CVICU: Management of Post-Op Cardiac Surgery Patients

On By eddyjoemdIn CVICU

This post is a collection of evidence-based practices in the management of patients in the cardiac and cardiothoracic ICU (CVICU) with my personal take on it. I am working on improving this page regularly. The last update was on 10/06/22.

Let’s start off with the basics. Patients who have cardiac surgery, especially those who go “on pump”, come out of the OR quite sick. Depending on your institution, these patients can be cared for directly by the cardiac surgeons, the anesthesiologist, or by the intensivist. I have seen different set-ups at different places. Your market may vary. If you want to check out my personal thought process and style when care for patients s/p cardiac surgery in the CVICU, click here.

Table of Contents

  • Optimizing the Handoff from the CVOR to the CVICU
  • Learning to Use the Swan-Ganz (Pulmonary Artery) Catheter
  • Goal Directed Hemodynamic Therapy
    • SvO2 and Lactate
    • Stroke Volume and DO2I
    • Stroke Volume
  • Guidelines for Perioperative Medications
  • Should we fast-track patients? (Updated on 4/7/22)
  • Managing Blood Products
  • Acute Kidney Injury
  • Methylene Blue
  • Peri-operative Afib
  • Cardiac Arrests in the CVICU
  • Pain Control and Delirium in the CVICU
  • ECMO in the Cardiac Surgery Population
  • Why do we give everyone a statin?
  • Is the incentive spirometer really necessary?

Handoff from the Anesthesiologist to the Intensivist in the CVICU

There’s no better way to build rapport and confidence amongst a team than direct communication between healthcare professionals. To read the body language of your colleague and interact with them after the patient arrives in the CVICU from the OR is key. Some hearts are routine and the dynamics are a bit more nonchalant. Some hearts are a quite sicker and there’s lots that one needs to know. A proper handoff can assist with making sure that all the issues that have happened, are key factors of the patient themselves, and predicting what could happen are addressed.

In 2017, Gleicher, et al published in a CVOR to CVICU Transition Note that is free for you all to download. Respect for copyright won’t allow me to post it directly here. They state that subpar handovers lead to “incorrect treatment plans, diagnostic delays, patient complaints, increased length of stay, and increased mortality”. I would personally add that it contributes to a lack of trust amongst the teams caring for these patients. If you’re unclear of what the anesthesiologist or surgeon did in the OR, that could lead to doubt in their capacity to do their job properly. This isn’t very time consuming to achieve either. This all takes less than 3 minutes if you can restrain yourself from injecting playful commentary. There are some basics that I will not mention for the sake of your attention span and mine such as identifying the patient which is a given.

ADDENDUM: On 11/23/21, Danielle LeVeck, DNP, ACNP/CNS shared an article with me by Chattergee et al. which reviews the protocols for handoff in the CVICU. You can download this full free paper HERE.

Procedure details

It is important to learn from the surgeon what was done in the OR. Where the grafts were taken from. If the patient is oozy or not. How long the pump run or cross-clamp time was. More to come.

Co-morbidities

It is important to learn your patient for obvious reasons upon arrival to the CVICU. Do they have a history of a stroke? If so, what are their precise sequelae of this? You don’t want to call a “Code Stroke” on something that has been there for years, nor do you want to miss a CVA and then window of opportunity to retrieve the culprit.

Does the patient have hypertension that is being treated with ACE inhibitors? We know that these two families of medications can contribute to vasoplegic syndrome which is a game-changer in how we manage these patients in the post-op period.

Is there the possibility that the patient could withdraw from alcohol during their hospitalization? You need to be able to predict this stuff.

Does the patient take SSRI’s for depression and therefore take the possibility of using methylene blue for vasoplegic syndrome out of your toolbox?

Let me know what I may have missed as this is a work in progress.

Intraoperative Course (Prior to the CVICU)

When discussing the intraoperative course upon arrival in the CVICU with the anesthesiologist, I like to know first what was the situation with the airway. Was it an easy airway? Anything anatomical I need to worry about like cervical fusion? I extubate some patients directly to non-invasive ventilation or high-flow nasal cannula and want to make sure that I have a safe exit strategy in case they need to be reintubated.

I typically ask the anesthesiologist here about what the heart looked as soon as the TEE was performed. I say I ask but many time the information is offered. Also their pre-op ejection fraction and how the valves looked. I ask about what their initial numbers on the pulmonary artery catheter looked like. What was their initial cardiac index/output starting the case. What are their baseline pulmonary artery pressures. You need to set baselines for this stuff to better identify when your patient is deteriorating. Remember, this is all about the details.

