Reference Guide

Post-Operative CVICU Management

Immediate post-op reception, fast-track recovery, neurological care, and multidisciplinary rounds

Handoff: Structured handoff from OR team — procedure, CPB time, cross-clamp time, bypass grafts/valve type, intraoperative complications, current drips, pacing wires, chest tubes
A-B-C Assessment: Confirm ETT position, connect ventilator, verify bilateral breath sounds, connect all lines and transducers
Hemodynamics: Connect arterial line, CVP, PA catheter (if present); assess MAP, HR, rhythm, filling pressures
Chest Tubes: Connect to suction (−20 cmH₂O); document initial output; assess for air leak
Pacing Wires: Test capture and sensing; set appropriate mode and backup rate
Labs on Arrival: ABG, CBC, BMP, coagulation profile (PT/INR, aPTT, fibrinogen), lactate
CXR: Confirm ETT position, line positions, pneumothorax, effusions, mediastinal width
Rewarming: Target core temp ≥36°C; active rewarming if hypothermic; avoid shivering (increases VO₂)
Bleeding Assessment: Hourly chest tube output; coagulation-guided transfusion (protamine, platelets, FFP, cryoprecipitate, TXA)

Target extubation: Within 6 hours for uncomplicated cases (reduces VAP, ICU LOS)
Criteria: Hemodynamically stable, warm, not bleeding (CT output <100 mL/hr), awake and following commands, adequate gas exchange (FiO₂ <0.50, PEEP ≤5)
Analgesia-first approach: Fentanyl/hydromorphone + dexmedetomidine for smooth emergence; minimize benzodiazepines
Post-extubation: HOB >30°, incentive spirometry, early mobilization (sitting in chair POD 0–1, ambulating POD 1–2)
High-risk patients for delayed extubation: Prolonged CPB (>180 min), reoperations, MCS, severe LV/RV dysfunction, neurological concerns
Post-extubation respiratory failure: NIV (CPAP/BiPAP) before reintubation; HFNC for comfort

Stroke (1–5%): New focal deficit on awakening; urgent CT → consider CT angiography/perfusion; neurology consult; thrombolysis generally contraindicated post-sternotomy (discuss with team)
Delirium (25–50%): Most common neurological complication; CAM-ICU screening every shift; non-pharmacological bundle (reorientation, sleep hygiene, early mobilization, avoid benzodiazepines)
Delayed Awakening: Residual anesthesia, hypothermia, metabolic (hypoglycemia, uremia), seizures, stroke → systematic evaluation
Seizures: EEG monitoring if suspected; correct metabolic derangements; levetiracetam first-line
Targeted Temperature Management: For cardiac arrest survivors (ROSC after VF/pulseless VT); target 32–36°C for 24h per TTM2/HYPERION data
Peripheral Nerve Injury: Brachial plexopathy (sternal retraction), phrenic nerve palsy (topical cooling during surgery) → diaphragm ultrasound

Daily Goals Sheet: Each patient has documented daily goals reviewed by the entire team
FASTHUG-MAIDENS Mnemonic: Feeding, Analgesia, Sedation, Thrombo-prophylaxis, HOB elevation, Ulcer prophylaxis, Glucose control, Medication reconciliation, Antibiotics review, Indwelling catheters, De-escalation, Electrolytes, Skin/pressure care
Rounding Team: Cardiac intensivist, CT surgery, bedside nurse, pharmacist, RT, dietitian, social work/case management, APP
Structured Handoff (I-PASS): Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver
Family Communication: Daily updates; structured family meetings for complex patients; shared decision-making for goals of care
Quality Metrics: CLABSI, CAUTI, VAP rates; surgical site infections; unplanned readmissions; mortality benchmarks

Protamine: Ensure adequate reversal of heparin (1 mg per 100 U heparin given); check ACT; additional protamine 25–50 mg if ACT elevated
Tranexamic Acid (TXA): 1 g IV bolus ± infusion; standard of care to reduce post-CPB bleeding (ATACAS trial)
Platelet Dysfunction: CPB causes acquired platelet dysfunction; transfuse platelets if count <100K or qualitative defect with ongoing bleeding
Fibrinogen: Target >200 mg/dL (some advocate >250 for active bleeding); cryoprecipitate (10 units) or fibrinogen concentrate
FFP/PCC: For elevated INR with active bleeding; 4-factor PCC for warfarin reversal
Point-of-Care Testing: TEG/ROTEM-guided transfusion reduces blood product utilization; systematic algorithm recommended
Surgical Re-exploration: Required in 2–5%; indications: >200 mL/hr for 2–4h, >1500 mL/24h, sudden increase, hemodynamic instability

S.K.

The World-Class Cardiac Intensivist

This content is for educational reference only. Always follow institutional protocols and exercise clinical judgment.

Immediate Post-Op Reception