Seminars in thoracic and cardiovascular surgery
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Semin. Thorac. Cardiovasc. Surg. · Oct 2000
Cardiothoracic intensive care: operation and administration.
The cardiothoracic surgery intensive care unit (CTICU) has evolved as a separate entity from the general surgical intensive care unit as management for cardiac surgery patients has become streamlined and algorithm driven. Critical care is best managed when the service is designed for a homogeneous population with a circumscribed set of medical and surgical issues. The repetition involved with the subspecialty care allows health care providers such as primary care nurses, nurse practitioners, physician assistants, and other ancillary services to become appropriately focused on issues pertinent to this population. ⋯ A responsible physician should be available in the CTICU, especially during the immediate postoperative period when physical assessment and direct hands-on involvement are essential. In an era when the operative team (ie, cardiac surgeon and cardiac anesthesiologist) must return to the surgical suite soon after the patient arrives in the intensive care unit, the presence of a physician dedicated to postoperative medical and surgical management becomes mandatory. According to the Joint Commission on Accreditation of Healthcare Organizations, "Each special care unit is properly directed and staffed according to the nature of the special patient care needs anticipated and scope of services provided." The assignment of staff is designed to match experience with patient acuity.
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Semin. Thorac. Cardiovasc. Surg. · Oct 2000
ReviewManagement of bleeding and coagulopathy after heart surgery.
Mechanisms of bleeding common to virtually all patients after heart surgery are platelet dysfunction, enhanced fibrinolysis, dilution of all components of the coagulation system, and the presence of heparin and protamine. The use of warfarin is increasing in patients with heart disease requiring surgery. The replenishment of vitamin K-dependent factors beyond a normal prothrombin time is not assessable, and the dilution associated with cardiopulmonary bypass can reach coagulopathic levels. ⋯ When bleeding is observed in the postoperative period, a sequential assessment of the probable cause leads to initial therapy while laboratory test results are obtained. Ongoing assessment for hemodynamic instability caused by accumulated mediastinal blood is needed while managing the bleeding patient. A chest radiograph and transesophageal echocardiogram can be useful in diagnosing cardiac tamponade.