post-op cabg care - page 2
What type of care do your fresh cabg patient require that is routine. I am interested in seeing how much FLUID other hospitals give their patients related to starting of IV gtts. I think we fluid... Read More
Jan 24, '05In our cabg's we just have a left atrium cath and a CVP cath, that we pull out in the morning after surgery.
Almost of our patients stay at ICU just for 20 - 24 hours .
We only put SG if we have a non linear pos op like dependency of vasoactive drugs, low urinary output, prolonged mechanical ventilation...
Jan 24, '05With some MD's we always have a swan. With some of the other MD's we almost never do unless they are really really sick. This has just been a recent thing with them not putting in swans in some pts & we don't like it (no SvO2, CO, CI, etc.). It's good to know other places don't use them sometimes!
Nov 6, '08First we give 2 Liters of NS (1 liter bolus at a time)
Then we give 2 albumins
Then we call the MD for more orders
Remember, it is important to worry about fluid overload...but we can always give them a diuretic!
Nov 6, '08The thread you're replying to is several years old; remember practices may have changed by now.
Nov 6, '08For the most part fluids are titrated to hemodynamic parameters. If the patients SVR is elevated and CI<2.1 then fluids are indicated- esp if PAP/CVP are lower than the patients pre-op values. Most of our patients end up 1.5-2.5L positive in the first 24hrs and are often 3+L positive by the time they transfer to the floor. Post op patients have poor protein stores and diminished vascular tone. They end up third spacing a lot of fluid. Even though they are "fliuid overloaded" by I&O if you don't fill the vascular space you are going to have a patient in renal failure -either from excessive dehydration in the vascular space, hemodynamic instability or excessive use of pressors to maintain VS. By the way, there have been studies that suggest excessive fluids post op CABG results in in increased rate of atrial ectopy. We usualy feel lucky to keep a patient <3L+ in the post-op period. As a rule we try to give colloid first followed by crystalliod. After 2-3 L of fluid load it us best to check an H&H in case you are due for cells.
Nov 7, '08We used to routinely give our post CABG pts dex saline 1ml/kg/hr, although most surgeons do not want this.
Typically our patients end up being 2lts positive at end of day of surgery.
Usually the patient will recieve filling in the form of colloid inrelation to their heamodynamic status, we would give pts with a moderate- poor LV less filling and in those cases may be more likely to start inotropes rather than risk over filling them.
If they have a lot of bleeding they will recieve the appropriate blood products.
Typically we aim for pt's to be extubated and onto oral fluids within 6 hours.
In my experience most cardiac pt's are on diuetics anyway and have pre-existing problems with this. If the U/O tails off, or is mediocre they will get lasix or if found to be very positive next day will usually get 20mg IV to help off load them.
Hope that helps
Nov 15, '08:redpinkhe I think it depends on the program and how sick the patients are pre-op, nontheless post-op. The hospital I work at does 50 cases weekly...and we recover some sick patients. We use D5 1/3 NS for maintenance. We use 2-3 L of NS or LR for fluid resusciation. Colloids are used next up to 500cc with/without Calcium.
We use only Diprivan 30-50mcg/kg/min for the first day or two...then change to Fentanyl/Versed for sedation. Very typical to have one or two pressors, ie; Norepi and Dopa. 80% of the time we start an insulin gtt.A t least one patient a week will come out open chest and they have 1-2 LA lines and a CCO swan. We have all standing orders for vasoactive drugs. Very rare we call the attendings unless the patient needs to go back to the OR. :redpinkhe
Nov 23, '08Hi 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)
Nov 23, '08All 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.
Nov 24, '08We 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
May 21, '09In 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?
May 26, '09We 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.