The anesthesiologist will also let you know how much fluid the patient received during the surgery. Here you need to know how much blood products and which ones were provided, how much cell-saver, how much crystalloid and how much colloid the patient was given. At some institutions the patient may even be provided with a slug of furosemide prior to transfer from the CVOR to the CVICU.

If the patient is shocky, the patient may come up on some vasopressors and/or inotropes. Face to face communication will assist on sorting out why certain regimens were chosen for this patient. Remember, the anesthesiologist has the ability to actually look at the heart via TEE to judge the responses of the inotropic agents as opposed to us using some device to tell us (unless you know how to do TEE’s).

The anesthesiologist will also let you know how the heart looked after the surgery. You’ll know what the pre-op and post-op ejection fraction is. You’ll know exactly what the right heart looked like. If it was weak, please do not pound it with fluids. It can only take so much. Any other strange events will be relayed as well.

Let’s not forget about the temporary pacemaker. What settings are the patients on and why. I considered making a pacing video but there are already so many that are so much better than what I would create that I am just going to defer to them. Knowing where the chest tubes are and how much they’ve put out is extremely helpful as well. Mind the chest tube output, or lack thereof because that’s also bad. The ventilator settings part of it is the easy part, to be honest. Usually a patient has an ABG performed immediately upon arrival to the CVICU and the ventilator can be easily titrated.

Ultimately, you want to make sure that your patient is stable enough to extubate successfully within 6 hours of coming off of pump. You don’t want the patient to be on jet fuel. What are some of the outcomes that are improved by these direct handoffs? Kaufman, et al. found that there were fewer unplanned extubations and a shorter mean ventilator time per patient in hours. Gleicher et al. found that there was a “more reliable transfer of critical content and improved patient care planning”.

Now that the handoff has been accomplished, let’s move on to looking at how we are going to provide fluids and vasopressors/inotropes.

What are the effects of cardiopulmonary bypass on inflammation?

Squiccimarro E, Stasi A, Lorusso R, Paparella D. Narrative review of the systemic inflammatory reaction to cardiac surgery and cardiopulmonary bypass. Artif Organs. 2022 Jan 21. doi: 10.1111/aor.14171. Epub ahead of print. PMID: 35061922.
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Learning to Use the Swan-Ganz (Pulmonary Artery) Catheter

I will get to my personal breakdown on this but, for the moment, these authors did a better job than I ever could at breaking down the pulmonary artery catheter. Feel free to download these papers as they are free and a fantastic resource. Something you can do is screenshot the images and save them in a little folder on your phone that you can look to as a reference. That’s how I got through residency without carrying around silly books in my pocket like the other residents.

That being said, the PA catheter, at least I feel, is going to make a comeback. Why you ask? It’s a great way to estimate cardiac output and systemic vascular resistance, as well as CVP. You know, the three variables needed to calculate the mean arterial pressure. MAP = (CO x SVR) + CVP. If someone is in shock, you can better identify if it’s a cardiac output problem or a systemic vascular resistance problem. Once you know which of the two (or both) are causing the problem, then you can fix it.

Part 1
Bootsma IT, Boerma EC, de Lange F, Scheeren TWL. The contemporary pulmonary artery catheter. Part 1: placement and waveform analysis. J Clin Monit Comput. 2021 Feb 10. doi: 10.1007/s10877-021-00662-8. Epub ahead of print. PMID: 33564995.
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Part 2
Bootsma IT, Boerma EC, Scheeren TWL, de Lange F. The contemporary pulmonary artery catheter. Part 2: measurements, limitations, and clinical applications. J Clin Monit Comput. 2021 Mar 1:1–15. doi: 10.1007/s10877-021-00673-5. Epub ahead of print. PMID: 33646499; PMCID: PMC7917533.
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Goal-Directed Hemodynamic Therapy in Cardiac Surgery

There are different ways in the literature describing how you can provide goal-directed hemodynamic therapy (GDHT). Goal-directed hemodynamic therapy can be defined as the use of cardiac output or similar parameters to guide intravenous fluid or inotropic therapy. Now, it is important to know that using GDHT is not the absolute answer to determining the fluid status as pointed out by Dr. Gerard Manecke in a recent editorial. He stated that “Volume responsiveness, in itself, does not indicate anything other than that administration of fluid would increase cardiac stroke volume.” It does not determine whether someone is truly euvolemic, hypervolemic, or hypovolemic.

This is where the data from our PA catheters such as CI/CO, SV, and other parameters that we use for volume responsiveness have to also correlate with the targeted mean arterial pressure and other parameters. This is the art of all this. Fluid/volume responsiveness is not the end-all-be-all but definitely a tool to bring us closer to the holy grail which we are not going to find anytime soon of knowing with exact precision which patients will and will not benefit from fluid administration.

