Re: post-op cabg care

Hi its really interesting finding out what you do in the US, I work in a 25 bedded CC area in the UK, which provides a full range of cardio thoracic care, from CABG to transplants. We do about 50 ops a week. A typical patient on our unit following CABG/ valve surgery will get approx 80ml/hr crystalloid an hour, we give dex saline, and use this to top up iv K if it goes below 4.5 on ABG, which we do ourselves on the unit. We are given peramiters for MAP (65-90 normally) and CV pressure (usually 8-12 ) and use colloid to keep to this. Blood if Hb is below 8 or Gelofusine if above 8. We will give 250 mls bolus if UO is tailing off, then 40 mg furosimide if that doesn't improve UO.

We give 40 mg Furosimide IV and 5mg amiloride PO on the first day post op. We use PA catheters if the patient needs further support (IABP or vasoactive drugs)

Re: post-op cabg care

All our patients have Swans at our center. Volume resuscitation is determined by a patients individual hemodynamic needs and is nurse driven as to how much is given and when initially post-op, up to 5 units of Albumin 5%. It is highly patient specific, depending on LV function, preload dependence, LV compliance, etc. We have total fluid limits, including IV gtts of 40 to 60ml per hour that no one pays any atttention to because it can be impractical. There are 24 hour fluid limits of anywhere from 1500 to 2400 ml that we devide up into thirds and target for an 8 hour shift using NS to meet the target over an 8 hour period, again including gtts but not albumin, which is tracked separately on a blood balance sheet with chest drainage and other blood products that may need to be given. What turns out to be excessive volume the next day after surgery is from very active third spacing by post CPB pts for 8-12 hours post-op et volume must be maintained to optimize filling and preload and hemodynamic performance. Off pump pts have far less endothelial leak than on-pump and therefore will generally need less volume resusitation. Giving Lasix to patients is common if they do not adequately mobilize their third space fluid or are fluid long from blood products for post-op bleeding or simply required a larger preload initially post-op. The concentration of IV drips and the amount of NS given is, again, nurse driven. Given the pronounced tendency for the post CPB patient to have endothelial leak and many patients need to have adequate preload intitally post-op to allow for dialling in their blood pressure to desired limits with Nipride, it is not at all uncommon to need to give Lasix the following day when the leak has stopped and things have stabilized. It is by no means an error if your patient needs Lasix to divest themselves of third space fluid the next day.

Re: post-op cabg care

We generally have orders for one liter of albumin 25%. Beyond that we look at the hemos and let them guide us. I have noticed that in the last 2 years or so, the fluid requirements seem to be less. It may be because we are doing so many more off pump

Re: post-op cabg care

In our CVICU--we have very different treatments depending on the surgeon, and it appaers that this inconsistent trend is everywhere from reading the above posts.
Does anyone know of any evidence-based literature that will validate or provide standards and guidelines for the use of fluids, and what type, when and how much for the immediate post-op open heart patient?

Re: post-op cabg care

We use the hemodynamics as a guide to volume replacement, taking into consideration the pt's EF from preop ECHO. As a general rule though valves require much more fluid than CABG-in that case we use 250ml hespan once, then albumisol thereafter. Dumping LR or NS into a pt just causes third spacing, as it leaves the vascular system very quickly after administration whereas albumisol has the pull of the larger molecule. We did try to run the CABG a little on the dry side, by the way, ususally to a PAD of 12 (normal for average, but then we don't take care of the normal now do we?) Generally, our docs will order Lasix 10mg IV as a standard POD1 routine unless contraindicated. About 95% CVS pts are out of CVICU by 1100on POD1 with our routine.