According to Thielmann, the increase in markers of myocardial damage, can be used to discriminate between perioperative stroke related to the placement of coronary artery bypass bridge, or another cause. So analyzing 3308 patients with MVR, I conclude that the 94 who underwent coronary angiography, 56 had stroke related to the placement of coronary artery bypass bridges, 38 was not related to the procedure. Levels of troponin I, rather than CK / CK-MB rose significantly in the first group with respect to the second, considering the troponin I as the best marker to discriminate between IM surgery associated with those who are not associate the procedure with a cutoff of 10.5 ng / ml, and those in which MI was directly associated with the placement of non-hemoductos with a cutoff of 35.5 ng / ml.

In peri-operative myocardial infarction not associated with coronary bypass grafts, is due to mechanisms such as inadequate cardioplegic perfusion, incomplete revascularization, distal coronary microembolization caused by surgical manipulation, recent unstable angina, poor left ventricular function. This early detection of perioperative myocardial infarction plays an important role in treating either early coronary angiography and angioplasty, trying to preserve left ventricular function as a predictor of long-term survival. Obviously the presence of perioperative myocardial infarction is associated with a high rate of heart failure and long-term mediately, as evidenced by Steuer, analyzing patients with MVR 7.493 assessing the number of readmissions for heart failure. Found that 7.7% (576) were readmitted for heart failure. Of these, 20% (114) had perioperative myocardial infarction. 76,77,78,79,80,81

Intensive Care Management of Patients in the First 24 Hours After Cardiac Surgery 27

dopamine)

b. postoperative

vasopressin 94,95,96,97,98

is a marker of poor prognosis.

dose is 0.05 to 0.1 unit / minute.

a. In operating room, with open chest

excellent observation of left ventricular contractility.

apreciaciónde good left ventricular contractility.

3. Other

Vasopressor requirement (> 0.5 mcg / kg / min noradrenaline or> 10 mcg / kg / min

PVC hypotension with low (<5 mm Hg) refractory avolumen associated with

PVC hypotension with low (<5 mm Hg) refractory avolumen associated with echocardiography (bidimensionalcon good window or transesophageal) with

The main therapeutic goal is sustain perfusion to vital organs like the kidney, brain, liver and heart. This also implies the initial use of volume, the use of two types of drugs, drugs with pressor effect, linked to its exclusive or non-selective action on alpha adrenergic receptors, such as metaraminol or phenylephrine among the first, and epinephrine, norepinephrine or dopamine among the latter. The use of drugs associated with betaadrenergic effect, will result in some measure, an increase of myocardial oxygen consumption in the same direction, their association with postoperative arrhythmias, has also been reported. The second drawback associated with, and probably the most important clinical refractoriness to vasopressors is that certain forms of vasoplegia postoperative manifest. This refractoriness drugs raises the utility of antagonists or inhibitors of NO and the enzyme guanylate cyclase, we consider a rational therapeutic approach more physiological. Two drugs are the most studied, methylene blue, and

Methylene Blue (AM): its therapeutic action is based on the inhibitory effect of NO or blocking of the enzyme guanylate cyclase. This drug has been considered in several isolated reports in a series without a control group and essentially in a randomized control group. Leyh et al. reported 54 patients with refractory postoperative vasoplegia the use of norepinephrine, treated with 2 mg / kg AM. Fifty-one patients showed favorable hemodynamic changes in the course of one hour post-treatment. Three patients died in the hospital course of the picture (5.6%). The study lacked a control group. Another key finding is the shorter of the table between those treated with AM. In these, vasoplegia resolved completely within two hours after the start of infusion, whereas in those managed conventionally, the box is extended in time, such extension of time associating with a higher incidence of complications and late onset sepsis and multiorgan dysfunction . Several authors have agreed with this finding, giving unfavorable prognostic value of the persistence over time of the SV, accepting that a breakpoint located between 36 and 48 hours

Vasopressin: Vasopressin (antidiuretic hormone arginine vasopressin), Argenziano et al. described the association between the shock with vasodilatation after bypass surgery and deficiency of vasopressin. Which is secreted by the neurohypophysis regulates tubular permeability to water, typically having limited participation in the control of BP. Under conditions of hypotension, such as bleeding or vasoplegia itself is a rapid depletion of endogenous. It allows a rapid reversal of hypotension, especially in patients refractory to vasopressors. In addition, the hormone increases vascular sensitivity to catecholamines and increases urine output, based on its direct action on glomerular efferent arteriole, unlike catecholamines, whose site is located on the therapeutic afferent arteriole. The proposed