The subsequent studies I have reviewed should shed some light as to why using parameters for fluid responsiveness in the setting of GDHT helps outcomes for patients. What we are trying to avoid is the arbitrary utilization of fluids based on parameters that have no evidence-based rationales outside of historical clinical gestalt. In the literature, one could find certain parameters. These include stroke volume variation (SVV), delta stroke volume (ΔSV).

SvO2 and Lactate

The first study I was able to find looking at GDHT was Pölönen et al. back in 2000. Here, they used SvO2 and lactate levels as their goals. They were able to shorten the length of stay and decrease morbidity in the experimental arm. Patients received more crystalloids (2271±1523 vs 1970±1219 mL, p<0.05) and colloids (922±431 vs 802±408 mL, p<0.01) in the experimental arm. No mention in differences in renal failure.

Stroke Volume and DO2I

In 2005, Pearce et al. published a paper titled “Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial”. They used CVP, cardiac output, and DO2I which is something that I do not have access to at my shop and is a proprietary technology of LiDCO Ltd.

The control group received fluid boluses based on CVP while the GDT group looked at improvements in the stroke volume. Patients received dopexamine, which is a synthetic analogue of dopamine, depending on the DO2I. If the cardiac index dropped below <2.5, the patients would receive epinephrine.

The GDT group received the same amount of crystalloids (a little less than a liter), more colloids (almost 2 liters vs. 1.2 liters!), and more dopexamine. The found that DO2I was useful as was the stroke volume rise. CVP and lactate were not useful.

In exchange for their hard work, the patients in the GDT group were rewarded with fewer complications, and shorter mean and median duration of hospitalization. There was no difference in the duration of ICU stay nor mortality. No mention of acute kidney injury here.

Stroke Volume

In 2015 Osawa et al. published a prospective randomized controlled trial looking again at Cardiac Output-guided hemodynamic resuscitation. In this trial including 126 patients, the total median amount of fluid provided to the patients was 1.06L in the GDT arm and 0.89L in the usual care arm. That’s quite the difference from the Thompson study mentioned before where they were almost at 3L. Rather than using stroke volume here, they used stroke volume index (SVI) whenever the cardiac index was less than 3L/min/m2. They have a cool algorithm in the paper which I can’t share because of copyright issues. No difference in AKI in this paper.

For those unfamiliar with SVI, it is SV/body surface area. They used absolute numbers in the Osawa study as opposed to a change in SV in the Thompson paper. I personally am more of a fan of the delta stroke volume because of all the individual factors that one needs to take into account for stroke volume such as venous return, filling time, autonomic innervation, hormones, and vasodilation or vasoconstriction. I don’t have any data right now to support my bias.

Thompson et al.

SVV for Fluid Responsiveness

In 2017, Xu et al. published a randomized controlled trial using goal-directed fluid restriction using SVV and cardiac index. This is on patients with one-lung ventilation who you cannot just bombard with fluids because you will lose the one lung the patient has. They laid out a cool evidence-based algorithm which I cannot copy for you here because of copyright issues.

The authors found that using this protocol, patients were extubated sooner, required less norepinephrine (but more dobutamine), less overall fluids (about 12%), less pneumonia, and a shorter length of stay.

Don’t forget that stroke volume variation has its intrinsic limitations which I have covered in the past. CLICK HERE to learn more.

Goal-directed perfusion reduces AKI

Magruder, et al. looked at intra-operative management of CABG patients and found that these was less acute kidney injury later in the CVICU when certain targets were met.

Giving too much fluid is bad.

Haase-Fielitz et al. published a single-center, prospective cohort study with 282 patients where they wanted to see how certain interventions affected the incidence and severity of acute kidney injury. All in all they found that a “reduced mean arterial pressure and increased fluid balance were independently associated with increased mortality and need for RRT.” But what does that mean?

What is the ballpark amount of fluids cardiac surgery patients receive in the post-op period?

We’ve all seen patients receive liter after liter of fluids to make the blood pressure pretty in the resuscitation of cardiac surgery patients in the CVICU.

  • Pölönen 2000: Total crystalloids (2271±1523 vs 1970±1219 mL, p<0.05) and colloids (922±431 vs 802±408 mL, p<0.01).
  • Osawa 2015: Total fluids (mL), median (IQR) 1,056 (257–1,568) 894 (229–1,595) p=0.85

Before we go down this rabbit hole, how much fluids do patients generally receive in the intra-op period before the reach the CVICU? Haase, et al in 2011 reported patients receiving between 2.4 to 2.5L of infusions.

Thompson et al. created a prospective observational trial protocol looking at an increase in stroke volume to determine fluid responsiveness. Note that they did not provide a whole liter of fluids per fluid challenge but rather used 250cc boluses of Ringer’s Lactate. Those 250cc’s went in within 5 minutes, by the way. If the CVP of the patient increased by 5mmHg or more, then the fluid challenges would stop due to concerns of volume overload, RV failure or tamponade. Note that they did not use an arbitrary number for CVP such as 8. They used delta CVP. This is because everyone is different regarding their CVP. Shooting for the same CVP value in everyone is a practice that should be kept in the relics of medicine.

They provided patients with a median of 2.9L in the goal directed therapy group where they used 250cc boluses and changes of stroke volume greater than or equal to 10% to deem the patient fluid responsive. In the control group, the patients received a median of 2.7L. That doesn’t seem like a big difference to me, nor was the amount of fluids statistically significant (p=0.09). But the patients in the GDT group had fewer acute kidney injury (AKI), less need for renal replacement therapy (RRT), less readmission to the ICU, and shorter duration of hospitalization.

The rationale as to why the patients did better in the GDT group as opposed to the control group was that they received fluids earlier in the admission to the CVICU before the hemodynamic compromise took place. In the control group, providing fluids was reactionary. The LiDCOplus device was used in this study.

Guidelines for Perioperative Medication Management

Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg. 2018 Jan 1;53(1):5-33. doi: 10.1093/ejcts/ezx314. PMID: 29029110.
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Should we be fast-tracking patients? (Updated 4/7/22)

MacLeod JB, D’Souza K, Aguiar C, Brown CD, Pozeg Z, White C, Arora RC, Légaré JF, Hassan A. Fast tracking in cardiac surgery: is it safe? J Cardiothorac Surg. 2022 Apr 6;17(1):69. doi: 10.1186/s13019-022-01815-9. PMID: 35382846.
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Managing Blood Products in the CVICU

Huang J, Firestone S, Moffatt-Bruce S, Tibi P, Shore-Lesserson L. 2021 Clinical Practice Guidelines for Anesthesiologists on Patient Blood Management in Cardiac Surgery. J Cardiothorac Vasc Anesth. 2021 Dec;35(12):3493-3495. doi: 10.1053/j.jvca.2021.09.032. Epub 2021 Sep 24. PMID: 34654633.
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Koch CG, Sessler DI, Mascha EJ, Sabik JF 3rd, Li L, Duncan AI, Zimmerman NM, Blackstone EH. A Randomized Clinical Trial of Red Blood Cell Transfusion Triggers in Cardiac Surgery. Ann Thorac Surg. 2017 Oct;104(4):1243-1250. doi: 10.1016/j.athoracsur.2017.05.048. Epub 2017 Aug 16. PMID: 28821336.
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Sanaiha Y, Hadaya J, Verma A, Shemin RJ, Madani M, Young N, Deuse T, Sun J, Benharash P; University of California Cardiac Surgery Consortium. Morbidity and Mortality Associated With Blood Transfusions in Elective Adult Cardiac Surgery. J Cardiothorac Vasc Anesth. 2022 Nov 17:S1053-0770(22)00799-6. doi: 10.1053/j.jvca.2022.11.012. Epub ahead of print. PMID: 36462976.
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Why do CVICU Patients develop acute kidney injury?

Sirvinskas et al. noted that acute kidney occurs in about 8% of patients who undergo cardiopulmonary bypass and have bad kidneys to start and then 3-4% of the normal kidney population. Overall 5-30% of patients develop AKI. Other factors include:

  • age
  • baseline renal function
  • presence of diabetes
  • duration of cardiopulmonary bypass and aortic cross-clamping
  • complexity of surgery

More recently, Wittlinger et al. looked at retrospective data to attempt to calculate a risk assessment of acute kidney injury following cardiopulmonary bypass. Using a collection of 365 patients, they were able to determine that the risk for AKI was diminished when “surgery and ischemia time will be kept short, when blood loss is mitigated to a minimum and when surgery is performed under non-hypothermic conditions.” Sounds like a good deal of the responsibility of AKI is in the hands of our friendly neighborhood CT surgeon.

Why does AKI happen with cardiac surgery? It is definitely multifactorial. Per Shen, et al., these include “sudden change of kidney microcirculation caused by ischemia-reperfusion injury, renal vasoconstriction, hemodilution, and non-pulsatile blood flow during cardiopulmonary bypass”.

Hypovolemia is bad. You can’t keep the patients too dry. Patients have hypovolemia because of “inflammation, protein loss, capillary leakage, and vasoplegia”. On the flip side, overloading patients with fluid causes its own issues where there’s a strong association of with multi-organ dysfunction which includes AKI.

Haase, et al published a retrospective observational cohort study in 2012 looking at the effect of certain intra-operative measures on post-operative acute kidney injury. Patients received between 2.4-2.5L in the two group of fluids. They found that, more importantly than fluids, the incidence of anemia and the management of said anemia played a larger role on post-operative AKI than hypotension.

Oversimplifying, they found that there may sweet spot in where to transfuse blood for these patients. If the hemoglobin is less than 8g/dL, the AKI incidence increases from 15-30%. This is why the cardiac surgeons always transfuse if it’s less than 8g/dl. If the hemoglobin is above 8, however, you should not transfuse the patient. This is because the incidence, per this paper, of AKI increased by 40-50%. That’s quite the significant jump. Again, this is intraoperative. If you are to combine anemia AND hypotension, things get bad there, too. The AKI incidence for both anemia and hypotension is about 34%.

Thompson et al. created a protocol looking at an increase in stroke volume to determine fluid responsiveness. Note that they did not provide a whole liter of fluids per fluid challenge. They used 250cc boluses of Ringer’s Lactate. Those 250cc’s went in within 5 minutes, by the way. If the CVP of the patient increased by 5mmHg or more, then the fluid challenges would stop due to concerns of volume overload, RV failure or tamponade.

In the previously mentioned Shen, et al. retrospective cohort study looking at exploring appropriate post-operative fluid management, they found a U shaped association between postoperative fluid intake and AKI. The mortality in the patients who suffered AKI was 6.3% versus just 0.6% in the non-AKI group.

Vasoplegia

Muhammad R, Dharmadjati BB, Mulia EPB, Rachmi DA. Vasoplegia: Mechanism and Management Following Cardiopulmonary Bypass. Eurasian J Med. 2022 Feb;54(1):92-99. doi: 10.5152/eurasianjmed.2022.20394. PMID: 35307639; PMCID: PMC9634875.
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Methylene Blue in Post-Op Vasoplegia

Petermichl W, Gruber M, Schoeller I, Allouch K, Graf BM, Zausig YA. The additional use of methylene blue has a decatecholaminisation effect on cardiac vasoplegic syndrome after cardiac surgery. J Cardiothorac Surg. 2021 Jul 28;16(1):205. doi: 10.1186/s13019-021-01579-8. PMID: 34321019; PMCID: PMC8320154.
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Perioperative Atrial Fibrillation

Pierik R, Zeillemaker-Hoekstra M, Scheeren TWL, Erasmus ME, Luijckx GR, Rienstra M, Uyttenboogaart M, Nijsten M, van den Bergh WM. Early Thromboembolic Stroke Risk of Postoperative Atrial Fibrillation Following Cardiac Surgery. J Cardiothorac Vasc Anesth. 2021 Jul 21:S1053-0770(21)00611-X. doi: 10.1053/j.jvca.2021.07.030. Epub ahead of print. PMID: 34454821.
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Cardiac Arrest in the CVICU

I have covered this topic in the past. CLICK HERE to download the guidelines.

Pain Control in the CVICU

Boswell MR, Moman RN, Burtoft M, Gerdes H, Martinez J, Gerberi DJ, Wittwer E, Murad MH, Hooten WM. Lidocaine for postoperative pain after cardiac surgery: a systematic review. J Cardiothorac Surg. 2021 May 31;16(1):157. doi: 10.1186/s13019-021-01549-0. PMID: 34059093; PMCID: PMC8166031.
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Brescia AA, Clark MJ, Theurer PF, Lall SC, Nemeh HW, Downey RS, Martin DE, Dabir RR, Asfaw ZE, Robinson PL, Harrington SD, Gandhi DB, Waljee JF, Englesbe MJ, Brummett CM, Prager RL, Likosky DS, Kim KM, Lagisetty KH; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC); Michigan Opioid Prescribing Engagement Network (Michigan OPEN). Establishment and Implementation of Evidence-Based Opioid Prescribing Guidelines in Cardiac Surgery. Ann Thorac Surg. 2020 Dec 4:S0003-4975(20)32084-1. doi: 10.1016/j.athoracsur.2020.11.015. Epub ahead of print. PMID: 33285132.
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10.1016/j.athoracsur.2020.11.015

ECMO after Cardiac Surgery

Brewer, J.M., Tran, A., Yu, J. et al. ECMO after cardiac surgery: a single center study on survival and optimizing outcomes. J Cardiothorac Surg 16, 264 (2021). https://doi.org/10.1186/s13019-021-01638-0
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Why do we give everyone a statin during their CVICU stay?

Pan E, Nielsen SJ, Mennander A, Björklund E, Martinsson A, Lindgren M, Hansson EC, Pivodic A, Jeppsson A, Statins for Secondary Prevention and Major Adverse Events after Coronary Artery Bypass Grafting, The Journal of Thoracic and Cardiovascular Surgery (2021), doi: https://doi.org/10.1016/j.jtcvs.2021.08.088.
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Is the Incentive Spirometer really necessary?

Let’s talk about something that’s ubiquitous and yet has some poor data behind it. As the title says, I’m referring to the incentive spirometer. I’ve always shrugged my shoulders when patients refuse to do it as often as they should (you know, the plastic device is over by the windowsill and the patient is on the other side of the room) and perhaps incorrectly so after this study. The sample size seemed a bit small in this study by Eltorai et al., 80 in each group, and the primary outcome is radiologist based and they always recommend to correlate clinically. Either way, they were able to show some good secondary outcomes and in a world where we are being evaluated for every single extra day in length of stay, that may be the single biggest finding of this study (at least in my opinion). As mentioned in the study, we spend a billion dollars a year on these things. Guess I need to invest in those companies haha. But seriously, there’s no way we are getting them out of our facilities to save that cash so we might as well use them properly. That was not financial advise, by the way. 

Citations for the CVICU:

THE GOLD STANDARD PAPER
St André AC, DelRossi A. Hemodynamic management of patients in the first 24 hours after cardiac surgery. Crit Care Med. 2005 Sep;33(9):2082-93. doi: 10.1097/01.ccm.0000178355.96817.81. PMID: 16148484.
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The FULL ARTICLE is NOT FREE 🙁

HOW THE GERMANS MANAGE THEIR CVICU PATIENTS
Carl M, Alms A, Braun J, et al. S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and carCarl M, Alms A, Braun J, Dongas A, Erb J, Goetz A, Goepfert M, Gogarten W, Grosse J, Heller AR, Heringlake M, Kastrup M, Kroener A, Loer SA, Marggraf G, Markewitz A, Reuter D, Schmitt DV, Schirmer U, Wiesenack C, Zwissler B, Spies C. S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system. Ger Med Sci. 2010 Jun 15;8:Doc12. doi: 10.3205/000101. PMID: 20577643; PMCID: PMC2890209.
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IMPROVING HANDOFFS BETWEEN SPECIALTIES
Gleicher Y, Mosko JD, McGhee I. Improving cardiac operating room to intensive care unit handover using a standardised handover process. BMJ Open Qual. 2017 Nov 6;6(2):e000076. doi: 10.1136/bmjoq-2017-000076. PMID: 29450275; PMCID: PMC5699157.
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Kaufmnan J, Twite M, Barrett C, Peyton C, Koehler J, Rannie M, Kahn MG, Schofield S, Ing RJ, Jaggers J, Hyman D, da Cruz EM. A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period. Jt Comm J Qual Patient Saf. 2013 Jul;39(7):306-11. doi: 10.1016/s1553-7250(13)39043-6. PMID: 23888640.
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Chatterjee S, Shake JG, Arora RC, Engelman DT, Firstenberg MS, Geller CM, Hirose H, Lonchyna VA, Lytle FT, Milewski RKC, Moosdorf RGH, Rabin J, Sanjanwala R, Galati M, Whitman GJ; Society of Thoracic Surgeons Workforce on Critical Care. Handoffs From the Operating Room to the Intensive Care Unit After Cardiothoracic Surgery: From The Society of Thoracic Surgeons Workforce on Critical Care. Ann Thorac Surg. 2019 Feb;107(2):619-630. doi: 10.1016/j.athoracsur.2018.11.010. Epub 2018 Nov 27. PMID: 30500341.
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GOAL DIRECTED THERAPY in the CVICU

Manecke G. Volume Responsiveness: What It Does Not Tell Us. J Cardiothorac Vasc Anesth. 2021 May;35(5):1307-1309. doi: 10.1053/j.jvca.2020.12.038. Epub 2021 Jan 2. PMID: 33455888.
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Pölönen P, Ruokonen E, Hippeläinen M, Pöyhönen M, Takala J. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg. 2000 May;90(5):1052-9. doi: 10.1097/00000539-200005000-00010. PMID: 10781452.
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Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care. 2005;9(6):R687-93. doi: 10.1186/cc3887. Epub 2005 Nov 8. PMID: 16356219; PMCID: PMC1414018.
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Goepfert MS, Richter HP, Zu Eulenburg C, Gruetzmacher J, Rafflenbeul E, Roeher K, von Sandersleben A, Diedrichs S, Reichenspurner H, Goetz AE, Reuter DA. Individually optimized hemodynamic therapy reduces complications and length of stay in the intensive care unit: a prospective, randomized controlled trial. Anesthesiology. 2013 Oct;119(4):824-36. doi: 10.1097/ALN.0b013e31829bd770. PMID: 23732173.
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Kaufmann KB, Stein L, Bogatyreva L, Ulbrich F, Kaifi JT, Hauschke D, Loop T, Goebel U. Oesophageal Doppler guided goal-directed haemodynamic therapy in thoracic surgery – a single centre randomized parallel-arm trial. Br J Anaesth. 2017 Jun 1;118(6):852-861. doi: 10.1093/bja/aew447. PMID: 28575331.
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Dushianthan A, Knight M, Russell P, Grocott MP. Goal-directed haemodynamic therapy (GDHT) in surgical patients: systematic review and meta-analysis of the impact of GDHT on post-operative pulmonary complications. Perioper Med (Lond). 2020 Oct 15;9:30. doi: 10.1186/s13741-020-00161-5. PMID: 33072306; PMCID: PMC7560066.
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Osawa EA, Rhodes A, Landoni G, Galas FR, Fukushima JT, Park CH, Almeida JP, Nakamura RE, Strabelli TM, Pileggi B, Leme AC, Fominskiy E, Sakr Y, Lima M, Franco RA, Chan RP, Piccioni MA, Mendes P, Menezes SR, Bruno T, Gaiotto FA, Lisboa LA, Dallan LA, Hueb AC, Pomerantzeff PM, Kalil Filho R, Jatene FB, Auler Junior JO, Hajjar LA. Effect of Perioperative Goal-Directed Hemodynamic Resuscitation Therapy on Outcomes Following Cardiac Surgery: A Randomized Clinical Trial and Systematic Review. Crit Care Med. 2016 Apr;44(4):724-33. doi: 10.1097/CCM.0000000000001479. PMID: 26646462.
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McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M. Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery. BMJ. 2004 Jul 31;329(7460):258. doi: 10.1136/bmj.38156.767118.7C. Epub 2004 Jul 8. Erratum in: BMJ. 2004 Aug 21;329(7463):438. PMID: 15242867; PMCID: PMC498021.
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Giglio M, Dalfino L, Puntillo F, Brienza N. Hemodynamic goal-directed therapy and postoperative kidney injury: an updated meta-analysis with trial sequential analysis. Crit Care. 2019 Jun 26;23(1):232. doi: 10.1186/s13054-019-2516-4. PMID: 31242941; PMCID: PMC6593609.
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Magruder JT, Crawford TC, Harness HL, Grimm JC, Suarez-Pierre A, Wierschke C, Biewer J, Hogue C, Whitman GR, Shah AS, Barodka V. A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg. 2017 Jan;153(1):118-125.e1. doi: 10.1016/j.jtcvs.2016.09.016. Epub 2016 Sep 19. PMID: 27832832; PMCID: PMC5517016.
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Carsetti A, Amici M, Bernacconi T, Brancaleoni P, Cerutti E, Chiarello M, Cingolani D, Cola L, Corsi D, Forlini G, Giampieri M, Iuorio S, Principi T, Tappatà G, Tempesta M, Adrario E, Donati A. Estimated oxygen extraction versus dynamic parameters of fluid-responsiveness for perioperative hemodynamic optimization of patients undergoing non-cardiac surgery: a non-inferiority randomized controlled trial. BMC Anesthesiol. 2020 Apr 18;20(1):87. doi: 10.1186/s12871-020-01011-z. PMID: 32305061; PMCID: PMC7165409.
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Thomson R, Meeran H, Valencia O, Al-Subaie N. Goal-directed therapy after cardiac surgery and the incidence of acute kidney injury. J Crit Care. 2014 Dec;29(6):997-1000. doi: 10.1016/j.jcrc.2014.06.011. Epub 2014 Jun 23. PMID: 25060640.
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Xu H, Shu SH, Wang D, Chai XQ, Xie YH, Zhou WD. Goal-directed fluid restriction using stroke volume variation and cardiac index during one-lung ventilation: a randomized controlled trial. J Thorac Dis. 2017 Sep;9(9):2992-3004. doi: 10.21037/jtd.2017.08.98. PMID: 29221272; PMCID: PMC5708410.
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Zhang J, Chen CQ, Lei XZ, Feng ZY, Zhu SM. Goal-directed fluid optimization based on stroke volume variation and cardiac index during one-lung ventilation in patients undergoing thoracoscopy lobectomy operations: a pilot study. Clinics (Sao Paulo). 2013 Jul;68(7):1065-70. doi: 10.6061/clinics/2013(07)27. PMID: 23917675; PMCID: PMC3715019.
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Kapoor PM, Magoon R, Rawat R, Mehta Y. Perioperative utility of goal-directed therapy in high-risk cardiac patients undergoing coronary artery bypass grafting: “A clinical outcome and biomarker-based study”. Ann Card Anaesth. 2016 Oct-Dec;19(4):638-682. doi: 10.4103/0971-9784.191552. PMID: 27716694; PMCID: PMC5070323.
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Kapoor PM, Magoon R, Rawat RS, Mehta Y, Taneja S, Ravi R, Hote MP. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann Card Anaesth. 2017 Jan-Mar;20(1):83-89. doi: 10.4103/0971-9784.197842. PMID: 28074802; PMCID: PMC5290703.
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Li P, Qu LP, Qi D, Shen B, Wang YM, Xu JR, Jiang WH, Zhang H, Ding XQ, Teng J. Significance of perioperative goal-directed hemodynamic approach in preventing postoperative complications in patients after cardiac surgery: a meta-analysis and systematic review. Ann Med. 2017 Jun;49(4):343-351. doi: 10.1080/07853890.2016.1271956. Epub 2017 Feb 2. PMID: 27936959.
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Ramsingh D, Hu H, Yan M, Lauer R, Rabkin D, Gatling J, Floridia R, Martinez M, Dorotta I, Razzouk A. Perioperative Individualized Goal Directed Therapy for Cardiac Surgery: A Historical-Prospective, Comparative Effectiveness Study. J Clin Med. 2021 Jan 21;10(3):400. doi: 10.3390/jcm10030400. PMID: 33494308; PMCID: PMC7864512.
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Acute Kidney injury in the CVICU

Wittlinger T, Maus M, Kutschka I, Baraki H, Friedrich MG. Risk assessment of acute kidney injury following cardiopulmonary bypass. J Cardiothorac Surg. 2021 Jan 6;16(1):4. doi: 10.1186/s13019-020-01382-x. PMID: 33407652; PMCID: PMC7789772.
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Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, Zarbock A. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med. 2017 Nov;43(11):1551-1561. doi: 10.1007/s00134-016-4670-3. Epub 2017 Jan 21. Erratum in: Intensive Care Med. 2017 Mar 7;: PMID: 28110412; PMCID: PMC5633630.
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Haase M, Bellomo R, Story D, Letis A, Klemz K, Matalanis G, Seevanayagam S, Dragun D, Seeliger E, Mertens PR, Haase-Fielitz A. Effect of mean arterial pressure, haemoglobin and blood transfusion during cardiopulmonary bypass on post-operative acute kidney injury. Nephrol Dial Transplant. 2012 Jan;27(1):153-60. doi: 10.1093/ndt/gfr275. Epub 2011 Jun 15. PMID: 21677302.
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Shen Y, Zhang W, Cheng X, Ying M. Association between postoperative fluid balance and acute kidney injury in patients after cardiac surgery: A retrospective cohort study. J Crit Care. 2018 Apr;44:273-277. doi: 10.1016/j.jcrc.2017.11.041. Epub 2017 Dec 1. PMID: 29220757.
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg. 2018 Jan 1;53(1):5-33. doi: 10.1093/ejcts/ezx314. PMID: 29029110.
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POST-OPERATIVE BLEEDING
Despotis G, Avidan M, Eby C. Prediction and management of bleeding in cardiac surgery. J Thromb Haemost. 2009 Jul;7 Suppl 1:111-7. doi: 10.1111/j.1538-7836.2009.03412.x. PMID: 19630781.
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POST OP PAIN CONTROL
Boswell MR, Moman RN, Burtoft M, Gerdes H, Martinez J, Gerberi DJ, Wittwer E, Murad MH, Hooten WM. Lidocaine for postoperative pain after cardiac surgery: a systematic review. J Cardiothorac Surg. 2021 May 31;16(1):157. doi: 10.1186/s13019-021-01549-0. PMID: 34059093; PMCID: PMC8166031.
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Brewer, J.M., Tran, A., Yu, J. et al. ECMO after cardiac surgery: a single center study on survival and optimizing outcomes. J Cardiothorac Surg 16, 264 (2021). https://doi.org/10.1186/s13019-021-01638-0
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Eltorai AEM, Baird GL, Eltorai AS, Healey TT, Agarwal S, Ventetuolo CE, Martin TJ, Chen J, Kazemi L, Keable CA, Diaz E, Pangborn J, Fox J, Connors K, Sellke FW, Elias JA, Daniels AH. Effect of an Incentive Spirometer Patient Reminder After Coronary Artery Bypass Grafting: A Randomized Clinical Trial. JAMA Surg. 2019 Jul 1;154(7):579-588. doi: 10.1001/jamasurg.2019.0520. PMID: 30969332; PMCID: PMC6583822.
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Keywords: CVICU, cardiac surgery, hemodynamic management, bleeding, goal-directed resuscitation, goal-directed, fluid therapy, volume responsiveness, fluid responsiveness.

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